Latest / Becker’s Healthcare Podcast / Hip Replacement Innovations, Robotics and Patient Safety with Dr. Daniel Sun

Transcript

Hip Replacement Innovations, Robotics and Patient Safety with Dr. Daniel Sun · Becker’s Healthcare Podcast

• 0:00
  - Hi, everyone, and welcome to the Becker Spine
• 0:02
  - and Orthopedic podcast. I'm Haley Bosek, a staff
• 0:05
  - writer here at Becker Spine Review. Today, we're
• 0:07
  - pleased to be joined by Doctor. Daniel Sun,
• 0:09
  - an orthopedic surgeon at Tufts Medical Center and
• 0:11
  - assistant professor at Tufts University School of Medicine.
• 0:14
  - Doctor. Sun specializes in hip and knee arthritis
• 0:17
  - care, including interior hip replacement, knee and partial
• 0:20
  - knee replacement, robotic arm assisted surgery, and complex
• 0:23
  - revision cases such as periprosthetic
• 0:25
  - joint infections and fractures.
• 0:27
  - Hip replacement has changed dramatically over the last
• 0:30
  - two decades.
• 0:31
  - Patients who once spent days in the hospital
• 0:33
  - and weeks on a walker are now going
• 0:34
  - home in the same day, sometimes walking with
• 0:36
  - hour... Within hours of surgery.
• 0:38
  - Anesthesia has become more targeted, surgical techniques less
• 0:42
  - disruptive, and implants are being designed to last
• 0:44
  - longer than ever, which matters as patients come
• 0:46
  - to surgery younger and more active. But every
• 0:49
  - advance raises new questions. Are faster recoveries always
• 0:52
  - better? Which innovations are truly improving outcomes? And
• 0:55
  - what you're mostly marketing? And as payers push
• 0:57
  - care into outpatient settings, how do surgeons make
• 1:00
  - sure speed doesn't come at the expense of
• 1:01
  - safety?
• 1:02
  - Today, we'll dig into what's really changed in
• 1:04
  - the hip replacement, what the evidence says, and
• 1:06
  - where doctor Sun thinks the field is headed.
• 1:09
  - So let's just get started. You, said in
• 1:11
  - a recent article that due to ongoing innovations
• 1:13
  - in the field, hip surgeries are now not,
• 1:15
  - quote, your grandmother's hip replacement. From where you
• 1:18
  - stand, what's the single biggest change that makes
• 1:20
  - this true? And, what maybe has stayed stubbornly
• 1:23
  - the same?
• 1:24
  - Yeah. I think that our modern protocols for
• 1:27
  - getting patients up and moving have really been
• 1:29
  - the biggest difference maker. You know, something like
• 1:32
  - maybe twenty years ago, patients would expect to
• 1:34
  - stay at least three, four, five days in
• 1:37
  - the hospital
• 1:38
  - hip or knee replacement. And like you said,
• 1:40
  - these days,
• 1:41
  - sometimes they go home hours later after the
• 1:43
  - operation.
• 1:44
  - And I think that's been a real game
• 1:45
  - changer for us as physicians
• 1:48
  - and also for patients, you know, to get
• 1:50
  - them back to comfort in their home safely,
• 1:52
  - is, I think, huge for their recovery. What
• 1:55
  - stays definitely the same, I think,
• 1:57
  - is, you know, the biggest thing that we've
• 1:59
  - had a hard time putting a dent into
• 2:01
  - is the risk of infection after a joint
• 2:03
  - replacement.
• 2:04
  - We've tried a lot of different things. The
• 2:05
  - rate of people who get that complication have
• 2:07
  - stayed relatively the same,
• 2:09
  - despite a lot of the different things that
• 2:10
  - we've tried. So that's a big topic for
• 2:12
  - us.
• 2:13
  - Absolutely. And when we're sort of thinking of
• 2:15
  - those innovations such as interior approaches, robotics, and
• 2:18
  - new implant material, you know, you're seeing all
• 2:20
  - this hype every day. Which do you think
• 2:22
  - has made the most measurable difference in outcomes
• 2:25
  - and maybe what gets a little more credit
• 2:26
  - than data supports?
• 2:29
  - I think that the biggest thing that's made
• 2:31
  - the biggest difference for patients actually has been
• 2:33
  - the piece of plastic that we're currently using.
• 2:37
  - It's referred to as highly pro... Polyethylene,
• 2:40
  - and first got popularized in kind of the
• 2:42
  - late nineties, early two thousands.
• 2:45
  - And it's been a real game changer because
• 2:46
  - the wear through the plastic used to cause,
• 2:49
  - a lot of bone resorption and bone complications.
