New Technology

New technology is one of the most coveted characteristics of the American medical system. We are blessed to be in an era, and more importantly a country that affords us the choice of a vast array of technology. However, not every new technology is good. There is an old saying in medicine; “Don't be the first one to try it, nor the last.” This especially holds true in various new introductory technologies. While I am involved in a number of investigative studies, these are all Institutional Review Board based assessments where patients have the choice to evaluate and investigate newer ideas for improving health care. I have and always will be an advocate of this system such as the proven benefit of computer assisted surgery and tissue sparing incisions (see articles 1, 2, and 3 under publications). However, when it comes down to some of the more invasive or permanent fixation appliances such as total joint replacements, there needs to be a second tier of consideration. That is, a peer reviewed article on the performance of new systems that proves their worth. Several examples of this in present news is a “30 year knee” and a “cruciate maintaining knee.” While exciting, both of these are somewhat of a smoke screen. In the case of the “30 year knee”, the outcomes were not based in clinical practice, but rather on artificial wear rates with plastic on metal. As it turns out, 5 years later it has the same outcome as other devices of that era. In the case of the cruciate sparing or bicruciate knee, it is an old concept that was once used long ago and has now been reintroduced with newer glitzy devices. However, in both cases, there is no published data testifying to their success. This should be your first clue about new technology. It is also a disconcerting construct with the institution of many of the implants being inserted with a paucity of objective measurement metrics. That being said, given the high frequency of postoperative pain complaints in total knee replacement surgery, the cruciate sparing knee may hold promise in the future of better outcomes, however, none have been proven yet and we are still waiting with bated breath.

The metal-on-metal hip was one of the tragedies of the orthopaedic community in recent years. While in primate and rodent literature the metal-on-metal byproducts demonstrated numerous side effects, it was a concept that held promise in that it might be a more stable hip construct to prevent dislocations. However, this has not worked out well at all in practice and it continues to be the subject of great debate.

I would be remiss to not acclaim technology as being the one thing that we will continue to focus our interest on for improvement and excellence in joint replacement surgery. However, I do feel we owe the patient a great deal of respect and even more importantly a large role in the decision making process. In the end, it is because we are all willing to try different things, that make medical advances possible, but we all have to keep this in a balanced perspective.

References

1. Smith et al, Failure Rates of Metal on Metal Hips Resurfacings: Analysis of data from The National Joint Registry for England and Wales, Lacet 2012, 17:380,1759.
2. Porat et al, Causes of Failure of Ceramic-on-Ceramic and Metal-on-Metal Hip Arthroplasties, Springer 2011.
3. Desloges et al, Do Revised Hip Resurfacing Arhroplasties Lead to Outcomes Comparable to Those of Primary and Revised Total Hip Arthroplasties?,Springer 2012.
4. Russell et al, Patient Specific Instrumentation Does Not Improve Alignment in Total Knee Arhroplasty, Journal of Knee Surgery 2014:27:501-504.
5. Lionberger et al, Patient Specific Instrumentation, The Journal of Arhthroplasty 29 (2014) 1699-1704.