Orthopaedics What s New in 2015 What Really Works in Orthopaedics: Does Advertising Change our Practice Warwick J. M. Bruce Clinical Professor The University of Sydney
Concord Hospital Sydney Australia
the surgeon is no longer proud when he sees the rows of amputation stumps that he has left behind himself; he sees them rather with sorrow as witnesses documenting the imperfection of his art Professor Bernhard von Langebeck
What s wrong with Surgery Money Ego Advertising The villains Companies Surgeons Patients
How have we done?
PATELLOFEMORAL REPLACEMENTS
NJRR Australian Orthopaedic Assoc 2008 5 yr cumulative revision rate 13.8% <55 yr 17% 5 yr Males twice revision rate 21.3% 5 yr
Arthrosurface HemiCAP Age: <35 35-60 >60 The New Continuum: After Biology before Joint Reconstruction
Results Histology A B Goat 3 at POW 26. Remodeling trabecular bone abuts much of the anchoring screw and resurfacing unit. The subchondral bone plate is thickened immediately lateral to the implant. The central cannulation of the anchoring screw is bone lined. Articular cartilage migrates across the resurfacing unit margins. There is no evidence of cyst formation 1+x OM.
NJRR Australian Orthopaedic Association 2008 2 yr cumulative revision 16.5% Revision UKR 62.5% TKR 37.5%
Advances: Spacer R Hallock Orthopaedic Clinics North America Oct 2005, Vol 36, No 4, 505 512 62% revised in 2 years ( high failure rate reported 2004 ) NJRR 2006
NJRR Australian Orthopaedic Association 2008 9 InterCushion unispacers 100% revision Zimmer unispacer 56.7% revised (3yrs) 40% first year
Medial Spring High infection rate I was told 27% by company representative These are sold without adequate trial
Revolutionary knee replacement operation in. 50% of patients currently requiring a knee replacement will be suitable for this new technology
National Joint Replacement Registry 2004 14.2% of all knee replacements 3.2% failure ( TKR 1.4% failure) NSW and SA most ( Vic third ) SA 2.3 times Victoria per 100,000 NSW 1.9 times Victoria per 100,000 Preservation 4.1% failure since introduction 2.5 yrs before Hospitals performing most procedures highest level failure
UNICOMPARTMENTAL 37.3% fewer unicompartmental knees in 2010 compared to 2003 9yr revision rate 13% compared to 5% of TKRs
Other Factors Adequate Operative numbers Swedish Knee Arthroplasty Register Number of Mobile bearing UKR/Unit/Year effects outcome Threshold >23/yr Robertson et al JBJS(Br) 2001;83-B:45-9 Unrealistic means need to do 230 knees per year (NJRAOA 9.7%)
Best unicompartmental results not significantly different from the best rate for TKR Murray D:JBJS Nov 1998 143 knees, 34 died 109 still living Time since operation 7.6 yrs ( maximum 13.8 ) One knee lost to follow up 10 yrs cumulative survival rate 98% Excluded 39 failures Excluded 28 ACL Excluded 9 previous HTO Excluded 2 knees AVN
True Survival 100 80 60 40 20 Murray D ACL HTO AVN/T 0 10 YRS
Minimal Incision: Swedish Registry 2003 Risk ratio for revision Miller Gallante UKR higher than Link UKR Not the case during the 1990 s revision rate similar During the 2000 s Link UKR 22% mini incision, Miller Gallante UKR 72% mini incision.there are indications showing that the mini-incision increases the revision rate.it is conceivable that the new operating procedure may further deteriorate the long-term results.
