Scott Zellner, senior director of U.S. Joint Reconstruction and Outpatient Marketing at DePuy Synthes, began with a history of the anterior approach to total hip replacement when we discussed his company’s involvement with the procedure.
“The modern era of hip replacement started in the 1950s and 1960s, and the traditional approach — the posterior approach — led the way,” Zellner said. Those early efforts are attributed to Sir John Charnley, a British orthopedic surgeon. Charnley pioneered the hip replacement operation in the UK and established Wrightington Hospital as a premier destination for orthopedic surgery, and hip surgery in particular.
“The anterior approach in the United States really started with another pioneer named Dr. Joel Matta. He was the one to bring the anterior approach to the U.S. from Europe and has continued to evolve and perfect the technique,” Zellner explained. DePuy Synthes worked with Matta in 2004 to create its professional education programs. He is sought after by surgeons across the country to teach the technique. DePuy Synthes provides courses nearly every month, helmed by Dr. Matta and many colleagues whom he has personally taught.
Just Like Woodstock – A Whole Lot Of Hippies Out There…
Regarding the market for anterior approach hip replacement, Zellner stated, “In the United States about 420,000 hip replacements are performed a year, as of 2016, which is just about doubling the volume from 10 years ago.”
“This is due in great part to the aging of baby-boomers and their attitude that they are going to live life to the fullest. They are not going to let anything get in the way of making the next chapter of their lives as productive as possible. They are demanding solutions to help them deal with their joint pain,” Zellner continued. “In 2004, the percentage of surgeons performing hip replacement surgery using the anterior approach was in the low single digits. Now, according to an American Association of Knee and Hip Surgeons norms poll from last November, 34 percent of surgeons are using the anterior approach.”
The obvious question for Zellner was “why?” What drove a ten-fold increase in anterior procedures over the course of a little more than a decade?
“It starts with the patient. Patients are not going to live with pain anymore. They are not going to sacrifice their quality of life. They are going to demand solutions for, in this case, hip pain,” Zellner said. According to Zellner, patients are able to go home sooner following hip surgery using the anterior approach —compared to the posterior approach — and they have a shorter length of stay in the hospital. Also, patients are more likely to go directly home, versus spending time in a skilled nursing facility.
“Our healthcare system is moving from volume to value, and our customers are getting measured not only on a great clinical outcome, which both the traditional and the anterior approach will deliver, but also on the overall patient experience and reduction of the overall cost of care,” Zellner said. “From a patient experience perspective, the anterior approach works around the soft tissue and is muscle-sparing, so patients recover quicker. In addition, studies have shown the anterior approach patient is having 40 to 45 percent less cost related to post-acute care.”
These results are a win-win scenario for the patient and the healthcare system.
Bundling Payments Could Save A Bundle
Speaking of cost, I asked Zellner about the role payer organizations (Medicare and private payers) have in the rise of the anterior approach to hip replacement surgery.
“[Payer organizations] are providing incentives, things like bundled payments. They are creating incentives for health care systems and health providers to improve care, reduce overall cost, and improve the patient experience. I think one of the reasons we are finding more customers interested in the anterior approach is there’s a way to win in a bundled pay environment,” Zellner said. “We can achieve a good clinical outcome, at the same time improving the patient experience. And, because they are spending less time in the hospital and they often don’t have to go to a skilled nursing facility, recovery is faster.”
Thus, reduced overall cost through the episode of care appears to be driving the increasing popularity of the anterior approach.
Timing Is Everything
Knowing several people who have recently undergone hip replacement surgery, I was curious about the differences in their situations. One person was told he was too young and had to wait a few years to have hip replacement surgery, while another avoided the surgery for quite some time — until the pain was too great to endure.
“We’ve done a lot of research on the patient pathway and what we typically hear, though not in every case, is patients are told replacement surgery is the step of last resort. We don’t know if that’s in the best interest of the patient, or in the best interest of healthcare,” Zellner said. “Sometimes, when patients are told it’s too early to have hip replacement surgery, they seek out a second opinion, and subsequently have surgery earlier. Some patients will go seven, nine, even 11 years with this pain before they ultimately choose replacement surgery.”
He continued: “Having the surgery at the right time is really important. When you are dealing with hip pain, you can take medication or have cortisone shots, but at some point in time it begins impacting your life and you become less active. We’ve seen studies that patients who delay surgery for long periods of time will end up gaining weight. They can end up with co-morbidities like high blood pressure, type 2 diabetes, or high cholesterol. We have a patient that is injured who now becomes medically ill, and that’s not good for the patient and it’s not good for the healthcare system.”
Finally, I asked Zellner what he sees on the horizon for the anterior approach to hip replacement surgery.
“I think we are going to see this trend toward the anterior approach continue. In the next three to five years, we will likely get to a 50/50 mix of anterior and posterior approaches to hip replacement. That will be driven by how customers are incentivized by these bundles, but there has also been a very strong trend toward outpatient joint replacement surgery with patients not even spending a night in the hospital and going home the same day,” Zellner said. “We’re seeing a lot of surgeons and health care providers interested in outpatient total joint replacement looking at the anterior approach as a natural way to go. It helps relieve pain and allows patients to get their lives back.”