Professor David Barrett, lead consultant at Southampton University Hospital and Professor of Orthopaedic Engineering, and one of the design surgeons for ATTUNE Knee System, discusses how innovation is improving the surgical process for total knee arthroplasty
Osteoarthritis (OA) is the most common form of arthritis[i] and is one of the leading causes of disability[ii]. Over 250 million people are affected globally[ii], with 8.5 million of them being in the UK alone[iii] . It is clear that OA presents a huge public health challenge, and one that is too expensive to ignore.
Total knee arthroplasty (TKA), commonly known as knee replacement surgery, is the gold standard treatment for OA, and the number of procedures carried out annually is projected to grow 189% by 2030, representing 1.28 million procedures annually[iv]. The success of TKA as a treatment for OA has led to its increasing use in younger patients, with a recent study indicating an increase of 18% in patients aged between 55 and 64[v], and a huge 188% increase among people aged 45 to 64[vi].
Patients seeking TKA struggle with daily function; normal activity is curtailed, and they can experience significant amounts of pain. TKA offers a high level of patient satisfaction in most patients[vii] but up to 20% of patients (mainly from the younger age group) are still dissatisfied after the procedure, with many reporting pain or discomfort around the knee, noise or vibration with movement, and difficulty when squatting, kneeling or negotiating stairs[viii],[ix],[x],[xi]. Younger patients may have more work or family commitments, as well as a higher expectation of their ability to resume normal activities such as sport. As well as affecting patients, these complications also impact health services, with revision procedures adding to an already burdened healthcare system.
The use of Patient Reported Outcome Measures (PROMs) in TKA is a key metric for the success of surgery. Allowing patients to score their satisfaction across a number of factors, including pain, daily living, sports and recreation, knee-related quality of life, and other symptoms, gives an accurate reflection of the perceived success of surgery and the likelihood of revision surgery being necessary in the future. Clinical trials have shown significant differences in PROMs measures from different implant systems, including improved patient confidence, increased activities of daily living and, most critically, increased quality of life[xii],[xiii].
It’s clear therefore that different knee systems offer different levels of benefit to patients. If we’re to keep patient outcome as our focus and goal, and product innovation must therefore be patient centric. From an initial goal of increasing longevity of the implant, in recent years the goal of innovation has been to address unmet patient need. It is only by considering the patient perspective that we’ll be able to realise the true transformational potential of this surgery, giving patients that freedom of pain-free movement they need.
Professor David Parkin, Honorary Visiting Professor, City University, London, co-author of the recently published whitepaper entitled “Advancing Patient Outcomes and Economic Value in Total Knee Arthroplasty: The Evidence of the ATTUNE® Knee System”, has another perspective on the need to address the burden of OA.
“When we consider the economic impact of increasing numbers of TKA procedures, it may be reasonable to consider whether health systems can afford to treat a condition that is not, after all, a threat to life. This would be a false economy as knee surgery offers huge value in terms of reducing pain and increasing movement.
“It is critical to factor into any discussion about cost effectiveness the ability of the patient to resume work. The costs associated with a reduced ability to work, which may also include the cost of care, was estimated in a US study to be $39,565 over a lifetime[xiv]. Taking into account the cost of TKA, the procedure generates an average societal saving of $18,930 per patient, mostly from patients increasing their earning potential over a lifetime. When such significant savings can be realised, it’s clear that TKA has the potential to reduce the societal burden of OA, but only if the procedure, and replacement system selected, truly addresses the needs of the patient in the first procedure and without the need for revision.”
We’re in an exciting time for orthopaedic surgery in general, particularly with TKA. New technology is set to evolve how surgeons, and the whole healthcare team, manage patients’ care from pre-admission to long-term recovery. This will not only improve the patient experience but enable health systems to find efficiencies. The more a patient’s specific anatomy and soft tissue is understood, the more accurately the implant can be placed, giving the patient long-lasting satisfaction, and avoiding the need for revision surgery in years to come.
Reducing healthcare utilisation is only part of the solution to finding more capacity. Digital workflows can transform the surgical process and create increased consistency and quality across the surgical process as a whole. Synchronised digital workflow technology and real-time insights reduce variability and work to support surgical teams by giving them increased, and more detailed, information. The development and adoption of artificial intelligence (AI) has real potential in the field of orthopaedics. Some AI technologies help surgeons build efficiencies during procedures, while others give healthcare teams crucial and unprecedented insights into how patients are healing from traumatic injuries.
