Q: What do you see as the major challenges and opportunities currently facing orthopedics?
Dr. Alejandro Gonzalez Della Valle: Total joint replacement surgery is rapidly changing in the 21st century. Advancements in the execution and postoperative care of patients coupled with favorable long-term results of the procedures have resulted in expansion of the indications for total joint replacement to patients that in the past would have been considered too sick, too young or too active for the surgery. This scenario has imposed the following challenges to the practicing orthopedic surgeon:
A. The challenge of increasing safety of total joint replacement: With advancements in anesthesia, surgical technique and perioperative care of patients undergoing total joint replacement, safe and satisfactory results are obtained in the majority of cases. However, there are still patients in whom total joint replacement carries significant risks for complications. Patients who are debilitated, malnourished, immunosuppressed, or who suffer from significant cardiovascular, pulmonary, renal or hepatic disease are at a particularly higher risk [1]. The preoperative assessment and postoperative care of these high risk patients is more time and resource consuming than that of the majority of patients with no major medical comorbidities. The adult reconstructive surgeon of the 21st century faces the challenge of developing perioperative pathways for the safe and efficient care of these high risk patients. Such pathways should contemplate the selective, efficient and rational allocation of medical and technical resources based on the patient’s individual risk.
B. The management of patients’ expectations prior to joint replacement surgery: When considering hip or knee replacement surgery, patients have a pre-conceived image of their final result in terms of pain relief and function (“recovery expectations”). Similarly, after a thorough examination and discussion with the patient, the surgeon recommending joint replacement surgery also develops expectations for recovery for each individual patient. The physician’s expectations are based on multiple factors including his or her experience with other patients, the patient’s motivation, preoperative functional condition, medical history, current diseases, condition of other joints, etc. Ideally, the patient’s and physician’s expectations should be aligned. When a patient has expectations that are unrealistically high, the unmet expectation after surgery may diminish the patient’s perceived satisfaction. Conversely, a patient with preoperative expectations that are too low may not engage enthusiastically in the different phases of recovery and may have a sub-optimal result [2]. With the expansion of indications for total joint replacement to younger and more active patients, the surgeon faces the challenge of improving preoperative patient-physician dialogue to make sure that expectations are aligned. This will ultimately increase the patient’s perceived satisfaction.
C. The challenge of providing balanced patient education in light of the increased use of direct-to-consumer marketing in orthopedics: With the increased use of direct-to-consumer marketing by orthopedic manufacturers, the dialogue between the orthopedic surgeon and the patient has dramatically changed. Oftentimes, patients considering total joint replacement surgery come to their medical consultation after researching the subject on the internet, and therefore, may have misconstrued ideas on the most relevant aspects of the procedure. In extreme cases, patients may come looking for a surgeon that will implant the prosthesis that they feel will most likely fit their needs, based on information provided by commercially related websites. During their office visit, the orthopedic surgeon must not only gain the trust of the patient, but also redirect his or her attention to what is most relevant and possible in light of the patient’s circumstances. This dialogue can be distractive and confusing to the patient; however, it is one that must be faced in order to enable the patient to make an educated decision for his or her care.
Q: Is there a specific new surgical technique or technology that is most exciting to you and why?
AGDV: In the span of a decade, hip and knee surgeons have witnessed the development and introduction of new techniques, technology like minimally invasive surgery, materials that allow enhanced uncemented fixation of implants, modern metal-on-metal and ceramic-on-ceramic bearings and so called “computer-assisted surgery” or “computer navigation”.
In my opinion, computer navigation is revolutionizing the way we think and approach joint replacement surgery. Adequate positioning of prosthetic components is essential for the joint replacement to function as similarly as possible to the natural joint and to diminish the natural wear and tear of the mechanical parts. The ability to properly position the different prosthetic components during total joint replacement increases with a surgeon’s experience; however, even in the most experienced hands, there will be a proportion of patients with malpositioned components. This may result in early prosthetic failure and complications. With the proper use of computer navigation, the number of “outliers” has diminished, resulting in a more consistent positioning of the replacement parts. This technology is evolving at a fast pace and will eventually be easier to use and available to the high and low volume surgeon. Its systematic use will likely result in more consistent total joint replacement outcomes.
Q: Is there an initiative undertaken at Hospital for Special Surgery in the past year that has proven to be beneficial and that you are particularly proud of?
AGDV: Hospital for Special Surgery has been a pioneer in perfecting and streamlining the execution of total hip and knee replacement. The advances in anesthesia, surgical technique and perioperative care are based on extensive basic, applied and clinical research that has been performed in HSS over that last four decades. HSS physicians, researchers and allied healthcare professionals are committed to continue building upon the previously mentioned body of research to make hip and knee replacement even safer and more cost effective.
Q: What do you see as the biggest opportunities for orthopedics in the next few years?
AGDV: The number of hip and knee replacements performed yearly in the US has increased exponentially in the last decade due to the baby-boomer effect, as well as the expansion of indications for surgery to the younger and to the sicker patients [1,3,4]. However, the number of orthopedic surgeons specializing in joint replacement surgery has been declining [3]. By 2016, the United States is likely to experience a significant shortage of orthopedic surgeons willing to do total joint replacements. If these predictions are accurate, 72 percent of those who need total knee replacements and 50 percent of those who need total hip replacements will not be able to obtain them [3]. Consequently, the arthroplasty workforce will be unable to meet the needs of a growing arthritic population. Joint replacement surgeons and hospitals will face the challenge of efficiently coping with the increase in volume while maintaining safety standards. Surgeons and hospitals will need to work together to increase efficiency.
Q: What factors have been critical to your professional success and popularity with patients, as indicated by your receiving the 2008 Patients’ Choice Award from Vitals.com for being one of New York’s favorite physicians?
AGDV: Hip and knee replacement surgeons treat patients who usually require “elective” surgery. This means that the patient is the one who ultimately makes the decision to have his or her hip or knee replaced. I make it a priority in my practice to convey a balanced view of benefits and drawbacks of the surgical procedure recommended for each patient, and in addition, I try to set realistic expectations for recovery. I respect my patients’ free will and trust their ability to make an educated decision for their own medical care. Allowing patients to speak and listening to their complaints and concerns have proven valuable in gaining my patients’ trust.
Q: What are your professional goals this year and for the next few years?
AGDV: Based on the previously mentioned challenges and the changes seen in the last decade, my goal for the following years is to continue striving for an orthopedic practice that balances patient care, education and research, which, to me, are the three indispensable pillars for the growth of orthopedic knowledge.
Learn more about Dr. Alejandro Gonzalez Della Valle.
References:
1. Memtsoudis S, Gonzalez Della Valle A, Besculides S, Garber L, Laskin R. Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. J of Arthroplasty 2009;24(4):518-527.
2. Ghomrawi H, Franco Ferrando N, Do H, Mandll, Gonzalez Della Valle A. How often Are Patient & Surgeon expectations for total joint arthroplasty aligned? 2010 AAOS Annual Meeting Poster Presentations #P140.
3. Kurtz S, Lau E, Ong K, Zhao K, Kelly MP, Bozic KJ. National projections of younger patient demand for primary and revision joint replacement. 2009 AAOS Annual Meeting Podium Presentations #183.
4. Odum SM, Iorio R, Fehring TK. Joint replacement access in 2016: A supply side crisis. 2009 AAOS Annual Meeting Poster Presentations #P043.
