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The Wait is Almost Over – An Imminent Return to Elective Orthopaedic Surgeries
Over the last year, many hospitals were forced to postpone elective surgeries to make room for critical care related to the COVID-19 pandemic. In England alone as of February, 4.7 million people were still awaiting their routine surgical procedures.1 Of these patients, NHS England reported that 388,000 had been waiting for greater than one year to have their non-urgent surgical procedures performed – a figure that had totaled only 1,600 prior to the start of the pandemic.1
This situation has put many orthopaedic patients in the same boat. For example, 100,000 people in the U.K. had their joint replacement procedures cancelled during Wave 1 of the pandemic, leaving them with untreated mobility and pain challenges.2
Of those waiting for a TKA or THA in the U.K., over one-third of them described their state of being as “worse than death” (WTD) – a situation twice as bad as that observed prior to the pandemic.3 Furthermore, the study correlated each additional month on a surgical waiting list with a decreasing quality of life (EQ-5D: -0.0135, p = 0.004).3 If we extend this disturbing phenomenon across the whole of Europe, it becomes easy to see that health care systems and surgeons everywhere now face a growing caseload of both urgent and elective arthroplasty and arthroscopy procedures.
Critical orthopaedic procedures have been ignored for far too long
Osteoarthritis (OA), a degenerative joint condition that affects approximately 250 million people worldwide, is one of the most frequent diseases leading to the need for joint replacement.2 Sadly, we also know that this condition frequently afflicts older individuals, who are also deemed by the CDC to be at the highest risk for hospitalization from COVID-19.4 Individuals over the age of 65 have a 35x higher risk of hospitalization and an 1100x higher risk of death from complications related to the virus,4 so it’s easy to understand why many put off their elective procedures due to fear of contracting the illness.
Compounding the issue, OA is on the rise due to demographic changes like an aging population.5 According to a paper using a comprehensive set of nationwide data from Germany, researchers projected a growth of approximately 143% in the incidence rate of Total Knee Replacement (TKR) procedures between 2020 and 2050.6 Interestingly, one study of 2 million knee replacements showed a 188% increase in knee replacements in people aged 45 to 64,7 showing a trend towards knee replacement in younger patients who are eager to get in and out of the hospital and back to using their knees as quickly as possible.
While many countries in Europe continue to face lockdowns and restricted OR capacity, many elective wards remain occupied by COVID-19 patients. Nurses find themselves pulled into other wards or diverted to vaccination hubs while hospitals face lower staffing levels than ever before. At the end of the spectrum, many ORs have closed down completely. But experts are assuring us that the pandemic will not last forever.
Medical professionals face huge challenges in addressing the mounting quantity of cases
In many cases, TKR is considered to be an elective orthopedic procedure. The COVID-19 vaccine, which has typically been made available to older people first, is slowly making it possible for orthopaedic patients to venture out of their cocoons of safety and into the OR and outpatient clinics. Now that people are becoming increasingly eager to return to their pre-COVID-19 lifestyles and activities, the time for a full return to elective surgeries will soon be upon us.
How can DePuy Synthes help surgeons, patients and healthcare systems work through this backlog?
Value-Based Healthcare (VBH) means everything these days
There’s no quick fix and it could take years to train more hospital staff to help with the burdon.1 As soon as hospitals are well-positioned to start resuming elective procedures, our goal is to allow them to achieve and maintain a high throughput of patients and return to performing orthopaedic procedures more efficiently and effectively. Since it’s unrealistic to think that hospitals can double the number of surgeons in order to catch up, we offer solutions intended to help educate and equip surgeons to deal more effectively with the backlog. Our focus on delivering value-based healthcare products and services will help us increase patient turnover once the restrictions start to disappear.
Focus on helping to increase patient throughput
Once the clinics can start operating again, one major goal will be to reduce the waiting lists. This need can be addressed by simplifying the time requirements related to diagnostics, scheduling, procedural efficiency, and follow-up care. In fact, patient throughput is a function of three factors: length of stay (LOS), OR time and reduction in complications.