• 2:51
  - And now that we've basically eradicated that problem,
• 2:55
  - patients with replacements are lasting much longer for
• 2:57
  - them.
• 2:58
  - And that's been a huge win and basically
• 2:59
  - taking out one major complication
• 3:01
  - from, you know, the the profile of things
• 3:03
  - that we're having to deal with.
• 3:05
  - I think maybe something that gets a little
• 3:06
  - bit more credit than it deserves might be
• 3:09
  - robotics right now, which is, kind of a
• 3:11
  - hot topic that's,
• 3:13
  - up for debate in our field. But, you
• 3:15
  - know, obviously,
• 3:16
  - lots of people hear robot. They're very excited
• 3:19
  - about it. They think that, you know, it's
• 3:20
  - gonna be this amazing technology that makes things
• 3:23
  - perfect and pain free.
• 3:25
  - And the reality is that all the robots
• 3:27
  - have helped to advance a lot of stuff
• 3:29
  - in our field. We're still not sure, I
• 3:31
  - guess, what the specific targets are for that
• 3:33
  - and how much is really gonna impact the
• 3:34
  - patient. Thinking kind of what you said about
• 3:36
  - the material that you're using in specific implants,
• 3:39
  - I've heard this more and more, and I'm
• 3:40
  - sort of curious your take, like
• 3:42
  - how much has observation of bone health been
• 3:45
  - important in your approach to surgery in the
• 3:47
  - last couple of years? Was it something you're
• 3:49
  - thinking about going forward and is it something
• 3:51
  - you're still watching to see if data comes
• 3:53
  - back and just in general, how much does
• 3:55
  - bone health affect, you know, your surgical outcomes?
• 3:58
  - Yeah. Definitely. I think bone health plays a
• 4:00
  - big, has a big impact on patients' recovery
• 4:02
  - afterwards. Definitely, you know, when we put the
• 4:04
  - metal in, we put it in quite tightly.
• 4:06
  - So in patients who have poor bone health
• 4:08
  - and bone quality,
• 4:09
  - the risk of, for example, fracture during the
• 4:11
  - operation is a bit higher. So it's something
• 4:14
  - something that we counsel patients on pretty extensively,
• 4:16
  - preoperatively.
• 4:18
  - You know, for the most part, bone remodeling
• 4:20
  - and improvements in bone health can be kind
• 4:22
  - of slow for patients. And, obviously, most people
• 4:24
  - who come to us hoping for a surgery
• 4:26
  - are not looking to have a surgery,
• 4:28
  - years down the line. So most of the
• 4:30
  - time, it just comes into the form of
• 4:32
  - patient counseling.
• 4:33
  - Sometimes we can use adjuncts during the surgery
• 4:35
  - like bone cement to help fix the metal
• 4:37
  - better into their bones and kind of give
• 4:39
  - the bone a little bit more sense. Those
• 4:41
  - quietly become one of the biggest drivers of
• 4:43
  - a better outcomes.
• 4:44
  - How has the way you and your anesthesia
• 4:46
  - colleagues manage patients changed, and what difference does
• 4:49
  - it make overall for patient safety in your
• 4:51
  - practice?
• 4:53
  - I think that, you know, the biggest thing
• 4:56
  - has been that we collaborate a lot with
• 4:57
  - the anesthesiologists.
• 4:59
  - At our hospital, we have a meeting every
• 5:01
  - month just to make sure we're all remaining
• 5:02
  - on the same page. This includes physical therapy,
• 5:05
  - nursing, just everyone in the perioperative space.
• 5:08
  - And, you know, with things like shorter acting,
• 5:11
  - spinal anesthetics,
• 5:12
  - nerve blocks around the anesthesia, and everyone agreeing
• 5:16
  - on, you know, preoperative pain medication protocols, postoperative
• 5:19
  - pain medication. Yeah. Absolutely. It's like that flow
• 5:22
  - between both pain management, anesthesia,
• 5:24
  - as long as the surgeon seems
• 5:26
  - like really critical to overall patient outcomes,
• 5:29
  - that sort of seems,
• 5:31
  - what's most important.
• 5:33
  - I also wanted to ask same day hip
• 5:35
  - replacement is becoming routine and CMS has pushed
• 5:38
  - more joint procedures into an outpatient and ASC
• 5:40
  - setting. And I'm curious from your perspective, is
• 5:43
  - faster recovery always better recovery and how do
• 5:45
  - you interpret that in your own practice?
• 5:49
  - Sure. So I think, you know, it's important
• 5:50
  - to distinguish between
• 5:52
  - faster discharge and faster recovery. So CMS is
• 5:55
  - definitely pushing for faster discharges.
