Helpful Virtual Tools for Orthopedic Surgeons

Anya Romanowski, MS, RD

Disclosures

June 08, 2017

Virtual reality simulated training and procedural videos are gaining popularity among surgeons. Not only do they allow users to view how to perform a procedure, but they also enable surgeons to try complex procedures and determine which one will lead to the best outcomes for patients.

Jon J.P. Warner, MD

To find out more about simulated trainings and preoperative planning, Medscape editor Anya Romanowski interviewed Jon J.P. Warner, MD, who is a co-owner and board member of VuMedi, a popular video education platform for surgeons. Dr Warner is chief of the Massachusetts General Hospital Shoulder Service, professor of orthopedic surgery at Harvard Medical School, and co-director of the Boston Shoulder Institute.

Utilizing Simulation Software for Preop Planning

Medscape: Can you talk about what simulation training offers surgeons and patients?

Dr Warner: Just like pilots use flight simulators, surgeons can utilize software that simulates surgery, and it automatically makes them better surgeons (just the same as pilots get better with simulation). There's a cockpit, and the simulator walks you through how to do the procedure in a very basic way.

As I am a proponent of value-based care and have learned at Harvard Business School from Michael Porter and his colleagues, surgical simulation is very exciting as a vehicle to provide value to patients, surgeons, and hospitals. Value is outcome divided by cost, and any poor outcome reduces value. Simulation offers the possibility of reducing errors and thus improving outcomes, and it can also reduce the costs of surgery.

We call this "trial without error," which is a very important concept. You trial everything you do before you go to the operating room. You know not only exactly what you will do, but you know exactly what you will use. You manage inventory, which means you don't have any trial and error in order to decide on the specific implant needed. It's not the Goldilocks approach (eg, from extremely harmful to extremely successful). It's an approach that improves accuracy of implant selection so that the surgeon knows exactly what implant he or she is going to use and where they're going to put it before they even go there.

When I see a patient before surgery—and I do this with every patient—I tell them, "Here's the virtual plan of your procedure. Yesterday, I sent this 3D plan to the staff who will help me do your surgery and showed them everything that we will be doing. Now I'm going to do your surgery, which I already did virtually." You can imagine the patient's reaction.

Medscape: I can imagine the positive reaction you receive when you share this information with patients.

Dr Warner: The reaction is one of reassurance and confidence. No matter what you think about all the rest of it, that is a very important buy-in by patients and a value add-on.

Be advised that I have a conflict of interest with the software program of the company I use; however, every single major arthroplasty company is pursuing this in some form or another. This is not a question of which is the best program of all of them; it is a movement, and it will transform orthopedic surgery.

The next step, which is coming soon, is augmented reality. Your virtual plan will live in front of you while you operate.

Virtual Simulation Versus Robotic-Arm Surgery

Medscape: How does this differ from robotic-arm surgery?

Dr Warner: That's a very important question. Several investment bankers just asked me that today. Robotics may not be necessary when one can do virtual surgery. Moreover, it is expensive.

Simulation is not expensive. In many cases, this service is free to the doctor. The augmented reality that will give you the overlying image of what you're doing will allow you to do these operations with fewer instruments and guides (with absolute accuracy while you do it, because you see it adjacent to what you do).

It will transform less experienced surgeons into better surgeons in terms of their outcomes. The value of that is too enormous to even say. In the United States, 80%-90% of all shoulder replacements are done by individuals who do five or fewer procedures each year. There is much literature on volume versus outcome in cardiothoracic surgery and orthopedic surgery. It's particularly prevalent in procedures that are not performed at a high volume, such as a hip replacement. Shoulder surgery is maybe 10% of that.

Consequently, you have a prescription for a disaster. If you can take the less experienced surgeon and give them a GPS through the surgery with instantaneous guides, it will be better; there will be fewer errors in judgement and better outcomes. And because they will have fewer failures, there will be an added value to all stakeholders (the hospital, patient, vendor, and the surgeons themselves), because it will be a more efficient and error-free process.

Medscape: Because this is a simulation, it is something that the surgeon can practice before the surgery.

Dr Warner: It's not an abstract simulation; it's an individualized, anatomical simulation of every single case. Every single patient has a virtual surgery before they have the real surgery.