Reducing LOS is usually a concern of the patient more than the practitioner, but with the onset of COVID-19, things certainly changed. With fewer nurses available due to the pandemic, reducing a patient’s LOS helps alleviate overall pressure on the system. Our ATTUNETM Knee System has been associated with LOS reductions.8 In one study, generalized estimating equation (GEE) models led to the conclusion that the adjusted mean LOS of patients who received our ATTUNE gradually reducing radius knee were “significantly shorter” than those who received a single radius knee (p < 0.001).8
In one study in Germany, the unadjusted mean LOS for patients implanted with the ATTUNE Knee was 2.1 days (95% CI 1.6-2.7, p < 0.001) shorter than patients implanted with the LCS Knee.9 In another study in Italy, patients treated with the ATTUNE Knee reported a 4-day (CI 3.5-4.5, p<0.0001) reduction in mean LOS compared to SIGMA Knee patients.10 Lastly, a study of 716 patients, of whom 238 received the ATTUNE Knee, showed that ATTUNE patients experienced a “statistically and clinically significant reduction in LOS” versus both the SIGMA Knee and Columbus® knee.11
Reduce OR time
One of the biggest constraints that hospitals face is in the OR and here’s how we can help. Cementless solutions for example, have been shown to save about 11.6 minutes per surgery compared to cemented solutions.12 Knee replacement surgery duration varies by surgeon but the mean operative time for cemented TKA equates to about 93.7 minutes.12 Therefore, an 11-minute boost per procedure could potentially allow time for the surgeon to see an extra patient per day – perhaps with a smaller treatment, like an arthroscopy. In a hospital with five operating theatres, for example, that’s potentially 5 extra medical visits or surgeries per day – at the hospital level, these time savings could translate into essentially having one more OR available for elective surgeries. So with ATTUNE, we have the possibility of shortening the length of stay,11 and cementless solutions have been proven to shorten OR time.12 Especially during COVID-19 times, this outcome can be viewed as a win-win for surgeons, patients and health systems.
Reduce rate of complications
High quality implants can result in fewer complications, and the occurrence of fewer complications can translate directly into shorter hospital stays and bypassing rehabilitation centers.8,13 When patients proceed faster through the mobilization scheme, they reach their discharge criteria earlier. Right after surgery, it’s all about mobilizing the patient. We often say that ATTUNE is a knee that can help your patients "get back sooner,”8,13 a motto supported by study results showing that 85% of ATTUNE Knee patients were able to be discharged in 3 days or less.13
Reducing complications is everyone’s goal. Each complication could block another bed and valuable timeslots needed for surgeries. And any problem that leads to resource requirements in the hospital could mean that fewer patients can be operated on. Therefore, a successful surgery and a streamlined recovery can potentially reduce the number of internal resources required per patient from the hospital’s perspective.
Fewer referrals to rehabilitation centers
The key then, really, is a good implant: using a knee implant that has demonstrated a reduction in LOS in the hospital,11 along with a reduced need for visits to a rehab center,13 can potentially mean a lower risk of COVID-19 exposure in a clinical setting. A good recovery program, when available in the hospital, can further accelerate discharge when hospitals move to ATTUNE. In the U.S. database study referenced above, 79% of ATTUNE Knee patients (1,387 / 1,766) were discharged to home.13 In fact, ATTUNE Knee patients had 39% lower adjusted odds of discharge to a skilled nursing facility compared to patients who received a Triathlon™ TKA.8
Similar results are found here in Europe. In a study carried out in a Dutch hospital with an established enhanced recovery program, patients who underwent TKA with ATTUNE were not only discharged earlier, but they also had a higher likelihood of going directly to their homes instead of to a rehab center.14 Patients were also 64% less likely to be discharged to a rehabilitation centre (instead of to the patient’s own home) compared to patients who received a SIGMA Knee.14
Helping surgeons get to the top of their game – as efficiently as possible
A surgeon’s learning curve on ATTUNE is often short; it can take about 5 cases to start becoming proficient with the products and procedures.15 So we focus on getting practicing surgeons up to speed and accelerating them as quickly as possible. Our virtual education platform helps support surgeons in their continued professional development. Our JJI offering of webinars and surgical videos in EMEA grows bigger and bigger all the time, encompassing 7 Knee webinars with greater than 800 participating surgeons. Local and global events, external society-organized events, and virtual events like our recent Global Orthopaedic & MedTech Summit 2021 and annual participation at leading industry educational efforts like AO Davos Courses keep us on top of gathering and disseminating highly valuable research to HCPs in and beyond Europe.
