If you need to get a partial or a total knee replacement, you might be interested to know that robotic technology is available that can increase the accuracy of a replacement procedure.
A CT scan of your knee is used to build a computer model, which robotically guides the surgeon to precisely replace the joint, resulting in better alignment and reducing the risk of early wear. However, getting your insurance company to cover this cost is not easy.
I was astounded this past week when a major insurance company refused to authorize the necessary CT scan, even though it approved the robotically guided total knee-replacement procedure. It didn't make sense. When it was explained to the insurance company that there is no way to put in this partial joint using the robot without the data captured from the CT, it said that "since the studies do not show a difference, we do not approve the scanning techniques to obtain the data." This Orwellian world is the path we are going down in standardized medicine.
Here's the dilemma: The studies the insurance companies refer to are based on the procedures done at high-volume artificial joint replacement centers, where surgeons do hundreds of total joint replacements each year. Outcome studies of their results show that when they do traditional total joint surgery using saws and guides, their accuracy of placement of the implants is about the same as when they use more modern computer navigation or robotic systems that improve accuracy.
However, most partial or total joint replacements are done by surgeons who do just one or two joints per month. Their accuracy is not as high as the high-volume total joint surgeon. Meanwhile, the outcomes of these joint replacements are completely unknown since outside of major medical centers, surgeons do not follow their patients over long periods of time, do not have outcome measures in place and the implant companies do not require tracking of the implants that are placed. In other words, the outcomes of most total joint replacements are unknown. Added to that are disturbing reports that up to 50 percent of total knee joint replacement patients still have pain.
What compounds the ignorance is that only 5 percent of all studies done in the field of orthopedics are high-level studies designed to show real differences. So really there is no data on the outcomes of what average total joint surgeons obtain from total joint surgery.
The frustrating interaction with the insurance company this past week highlights a number of issues. No. 1, insurance companies need to understand that while the literature doesn't show a specific benefit, the literature may not be reflective of what is actually going on in the community. The surgeons who realize that if their volumes are low, their accuracy may be low and rightfully turn to computer navigation and robotic devices to improve their accuracy. Even experienced surgeons, as in our practice, turn to robotics to provide another level of reproducible accuracy. Their judgment must be respected. They are the ones who know just how good they are and how much better they could become with newer technology.
No. 2, all surgeons should be required to do outcome studies on their patients. Given the existence of the Internet and smartphones, this is a relatively easy thing to accomplish these days. The data will reveal the wide range of actual outcomes.
No. 3, all implant companies should be required to have a product-tracking number on each and every implant placed into a patient, so actual data on each implant can be understood.
How we get the system to incentivize each of these changes is one of the challenges to improving health care. But to disincentivize excellence by blocking the use of new technology on the basis of flimsy data is not the way forward.
Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco. He pioneers advanced orthopedic surgical and rehabilitation techniques to repair, regenerate and replace damaged cartilage and ligaments. For more info, visit www.stoneclinic.com.