5 New Developments in Orthopedics

Rocco Monto, MD, a board-certified orthopedic surgeon specializing in reconstructive knee and shoulder surgery, shares his thoughts here on the top five developments in orthopedics. Dr. Monto, the team physician for the U.S. Under-17 Men's Soccer Team and a spokesman for the American Academy of Orthopaedic Surgeons, practices in Nantucket and Martha's Vineyard, Mass. and is affiliated with Nantucket Cottage Hospital.

1. Biologics. The use of biologics is changing the nature of orthopedics, as surgeons begin to understand and modulate how cells interact to enhance patients' own healing responses, says Dr. Monto. One example is platelet rich plasma therapy, in which a patient's own platelets are spun out and harvested and then injected into the injury site to promote accelerated and focused healing of the soft tissue.

Another example is the introduction of bone morphogenic protein, which stimulates the patient's ability to create more bone. Although helpful for treating many bone fractures, it has huge implications for spine fusion surgeries as it can be more reliable and require shorter hospital stays than traditional bone grafting techniques, Dr. Monto says.

"Biologics is really where the future of orthopedics is," he says. "We will see the scientist-surgeon emerge, as we are learning how to create a better biological envelope to work in."

2. Practice management shifts. Orthopedic surgeons are moving from a freelance to an employed model, frequently aligning with hospitals that agree to take over the management functions of their practices, Dr. Monto says. The challenges of integrating information-technology platforms, higher practice costs and flat or declining reimbursements all are driving this trend.

"Before, we'd just go to the operating room," he explains. "We're managers now, and that's a new role."

Dr. Monto left his own 15-year private practice to join Nantucket Cottage Hospital, part of Partners HealthCare, a little over a year ago.

"There's safety in numbers," he says. The effects of this shift are mixed for surgeons: They will likely have access to broader referral patterns but will also likely be subject to greater scrutiny and oversight. "Some surgeons are not used to that," he says.

3. Computer navigation in the operating room.
Computer-assisted surgery is being taken to new levels with methods that allow surgeons to make instruments patient-specific, and the use of this technology is likely to increase greatly in orthopedics in the near future, says Dr. Monto. Orthopedic surgeons now can use pre-operative MRI or CT scans to make individualized templates to customize the guides they use for knee replacement surgery, for example.

"More companies now are investing in this technology, whether to provide easier navigation in the operating room or to pre-navigate by getting 3-D scans of the knee to make a pre-custom knee," he says. This kind of computerized pre-operative planning is currently expensive, but if it leads to better outcomes or more durable knees, it could save money in the long run, he says.

4. Rise in minimally-invasive surgery. Patients continue to gravitate toward minimally-invasive procedures, a trend that crosses all orthopedic sub-specialties, Dr. Monto says. Whether it's an endoscopic discectomy vs. an open lumbar disc surgery, a total hip replacement vs. a less-invasive hip resurfacing, or a minimal approach to lumbar fusion, patients are attracted to the idea that less surgical trauma leads to a better surgical result.

"I'm not sure whether that's true, but patients certainly think it's true," he says. The changing technology involved in such procedures has required orthopedic surgeons to keep up with a constantly changing array of technology. "Adaptability is becoming a very important quality in your surgeon," Dr. Monto says.

5. The patient as consumer. Perhaps the biggest development shaping orthopedic practice is a trend toward more educated and discerning patients, Dr. Monto says.

"The patient is no longer just a passenger here," he explains. "They're actively investigating their care, they have access to information sources they didn't have before, they're smarter, they're sometimes better informed than the doctor is."

Patients who have researched their care options expect to be treated as a partner by their physician. Those surgeons that are able to provide patients with educational resources are likely to garner a more devoted patient population, while those that ignore the trend "do so at their own peril," Dr. Monto says.

Contact Barbara Kirchheimer at barbara@beckersasc.com.


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