Digital workflows and process improvements
Improving surgery outcomes is not only about the surgeon’s performance – teamwork, communication and disruption in the OR can also influence surgical performance and failures.16,17 Today, digital workflows can support OR teams while operating, providing step-by-step instructions, aiming to enhance teamwork and reduce variability in the OR. With technology from our Surgical Process Institute (SPI),* we aim to transform surgery through the empowerment of surgical teams to deliver consistent, high-quality care and efficiency in their OR and to reduce variability. Powered by SPI, the ATTUNE® Knee System will continue to deliver on its design promises and improved outcomes combining a world-class implant system with complimentary digital workflows to support surgical teams performing knee replacements.
Optimising patient pathways and working towards a 24-hour LOS
Our 24-hour project in the U.K. revolves around optimizing and streamlining the patient pathway from pre-admission to post-discharge care. One way to do this is by working collaboratively with hospitals to assess, implement and re-assess patient pathways with the aim of enhancing recovery and optimizing hospital capacity whilst maintaining satisfaction and surgical outcomes. The shift from inpatient to outpatient care represents our ultimate goal – all in the vein of reducing LOS and the associated costs while continuing to meet or exceed high quality of care standards.
The importance of connecting in an increasingly digital world
Continued evolution in the orthopaedics world brings with it increasing patient demand, higher expectations, and an unrelenting focus on driving efficiencies in costs, time, and resources. Together, our solutions help us embrace opportunities to address unmet needs in orthopaedics with the joint aim of empowering orthopaedic care teams to perform better and potentially enhancing patient outcomes along the way. We believe that disruptive technological innovation can help address many of these unmet needs on a growing basis – both in and out of the operating room.
VELYS™ Digital Surgery is a platform of connected technologies powered by data insights – designed to elevate the orthopaedic experience for patients, surgeons, and care teams – before, during and after surgery. With the VELYS Digital Surgery Platform, DePuy Synthes will leverage advanced technology and connected intelligence, in conjunction with its clinically backed portfolio of implants, to advance the future of orthopaedic care, improve surgery, and enhance patient outcomes and satisfaction.
Moving forward – together
The pandemic may have stalled a sizable number of surgeries, but our solutions and spirit have continued to evolve in new and exciting ways to help health care systems navigate a successful journey toward a post-COVID-19 surgical world. Helping surgeons build a strong provider-to-patient connection may enable a more positive patient experience, and we therefore see it as our mission to help them do this both in person and over a digital medium.
1 4.7 million waiting for operations in England. BBC News. 15 April 2021. https://www.bbc.com/news/health-56752599. Accessed 20 April 2021.
2 Too long to wait: the impact of COVID-19 on elective surgery. The Lancet Rheumatology. Volume 3, Issue 2, E83, February 01, 2021. https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(21)00001-1. Accessed 23 March 2021.
3 Clement, Nick D., Scott, Chloe E. H., Murray, James R.D., Howie, Colin R., Deehan, David J. IMPACT-Restart Collaboration. UK Nationwide Survey: The number of patients “worse than death” while waiting for a hip or knee arthroplasty has nearly doubled during the COVID-19 pandemic. https://online.boneandjoint.org.uk/doi/epub/10.1302/0301-620X.103B.BJJ-2021-0104.R1 Accessed 25 March 2021.
4 Older Adults - At greater risk of requiring hospitalization or dying if diagnosed with COVID-19. Centers for Disease Control. Updated 17 March 2021. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html. Accessed 23 March 2021.
5 The Lancet. Huge shifts in global age structure. https://www.thelancet.com/infographics/gbd-2019, last accessed March 2021.
6 Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the United States - an alternative projection model. Osteoarthritis Cartilage. 2017 Nov;25(11):1797-1803. doi: 10.1016/j.joca.2017.07.022. Epub 2017 Aug 8. PMID: 28801208.
7 The Risks of Early Knee Replacement Surgery. Arthritis Foundation. 2014. https://www.arthritis.org/health-wellness/treatment/joint-surgery/safety-and-risks/the-risks-of-early-knee-replacement-surgery. Accessed 20 April 2021.
