Outpatient knee replacement innovation: 5 thoughts from DePuy Synthes' Rajit Kamal

Rajit Kamal, vice president and global franchise leader, knees at DePuy Synthes, answers five questions about outpatient knee replacement technology.

Question: How is DePuy Synthes supporting the shift to outpatient knee replacement?

Rajit Kamal: We are seeing a persistent shift toward outpatient surgery for knee replacement procedures both in Hospital Outpatient Departments (HOPDs) and Ambulatory Surgery Centers (ASCs). We anticipate that up to 70 percent of knee replacement procedures could move to outpatient in the next decade from the approximately 20 percent today, making it one of the biggest shifts to outpatient of any orthopedic procedure. There are two prominent reasons behind this migration trend. First, patients, physicians and payors are accelerating this movement. Second, CMS added TKA to its ASC-payable list in the 2020 Medicare Hospital Outpatient Prospective Payment System and ASC Payment System Final Rule.

We are working with our hospital and surgeon customers to enable this transition. Outpatient sites of care require cost-effective, efficiency driven innovations and our products and solutions support these key areas. Additionally, our commercial channels are organized to effectively support outpatient settings. Our professional education showcases how to effectively migrate joint replacements to an ambulatory surgery center and offers best practices to enable this transition. Since 2014 we have educated more than 2,000 health care professionals — surgeons, administrators, anesthesiologists, nurses, pre-, peri-, and postoperative staff — through national and regional programs, on-site visitations and digital content.

We no longer view outpatient as an emerging site of care, we believe it is quickly becoming one of the main sites of care for knee replacement procedures and our innovations and commercial efforts are organized around serving this site of care.

Q: What technologies are you focused on?

RK: Our comprehensive ATTUNE® Knee System is our platform for innovation in knee replacement and we continue to expand around it with new implant offerings and enabling technologies. The ATTUNE Knee has been on the market for the last seven years with recent additions including the ATTUNE Cementless Knee which supports younger and more active patients, the tibial base with ATTUNE S+™ Technology designed to enhance tibial fixation, and the ATTUNE Revision Knee System, a comprehensive system that is designed to enable surgeons to effectively manage a broad range of complex primary and revision knee procedures. To date, the ATTUNE Knee has been provided for more than 900,000 patients worldwide in 53 countries.

Most recently we introduced VELYS™ Digital Surgery, a platform of connected technologies for orthopedics that leverage data insights from pre-op through surgical planning, intra-op, and post-op to enhance the entire experience for patients, surgeons and healthcare systems.

VELYS Digital Surgery is organized around personalization, automation and connectivity with a strong value proposition in outpatient settings. Over time, VELYS Digital Surgery will add new technologies like patient selection tools, robotics intraoperatively, advanced visualization, sensors and apps.

Q: What are you focused on beyond technological innovation?

RK: Our focus is to offer products and solutions that add value to our hospital and surgeon customers. In addition to products that add value (cost-effective solutions that improve clinical outcomes), we are focused on providing world class education to our customers. For example, bringing best practices around managing an ASC to our customers. We are also looking at innovative contracting solutions.

We also think of ways to reduce cost through efficiency. We are piloting a platform called Advanced Case Management that is designed to leverage technology to enable an ASC to provide the right implant to the right patient at the right time.

Q: Does the kind of knee implant used in an outpatient setting make a difference?

RK: Yes, we believe the kind of knee implant used makes a difference in terms of quicker recovery, reduced length of stay and efficiency.

Patient demographics in an outpatient setting bias toward younger, healthier and more active patients. They have higher expectations from their knee replacement surgery. DePuy Synthes has shown through our ATTUNE Knee portfolio that implant geometry, design and materials all matter and make a difference in terms of clinical and economic outcomes, implant survivorship, patient satisfaction and value-based care – all of which contribute to helping meet patient expectations.

The evidence for the ATTUNE Knee encompasses data demonstrating how the ATTUNE Knee addresses challenges in total knee arthroplasty that are relevant to the patient experience and outcome such as crepitus,1 patient satisfaction,2 stability,3 survivorship,4 fixation,5 and recovery.6 Clinical evidence on the ATTUNE Knee is available at www.ATTUNEEvidence.com (US) and www.ProvingThePromise.com (EMEA). In addition, according to the results of a large U.S. hospital administrative database review, ATTUNE Knee patients were 39 percent less likely to be discharged to a skilled nursing facility compared to patients who received another leading knee system.6

Another key factor for the outpatient setting is how the knee implant and instrumentation can support efficiencies. With the ATTUNE Knee we have INTUITION™ Instruments that are light, easy to use and intuitive. We also have INTUITION SOLO™ Instruments which are fully disposable instruments that reduce the time taken for instruments setup and clean up.

Q: What do you envision for knee replacement in the next five years?

RK: Knee replacement will look a lot different in terms of who will be getting knee replacements, where the surgeries will take place and what is done preoperatively, intraoperatively and postoperatively. Also, the number of people who need knee replacement is going to significantly increase, creating a need for solutions that drive OR efficiency.

Because of their active lifestyles, we expect more younger people to have a need for knee replacement, as well as an aging population of Baby Boomers – 10,000 turn the age of 65 every day. We expect to see increase in the use of cementless knees.

Digital surgery, which goes beyond robotics, will play a greater role, as will machine learning and artificial intelligence.

DePuy Synthes continues to innovate around the ATTUNE Knee Platform, the surgical approach and digital surgery technologies, all with the goal of helping improve functional outcomes for patients, performance for surgeons and value for stakeholders.


1 Martin JR, Jennings JM, Watters TS, Levy DL, McNabb DC, Dennis DA. Femoral Implant Design Modification Decreases the Incidence of Patellar Crepitus in Total Knee Arthroplasty. J Arthroplasty 2017;32(4):1310-1313.

2 Hamilton W, Brenkel I, Barnett S, Allen P, Kantor S, Clatworthy M, Dwyer K, Lesko J. Comparison of Existing and New Total Knee Arthroplasty Implant Systems from the Same Manufacturer: A Prospective, Multicenter Study. Poster Presentation # 06014, AAOS. Las Vegas, NV. 2019.

3 Clary, C.W., Fitzpatrick, C.K., Maletsky, L.P., & Rullkoetter, P.J. Improving dynamic mid-stance stability: an experimental and finite element study. Orthopaedic Research Society, 2012; 58th Annual Meeting San Francisco, CA. Poster Number 1044.

4 National joint Registry for England, Wales, Northern Ireland and the Isle of Man. 16th Annual Report. (2019). Table 3.27. Retrieved from: https://reports.njrcentre.org.uk/Portals/0/PDFdownloads/NJR%2016th%20Annual%20 Report%202019.pdf

5 Richardson, G., Turgeon, T., Gascoyne, T., Laende, E., Bohm, E., Dunbar, M. Roentgen stereophotogrammetric analysis (RSA) of the Attune posterior stabilized fixed bearing knee system. Poster Presentation at the 5th International RSA Meeting, 6-8 October 2018, Adelaide, Australia.

6 Etter K, Lerner J, Kalsekar I, de Moor C, Yoo A, Swank M. Comparative Analysis of Hospital Length of Stay and Discharge Status of Two Contemporary Primary Total Knee Systems. J Knee Surg. 2017. 1(212): 1-10. 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™.

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