Dr. Jess H. Lonner, attending orthopaedic surgeon at Rothman Institute and associate professor of orthopaedic surgery at Thomas Jefferson University, shares his insight.

Mediaplanet: How has technology affected healthcare in general?

Dr. Jess Lonner: Historically, some of the most important and impactful therapeutic innovations in healthcare undoubtedly include the development of antibiotics, vaccinations and anesthesia. Diagnostically, the x-ray and more advanced imaging such as magnetic resonance imaging (MRI) have played a pivotal role in diagnosing and treating an immeasurable number of diseases, injuries and other conditions. In orthopaedic knee surgery — my specialty — no one can argue with the fact that arthroscopic techniques and knee replacement surgery have been amongst the most important technological innovations for improving function, relieving pain and restoring quality of life for millions of patients.

MP: What advancements have recently been made that affect surgery?

"Arthroscopic techniques and knee replacement surgery have been amongst the most important technological innovations for improving function, relieving pain and restoring quality of life for millions of patients."

JL: Beyond implant designs, many of which have dramatically impacted outcomes in knee replacement surgery, recent developments that have made a substantial difference in orthopaedic care have occurred at several stages of the continuum:

1.  Improved diagnostic skill and education in identifying earlier stages of arthritis. 

The identification and treatment of earlier stages of arthritis  — or arthritis that affects a part of, but not the entire knee — is giving rise to tremendous growth in partial knee replacements as an alternative to total knee replacements.

There are practical reasons for the growing use of partial knee replacement surgery. Partial knee replacement preserves the articular cartilage, bone, menisci and cruciate ligaments in the unaffected compartments, thus preserving proprioception and more normal kinematics compared to total knee replacement. Knees treated with partial knee replacements feel more normal than those treated with total knee replacements.  The medical risks are considerably lower in partial knee replacements than total knee replacements.  The recovery from partial knee replacement is typically faster, with a higher percentage of patients able to get back to work sooner and more likely to be able to return to some level of athletic activity. This is particularly important if we consider today’s patient demographics – more than half of our patients are younger than age 65 and the fastest growing group of patients coming in for knee replacement surgery are 55 and younger.  Lengthy recovery, extended time out of work and the notion of hanging up one’s golf shoes are not options for many of our current patients.

Estimates vary regarding the penetration of partial knee replacement in the United States, but a current conservative estimate is that approximately 10 percent of knee replacements performed are partials.  This is a relative underutilization of a procedure that may be appropriate for 30 to 40 percent of surgical candidates who have single compartment knee arthritis.  It is projected that the numbers of knee replacements will explode by more than 650 percent over the next 25 years. If we consider that between 1998 and 2005, the utilization of partial knee replacements increased at an average yearly rate of 32.5 percent compared to total knee replacements, which increased by an average of 9.4 percent during the same time interval, one can only imagine the future growth rate of partial knee replacements — particularly as we train more current and future generations of residents in the use of partial knee replacements.

2. Enabling technologies and pathways.

Improved evidence-based pathways and protocols are often used by surgeon groups and hospitals to standardize care, reduce wasteful steps or procedures, lower costs and enhance outcomes. Data-driven treatment protocols have been an important development in recent years,

Improved postoperative pain management with methods other than narcotics has been an extremely important advance that has revolutionized the postoperative experience, reduced narcotic-related side effects, accelerated postoperative recovery and facilitated nursing care and physical therapy, while also accelerating the rate of patient discharges to home.

3. Enhanced surgical accuracy with robotic technology and the growing trend in outpatient partial knee replacement surgery.

We are increasingly being held accountable to optimize outcomes and control costs through a continuum of care. Medicare and commercial payors are putting a great deal of pressure on surgeons and hospitals to perform partial knee replacements on an outpatient basis. We are becoming more efficient surgically and proficient in early discharge protocols, pain control, patient education and managing patient expectations. Undoubtedly, an equivalent episode of care for a given procedure can be delivered at a fraction of the cost in an Ambulatory Surgery Center (ASC) compared to a hospital, and a growing number of surgeons around the country are now performing the majority of our partial knee replacements on an outpatient basis, and often in an ASC environment.

It is actually a natural progression to do partial knee replacements on an outpatient basis. We didn’t think we would or could do outpatient ACL reconstructions 25 years ago; now we can’t imagine not doing ACL’s on an outpatient basis. We are now entering that same transition period in the realm of partial knee replacement surgery. Relative costs to Medicare and other payors are less in an ASC than a general hospital, so they are welcoming in a big way this initiative.

MP: How have technologies, such as robotics, advanced healthcare?

JL: Precision of alignment and adequate soft tissue balance are important determinants of success and durability in partial knee replacement (to an even greater extent than in total knee replacement). To that end, robotic technologies have been shown, in our studies and others, to significantly improve alignment and reduce error in partial knee replacement surgery.

Robotic technologies are gaining tremendous momentum for use in partial knee replacement surgery. A relatively new technology for partial knee replacement since 2006, robotic technology is now utilized in some 15 percent of partial knee replacements performed in the United States and its impact is continuing to grow.

"Value is becoming the new health care metric – and value now means achieving the best outcomes at the lowest cost."

Value is becoming the new health care metric – and value now means achieving the best outcomes at the lowest cost. Additionally, cost is going to be measured through the entire episode of care, so if we minimize early secondary surgeries and reoperations by enhancing early outcomes — even if that means we do so by using a technology that adds some up-front cost to a procedure — then value has been achieved.

The enhanced precision and optimized outcomes have raised substantially the interest in robotics for partial knee replacement surgery, but until Navio PFS™ became available, it just wasn’t economically feasible for robotics to be used in most hospitals and certainly not ASC’s, since the prior robotic system cost upwards of $1 million. This new generation robot is offered at approximately one-third of the price of the predicate device and is now drawing a great deal of interest by orthopaedic surgeons, hospitals and ASC’s — not to mention a very expansive population of patients looking for the optimal treatment for their knee arthritis.