Aside from the large joints, what’s gaining traction in orthopedics? Well, try spine, extremities and biologics on for size.

What’s the so-called “next big thing” coming in the orthopedic space? Oh yeah, and let’s exclude the best sellers—traditional hips and knees.
So, out went the call to a variety of industry professionals, and back came a variety of viewpoints...

...Douglas Van Citters, Ph.D., assistant professor at Thayer School of Engineering at Dartmouth in Hanover, N.H., said he thinks the next big thing in the profession “will likely be the resurgence of the total shoulder and reverse shoulder arthroplasties. There have been a couple of false starts in the past two decades due to a fundamental misunderstanding of the materials used for bearing surfaces, the biomechanics of the glenohumeral joint (the joint formed by the shoulder and the upper arm), and the biology of the glenoid (the shoulder socket). But advances in polymer science and a better understanding of bone biology have led to designs and concepts that are likely to lead to better patient outcomes.”

He said that successes with both total shoulder and reverse shoulder designs would allow such procedures to reach a broad group of patients, providing improved quality of life and better function.
“If surgeons, manufacturers and patients start to see these successes in the shoulder, I believe that other extremities such as elbow, ankle and wrist won’t be far behind,” he added.

Addressing the trend toward biologics, Van Citters’ colleague John Collier, the Myron Tribus Professor of Engineering Innovation at Thayer School of Engineering, said, “I’m more encouraged toward developing cures for arthritis than in developing methods for growing healthy cartilage that we can implant into an unhealthy joint, although that approach may work for trauma patients.”

The “solution,” according to Collier, is about having fewer people with arthritis.

“We understand more about what causes arthritis and we can figure out what we can do to temper it,” he said. “It’s like heart disease. If you can change diet, you can change heart disease. I don’t know that anyone has tried to do that for arthritis yet, but it may be the case once they get in it that there are nutritional aspects, exercise aspects, physiological aspects of arthritis that you can identify so you help people out.”...

Better Tools For Diagnosis

...Dartmouth’s Collier and his colleagues have done research on measuring outcomes.

“We’ve done some projects in instrumenting implants and putting in devices that will feed back information about the status of the joint and what’s going on internal to it,” he said. “I think it has a valuable potential, but I don’t know that we know much yet about interpreting the signals.”

He said, “The problem we’ve got as a community is that we should set up an incentive process to keep track of what works and what doesn’t work very well. While we run this implant retrieval program here at Dartmouth, the subset of implants we get is about one-tenth of 1 percent of all failures. The U.S. doesn’t yet have a registry, so we can’t keep track of what’s going in and how well it’s working even in the broadest sense. In the absence of that, we don’t really know as we could about what’s performing well and what’s not.”

But, Collier said, the question remains: “Who’s going to pay for it?”

He added: “Most folks think it’s a great idea to collect the information as long as they don’t have to pay for it.”

Van Citters “absolutely” agrees that new orthopedic designs need to include better ways to measure such outcomes.

“This monitoring will use a variety of modalities and will take advantage of advances in imaging, in physical data collection, and in population monitoring. All of these exist to some extent, and it isn’t necessarily the case that the research community needs to come up with even more monitoring solutions.” Instead, he said that industry, government, the medical community, the legal community and the patients need to agree that such monitoring is appropriate and beneficial to society.

“I’ve seen a number of exciting advances in instrumented implants, sophisticated wear measurement techniques, and the ongoing effort to create a national implant registry,” he said. “The tools are at our fingertips, and they simply need to be used appropriately.”

Van Citters cautioned, however, that outcomes “need to be viewed in a much broader sense. We need to get beyond just data and registries, although both are still critical. The next step is to look at patient-reported outcome measures. The payer, whether it is the patient, the taxpayer, or the insurance pool, needs to be assured that they are getting the highest value for their dollar.”

He said that value means looking not only at short- and long-term outcomes such as range of motion, improvement in pain, satisfaction with activities of daily living, and so forth, but also at reductions in patient harm, decreased cost, and increased patient and family satisfaction with the care provided.
“These metrics and others can be included in a balanced scorecard for delivery of healthcare,” he said.