• 5:58
  - Whether that's necessarily associated with faster recovery or
• 6:01
  - not, you know, I think he's a little
• 6:02
  - bit patient dependent.
• 6:04
  - You know, of course, most of the people
• 6:06
  - who are being done as outpatient joints are
• 6:08
  - naturally going to recover a bit faster, so
• 6:10
  - I think that correlation is always going to
• 6:12
  - be there.
• 6:13
  - But I think that, you know, for the
• 6:14
  - patients that are qualified to be outpatient,
• 6:18
  - outpatient has been great for them. You know,
• 6:20
  - I think most patients do recover better in
• 6:22
  - the comfort of their own home. Yeah. Totally.
• 6:25
  - And that... Sort of thinking about that, a
• 6:26
  - lot of what I'm hearing is also, like,
• 6:28
  - candidate decision is really important.
• 6:30
  - And I'm curious how you decide who's a
• 6:32
  - good candidate for maybe same day discharge and
• 6:34
  - maybe who isn't. And has the patient patient
• 6:37
  - population for outpatient joint expanded maybe too fast,
• 6:40
  - not fast enough, or is it, like, really
• 6:42
  - just dependent on making sure you're just sending
• 6:44
  - the right person for the same day procedure?
• 6:47
  - Yeah. I think for for myself, somebody who's
• 6:51
  - good for outpatient surgery is somebody who's healthy
• 6:53
  - enough to tolerate the surgery.
• 6:55
  - Of course, number one, meaning that they don't
• 6:57
  - have any significant thing, for example, like cardiopulmonary
• 7:00
  - comorbidities
• 7:01
  - that really need a specialized anesthetic team.
• 7:04
  - It's somebody who has good support at home,
• 7:06
  - and that doesn't mean that they have to
• 7:07
  - have twenty four hour support. They have to
• 7:09
  - have, you know, someone readily available to help
• 7:12
  - them with tasks or come over in case
• 7:13
  - they're in some sort of,
• 7:15
  - you know, some sort of conundrum.
• 7:17
  - As far as has outpatient surgery expanded too
• 7:19
  - fast,
• 7:21
  - I think, you know, obviously, CMS is really
• 7:23
  - pushing things forward. And I think they're pushing
• 7:25
  - the pace at this point faster than the
• 7:27
  - surgeons are. For example, this year, CMS decided
• 7:30
  - that revision hip and revision knee could be
• 7:32
  - outpatient procedures,
• 7:34
  - which in my opinion is a little fast.
• 7:37
  - Of course, CMS wants to cut down costs.
• 7:40
  - But revision
• 7:41
  - hip and knee is, you know, there's a
• 7:43
  - wide variety there,
• 7:45
  - and a lot of complexity.
• 7:46
  - And I think pushing it towards the outpatient
• 7:49
  - coding system,
• 7:50
  - is almost encouraging surgeons to kind of take
• 7:52
  - on a little bit more risk.
• 7:55
  - Yeah. Kind of going deeper into that. I'm
• 7:56
  - curious. It's it's on the top of my
• 7:58
  - mind with bundled payment models like CMS and
• 8:00
  - team programs putting more financial pressure on episode
• 8:03
  - costs, sort of like what we were talking
• 8:05
  - about.
• 8:06
  - How do you balance the system rewarding both
• 8:08
  - speed and lower spending with protected patient safety?
• 8:11
  - You know, CMS kinda wants to see both
• 8:13
  - surgeons and physician wanna see patient safety, and
• 8:16
  - everybody likes the idea of speedy recovery,
• 8:20
  - but with less spending. So what do you
• 8:22
  - think in your practice? How do you balance
• 8:23
  - those?
• 8:25
  - Yeah. I think when we're thinking of things
• 8:27
  - like teams and bundled payment models and, you
• 8:29
  - know, surgical episode costs losers,
• 8:33
  - it's important to recognize that patient safety and
• 8:35
  - financial loss go hand in hand. Right? If
• 8:38
  - a patient is, not safely taken care of
• 8:40
  - and they come back to the hospital, well,
• 8:42
  - that's a huge financial hit for you in
• 8:44
  - a bundled payment system.
• 8:46
  - Whereas, you know, you just maybe spent a
• 8:48
  - little bit more on patient safety. Sure. Your
• 8:50
  - margin might be a little bit thinner. But
• 8:52
  - in the end, everybody kind of wins. So
• 8:54
  - I think those things do kind of go
• 8:56
  - hand in hand. Obviously, like you said, everyone's
• 8:58
  - trying to push the envelope as far as
• 9:00
  - where's the fine line between speed and safety.
