The anterior hip replacement approach is gaining steam — why that's good news for the ASC

Senior Director of U.S. Joint Reconstruction and Outpatient Marketing at DePuy Synthes Scott Zellner discusses the evolution of the Anterior Approach to total hip replacement and how the move to value-based care will propel future growth.

Question: What percentage of hip replacements are performed with the Anterior Approach?

Scott Zellner: An American Association of Hip and Knee Surgeons survey from November 2016 shows 34 percent of surgeons are doing the Anterior Approach, which is quite remarkable. Since 2004 we have partnered with Dr. Joel Matta, a pioneer in the space to conduct surgeon education about the Anterior Approach, and back then 1 to 2 percent of surgeons were doing it. To see this climb to 34 percent nationally is really remarkable. We are seeing numbers higher than the industry average; however, with upwards of 40 percent of DePuy Synthes users performing the Anterior Approach.

Q: How has it become one of the fastest growing surgical approaches in orthopedics today?

SZ: It starts with patients. Hip and knee patients often delay for years before they have surgery and unfortunately, they are told it has to be the last resort. In the interim, they might gain 40 pounds, develop high blood pressure and cholesterol. Younger patients, including baby boomers, are increasingly interested in talking with their doctor about treating their pain and getting back to activities they enjoy.

The Anterior Approach enables patients to undergo surgery and permit a shorter recovery period. We are seeing 30 percent shorter hospital stays and 18 percent more patients discharged to home with the Anterior Approach than with traditional surgery. Patients are attracted to the muscle-sparing, tissue-sparing benefits of the Anterior Approach and this is being spread through word of mouth.

Bundled payments and the trend toward outpatient surgery are driving the adoption of the Anterior Approach from the hospital and physician perspective. Our surgeon customers are getting rewarded or penalized by value-based contracts. They need to deliver great outcomes, but they are also evaluated on their cost of care and patient experience. Because of the short stay and less pain, patients discharged home are reporting a better experience and we are seeing a 45 percent cost reduction with Anterior Approach versus the traditional approach.

Q: How common is it for orthopedic surgery to be performed in an outpatient setting? Is this a growing trend? How is DePuy Synthes supporting such a shift?

SZ: It's growing fast and it's really local. There are cities like Minneapolis, Las Vegas, and Columbus, Ohio, where we are seeing high penetration of hip and knee replacements in the outpatient setting. Nationally, somewhere from 5 to 10 percent of total joints are performed in ASCs. In the next three to five years, I believe north of 30 percent of joint replacements will be performed in ASCs, dependent on what CMS does as it relates to outpatient payments.

If you are going to start doing hip replacements in an outpatient setting, the Anterior Approach is an approach to consider. Patients already expect a shorter hospital stay and they are expecting a faster recovery and normal return to daily living activities.

As many of our hip surgeons look at outpatient, they quickly realize the Anterior Approach is a smooth way to make that change. We also run outpatient professional education and encourage surgeons who are looking to go to an ASC to consider using the Anterior Approach in the hospital setting and then taking it to the ASC once they are comfortable with it.

Q: How has the technology and technique evolved over the years? What new technologies are available to enable the Anterior Approach to be performed on more patients?

SZ: Customers have had a concern about the learning curve for adopting the Anterior Approach. DePuy Synthes has been a leader in the space, but we are also working hard on technologies to reduce the learning curve and improve the reproducibility. We are just launching the ACTIS® Total Hip System, the first DePuy Synthes hip stem designed with the Anterior Approach in mind.

We also recently announced two partnerships, one is with Medical Enterprises Distribution, LLC to co-market the ME1000™ Surgical Impactor designed to replace the mallet in the OR. The ME1000 delivers more consistent and stable energy that is designed to automate bone preparation, implant assembly and positioning, and helps reduce the stress on surgeons. I can't tell you how many hip and knee replacement surgeons need shoulder replacements because the wear and tear is significant.

The second partnership is with JointPoint, Inc. to co-market its proprietary software platform that provides computer navigation, case planning and intraoperative feedback. This is all iPad-based; when you pair the new hip stem designed to be utilized with tissue sparing approaches such as the Anterior approach, with the ME1000, which allows optimal implant placement, you've really made this Anterior Approach and other hip replacements as reproducible and reliable as possible, while making the learning curve as small as possible.

Q: How significant is the learning curve for surgeons? What professional education and training is available?

SZ: Our goal is to minimize the learning curve. We put on workshops that include a half-day didactic learning session about the procedure and half-day cadaveric training. We surround the day with digital learning and after the day make available the opportunity for OR visitations. To date we have trained more than 11,000 surgeons on the Anterior Approach as described by Dr. Matta.

Q: What investments has DePuy Synthes made to help surgeons bring Anterior Approach to their patients?

SZ: Beyond the investments we've made in the implants and technologies and the learning centers, centers of excellence and preceptorships, we are trying to reach customers where they are and when it's convenient for them. We can host national, regional and local programs; we think this is the right thing for patients, surgeons and hospitals and we are willing and able to help train where needed.

Q: What is the future of Anterior Approach? Will it become more common than traditional approaches?

SZ: I think I would still expect to see both approaches available in the US. Residents and fellows are training on the anterior procedure, which means they won't have the extra learning curve heading into their practice. I believe you'll see a mix where more than 50 percent of surgeons are doing the Anterior Approach in the future.

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