Because I work in a teaching institution, the fellows whom I teach all do the virtual surgery, and we compare our plans of treatment. I know exactly where their variances are from mine before we even go to the operating room. They become better surgeons before they even help me do the surgery.

That is transformative, and that is the definition of disruptive technology. The next new joint replacement or computer widget is just that.

It's like golf clubs. Everybody promises the next greatest golf club that's going to make you hit the ball straighter. That's not what it's about; it's the swing that does it. It's the same thing for pilots and for surgeons. If you improve the ability of pilots to fly and surgeons to do procedures with fewer errors, everybody benefits. That's what this is essentially about.

As Christian Gerber, who is one of my colleagues and world-famous shoulder surgeon, said, "Many operations fail before the surgeon walks in the room, because the rationale for the surgery and the plan are inadequate." This allows you to select patients who will not do well with a conventional replacement, and who might do better with a reverse replacement and avoid failure that would otherwise happen because your decision-making was incorrect. In that way, we avoid those problems before we get there. That's very important.

Medscape: Does it take into consideration any possible complications that can occur, such as infections?

Dr Warner: As far as infection goes, about the only thing that I can tell you relevant to that is, we know that infection is correlated to speed of surgery. So, if you speed up the surgery, because you know exactly what you're going to use and you don't have to do trial and error in the operating room, you reduce infection rates.

Medscape: Does it also adjust for different types of prosthesis (eg, metal-on-metal or polyethylene)?

Dr Warner: First of all, we're talking about the shoulder, not the hip; no metal-on-metal shoulders are commercially available now. Virtually every shoulder implant is high-density polyethylene and chrome-cobalt, or some variant of that. There are technologies under way to maybe change that, in terms of ceramic or things of that nature. But that's not made its way to the shoulder yet, largely because of volume and pricing issues.

Medscape: So your simulation is mostly used just for the shoulder at this time?

Dr Warner: What we're talking about here is completely for the shoulder. The hip colleagues won't like this, but the shoulder is far more complex than the hip. The hip is a ball in a socket; the shoulder is a ball on a socket. The degree of freedom we have in the shoulder (which allows you to play sports, use your arms, and put your hands in different places) is far greater than that of the hip. All the hip has to do is rotate. The shoulder has much more complex forces across it from the standpoint of the loads the components will see, and those forces can contribute to failure in a much more accelerated way than in the hip. Components that are placed in suboptimal positions will absolutely result in failure. Simulation before surgery avoids that error.

The more common the procedures are, the fewer the complications and the more reliable the outcomes. Most residents in their training have very limited exposure to shoulder replacement surgery. Consequently, it's not surprising that there is a volume and outcome association once they're in practice that is much more dramatic than it is in shoulder arthroscopy, hip replacement, or knee replacement.

Tools for Tracking Patient Outcomes

Medscape: There's been a lot of focus lately on patient satisfaction and outcomes. How have you been tracking patient outcomes?

Dr Warner: We track the outcomes for every one of our patients. If you go to the "How Fast Will I Recover?" section for patients on our website, this is one of our many quality measures. All patients input information on pain and functional recovery, so we get what's called a "recovery curve." If you look at primary shoulder replacement, the colors represent different standard deviations. By 2 weeks, the pain level is 2 out of 10—and that's the average.

Functional recovery is shown here as well, as assessed by patients using the SANE (Single Assessment Numeric Evaluation) instrument: "Out of 100% being normal, I rate my shoulder ___%."

This is very important, because as a rule, patients will define their outcomes not only on the basis of pain relief, but also their ability to return function to do the things they love (eg, tennis, golf, swimming, or other sporting activities that require use of the upper extremity), which is very much the case in individuals in their active older or middle years. More important, the average age of shoulder replacement patients is much younger than that of hip and knee replacement patients, so the expectations are much higher for recreational sports.

If you think for a moment, what requires you to be able to use your arms? All of the sports I just described, which are very much a part of social interaction and give people purpose and enjoyment in life, are predicated on a shoulder that moves and puts the hand in space. If you have a virtual plan, you have high reliability of returning people to that level of function.

Medscape: I overheard some discussions on using sensors to monitor and track patients' movements after surgery. Do you have anything to add about this?