Simple vs. Complex TKR Advance knee Cheap Symmetrical Reliable Journey Knee Left and right Beautiful laboratory studies Sophisticated kinematics Medial pivot principles
Revison Rates Primary TKR by Surgeon
Revison Rates of Primary TKR by Surgeon Surgeon N Revised N Total Obs. Years Revisions/100 Obs. Yrs (95% CI) Dr W Bruce Advance (NMP)* 4 92 896 0.45 (0.12, 1.14) Other Surgeon Advance (NMP)* 12 335 1444 0.83 (0.43, 1.45) Other Total Knee 13672 396045 1946880 0.70 (0.69, 0.71) TOTAL 13688 396472 1949220 0.70 (0.69, 0.71)
Hip Replacement Anterior approach Done for 100 year
Mini Anterior Approach NJRR 2010 The Quadra H femoral stem has been used in 837 procedures and has a one year cumulative percent revision of 3.1%. It has over five times the risk of revision in the first two weeks compared to all other total conventional hip replacement. Cumulative Percent Revision 12% 10% 8% 6% 4% Quadra- H/Versafit Male Quadra- H/Versafit Female Other Male Other Female HR - adjusted for age Quadra- H/Versafit Male vs Quadra- H/Versafit Female Entire Period: HR=0.74 (0.35, 1.54),p=0.418 Quadra- H/Versafit Female vs Other Female Entire Period: HR=1.40 (0.87, 2.26),p=0.164 Quadra- H/Versafit Male vs Other Male Entire Period: HR=1.12 (0.63, 1.98),p=0.695 Other Male vs Other Female Entire Period: HR=0.92 (0.86, 0.99),p=0.024 2% 0% 0 1 2 3 4 5 6 7 8 9 10 Years Since Primary Procedure
Remember most people do Anterior Approach in Easy Hips
100% marketing DAY ONLY
The Facts Two meetings Arthroplasty Society Advances in Joint Replacement Lucerne I have done second joint of these surgeons I had a hip replacement Large inscision Only on panadol BP 80 / 60 not allowed out of bed Operating 4 weeks Golf 8 Skiing 3 months
ASR Withdrawn from Australia in 2009
Metallosis
Resurfacing No of procedures in 2010 was 22.1% less than in 2009 and 48.6% less than its peak in 2005 3.6% of THR s are now resurfacings
Surface Replacement: Revision by Type of Prostheses Femoral Component Acetabular Component Year 1 Year 2 Year 3 Year 4 Year 5 BHR BHR 1.6 (1.3, 1.9) 2.0 (1.7, 2.4) 2.5 (2.1, 2.9) 2.9 (2.5, 3.5) 3.7 (3.1, 4.4) ASR ASR 4.1 (2.8, 5.9) 5.2 (3.5, 7.6) Durom Durom 3.8 (2.5, 6.0) 5.0 (3.3, 7.5) Cormet 2000 (HAP) Cormet 6.3(2.9, 13.5) 7.4 (3.6, 14.8) 9.2 (4.6, 17.9) All Resurfacing 1.8 (1.5, 2.1) 2.2 (1.9, 2.6) 2.7 (2.3, 3.1) 3.1 (2.7, 3.6) 3.8 (3.2, 4.6) Data: 1 st September 1999 to 31 st December 2006
Outcomes: Resurfacing By Head Size (OA only) HR=3.35 P<0.001 <50 mm 7.5% >=50 mm 1.9% Data: 1 st September 1999 to 31 st December 2006
Outcomes of BHR and ASR <50 mm Head Size P = 0.015 ASR At 2 years = 6.6% BHR At 2 years = 3.2% Data: 1 st September 1999 to 31 st December 2006
Volume BHR and success 74% of hospitals performed less than 30 cases in 7 years 64% of hip resurfacings were performed at 16 high volume hospitals >100 cases 249 (3.1%) of the resurfacing procedures were revised. Percentage of Hospitals 45 40 35 30 25 20 15 10 Resurfacing Cases by Hospital 1999-2006 Australian Joint Registry High Volume Hospitals 5 0 <10 10-19 20-29 30-39 40-49 50-99 100-299 300-499 > 500 Total Cases Performed
Least Experienced Hospitals vs. all Others 9 Survivorship of Hip Resurfacing and Hospital Volume When adjusted for differences in the age and sex of the patients, the risk of revision was 66% greater in hospitals performing <25 cases. Cumulative Revisions (%) 8 7 6 5 4 3 2 1 0 p=0.004 0 1 2 3 4 5 Years Post Operation
Results My Corail Stems vs. Australia
My Revisions All major revisions due to Manufacturer Corail stem revisions 4 stems revised Revision diagnosis Implant breakage stem (2 patients) Osteolysis (2 patients) neither stem loose ASR MINOR revisions 1. Infection 2. Ceramic fracture 3. Prosthesis dislocation
Bearing Surfaces
What s going to Happen?
