Ignored Failures Of A High-Volume Joint Replacement Society, a Forbes Article by Dr. Ramkumar
There’s just not enough time – or enough incentive – to convey and process the gravity of undergoing a joint replacement.
The patient is in pain and just wants relief. The surgeon embodies a way out but must diagnose, educate, and clarify any misinformation from Google or their second cousin’s neighbor in a span of minutes. Meanwhile, the faceless system puppeteers both doctor and patient by prioritizing volume over connection, speed over quality, and profits over everything.
The high-volume nature of these operations forced insurance plans over the last two decades to rethink how these operations are paid for. In partnership with the American Association of Hip and Knee Surgeons (AAHKS), the Center for Medicare and Medicaid Services introduced the bundled payment model that pays a flat rate for an “episode of care.” This financially covered the joint replacement and all associated services in the 90 days that follow the operation. Symbolically, this was the first domino in the corporatization and mass scaling of the two most common surgical procedures under the guise of “value-based care.” With this paradigm shift came “lean” initiatives that did enable new efficiencies but simultaneously devalued the surgical team, downshifted costs to patients, and displaced risk to the surgeon.
With both economies and scale in hand, a High-Volume Joint Replacement Society was born.
In this Society, patients are orphaned by both their insurance plan – who deny and delay as long as possible to avoid paying – and by their health system – now emboldened to demand cash up front before surgery. This leaves surgeons as the chief custodian tasked with navigating the patient through this hedge maze. Meanwhile, surgeons receive constant downward pressure themselves as 78% are now employed by a corporate entity.
The volume of hip and knee replacements are projected to rise dramatically over the next 35 years. These total hip and knee arthroplasty procedures represent the highest surgical expenditure for Medicare. By 2060, Medicare anticipates hip replacements to increase 659% (nearly 2 million annually) and for knee replacements to increase 469% (nearly 3 million annually).
The ubiquity of artificial joints in this Society and its overall resounding success has socially engineered our perception to convince us that metal and plastic means “happily ever after.” Disturbingly, the emphasis on volume makes it easier to sign a patient up for surgery than it is to educate and empower patients to make a balanced, personal decision about the realities after joint replacement. Between patients wanting immediate relief, insurance plans denying appropriate recommendations, and systems blindly encouraging surgery, the surgeon remains the sole and stalwart arbiter of the Society split across three unique interests.
Despite all the good that arises from providing patients with access to lifestyle-altering surgery, there’s one glaring problem. Scaling human life isn’t the same as scaling product in a factory. What happens when these artificial joints eventually fail en masse? It’s obvious that as more procedures are performed, more failures are bound to occur.
Less obvious is that failure of a joint replacement isn’t typically due to worn parts that can be fixed with a simple “tire change” operation. A joint replacement can fail from infection, instability, loosening, wear, or fracture. The outcomes after revising a failed joint replacement are rarely as good as getting it right the first time. There is less available bone for reconstruction, the next implants are larger and less “natural,” and the required dissection is more invasive – not to mention the risk of complications skyrocket with subsequent surgery. To add insult to injury, 22.6% of these twice-operated joints will go on to a third operation for failure yet again.
Even if the patient is seemingly out of the woods and doing great, complications may still arise. There remains a 10% risk of dislocation five or more years after hip replacement – and we are only just starting to understand why this occurs. Infection remains the most devastating complication, and this doesn’t necessarily happen right after surgery. It can occur 10, 20, or 30 years later out of nowhere. It may be due to a tooth infection, a skin cut on the arm, recent illness, poor dietary choices, or for no apparent reason whatsoever. If an infection does occur after a joint replacement, the risk of dying can be as high as 26% within 5 years. These are worse odds than a diagnosis of breast cancer, melanoma, prostate cancer, and bladder cancer. Further complicating the matter is that infection after a joint replacement can be surprisingly subtle and thus sometimes difficult to recognize. The gold standard for treating an infected joint replacement involves two additional surgeries and over a month of intravenous antibiotics. Even then, this strategy is far from a guarantee. And if infection persists, amputation is a possibility if the limb can’t be saved. Other reasons for failure of a joint replacement include the better-known risks that the implants can wear or the surrounding bone can fracture. And of course, any reoperation to address a failed joint replacement for reasons other than infection increases the risk of developing subsequent infection.
The expected failures from the High-Volume Joint Replacement Society could be rationalized and relegated to a line item of “spillage.” Well, this spillage is forecasted to increase at a rate of 101% (failed hips) and 520% (failed knees) by 2060. Worse, the current infrastructure strongly disincentivizes hospitals and surgeons from caring for patients with a failed joint replacement due to the significant resources involved. Hospitals incur 76% higher costs when caring for these patients compared to first-time hip and knee replacement patients. On average, these patients stay 4 days longer in the hospital compared to first-time joint replacement patients. Within 90 days of the revision operation, 28% of patients will visit the emergency room for concerns that range from persistent pain and wound healing issues to life-threatening blood clots and recurrent failure.