Dr Warner: Kinematic analysis is something that's been done by many people, particularly in sports. It's only a direct extension of what patients will tell you anyway. They know what they do. We've done biomechanical kinematic analyses using radiographic imaging in two planes to look at the way the joint moves and how close we can get it to move like a normal joint. But in sports performance, people are looking to optimize sports functioning. There has been relatively limited work in terms of the aging athlete and looking at how you might address things.

For example, I'm very interested in golf, and one of the things I talk about with other players is how they can improve their golf swing by certain mechanical changes, because most swings are affected by poor mechanics. If you have a shoulder replacement, you want to be certain that you optimize the large muscles, and your trunk rotation and core stability are essential. It's certainly essential to protect the shoulder. Except that if you have a flexible shoulder that functions like a normal shoulder, you will have fewer forces on it when you swing a golf club or play tennis. I suppose you could do a motion analysis, but you can also achieve that aim without these complex methods.

The Value Pledge and Care Bundles

Medscape: Is there anything else you want to talk about—things that excite you in terms of your own research?

Dr Warner: A broader principle is that we all understand a term that has been used repeatedly: "value-based care." Value is a concept that has been twisted and misrepresented by many different entities. It's sort of a popular catch-term.

My interest in value relates to my experience at Harvard Business School working with Michael Porter and colleagues and understanding this concept in the context of shoulder care. Everything that I do is predicated on improving the value I can deliver to my patients. Because value is outcome divided by cost, we have two options: Either we can improve outcomes, or we can lower costs. Of course, we should try to improve both.

As a general rule, all healthcare is driven by large organizations that are mostly focusing on cost, and we are racing to the bottom in reducing costs without improving outcomes. The sad point is that if we focus only on cost, we lose innovation that benefits patients and improves outcomes. There is a constant tension and argument about this problem, more with doctors and hospitals than with insurers.

In fact, if you look at our value pledge, we go over all of the elements that make value for patients: communication, transparency, accountability, and so on. We talk about the tension in value between all of the entities involved and how we're going to deliver true value.

If you look at designing a bundle, this is our work at Harvard Business School with the collaboration of a large HMO, creating a single bundle payment guaranteeing outcomes for rotator cuff repair. Because we know our outcomes, we can deliver absolute value by controlling costs and guaranteeing the outcome over a 1-year cycle of care. This is completely contrary to the fee-for-service model that encourages process and volume rather than quality.

Medscape: The issue with some of the surgeons I've spoken to is that the Centers for Medicare & Medicaid Services bundles never take into consideration the high-risk patient.

Dr Warner: This is redefining healthcare. Right now, we have three limited options: the fee-for-service, capitation, and employment models. In this instance, you have to do risk stratification. You can only guarantee outcomes to a certain degree if you manage the risk and show your ability to deliver on your promises.

It's a perfect example of how we should manage margins and not revenue. It's not that we need to reduce the revenue and manage the margin by managing risk incentive. However, when you build these kinds of things, and if you build trust with the insurance companies and the patients, then you have modifiers for complexity that assume a certain level of guarantee for the risk you take in caring for those high-risk individuals.

It's completely different from saying, we'll compensate you on the basis of relative value units or some other fee for the service that has absolutely nothing to do with the risk and the outcome. This is the ethical high road, and it's also the only way that everybody benefits; the hospital, doctor, patient, and insurer. That protocol is the opposite of a zero-sum game, which is what happens with everything else.

In the United States, we deliver the most expensive healthcare without truly improving outcomes. Interestingly, the value is getting what you need—not more, not less—when you need it. We're great at delivering too much of something that doesn't work.

Medscape: So this will minimize the waste and improve the outcome. And at the same time, it offers different types of payment models.

Dr Warner: Yes. The true concept of bundles is that you are rewarded for taking risk, but you have to give guarantees and you have to be paid for the outcomes of what you do. Unfortunately, it threatens peoples' livelihoods, because many neither take the effort to measure nor want to be measured.

If you look at the Codman Shoulder Society site—which I'm very passionate about, and it affects everybody, no matter your specialty—it goes over what value is and why we do what we do. Ernest Amory Codman, MD, FACS, was the "father of outcomes," and he was persecuted for his belief that the end result of the patient is the most important goal of care delivery. He believed that if we followed every patient and they didn't have a good outcome, we should refund the cost of the care. He said this about 100 years ago.

