Orthopaedic Leaders Discuss Recent Surgical Innovations and Where the Specialty Is Heading

Orthopaedic surgery is one of the youngest branches of medicine and is intricately linked with innovation. By presenting how trends in innovation have been integrated into the respective practice models of two established thought leaders with more than 20 years of experience—Douglas W. Lundy, MD, MBA, FAAOS, in trauma, and Selene G. Parekh, MD, MBA, in foot and ankle surgery—this article aims to provide a lens to frame the relationship between innovation and orthopaedic surgery. Dr. Lundy is chair of orthopaedic surgery and chief of orthopaedic trauma surgery at St. Luke’s University Health Network. Dr. Parekh is a professor at Rothman Orthopaedic Institute and the fellowship director of Rothman’s foot and ankle surgery fellowship program.

AAOS Now: What does innovation mean to you regarding orthopaedic surgery?
Dr. Lundy: The typical American way of thinking about innovation is, “How do I seize market share and margin and, therefore, profit?” In healthcare, there is a certain ethical overlay on it—innovation is meaningful only if you can increase access, decrease cost, and improve quality of care. It is important to be on the cutting edge and not the bleeding edge for most technologies.

Dr. Parekh: Innovation can come in many different forms. It can be procedure-based (e.g., surgical, clinical), implant-based, technique-based, or logistic-based. Regardless of how you apply it, innovation is doing something differently to improve patient outcomes or making it easier to do something in the operating room.

How has minimally invasive surgery (MIS) evolved since you started, and what do you see as its role in orthopaedics going forward?
Dr. Lundy: LISS [less invasive stabilization system] is a great example of this, although we’ve shifted to more locking technology with the techniques that we learned with LISS. MIS is important in trauma [because it] protects the soft-tissue envelope, but sometimes the size of the incision can help with a better reduction. In hand surgery, spine, and total joints, there is a tremendous push toward MIS, and I think it’s more warranted there.

Dr. Parekh: MIS is the rage in foot and ankle surgery. As we try to move more patients to the outpatient setting, where patients can recover at home and lower their costs, MIS facilitates this outpatient pathway. This is going to behoove orthopaedics, regardless of subspecialty. How much this impacts each subspecialty depends on the subspecialty. In foot and ankle, MIS is a game changer. In oncology, if you need to do a big resection, then you do what must be done.

How has 3D printing of patient-specific implants evolved in your field?
Dr. Lundy: The urgency of a trauma setting generally pushes back on the ability to do 3D-printed implants. However, in trauma specifically, defect-specific custom implants made of trabeculated metal are a great example of this in a delayed reconstruction setting.

Dr. Parekh: 3D printing in general allows us to tackle orphan diseases, difficult problems for which we do not have good solutions, and allows us to think of pathologies in different ways. 3D printing and standard implants are almost completely separate entities. For routine problems, 3D printing has an edge in that you can have a cage in the spine or a wedge in foot and ankle that may actually have better ingrowth when they are 3D printed than when they are manufactured in a standard fashion. This allows for better outcomes. For rarer issues, such as avascular necrosis of the talus, patients traditionally had the option of a fusion, whereas now we have a joint-sparing mobile option with a 3D-printed total talus replacement. This type of technology is allowing us to treat pathologies such as Mueller-Weiss syndrome, talar subsidence after a total ankle replacement, and talar non-unions with significant collapse.

What has been your personal experience with robotic-assisted surgery?
Dr. Lundy: The problem with trauma surgeons is that they tend to be more blue-collar, old-school, “get it done” surgeons. However, using navigation for placing percutaneous screws in the pelvis is undeniably one area in which innovation and robotic assistance have improved the way we approach trauma surgery and is leaps and bounds better than how we would have to do things when I was in training. However, there is definite utility for robotic assistance in spine and total joints.

Dr. Parekh: These new technologies are coming your way whether you like it or not, so you need to learn how to adapt and adopt them into your practice. Augmented reality/virtual reality is a great example of this. As these technologies develop, you will have early adopters, they will show proof of concept, and this will percolate throughout and may eventually become standard of care.

What innovation has totally revolutionized your field?
Dr. Lundy: It is as simple as locking technology. Not only was the technology different, the way the fractures healed was also different than anything we had seen before. Another huge innovation in trauma was coated implants with antibiotic coverage or osteoinductive substances. The value paradigm for this technology, however, is still a topic up for debate.