8 Etter K, Lerner J, de Moor C, Yoo A, Kalsekar I. Comparative Analysis of Hospital Length of Stay and Discharge Status of Two Contemporary Primary Total Knee Systems. Journal of Knee Surgery. 2017; 193: 1-33. DOI https://doi.org/10.1055/s-0037-1604442. Premier Perspective™ Database analysis including 38 hospitals, representing 1,178 primary, unilateral TKAs with the ATTUNE Knee and 5,707 primary, unilateral TKAs with Triathlon™.
9 Brüggenjürgen B, Muehlendyck C, Gador L, Katzer A. Length of Hospitalisation After ATTUNE® Knee Joint Arthroplasty (TKA): Results of A German Retrospective Database Analysis. Value in Health. 2017 Oct 1;20(9):A597.
10 Pipino G, Paragò V, Corso KA, Wigham R, Holy CE, Do Rego B. Economic Outcomes Of The ATTUNE® Knee System: Analysis Of Real World Length Of Stay In An Italian Hospital. Value in Health. 2017 Oct 1;20(9):A595.
11 Mantel, J, Corso, KA, Wei, D, Jayakumar, P, Higgins, M, Westbrook, A. Economic Effectiveness Of The Attune® Knee System - Analysis Of Real World Hospital Length Of Stay And Incidence Of Early Complications. Value in Health Journal. Volume 20, Issue 9, PA579, October 01, 2017. https://doi.org/10.1016/j.jval.2017.08.1023.
12 C. M. Lawrie, M. Schwabe, A. Pierce, R. M. Nunley, R. L. Barrack. The cost of implanting a cemented versus cementless total knee arthroplasty. Knee Society. The Bone & Joint Journal Vol. 101-B, No. 7_Supple_C. 30 June 2019. https://doi.org/10.1302/0301-620X.101B7.BJJ-2018-1470.R1. Accessed 29 March 2021.
13 Etter, K, Lerner, J, de Moor, C, Yoo, A, Kalsekar, I, Danielson, V. Hospital Length of Stay and Discharge DIsposition after Primary Total Knee Arthroplasty. Real-world Analysis of 1,766 Patients who Received the ATTUNE Knee System. March 2016.
14 Meermans G, Galvain T, Wigham R, Do Rego B, Schröer D. Comparative Analysis Investigating the Impact of Implant Design on Hospital Length of Stay and Discharge Destination in a Dutch Hospital With an Established Enhanced Recovery Program. J Arthroplasty. 2020 Jan;35(1):182-187. doi: 10.1016/j.arth.2019.08.040. Epub 2019 Aug 23. PMID: 31522851.
15 Whittaker, John-Paul et al. “Learning curve with a new primary total knee arthroplasty implant: a multicenter perspective with more than 2000 patients.” Arthroplasty today vol. 4,3 348-353. 9 Jul. 2018, doi:10.1016/j.artd.2018.05.004.
16 Wiegmann, DA et al. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery 2007;142:658-65.
17 Gawande, AA et al. Analysis of errors reported by surgeons at three teaching hospitals. Surgery 2003;133:614-21.
* Surgical Process Institute:
- The Surgical Procedure Manager v2.0 or higher (the “Software”) is placed on the market by Surgical Process Institute Deutschland GmbH (“SPI”).
- The Software is not a medical device. It is for use by (i) medical staff licensed for practice, and (ii) in a hospital setting, (“Authorized Users”).
- The Software enables Authorized Users to document hospital generic and/or staff-specific process steps for certain medical interventions, such steps as designed and agreed to by the Authorized Users (the “Workflow”).
- IMPORTANT: Certain workflows used in the Software come with pre-filled steps for implantation of medical devices marketed by the Johnson & Johnson Medical Device Companies (“JJMDC”) in line with the Instructions for Use and/or Surgical Technique Guide of such medical devices. However, those workflows do not Necessarily include all the RELEVANT information FOR SUCH medical devices and do not replace the FULL INFORMATION IN THE instructions FOR USE AND/OR surgical technique guide. Please refer to https://www.e-ifu.com/ for the full information of the JJMDC medical devices.
- Where the Software displays the Workflow as designed and agreed by the Authorized User, SPI assumes no liability for the individual process steps, their accuracy, correctness, completeness or quality of the medical information and content as incorporated in the Software. The Authorized User remains solely responsible and liable towards its patients for the medical intervention carried out while using the Software.
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