Green orthopedics: Spend our precious health care dollars wisely
Frederick A. Matsen III, MD, one of the world’s leading experts in shoulder and elbow surgery, brings more than 5 decades of experience to his Guest Commentary.
Renowned for pioneering techniques he developed at the University of Washington, such as the "ream-and-run" procedure, extensive capsular releases, open Bankart repairs and the Simple Shoulder Test, his insights are highly valued by those who manage shoulder and elbow conditions. His leadership, including more than 20 years as chair of the department, positions him as a credible voice in all areas of orthopedic surgery, especially on topics like cost-effectiveness and innovation, which are central to this Guest Commentary.
Matsen advocates for utilizing the best techniques and technologies to enhance patient comfort and function without incurring unnecessary costs. Importantly, new technology does not automatically constitute an improvement if outcomes are lacking or do not match those of historical procedures. This approach aligns with value-based care, ensuring that costs are justified primarily by improved outcomes.
Matsen discusses that each technological innovation brings additional costs, such as research, development, consultant fees, marketing, learning curves, recalls and complications, which are often overlooked by orthopedic surgeons and frequently introduced without thorough clinical outcome studies. Furthermore, FDA-cleared technologies do not guarantee effectiveness, safety or improved outcomes, highlighting the need for rigorous clinical evaluations after new technology is integrated into the orthopedic care model.
As health care delivery shifts away from a fee-for-service model to a value-based care model, orthopedic surgeons will significantly influence the cost of care while being accountable for the quality and outcomes of care, which may or may not be enhanced by the latest technology.
- Anthony A. Romeo, MD
Chief Medical Editor, Healio | Orthopedics Today
Orthopedic surgery is a marvelous field because we can make meaningful improvements in the comfort and function of patients disabled by arthritis, instability, tendon tears, developmental disorders and fractures.
As orthopedic surgeons, we are by our very nature innovative and creative. We are engaged in a constant search for more effective and safer means of treating the patients who put their trust in us.
‘Green orthopedics’
The term “green orthopedics” is used to indicate the thoughtful application of techniques and technologies that improve the comfort and function of our patients without incurring needless costs. This concept is particularly important at this time when there is an exponential increase in expensive technologies, many of which have not been demonstrated to improve patient outcomes.
The fact is that as orthopedic surgeons we have power over a substantial portion of the health care budget of the United States because we treat a large number of patients, and our surgical treatments are expensive. But from the Spider-Man comics and related media, we learn that “... with great power comes great responsibility.”
Using my field of shoulder surgery as an example, during the last several decades, there has been a virtual explosion in the techniques and technologies for rotator cuff surgery, such as new repair techniques, platelet-derived growth factors, bone marrow extracts, scaffolds, patch augmentation, subacromial balloons, tendon transfers and superior capsular reconstruction. Yet the evidence that these approaches have significantly improved the clinical outcomes (ie, patient self-assessed comfort and function) seems lacking.
Similarly, in the field of shoulder arthroplasty there has been a dramatic increase in the techniques and technologies cleared by the FDA through the 510(k) process (which only requires that the new device is “substantially equivalent” to a previously marketed device, rather than demonstrating its safety and efficacy). Yet evidence that these innovations have led to clinically significant improvements in patients’ comfort and function is, again, lacking.
Each technological innovation carries with it increased costs related to research, development, consultant fees, marketing, individual surgeon learning curves, recalls and unanticipated complications. As an example, it appears that the increasing use of 3D CT-based planning may be driving the increased use of more expensive technologies for managing glenoid retroversion, such as special glenoid components and the use of reverse rather than anatomic shoulder arthroplasty. Yet recent publications suggest postoperative glenoid retroversion does not have a major effect on the clinical outcomes of shoulder arthroplasty. The available evidence indicates that the surgeon’s technique in achieving excellent seating of the glenoid component is the most important thing.
Be the best stewards
In conclusion, it is certain that new technologies will come to the market place each month. We recognize that FDA “clearance” does not assure either the effectiveness or the safety of these innovations.
Thus, it seems appropriate that we ask the advocates of these new orthopedic innovations to demonstrate that the increment in cost yields a commensurate increase in the quality of the outcome realized by the patient. In this way, we can be the best stewards of the health care expenses that are under our control.
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For more information:
Frederick A. Matsen III, MD, is a professor, department of orthopaedic surgery and sports medicine, University of Washington Medical Center. He can be reached at matsen@uw.edu.
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