What’s clear is that there is not a single solution to addressing the burden of OA on patients, their loved ones, and wider society. As we emerge from the pandemic, healthcare systems will need to focus on restarting elective procedures. In the UK alone, a recent study suggested that 4.7 million people were waiting for treatment as of February 2021[xv], and another UK-wide survey showed that 1 in 4 people waiting for a TKA reported their quality of life so poor it was considered ‘worse than death’[xvi], with a direct correlation between waiting time and deterioration in health-related quality of life.
However, given its growing economic impact, healthcare systems must find a way to deliver gold-standard care in the form of TKA so that it suits the patient and meets their needs, while also being cost effective for health systems. This pandemic accelerated uptake of new technologies that increase efficiency and capacity, such as videoconferencing, and it is imperative that the use of new technologies doesn’t revert to pre-pandemic levels. Surgeons and healthcare teams must take advantage of the promise that new technology brings to better map procedures to patients, to drive consistency and efficiency, and reduce the need for surgical revisions. Only then will we be able to avoid overwhelming health systems and, most importantly, help patients achieve the surgical outcome that will enable them to resume normal life.
[i] Moskowitz RW. The burden of osteoarthritis: clinical and quality-of-life issues. The American Journal of Managed Care, 01 Sep 2009; 15(8 Suppl): S223-9, PMID:19817508, https://europepmc.org/abstract/med/19817508, last accessed 10-18-19
[ii] Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet, 2019; 393 (10182): p1745-1759. DOI: https://doi.org/10.1016/S0140-6736(19)30417-9, last accessed 10-18-19
[iv] AAOS 2018 Annual Media Center, Projected volume of primary and revision total joint replacement in the U.S. 2030 to 2060. 6 March 2018. https://aaos-annualmeeting-presskit.org/2018/research-news/sloan_tjr/, last accessed 14 November 2020
[v] Blue Cross Blue Shield. The Health of America. Planned Knee and Hip Surgeries are on the Rise in the U.S. January 23, 2019. https://www.bcbs.com/the-health-of-america/infographics/planned-orthopedic-proceduresincluding-knee-and-hip-replacement, last accessed 10-18-19
[vi] Arthritis Foundation. The Risks of Early Knee Replacement Surgery. 2014. https://www.arthritis.org/health-wellness/treatment/joint-surgery/safety-and-risks/the-risks-of-early-knee-replacement-surgery, accessed November 2020
[vii] Shan L, Shan B, Suzuki A, Nouh F, Saxena A. Intermediate and long-term quality of life after total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Am 2015;97:156-68
[viii] Bourne RB, Chesworth B, Davis A, Mahomed N, Charron K. Comparing patient outcomes after THA and TKA: is there a difference? Clin Orthop Relat Res 2010;468:542-6
[ix] Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 2010;468:57-63
[x] Parvizi J, Nunley RM, Berend KR, Lombardi AV Jr., Ruh EL, Clohisy JC, Hamilton WG, Della Valle CJ, Barrack High level of residual symptoms in young patients after total knee arthroplasty. Clin Orthop Relat Res 2014;472:133-7
[xi] Sharkey PF, Miller AJ. Noise, numbness, and kneeling difficulties after total knee arthroplasty: is the outcome affected? J Arthroplasty 2011;26:1427-31
[xii] Pham T, van der Heijde D, Altman R, Anderson J, Bellamy N, Hochberg M, Simon L, Strand V, Woodworth T, Dougados M. OMERACT-OARSI Initiative: Osteoarthritis Research Society International set of responder criteria for osteoarthritis clinical trials revisited. Osteoarthritis and Cartilage, (2004) 12, 389–399
[xiii] Fisher D, Parkin D. Optimizing the Value of Your Patients’ TKA: How to Leverage Data from Patient Reported Outcomes, Becker’s Hospital Review, webinar recording, Oct 2019, www.ATTUNEevidence.com/clinicalevidence, last accessed 10-18-19
[xiv] Ruiz D Jr., Koenig L, Dall TM, Gallo P, Narzikul A, Parvizi J, Tongue J. The direct and indirect costs to society of treatment for end-stage knee osteoarthritis. J Bone Joint Surg Am 2013;95:1473-80
[xv] O’Dowd A. NHD waiting list hits 14 year record high of 4.7 million people. BMJ 2021;373:n995. NHS waiting list hits 14 year record high of 4.7 million people | The BMJ
[xvi] Clement N et al. The number of patients ‘worse than death’ while waiting for a hip or knee arthroplasty has nearly doubled during the COVID-19 pandemic. Bone Joint J 2021;103-B(4):672–680. The number of patients “worse than death” while waiting for a hip or knee arthroplasty has nearly doubled during the COVID-19 pandemic (boneandjoint.org.uk)