The operating room is not impervious to the pressures of the current healthcare environment — one in which improving efficiency and reducing cost are critical for healthcare providers to thrive. To streamline processes and cut costs, many healthcare providers have tackled the task of reducing clinical variation. Across the care continuum, operating rooms provide great opportunity for reducing variation by implementing the use of surgical systems.
[This content is sponsored by DJO Surgical]
Revision total knee arthroplasties represent one of many procedures that can be made more efficient through the use of a system. Revision total knee arthroplasty is the replacement of the previous failed total knee prosthesis with a new prosthesis. The procedure requires extensive preoperative planning, specialized implants, prolonged operating times and mastery of difficult surgical techniques.
Medical device manufacturer DJO Surgical offers the Exprt™ Precision System: Revision Knee to boost the efficiency of this complex procedure. The comprehensive two-tray system was designed by DJO Surgical engineers along with a team of design surgeons including the three participants in this roundtable — C. Lowry Barnes, MD, chair of the Department of Orthopaedic Surgery at the University of Arkansas for Medical Sciences (Little Rock), James A. Browne, MD, orthopedic surgeon (Charlottesville, Va.) and Michael J. Taunton, MD, orthopedic surgeon (Rochester, Minn.).
The following discussion was edited lightly for length and clarity.
Question: How long have you been doing revision knee surgeries? What is the most challenging part about the procedure?
Dr. C. Lowry Barnes: I have been doing revisions for 23 years, and revisions consistently represent about 30 percent of my hip and knee practice. The most challenging part of the procedure is managing stability, joint line and bone loss.
Dr. James Browne: I finished my adult reconstruction fellowship almost five years ago and have been doing a significant volume of revision knee arthroplasty procedures since that time. There are a variety of reasons why knee replacements are revised and the challenges often depend upon the cause of failure. Compromised soft tissues, deficient ligaments and bone loss are all challenging issues. Periprosthetic joint infection may be the greatest challenge in terms of long-term outcome.
Dr. Michael J. Taunton: I have been performing revision knee procedures for eight years. Every revision knee is different, which keeps our job interesting and challenging. The most challenging portion of revision total knee surgery is insuring stability of the knee ligaments throughout range of motion.
Q: How do primary knee surgeries differ from revision knee surgeries?
CLB: Primaries are much more predictable regarding intraoperative findings and subsequent challenges. Revisions often have multi-factorial problems leading to revision. The patient may have flexion instability in association with component malrotation, for instance.
JB: Many primary knee replacement surgeries follow a straightforward series of surgical steps. Revision surgery tends to be more complex and less predictable. Revision surgery typically takes longer and is associated with a higher rate of complications.
MT: In primary surgery, the behavior of the bone and soft tissues above the knee is fairly predictable. In the setting of revision, the surgeon must identify then address why the prior total knee failed. Through correct identification, the surgeon may have a full understanding of how to fix the problem. Then, the surgeon must use the remaining bone and soft tissue, usually in a compromised state, to reconstruct the knee joint.
Q: When you first started doing revision knee surgeries, what sort of procedure-specific tools and products were available to you?
CLB: Most orthopedic implant companies have revision knee systems with many bells and whistles from both an implant system and instrumentation system. Over time, experienced revision knee surgeons use fewer and fewer instruments and more and more constraint between components.
JB: Bone loss and ligament deficiency are common problems that need to be addressed with revision knee surgery. The specialized implants used for revision knee surgery include augments, stems and additional prosthetic constraint to address these issues. Specialized revision implants have been available for decades, although each system has its limitations. Modern knee revision implants have also gotten very expensive and have contributed to the increasing financial burden of revision knee surgery.
MT: Overtime, the availability of complex systems has increased, but surgeons continue to use the basic principles of ligament balancing and prosthetic constraint to manage complex situations.
Q: Over time, how has the procedure and its associated tools and products changed?
CLB: Revision total knee replacement has become highly instrumented and systems have many modular approaches to implant customization. Unfortunately, these changes have been coupled with significant increases in cost to the hospital and, therefore, the healthcare system. Many revision knee implants have "discounted" implant costs of more than $15,000.
JB: Revision knee replacement systems and their associated instruments have gotten increasingly complex and expensive over time. Current systems have numerous parts and typically require several pans of instruments. Many revision knee surgeons agree that the number and complexity of steps has gotten excessive. This has had the effect of reducing operating efficiency and increasing costs. The high cost of revision knee implants is a big portion of the overall resource consumption in revision surgery.
MT: The instrumentation and implants have become increasingly complex, and expensive, consuming more resources for each procedure.
Q: What inspired you to try designing and developing your own revision knee surgery system, and how did you start that process?
CLB: I am a true believer in a value-based approach to orthopedics. I realized many of my revision knee procedures used very similar augments of the distal and posterior femur and was convinced many revision knees could be addressed with "pre-augmented" implants at a much better value to the healthcare system.
JB: Healthcare has entered a new era of value. Value is defined as the health outcomes achieved for patients relative to the costs of achieving them. We realized there was a tremendous opportunity in the revision knee market to eliminate some of the unnecessary complexity and increase efficiency in the operating room while still delivering proven modern technology. DJO Surgical assembled a like-minded group of high-volume revision knee surgeons and engineers to tackle this project and provided us with the resources necessary to innovate.
MT: Currently, most revision systems contain multiple modular augments for managing bone loss. This leads to instrumentation that is complex, and housed in as many if not more than eight pans. The implants also are complex, with multiple modular components. For many revision knee surgeries, the extensive sets of augments and instrumentation are not needed. We sought to design a revision knee system that incorporated many of the buildups and features we needed in a majority of revision cases, with a focus on efficiency and simplicity.
Q: What exactly sets the Exprt Revision Knee System apart from others?
CLB: The Exprt Revision Knee System is an implant system that can probably treat 75 to 80 percent of revision knees in the hands of an experienced knee surgeon and offers the value proposition of decreasing implant procedural costs by about $10,000 per case.
JB: I see the Exprt Revision Knee System as being a disruptive innovation in the revision knee market. This system provides a high-quality implant with a streamlined efficiency, all at a dramatically lower cost. A simple yet sophisticated two-tray system has replaced the traditional eight-tray system. The implants have built in augments to compensate for bone loss, a single radius design, appropriately cross-linked vitamin E polyethylene and the degree of constraint necessary to address the majority of revision scenarios. The cost reductions are unprecedented with 40 to 70 percent savings over comparable revision systems. In today's value-driven healthcare market, this knee system provides a high-value, cost-effective option for a majority of knee revision patients.
MT: The Exprt Revision Knee System seeks to manage a majority of revision total knee cases with an efficient, simple system that drives value. The instrumentation is streamlined, straightforward and user-friendly. The implants incorporate augmentation into the distal and posterior femur, as well as the tibial plateau. The constraint and stem selection is designed to meet the bone and soft tissue defects found in most revision situations. Combined, the instruments and implants provide a valuable toolbox for the revision knee surgeon, with increased efficiency.