• 9:03
  - But I think as long as the hospital
• 9:05
  - systems are, you know, conscientious and have meetings
• 9:08
  - to make sure things are appropriately taken care
• 9:10
  - of, which I think most hospitals out there
• 9:12
  - are. Yeah. Yeah. And that's always the dreaded
• 9:14
  - thing that I'm hearing from physicians to surgeons.
• 9:16
  - Like, no matter what you do, whatever you
• 9:18
  - spend, you just don't want readmission. Right? Like,
• 9:20
  - that's the main goal.
• 9:22
  - Yes. And kind of towards that too, patient
• 9:24
  - education has been a huge,
• 9:26
  - huge tool as far as decreasing
• 9:29
  - e... ER admissions,
• 9:30
  - you know, readmissions to the hospital. So I
• 9:32
  - think,
• 9:33
  - patient education has really expanded too, as we
• 9:36
  - lead up into the surgery. Yeah. And I
• 9:38
  - don't think you can talk about orthopedics without
• 9:40
  - talking about that looming topic of an ever
• 9:42
  - aging population.
• 9:44
  - And, patients are coming to hip replacements younger
• 9:46
  - and more active, and how many expect them
• 9:49
  - to see a new joint last than the
• 9:51
  - rest of their life. So I'm sort of
• 9:53
  - curious about that. How close are we to
• 9:55
  - a hip replacement that truly lacked a lifetime?
• 9:59
  - Yeah. So, you know, depending on what age
• 10:01
  - they are, I think, for some people that's
• 10:03
  - already a realized reality, especially with the newer
• 10:05
  - plastic like we talked about before.
• 10:08
  - You know, it's been on market for, you
• 10:10
  - know, close to thirty years now,
• 10:12
  - and the plastic wear properties have been looking
• 10:15
  - really, really good. And, typically, the plastic would
• 10:17
  - be the main limiting step as far as,
• 10:20
  - you know, what people would consider to be,
• 10:22
  - needing a piece of the hip or knee
• 10:24
  - replacement changed, if at all. And so with
• 10:27
  - the plastic lasting, you know, really, really strong,
• 10:29
  - even thirty years out, we're not even sure
• 10:32
  - how long it is gonna look good for
• 10:33
  - because it hasn't even been on market for
• 10:35
  - that long yet.
• 10:36
  - So I think we're getting, you know, closer
• 10:38
  - all the time. There's been improvements in the
• 10:41
  - plastic and the implants that we use. Obviously,
• 10:43
  - technology,
• 10:45
  - robotics or other types of enabling technology has
• 10:48
  - also been huge as far as improving patient,
• 10:51
  - implant longevity.
• 10:52
  - Yeah. I'm also curious where do revision surgery
• 10:56
  - and joint infections... Like, you treat all of
• 10:58
  - these... Like, while we're on the topic of
• 11:00
  - that, what do these failed cases teach you
• 11:02
  - about maybe what we haven't solved in,
• 11:06
  - hip repair in the first place when you
• 11:08
  - when you go back in those revision surgeries?
• 11:10
  - What's the most common thing you're seeing when
• 11:12
  - you're going in?
• 11:14
  - Yeah. So I think, you know, some of
• 11:15
  - the top reasons why people need their hips
• 11:17
  - and knees are done. Number one is infection
• 11:19
  - like we talked about. We've tried a lot
• 11:20
  - of different things. Unfortunately, haven't been able to
• 11:22
  - make a huge dent in this, pre catastrophic
• 11:25
  - problem for patients.
• 11:27
  - You know, mechanical instability or fractures are also
• 11:30
  - leading causes for why people need all of
• 11:32
  - that stuff redone.
• 11:34
  - And, you know, ultimately,
• 11:37
  - sometimes I think just, no matter what you
• 11:39
  - do, know, unfortunate complications do happen, but it's
• 11:42
  - important.
• 11:43
  - And I think everyone across our country has
• 11:45
  - been doing a really good job of this
• 11:47
  - to optimize patients as much as possible, meaning
• 11:50
  - that, you know, we don't just look at
• 11:52
  - a patient with arthritis and sign them up
• 11:53
  - for surgery the next day anymore.
• 11:55
  - Most hip and knee surgeons out there are
• 11:57
  - making sure that everything that can be optimized
• 11:59
  - is optimized,
• 12:01
  - so that we can decrease the risk of
• 12:02
  - all these complications.
