By: 15 April 2019
Look beyond orthopaedics to gear up for the 2020s and beyond

Technologies making headway in other sectors can unlock improvements in the efficiency, effectiveness and patient satisfaction of orthopaedic surgery. But a collaborative approach is needed, and we have to act now, says Brian Lambton, Global Professional Education Manager, Corin Group

It’s 50 years since knee replacement surgery was first performed, and almost 60 years since Professor Sir John Charnley completed the first full hip replacement. These once pioneering operations have become some of the most commonly performed and successful surgical procedures in medicine. Long-term survivorship and clinical outcomes are good, with most patients enjoying an active life following surgery.

However, multiple studies suggest that around 10-20 per cent of post-operative knee patients report some level of dissatisfaction. This is significant, especially in view of the growing trend for patient-reported outcome measures (PROMS) to be factored into overall clinical outcomes. In this environment, patient satisfaction becomes a critical success factor. And we also need to consider the bigger picture: with an aging population and over-stretched healthcare providers, the orthopaedic value equation is under extreme pressure.

How can you improve clinical outcomes and PROMS while reducing the cost of the care cycle? This is the million-dollar question facing the orthopaedic sector. And digital technologies that have already been proven in other sectors might just hold the answer.

One thing is clear, implant innovation is not enough in itself. We need to dig deeper, analyse the entire end-to-end patient experience, then leverage insights to address satisfaction and efficiency issues. To achieve this, we’ll need to embrace technologies and approaches that have been proven elsewhere. This article outlines three considerations that should be at the top of the agenda for any organisation that’s serious about augmenting the effectiveness and value of orthopaedic surgery.

The big data factor

There has been much hype about big data across commercial industry sectors in the past decade. The exponential rise in personal smart devices has accelerated the digital revolution. And all that online activity generates reams of data surrounding people’s behaviours, values, attitudes and interactions. For a time, the commercial sector was overwhelmed by the sheer quantity and complexity of big data. But today, specialist data analysts and data scientists – working with robust technologies – can handle it more intelligently to identify and leverage valuable insights.

In the commercial world, this means consumers benefit from more personalised shopping experiences and services tailored to their needs and expectations. Companies are adopting more agile working practices so they can continually evolve in line with changing customer demands. Their goal is to achieve differentiation, customer satisfaction and competitive

There is much scope for this ethos to be embraced in the orthopaedic sector. With digital technologies we can track patterns in patient outcomes and the factors influencing them, then use these insights to optimise the entire treatment pathway. By fully understanding trends at the macro level, it is possible to improve patient experiences and outcomes efficiently at the micro level. So, the approaches commercial organisations use to boost customer satisfaction and competitive advantage can be deployed in orthopaedics for better patient satisfaction and healthcare value.

Personalised orthopaedic surgery

Enhanced personalisation is one of the biggest commercial advantages associated with big data. Industries as diverse as food and drink, personal care and fashion are investing in ways to translate insights into product offerings that resonate with consumers. Closer to home for orthopaedics is the pharmaceutical industry, which is embracing personalisation to better manage risk and improve treatments, for instance via controlled dosage of drugs. Understanding when a patient would be unlikely to respond to a dosage level, or worse, exhibit a negative reaction, can save lives, accelerate treatment and ultimately lead to better cost-efficiency.

Personalisation has been a hot topic in orthopaedics for some time, generally in relation to factors such as implant sizing. However, more advanced personalisation is required to drive further improvements in the value equation and address patient dissatisfaction.

For instance, when it comes to hip replacements there is no common consensus on position and orientation during implant alignment. This is further complicated by the fact that pelvic rotations, which have a significant bearing on functional acetabular orientation, are patient-specific.

Advanced imaging technologies offer new ways to personalise hip surgery by improving the accuracy of implant placement based on a patient’s unique anatomical geometry. Pre-operative simulations taking patients through a range of dynamic activities – such as sitting, standing, stair climbing – can provide insights about the relationship between different parts of their body. This enables prediction of the likely in vivo behaviour of implants, enabling the surgeon to optimise implant orientation based on how the patient moves. Important decisions about the placement of components can be made before the procedure, reducing the length of surgery, which is better for the patient and enhances the value equation.

Likewise, the way the knee moves varies between different patients doing the same activity, and for the same patient doing different activities. Movement is both activity-dependent and patient-specific. This complexity and individuality cannot be accounted for with traditional 2D mechanical alignment of knee replacement components. We know that cartilage and ligaments also need to be considered, and MRI-informed positioning can help facilitate better placement of implants. Going forward, the industry needs to fully explore the possibility of kinematic alignment, where the 3D orientation of an individual’s knee influences the positioning and placement of implant components.  

This ability to conduct hip and knee replacement surgery with positioning and placement tailored according to an individual’s anatomy and functional dynamics is not a pipe-dream. The technologies exist and using them to personalise orthopaedic surgery could deliver tangible improvements to PROMS. It also aligns with the ‘done once, done well’ ethos, reducing potential future costs associated with revisions when surgery is deemed unsuccessful.

As we head towards the 2020s, it’s time for the patient to take centre stage, and for the orthopaedic industry to embrace proven tools to achieve personalisation at scale. It’s better for the individual and better for the healthcare system that surrounds them. 

Personalised patient experience

With the scope and scale of change outpacing the capabilities of any individual industry, commercial-off-the-shelf (COTS) products are an effective means to harness new technologies. They offer tried-and-tested standard features intentionally developed to enable quick and easy adaptation for specific applications.

This approach is commonly used in the development of business process software to improve performance in functions such as accounting. Individual organisations reconfigure the standard features to meet their specific business requirements without the need for extensive programming. The model enables businesses to quickly and easily benefit from the latest developments in a way that meets their specific needs without having to start from the ground-up.

It’s not just enterprise software that can benefit from this model, it can be applied to hardware as well. For instance, COTS robotic arms can be used for certain aspects of implant manufacture. Once reconfigured by robotic engineers, they can enhance the reliability, speed and repeatability of processes such as linishing. But COTS also has much to offer at the front end of the patient experience.

The wearable activity wristbands that have become popular with consumers in recent years are essentially a COTS device. As well as counting steps, they can include sensors to gather physiological information such as heartrate, skin temperature and sleep patterns. Data can also be inputted by the user – from mood to calorie consumption to levels of pain experienced. What’s more, they offer the potential for connectivity via smartphones.

These wristbands have the potential to add a new dimension to orthopaedic surgery, providing a valuable insight interface between the surgical team and the patient.

Recovery time after surgery can vary greatly between patients, and there are many influencing factors from pre-operative fitness to mental health to an individual’s pain threshold. Consequently, one-size-fits-all recommendations for exercise and rest to aid recovery don’t represent the best way to optimise outcomes.  

How can activity wristbands help?

From the first patient visit, they can be used to track physiological and psychological indicators. This arms the surgical team with a baseline understanding of an individual’s personal characteristics and behaviours that are likely to influence recovery.

Following surgery, the patient continues to wear the device, and receives personalised guidance to help them resume normal activities at an appropriate pace. The surgical team is alerted if a patient is too active or not active enough, triggering real-time, intuitive support. This ensures the patient receives reminders, tips and advice tailored to their needs. And the surgeon can monitor progress, providing expert guidance to enhance the route to recovery.

Ultimately, the patient benefits from close and continuous post-operative management, and feels empowered to take more control over their path back to fitness. This results in a closer, more engaged surgeon-patient relationship throughout the patient pathway, where patients feel reassured and motivated to do what’s needed to improve recovery. It all adds up to a better all-round orthopaedic outcome. 

Insight-led collaboration is the future

The NHS – and indeed the global healthcare system – needs the right tools to achieve numerous orthopaedic goals. These range from incremental improvements in long-term implant survivorship to enhanced patient satisfaction evidenced in PROMS scores. And, with an aging population, keeping costs stable in real terms demands reducing them year-on-year per capita. This is perhaps the biggest challenge of all.

In the face of these complex demands, advanced personalisation, supported by digital technologies, needs to be at the very centre of future care plans. Enhancing concepts such as ‘once and done’ with personalised approaches could deliver huge financial benefits. After all, the cost of a revision is around double that of a standard joint replacement.

But can the NHS and other healthcare providers make this step-change alone? Probably not. Pockets of best practice are not going to go far enough. It all needs to be joined-up, and this can only be achieved via collaborative end-to-end solutions. Healthcare providers (including health insurance organisations), supplier companies, hospitals and patients themselves, all have a part to play.

It’s a multi-faceted and challenging situation with no straightforward solution. But as President Kennedy said: “We do these things not because they are easy, but because they are hard.” And we can achieve more if we tackle the hard things together, adapting technologies and approaches that have been proven in other sectors.

Establishing a digital ecosystem where all parties are joined-up offers an effective way to achieve the best aspects of patient-specific planning and support. From an orthopaedic perspective, that means optimised instrument and implant delivery, hospital cost-efficiency, greater patient throughput, lower revision rates and, of course, shorter waiting lists.

So, is this all available yet? At the moment, the answer is no. But it is coming. Companies are working on ways to address all of these challenges, bringing them to the market gradually, and developing focused solutions with built-in agility and scalability.

To quote Bill Gates: “We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten.” We need to keep this in the front of our mind and aim high as we head towards the 2020s. The time for action is now because patients are waiting for us to come together to provide better, more affordable healthcare. We can only achieve this by making personalisation and value the core drivers for healthcare delivery.