Marking a Decade of Constants

Credit the romance novels. Or Mother Nature.

Either could have inspired French novelist/critic/journalist (and floriculture fanatic) Jean-Baptiste Alphonse Karr to conceive the famous axiom plus ca change, plus c’est la meme chose—the more it changes, the more it’s the same thing, typically translated as “the more things change, the more they stay the same.”

It seems like the ultimate oxymoron, but Karr’s epigram actually is quite profound. And true.

Consider, for example, the past decade in orthopedics. On one hand, the technological advances have been mind-boggling: Customized replacement joints now trump traditional (standard) models for fit and functionality; computerized navigation systems are today’s implant positioning gurus; surgical robots can outperform (and outlast) humans in bony surface preparation; and nanotech sensors can detect post-surgical complications (poor bone ingrowth, infection, implant dislocation, etc.) as they occur.

Surgery itself is not as barbaric, either. Arthroscopic procedures—usually conducted on an outpatient basis—minimize scarring and expedite overall recovery. They’re also typically less painful. The anterior approach to hip replacement produces similar results—patients usually are walking on their new joints mere hours after surgery and return to normal activities in four to six weeks.

“The biggest single surgical [development] in the last 10 years has been the anterior approach to the hip,” said Roy K. Aaron, M.D., an orthopedic surgery professor at Brown University’s Warren Alpert Medical School, who also is director of the Orthopedic Cell Biology Lab and head of the orthopedic program in Clinical/Translational Research. “It’s a variance of an old pediatric approach to get to the hip that’s been modified and extended somewhat. That has really changed the way we think about hip replacement.”

3-D printing (aka, additive manufacturing) has influenced the industry’s mindset as well. The revolutionary technology is capable of producing hip joints, spare vertebrae, facial implants, cranial plates, temporary dental crowns, and bunion-busters quicker and with less toxicity than traditional manufacturing processes, using materials that are chemically similar to the defective parts.

Indeed, 3-D printing and countless other innovations truly have transformed orthopedics over the last 10 years.  But there are industry constants as well—underlying issues, controversies, and campaigns that have prevailed for Orthopedic Design & Technology’s entire existence.

Minimally invasive surgery (MIS), for instance, has triggered its fair share of debate during ODT’s lifetime. Still a relatively new technology a decade ago, the technique warranted a panel discussion at the 2005 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting in Washington, D.C. Proponents validated the technology’s  benefits with lots of data, boasting that 79 percent of MIS hip patients recovered at home using a cane versus 21 percent for those who chose traditional surgery. Moreover, supporters said patients undergoing quadriceps-sparing MIS knee arthroplasty recovered three times faster, experienced one-third less pain as well as 30 percent less blood loss, and gained an additional 10 degrees of motion at the end of the first and second years after surgery compared with those who had standard procedures.

The skeptics, however, warned against expecting MIS to be an end-all, be-all solution to conventional surgery. Not all subjects, they noted, are suitable candidates for the procedure (MIS success rates are dependent upon the type of injury and overall patient health).

MIS approaches, of course, are used routinely in orthopedic procedures nowadays, but the controversy surrounding this technology has not abated much. Reviews of clinical literature studying MIS approaches to lumbar fusion have revealed mixed results, though most outcome measures at least slightly favor the MIS group.

But not all outcomes and measures support MIS over open fusion, as minimally invasive surgeries are typically associated with longer operative times, which can translate to higher hospital costs. Increased radiation exposure due to necessary imaging and navigation is another concern for surgeons and other clinical staff.

Some surgeons also argue that a minimally invasive approach is less precise than open lumbar fusion, and its limited access makes it more difficult to address certain surgical complications. MIS procedures also require more technology, which can drive up costs for hospitals interested in starting a minimally invasive spine surgery program.

Minimally invasive surgery, of course, is only one of the numerous constants challenging the industry over the past decade. Others include a national joint replacement registry database, orthopedic political action committees, and the fluid concept of “orthopedic unity.”

In late 2004, the AAOS convened an Orthopaedic Specialty Societies Summit, with academy leaders, Council of Musculoskeletal Specialty Societies executives and orthopedic specialty group bigwigs brainstorming ways to help the “orthopedic community” speak with one voice.

More than a decade later, the industry is still searching for that unification.

“AAOS leaders seldom have a discussion without mentioning unity in some way,” AAOS First Vice President Gerald R. Williams Jr., M.D., of Philadelphia, Pa., told attendees of this year’s meeting in Las Vegas, Nev. “Our practice of orthopedic surgery is becoming increasingly specialized. We are more likely to be successful with one strong unified voice. Never has it been more important for us to be united.”

Perhaps the industry can find that coalescence in the next decade.