• 12:04
  - Yeah. We sort of talked earlier about the
• 12:05
  - idea of, you know, robotics and where they
• 12:07
  - stand with all these different innovations and what
• 12:08
  - you're looking at. And I'm curious with robotics
• 12:10
  - and navigation and AI driven planning and wearable
• 12:13
  - recovery tracking and personal implants, entering joint replacements.
• 12:16
  - There's so much exciting stuff, but I'm curious,
• 12:19
  - like, when you see it with people, I
• 12:21
  - keep reading AI, but I don't really know
• 12:23
  - what, you know, procedure, what is the hype,
• 12:25
  - what is actually worth it. This is what
• 12:27
  - people are sort of balancing when it comes
• 12:29
  - to the headlines. And I'm curious when you
• 12:32
  - weave through the curiosity,
• 12:34
  - what do you think ten years from now
• 12:36
  - will stick? What will help replacement look like?
• 12:38
  - What will it be? What do you hope
• 12:40
  - and, you'll be seeing, you know, in ten
• 12:42
  - years from now?
• 12:43
  - Sure.
• 12:45
  - Well, I think that,
• 12:46
  - you know, the the surgical approaches that we're
• 12:49
  - using now, I think, will kind of always
• 12:51
  - be around. You know, there's a variety approach...
• 12:54
  - Of approaches that people use out there.
• 12:56
  - You know, and experienced hands, they're all doing
• 12:58
  - a great job for the patients. So I
• 13:00
  - don't see any,
• 13:02
  - fewer surgical approaches being done, you know, ten
• 13:05
  - years from now. I think,
• 13:07
  - AI is here to stay. So I think
• 13:08
  - in ten years, AI is certainly gonna be
• 13:10
  - contributing
• 13:11
  - a lot to how we're putting in implants,
• 13:14
  - you know, whether that's implant positioning,
• 13:17
  - or how we think that certain implants are
• 13:19
  - going to affect patients' postoperative,
• 13:22
  - outcome and satisfaction scores.
• 13:24
  - So I think AI is definitely here to
• 13:26
  - stay. I think robotics and navigation
• 13:28
  - will continue to play a role. Just as
• 13:30
  - the technology gets better and better, I think
• 13:32
  - we're gonna be able to see, really where
• 13:34
  - they shine as far as what patients are
• 13:36
  - getting out of them.
• 13:37
  - And then as far as wearable technology, I
• 13:39
  - think, you know, smart implants are already on
• 13:42
  - the market.
• 13:43
  - And I think that some patients are really
• 13:45
  - enjoying that. And I know some companies have
• 13:47
  - found,
• 13:48
  - some really cool uses for their wearable technologies
• 13:51
  - and smart implants.
• 13:52
  - And I think as long as that continues
• 13:55
  - to get better as well, I don't... Can't
• 13:57
  - see how that and AI is going to
• 13:59
  - probably become a bigger facet of joint replacement
• 14:01
  - in the future. Totally. Yeah. Last question I
• 14:03
  - have here. What's one thing about hip replacement
• 14:05
  - that you'd like patients and referring physicians,
• 14:07
  - to leave this conversation with?
• 14:10
  - I think it would be that,
• 14:12
  - you know, although hip replacement is one of
• 14:14
  - the most common procedures we do, and the
• 14:16
  - vast majority of patients love their hip replacement
• 14:18
  - and get through the surgical episodes without a
• 14:20
  - hitch, it is not a minor procedure. I
• 14:23
  - think sometimes patients come in asking for hip
• 14:25
  - replacement or other referring physicians tell patients to
• 14:29
  - get a hip replacement,
• 14:30
  - almost treating it like a teeth cleaning when
• 14:32
  - it's actually a pretty major procedure with some
• 14:35
  - real complications
• 14:36
  - that are, potentials. And so, you know, although,
• 14:39
  - seems like everybody knows someone who's had a
• 14:41
  - hip replacement, you know, just keeping in the
• 14:43
  - back of their mind that it is still
• 14:44
  - a major operation.
• 14:46
  - Well, Doctor. Sun, thank you so much for
• 14:48
  - the conversation. It's really great to have people
• 14:50
  - with insights like you to help us wade
• 14:52
  - through all the interesting innovations.
• 14:55
  - Thank you so much for walking us through
• 14:57
  - how far hip replacement has come and for
• 14:59
  - being candid about the questions the field still
• 15:00
  - needs to answer. That's all for today's episode
• 15:03
  - of the Becker Spine and Orthopedic Podcast. A
• 15:05
  - big thank you again to Doctor. Danielson for
• 15:07
  - joining us and sharing his insight.
• 15:09
  - Thanks for listening, and we'll see you next
• 15:10
  - time.