His prescient belief in this is now the basis for this value approach that we are trying to follow. Instead, we've gone the route where many doctors have gotten wealthy on providing services that they say work great, but they don't measure a damned thing. That's not to say that everybody is motivated by just that, but human nature is human nature. I believe that everything will align itself if we pay for the outcomes we deliver, and we don't do that right now. We just pay for the process. Even Medicare mostly pays for a process, not for the value of what's delivered. And that's why healthcare costs are out of control.

The economics of healthcare is a very important thing in my way of thinking, because if you don't achieve a profit, if you don't have a margin, you cannot be innovative in anything. All of what I just showed you in 3D planning and patient-specific planning doesn't happen unless you generate a margin that sustains the company that creates it. To do that is essential to innovation and delivering value overall. If we continue not to do that, we're done developing and innovating things.

I would say that's a big nut to buy into, but I think shoulder is particularly of interest, because unlike hip and knee or spine (where they really have a better handle on it), shoulder is a shorter episode of care with an enormous variability in that care. The unfortunate secret is that there's a very high complication and failure rate for many of the procedures done by low-volume surgeons. There is no emphasis on measurement.

I'm writing a piece right now, a commentary on the association of volume with outcome. Surgeons who do fewer than 10 or 12 rotator cuff surgeries per year have a 25%-30% higher complication and failure rate than those who do more. But when a patient sees a doctor, they have no idea.

And so, in many instances, you roll the dice. The Internet is somewhat of a level playing field, but the Internet is a repository for advertising as well. How many vehicles do you have to know truly what your surgeon's experience is and what his or her outcomes are before you make a critical decision in your life about who's going to take care of you?

Volume and Surgeon Performance

Medscape: Is the volume determined by how complicated the surgeries are, or how many are scheduled during the day?

Dr Warner: No; it has to do with surgeons. We're talking about surgeon experience, not what happens during the day. The average orthopedic surgeon comes out of his residency having done hundreds of hip and knee replacements. And they probably do a lot of those in their practice, if we talk about a generalist. So, they don't have a lot of problems with those.

However, when you throw in a shoulder replacement or a rotator cuff repair, as is often the case, they have a much lower comfort zone for what they're doing, and because they haven't developed their skill set and decision-making in performance of the surgery, they have a higher complication and failure rate. It's been shown that it correlates to cost, time in the operating room, complications, and so on.

The patient-specific virtual planning tool is one vehicle to help those surgeons come up with plans that avoid those bumps in the road that otherwise they might make, and thus benefit the patient.

Medscape: Are there any other volume-based studies that you would like to talk more about today?

Dr Warner: We just finished a multicenter study looking at the impact of this virtual planning tool on low-volume and high-volume surgeons compared with radiography and regular CT. We found that when you use 3D planning, you narrow the variance between surgeons (skilled and unskilled) in decision-making, which means that everybody makes more accurate decisions and the way they put the components in is going to be more consistent. It will eliminate the errors that the less experienced surgeons will be making and make them more experienced because it will shepherd them through it. That's one example.

Inventory management is another one. You'll save an enormous amount of money if you go to the operating room understanding what you need. For example, each company that supplies the implants that are necessary to do a single shoulder replacement procedure probably moves about $70,000-$100,000 worth of inventory. If you know exactly what you're going to use, you might reduce that by 70% or something.

What do you think that would mean to savings in cost? Will that get passed on to the hospital and passed on to the patient? That's a true example of how we can translate this virtual planning tool into true value at a very practical level to all stakeholders.

Harvard Business School has a saying: "Do well by doing good." Any innovation must be sustainable because it makes a profit. But nothing really is innovative and an improvement unless it lowers cost and improves outcomes. That's the perfect example of a value-based approach.

Jon J.P. Warner, MD, has disclosed the following relevant financial relationships:
Stock: IMASCAP; VuMedi
Received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from: WRIGHT Medical (consulting)
Received financial support for research projects from: Smith & Nephew, ARTHREX, DonJoy, BREG (fellowship program support)

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