In scrutinizing the evolution of the broader surgical field, it might be logical to home in on the new devices transforming the very possibilities available to physicians. Sometimes, though, a revised approach is enough to alter practices and improve outcomes.
The anterior approach to hip arthroplasty is hardly new. It showed up in the literature all the way back in the 1930s and was first performed, by Robert Judet, in 1947.
The approach has been adopted with greater frequency in recent years. According to research, the anterior approach was used in 7 percent of primary hip procedures in 2014. The most recent numbers indicate its use has grown to 34 percent and climbing.
What accounts for this sharp rise for an approach that’s been around for decades?
To learn more, Surgical Products interviewed Scott Zellner, senior director of U.S. joint reconstruction at DePuy Synthes.
Let’s start with the basics. How common is hip replacement in the U.S.?
According to Global Data, the number of primary hip replacement procedures performed in the U.S. in 2016 was approximately 420,000 — nearly double the number of hip replacements performed 10 years ago. We are seeing a shift in age distribution with the percentage of total hip replacements increasing in younger age groups. A growing number of people in their 40s and 50s and the baby boomer generation want a more active lifestyle and are less willing to accept the limitations that accompany hip arthritis.
What percentage of hip replacements are performed using the anterior approach?
Based on the latest survey from the American Association of Hip and Knee Surgeons in November 2016, 34 percent of surgeons surveyed reported they were performing the Anterior Approach. DePuy Synthes is seeing numbers higher than the industry average, however, as adoption of the anterior approach among surgeons who use our products has gone from almost zero in 2004 to upwards of 40 percent in 2017. This is due in large part to our decade-long commitment to offering comprehensive professional education that helps increase reproducibility and reduce the learning curve of this innovative technique.
The anterior approach has been available for many years. How has it become one of the fastest growing surgical approaches in orthopedics today?
The posterior approach has been and still is a widely used technique for hip replacement surgery. The industry has seen a shift to the anterior approach in recent years for a few reasons.
It starts with the patient. We know there are many patients sitting on the sidelines with severe hip pain that wait years before they have hip replacement surgery. They are told things like surgery should be a last resort option, often putting their lives on hold due to the pain. In some cases, these individuals may start developing other co-morbidities such as obesity and diabetes.
Younger patients, including baby boomers, are increasingly interested in talking with their doctor about treating their pain and getting back to activities they enjoy. For either patient group, it’s important to look at solutions like the anterior approach. Clinical studies support that patients who have anterior approach experience a reduced length of stay, a shorter recovery period, and a lower risk of dislocation when compared to patients treated with another approach.
Additionally, as healthcare professionals are being evaluated on the 90-day bundle, they are looking for solutions that improve outcomes, optimize the patient experience and reduce the overall cost of care, all of which we believe the anterior approach supports. We believe that the anterior approach can impact categories that make up 58 percent of the 90-day cost bundle including improvements regarding readmission, length of stay, skilled nursing facilities, home care, and self-care.
Evidence shows patients who have the anterior approach have a 30 percent shorter hospital stay, 18 percent more are discharged to home, and they are three times less likely to dislocate compared to the traditional approach.
We also believe that the anterior approach has a strong fit within the outpatient setting and the technologies, training, and capabilities that we are bringing forward with anterior approach will continue to support this approach in the outpatient setting.
How has the technology and technique evolved over the years? What new technologies is DePuy Synthes investing in that can help enable Anterior Approach to be performed on more patients?
For more than 10 years, DePuy Synthes has been a leader in advancing technologies and solutions that offer a unified hip solution including a reproducible technique, implants with a strong clinical heritage, investment in innovative technologies, and comprehensive professional education to increase reproducibility and reduce the learning curve. While we’ve seen this growing trend around the anterior approach and are committed to helping surgeons learn how to incorporate it into their practices, we’re also dedicated to bringing products and technologies to market that support the best possible care to patients, no matter which approach a surgeon chooses.
For example, we developed and recently launched the ACTIS Hip — the first DePuy Synthes stem specifically designed to be utilized with tissue sparing approaches, such as the anterior approach — but that also supports our goal of enabling increased reproducibility whether used with the anterior or posterior approach.
We recently announced two new exclusive agreements to co-market enabling technologies that may help improve outcomes in both the anterior and posterior approaches.
We have an agreement with Medical Enterprises Distribution, LLC to co-market the ME1000 Surgical Impactor. This impactor delivers constant, stable energy that is designed to automate bone preparation, implant assembly and positioning. This in turn may lead to more consistent clinical outcomes and favorably impact patient satisfaction. And because the battery-powered ME1000 automates THA, there is also likely to be less surgeon fatigue and potentially less work-related injuries that can arise from mallet use.
We also have an agreement with JointPoint, Inc. to co-market its proprietary software platform to provide an easy-to-use, surgeon-friendly navigation system that may help deliver improvements in surgical outcomes. The software provides non-invasive computer navigation, pre-surgical digital templating, case planning, and intra-operative feedback during total hip replacement surgeries and easily integrates with the anterior approach.
How significant is the learning curve for surgeons? What professional education and training is available?
There is a learning curve for any approach a surgeon is learning for the first time, and that’s why DePuy Synthes has invested so heavily in professional education to train surgeons.
More than a decade ago we partnered with Dr. Joel Matta, the pioneer of anterior approach in the U.S., to provide training. To date, we have trained more than 11,000 surgeons on the anterior approach as part of our professional education. We offer full day learning centers, didactic and cadaveric labs, opportunities for OR visitations with Dr. Matta and other faculty members, visitations by an anterior approach field apecialist, digital resources, and a VuMedi surgery video featuring Dr. Matta.
We are finding these initiatives to be impactful as we hear stories of how surgeons have switched to using the anterior approach and are now training their fellows on this approach. As the adoption of anterior approach continues to grow, we are most excited about what this ultimately means in helping to advance and improve patient care.
What is the future of the anterior approach? Will it become more common than traditional approaches?
We believe there will always be a place for traditional approaches, but we forecast continued growth and adoption of the anterior approach as more surgeons learn the technique and as public awareness of the procedure grows. We are seeing a predominant number of surgeons are learning anterior approach in their residencies and fellowships so they are already skilled in the procedure.
We believe we will continue to see this advance over time and believe more than 50 percent of surgeons will be using the anterior approach in the next four to five years.