Dr. Parekh: 3D printing has changed the field quite a bit, as has MIS. Next up are new materials that are going to allow implants to be thinner, be stronger, and have antibiotic properties. Additionally, 3D printing of anatomic specimens, such as bone grafts with living cells in them, is being researched. In fact, in the future, people may not even be getting metal joint replacements—we may be able to 3D print a bone-cartilage type of replacement to help get their normal anatomy back.

How do you think diagnostic modalities will continue to advance going forward?
Dr. Lundy: CT has come a long way, especially intraoperative CT with navigation. Fluoroscopy will continue to get safer with lower radiation, as well. I think improvements with the way we diagnose infections is one of the next big things on the frontier.

Dr. Parekh: We are already seeing modalities decreasing in size. We now have handheld fluoroscopic machines. We will have more portable ultrasounds, including an ultrasound wand you can use with your smartphone, and it is readily available. Weight-bearing CT and dynamic imaging in general are going to become more prevalent in the near future.

What kind of innovations have you seen that lower costs and make orthopaedic surgery more efficient, and where do we still have room to go?
Dr. Lundy: Anything that makes things more accessible, less expensive, and with less waste. We have studies showing that less volume of implants may be needed in some surgeries, but industry will push the opposite way. In trauma specifically, there is a tremendous opportunity for the current packaging of external fixation devices and distal radius fracture plates to become even more efficient and effective.

Dr. Parekh: Innovation is usually associated with an initial higher cost. But as adoption increases, prices will decrease. An example is virtual scribes, which have made my clinic run much more efficiently. Artificial intelligence scribes will make things even more efficient, because notes will be done almost on the fly. As artificial intelligence takes more of a hold, it is going to revolutionize the way clinics are run.

What discussions do you have with your patients when offering them surgeries that involve new devices, combination products, pharmaceuticals, or biologics in surgical procedures?
Dr. Lundy: A lot of trauma surgery is using products off label. … For example, putting a proximal humerus plate in the tibia when it is not necessarily what it was approved for. Cadaveric implantation for bone-graft procedures is a topic which patients commonly ask about, and I give patients more information and spend more time explaining why we would use a certain product as well as its safety profile to address their concerns.

Dr. Parekh: You have to have an open discussion with patients about both traditional and cutting-edge options. You must make sure they understand the risks and benefits of both. Regenerative medicine may not be covered by insurance, and patients need to understand this and accept this prior to proceeding. They need to understand that there may not be a track record of success with some of these newer technologies. Essentially, you need to have an in-depth informed consent process when discussing new innovation with patients.

What did you think when you started to incorporate telemedicine into your practice, and do you think it is here to stay?
Dr. Lundy: Certainly, it is difficult with our reliance on imaging, but medical liability has not caught up yet. We have gotten better in the pandemic, and I am not sure it has stuck—but not for lack of quality. There are super high volumes with orthopaedic practices, and the biggest hurdle will be getting more orthopaedic surgeons to embrace it.

Dr. Parekh: I have continued to integrate telemedicine into my practice. There are tremendous benefits. For patients with routine follow-up care, they save on travel time, expenses, [and they] don’t have to take time off work. There are also downsides—when I video in with a new patient, my exam is limited. I do not like making any definitive treatment options or final treatment plans until the patient is seen by me in person. During [the COVID-19 pandemic], a lot of legislation had changed to allow for more telehealth to be able to take place due to necessity. One problem is that now, post-COVID, many states have gone back to creating hurdles in allowing telehealth to exist in a meaningful way.

What piece of advice would you give budding orthopaedic surgeons who want to help drive innovation in the field?
Dr. Lundy: Look at your motivation for trying to innovate. Look at cost-reduction opportunities. And finally, remember the value equation: value = (quality/cost) x access.

Dr. Parekh: Keep reading, but not just medical literature. Read about technology, read articles written by innovators. A lot of innovation is the product of cross-pollination from different fields. Disruptive ideas come from trying to bring things from other places.

Finally, do not be a slave to the literature and get boxed into only thinking about what the literature says. This can stifle innovation.

Akhil Sharma, MD, is a fourth-year orthopaedic surgery resident at St. Luke’s University Health Network in Fountain Hill, Pennsylvania. He is also a member of the AAOS Resident Assembly’s Innovation Committee.