Osteoarthritis In 2006, 46.4 million Americans (21.6%) had been diagnosed as having arthritis. In 2030 the number of Americans with arthritis will increase to nearly 67 million. Hootman JM Arthritis Rheum 2006
PROJECTIONS FOR HEALTHCARE COSTS An analysis of future public and private spending on health care in 21 industrialised nations (Kibasi et al 2012)
OECD OBESITY OVERVIEW 18 % in the OECD population are obese. 1/3 in Mexico, NZ and USA are obese. 1/4 in Australia, Canada, Chile and Hungary are obese. In Asian countries 2-4 % are obese. Severely obese people die 8-10 years earlier Obesity is estimated to be responsible for 1% to 3% (5%-10% USA) of health care expenditures.
OSTEOPOROSIS osteoporosis in 2005 in USA is estimated to increase from 10 million to >14 million people in 2020 In 2005, total fractures ~2.0 million (Fig. 1A) and costs to be more than $16.9 billion (Fig. 1B). Projection to 2025 Fractures are expected to grow to >3 million Costs are projected to grow by >48%, around at $25.3 billion. Burge et al., Journal of Bone and Mineral Research 2007
HIP ARTHROPLASTY The estimated demand for primary total hip and knee arthroplasty and revision. 2005 2030 INCREASE % Primary THR 208,600 572,000 174% Revision THR 40,800 96,700 137% Primary TKR 450,000 3.48 million 673% Revision TKR 38,300 268,200 601% Primary Primary Revision Revision Kurtz S., J Bone Joint Surg Am, 2007
USA MANPOWER Between 2000 and 2020, the demand for orthopaedic services increase by 23% orthopaedic surgeons will increase by only 2% during the same interval. Porucznik MA, AAOS 2007 The deficit of orthopaedic surgeons is estimated to be 12,000 to 15,600. Farley FA, J Am Acad Orthop Surg. 2007
PREDICTED RISE IN INFECTION FOR HIP AND KNEE REPLACEMENTS The relative incidence of Periprosthetic Joint Infection ranged between 2.0% and 2.4% of total hip arthroplasties and total knee arthroplasties and increased over time. Kurtz SM J Arthroplasty 2012
What should we concentrate on? Education of surgeons do it better What the patient wants: Stopping infections Stopping dislocations Getting the leg length right Reproducible and relatively pain free Not what surgeon wants New toy New approach Marketing edge on colleagues I do a lot of surgery because of word of mouth not advertising
What we should concentrate on? What government wants: Evidence based not advertising based What surgeons should want: Reproducibility in results and surgeon s ability to do it No complications related to implant No complications related to approach Laser or customised jigs for accurate implantation Advanced imaging for more accurate surgery
33 /19 54yr old female with 36mm MoP
Functional anteversion only 4 at seat-off Limited lumbar flexion 20
Functional anteversion now 17 at seat-off 41 /30 Doing very well @ 6 months
What we won t have Mini incsions adequate incisions Surgeons with unacceptable revision rates registry data Computer navigation or robots Money
CONCLUSIONS Nearly all resources will be treating obesity and osteoporosis Surgeons will be held accountable not just by patients but by government Registries will become powerful political tools which will not always be in the interests of patients and surgeons
Thank You