For the surgeons routinely managing the realities of failed joint replacements in terms of real human limbs and lives – and not line items – “economies of scale” starts to feel a lot more like calamities of scale. The surgery is complex and far more taxing mentally and physically. Compared to a first-time knee replacement, revising a failed knee involves 150% more physical work and 233% more mental burden in preparation. These revision operations average 3 hours, which is 50-60% more time than first-time procedures. Fixing a failed joint replacement is at great financial loss to the surgeon, system, and insurance plan when accounting for time spent. Surgeons who place patients first and routinely tackle the additional complexity despite systemically misaligned incentives stand to lose up to 55% revenue per day.
Dr. Andrew Wassef of the Long Beach Orthopedic Institute, an academic private practice in Southern California, serves as Fellowship Director in Hip and Knee Adult Reconstruction and performs over 100 revisions a year. He has a dedicated clinic to evaluating and managing patients with failed hip and knee replacements. The waitlist to schedule an initial consultation in his Southern California “revision clinic” is six months. “The number of neglected patients with failed joint replacements is staggering, and the stories they tell are hard to hear with many looking far and wide for an orthopaedic surgeon willing to treat them. The few surgeons qualified and willing to care for these complex patients endure greater liability, greater personal stress, greater complications, lower hourly reimbursement, and undue institutional pressure for these costly episodes of care. The script needs to flip. We should be enabling and rewarding the doctors who treat this vulnerable population – not demoralizing them,” said Dr. Wassef.
The downstream effects that can occur after deciding to undergo hip or knee replacement in this High-Volume Joint Replacement Society have forced us to rethink how we determine success of the operation. Previously, we defined success based on how long a replacement lasted. Perhaps we should begin framing the discussion in terms of lifetime failure risk, as suggested by researchers in New Zealand. As expected, younger patients undergoing knee replacement carry the highest lifetime risk of failure at 25.2%, which for some patients and surgeons may be enough information to delay undergoing the operation in the first place – especially after better understanding the outfall associated with a failed joint replacement.
Why is no one talking about this? The vast majority of patients do well and do have a new lease on life. Treating end-stage arthritis with a hip or knee replacement sounds like an intuitive and socially vetted response to mitigating the purgatory of chronic hip or knee pain. However, it needs to be on the terms of a well-informed patient and with the understanding that “one and done” may be the dream but not always the reality. Few surgeons and even fewer systems prefer to hide the fact – let alone advertise – themselves as a beacon of failed joint replacements given the cost of care, complexity, complication profile, and financial ramifications.
The emphasis on commoditizing patients by way of metal and plastic forebodes a titanic catastrophe of population-level proportions for which we presently have no formal plan of action. Preparation for the statistically inevitable volume of complex reconstructions should revolve around 3 Ps: Periprosthetic joint infection prevention, Preferred centers of excellence, and Preserving the native joint when possible.
Particular complications like infection after joint replacement are the subject of intense investigation due to its grim prognosis. Emmanuel Gibon MD, PhD is an academic hip and knee replacement specialist and Co-Founder of DeBogy Molecular, Inc – a biotech company that lends hope in combating infection by modifying implant surfaces to electrostatically eliminate bacteria on contact. “Periprosthetic joint infections are a plague that threatens the success of joint replacements as soon as the implants are put in, and it is a risk that never disappears. Infection is the most common complication after hip and knee replacement – no matter how successful the procedure is. This is a race against an epidemic that is getting out of control,” Dr. Gibon said.
Establishing preferred centers that specialize in managing failed hip and knee replacements is a starting point, as higher volume revision surgeons outperform lower volume ones. We should treat failed hip and knee replacements like we do nationally recognized organ transplant programs that receive federal funding for a multidisciplinary team of social workers, therapists, nutritionists, internists, infectious disease doctors, and surgeons who move in lockstep. The metrics for evaluating these programs that address failed joint replacements would be unique to these centers. Ideally, health insurance plans, federal programs, and medical device industry would be mutually invested to ensure care for these patients remains clinically, socially, and economically feasible.
A more sustainable solution involves distancing ourselves from the culture of commoditizing joint replacements. Without limiting access to those in dire need, surgeons should continue to ensure patients who are younger, have unrealistic expectations, or not yet optimal candidates maximally exhaust joint preserving strategies before proceeding with arthroplasty. Additionally, the advent of GLP-1 agonists for weight loss may help obese patients with hip and knee arthritis avoid the operation altogether or minimize complications thereafter.
When it comes to replacing hips and knees, surgeons are left fending off a system that prioritizes speed and scale. The failure of joint replacements themselves may be inevitable but belie a greater failure: the commoditization and commercialization of patients undergoing first-time joint replacements with no contingency plan for those requiring revision.
You can read the original article by Dr. Prem Ramkumar on Forbes Magazine Online:
