The changing landscape in total hip arthroplasty: part one

Listen to Andrew Duckworth, Jonathan Vigdorchik, George Haidukewych, Molly Hartzler and Thorsten Seyler discuss the changing landscape in total hip arthroplasty.

This episode is kindly sponsored by Smith & Nephew.

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[00:00:00] Welcome everyone to the first part of episode three of our Smith & Nephew sponsored special edition podcast series. I'm Andrew Duckworth and a warm welcome back to you all from your team here at The Bone & Joint Journal. As you may know, this special edition series is focusing on hip replacement surgery, including what the current issues are, what the emerging tech- technologies may be that help with these issues, and what the future may hold for this area.

In this episode, we will explore the evolving landscape of total hip arthroplasty with a particular focus on the innovation shaping the future of hip replacement. We'll cover the growing importance of intraoperative efficiency to the latest advancements in in stem design and personalised surgery, and we will examine how these developments are changing the landscape for patients and surgeons.

So for today's podcast, I have the pleasure of being joined by three guest surgeons and a colleague here from the BJJ. Firstly, I'd like to welcome back Dr George Haidukewych, who's an orthopaedic surgeon based at Orlando Health. George, great to have you with us. Good morning. Secondly, I'd like to introduce Dr

Molly Hartzler, who's an orthopaedic surgeon based at Wake Forest University. Molly, great to have you with us. Thanks for having me. Thirdly, I have the pleasure of welcoming Dr Thorsten Seyler, who is an orthopaedic surgeon based out of Durham, North Carolina. Thanks very much for joining us [00:01:00] Thorsten. Morning.

Excited to be here. And finally, I'd like to welcome back my editorial board colleague here at the journal, Dr Jonathan Vigdorchik, who is based at HSS in New York. Jonathan, great to have you have back with us. Yeah, thanks for having us and welcome to our speakers. So Molly, I thought we'd kick off with yourself.

I was hoping we'd talk about the use of day surgery centres and maybe look at your, for our listeners, your own experience of day case hip replacement surgery. Yeah, so I actually do same day surgery out of a small hospital that is mostly orthopaedic surgery is. So it's not a true ambulatory surgery centre, but we do run very similar to it.

In that efficiency is paramount. We spend a lot of time preoperatively optimising our patients. We use the Eris type protocols significant preoperative education. And then we have some constraints in terms of, you know, our shelf SA space the you know, the efficiency of turnovers and things like that.

And we've. Sort of slowly increased our same day discharge numbers, you know, both because of data showing that it's [00:02:00] safe to do so in certain patients. And then also, you know, I think one of the things that COVID did was sort of force people who weren't doing same day discharges to kind of move in that direction.

That's very interesting. And actually, like, like you say, I think COVID has sort of forced people in that, in that direction. Thorsten, do, do you have any co thoughts or comments on your experience with that? Yeah, so I operate in two settings. I, I do same day discharge in a hospital setting and at a free standing outpatient ambulatory surgery centre. Molly is right. We kind of got forced into, at least at the hospital setting, going into the, the same day discharge during COVID, and I think this is where we learned a great deal on, on outpatient surgery. And it helped us become certainly more efficient at the ambulatory surgery centre. And over the past two years, I would say we have really pushed the limits who we take to outpatient surgery.

I think most pa most surgeons when they start off cautious who they select the same day I would say at this [00:03:00] point, almost 80% of the patients that we see are candidates for same day discharge if they're comfortable. Okay. And the key to, the key to this is really truly a preoperative education.

Jonathan, would you agree with that? Yeah, I mean, over time we've seen an evolution from, you know, a week length of stay to three days to two days, and if you can get to one day length of stay, all you're doing is compressing all that preoperative and perioperative education, you know, into the.

Couple weeks leading up to the surgery period instead of trying to cram it all in while they're in the hospital. So our patients get physical therapy prior to surgery, so they learn how to use the walker and things. They get the home education or to get their home set up prior to surgery, not when they're in the hospital just sitting around doing nothing.

So as soon as you can get the two days, you can definitely get the one day. And if you're at one day, there's almost no difference in the same day discharge other than making sure that the patient is medically safe for that kind of setting. Yeah, absolutely. And, and George, do you have a similar setup where you are, you are based?

 [00:04:00] Yeah, we have relatively unique setup where we have an inpatient hospital and also a freestanding surgery centre that are right next to each other. So in our freestanding surgery center, those are the patients that are gonna go home for sure. A hundred percent chance they're going home. And in the hospital, I'll still do outpatient surgery similar to Molly and discharge 'em that same day if they meet criteria.

Sometimes you have that frail 72-year-old that you're not sure how she's gonna do with the anaesthesia or the older gentleman, maybe with some urinary retention. Sometimes we'll keep 'em overnight, but probably 85% of our patients are going home the same day. Some directly from a surgical centre, others from an inpatient hospital where we choose to do them outpatient.

So Molly, sort of moving on from that, what about how we're optimising efficiency in the setting? You know, for example, the concept of tray efficiency and how this can potentially help workflow. What benefits are we seeing there? Yeah, so we've had a big push towards tray efficiency.

We have had some overwhelm in our SPD department, our sterile processing. And so both on the hip and the knee side, we've tried to push towards you [00:05:00] know, single trays, the, you know, bare bones instrumentation that each of us needs. And then on the knee side peel, packing our trials and things like that so that we're only opening exactly what we need.

That's, it's helped both with sterile processing and also with turnovers because there are fewer trays to open. And then, you know, if something happens to be contaminated we can pass it off and, you know, get something identical in very quickly. Yeah, absolutely. That, that makes a lot of sense. And, and sort of related to that Thorsten, and if I can come to you, you know, the idea about the role of powered impactors.

I know this is a thing now, you know, what, what benefits are we seeing with regards, you know, things like ergonomics, efficiency and, and, and maybe implant placement, I suppose. Yeah, Andrew, this, this is we can go on and talk about this for an hour, probably. This is an in interesting point because I think a lot of this is driven by vendors.

And, you know, I recently published on this topic too and the data is truly limited. I, I don't, in in efficiency, we know using a powered impactor, you're gonna be a little bit faster, [00:06:00] you're a little bit more consistent, clinically translate to better fill. But in reality is. Most of these studies are done with newer stem designs, so they have a very different geometry to older stem designs.

So I'm, I'm not a hundred percent buying this at this point. And the, the long term data in terms of survival, even periprosthetic fractures is not there, there isn't the significance in there. If you look in the, in the papers and, and if you would survey everybody that's on the call, and I know George doesn't use it.

I, I have them, but I don't use it. There is something to it to impact a stem manually because that tactile feedback is something that I want to see as a surgeon. And I, I think in terms of efficiency, yet you gain a little bit of time, but I, I think clinically I haven't seen the value that, that is being sold to us.

That's, that's really interesting. And, and does anybody else have a sort of thought or feel or a different opinion on that? So I use power impactor for every case, and I have [00:07:00] for the entire six years of my career so far. For me it's less about efficiency and reproducibility and more about body preservation.

Even coming outta my fellowship, you know, where we did upwards of 900 cases in the year, you know, I was getting tendonitis and. You know, shoulder pain and things like that. And so, you know, to me to have a long career doing this big joint surgery, having a powered impactor is very helpful. I do think that with time you develop.

What the tactile feedback should feel like it does. The way the impactor feels does change as you get to size and things like that. But it takes time to, to trust it and to get to know it. So I think, you know, willingness to give it a little bit of time is, is part of it. But again, there's, there's no real data to kind of push people.

So preference is important. Yeah, but Molly, you bring up a really important point. I mean, I'm gonna go here because I want to over the many years that we've been training, I've been privileged to be at institutions that train a lot of [00:08:00] females. And over time they always say, I don't wanna go into joint replacement because it's too physically demanding.

I'm not strong enough. I don't think I can do the surgery. And I've always told them, you just have to do it smarter. Right. You can absolutely do it. So what you bring up in terms of the ergonomics, the body efficiency, you know, preserving your body and also opening up the field in our specialty, I think to people who are maybe less strong smaller stature that can do this operation in a more consistent manner, I think is super important with these types of smarter instruments as we get as we go forward.

Right. What are your thoughts there? Yeah, I, I agree. And I think you know, what I, what I usually tell my fellows is that, you know, I'm not an, especially, I'm tall, but I'm not especially like strong. And I can hit harder than, than the impactors. So there are times when I have patients with hard bone, I can't get the acetabulum down with the powered impact, or I put a stroke plate on there and get after it.

So it's important to know that the. You know, the impactor isn't giving you more force, [00:09:00] but it is, you know, it's saving, saving you hundreds of mallet strikes, you know, over time. So, or thousands even. So yeah, I think that that's, that's helpful. And then, you know, one of my. Partners just recently retired, and towards the end of his his last year, it was a lot of, you know, my hands hurt, my arms hurt, my shoulders hurt, and that's 25 years of doing this.

So I think, you know, it, it could potentially make our field a little bit more attractive to people who traditionally wouldn't be drawn to it because of potential physical limitations. But I do think that being attentive to, you know, body ergonomics and you know. Injury at work is important. I think that's very true, Molly, isn't it?

And actually we've gotta look after ourselves as well as, as well as our patients, as we, as we go through this. I think it's really, im- important. And maybe moving on from that Thorsten, you, you mentioned it briefly there about stem design, you know, and, and, and the, the, you know, what, what are the current trends we are seeing in terms of this and usage in the [00:10:00] US and why do you think we're seeing it?

So again, if you look at this, if you look at our registry the report from last year. There's one particular stem design that now has 30% of all stems that go in market share. We, we are gonna see that most of the vendors in, in the past 12 months have released a similar tri triple taper stem design to catch up with that with that stem.

So you definitely see a trend that goes away from a single wedge, a dual wedge to triple tapered stem, and while. One company right now owns 30%. I think you're gonna see in the next couple years, in the re in our registry, probably upwards of 50, 60% of the stems that go in are gonna go in, in a triple tapered design.

And on top of that, I think you're gonna see a shift back to using stems with a collar. Yeah, because I think that, that the data around the world using a collar is, is, is very [00:11:00] compelling. And I think this is something that. We definitely realise in the US but I think, I think that's where the trend is gonna go.

I think triple taper stems and then probably the combination with impactors because that's, that's. The marketing that we see coming from the vendors at this point. That's really interesting Thorsten. And, and, and George maybe come to yourself 'cause you know, are you seeing this as well, this sort of trend and, and you know, in terms of things like periprosthetic fracture rates, is that also having an impact, particularly with these collar stems?

Yeah, there's some pretty good data to, to try taper. Collared philosophy has a much lower fracture rate than say the tapered wedge. Or even in, in almost equivalent to some cemented stems, which is pretty impressive. So I think that design has taken over. I don't think we're ever going back to the wedge the medial lateral fit and fill type stems or any of that.

And I think the overwhelming majority, I, I agree with Thorsten that there's really no downside. To using a collar other than [00:12:00] perhaps extraction of a well fixed infected stem, which adds a layer of complexity, but that should be rare. And in our practice, and in pretty much all of Florida, the tri taper collar is taken over.

And even interestingly, in more elderly patients, there's pretty compelling data that they could perform as well as cemented stems. So now we're pushing the indications for uncemented fixation to some pretty capacious canals and getting away with it. We're not seeing a rash of periprosthetic fractures.

I don't know about you guys if you want to chime in on that. No, we see we've had the same experience. I mean, we've had four surgeons transitioned early, and we looked at our periprosthetic fracture rates where we went from 1% or 1.2% down to 0.1%. So that's kind of all comers. And a lot of us have cemented, you know, two or three in the last several years.

 I went over to the London hip meeting and Fares asked me to pre to present on triple taper collared stems in our data. And I thought, I'm walking into the UK talking about non cemented stems. This is not gonna go well. And I sat through a session where they're [00:13:00] presenting weight periprosthetic fractures with all their cemented stems and the upticks that they're seeing over time.

Yeah, there's some trouble with that, the registry data, but, and then I show up with a 0.1% non cemented stem fracture rate, and they're like, wow, maybe we should all start considering changing in the UK as well. So this is gonna be hopefully a worldwide phenomenon to help our patients. Right. Yeah.

That's very interesting, Jonathan. 'cause certainly as a trauma surgeon here, it's something that we're seeing a lot of. And it certainly, it feels like it's on, on, on the rise if certainly not, not a regular fixture in our trauma meetings, Thorsten do you have anything to, to add to that at all? Yeah, so I, I, I think when Jonathan talks about the fracture rate, this is similar, what we see.

I, I think an, another really nice feature of it is when I see some of. My partners that have been lifelong users of different stems and they, they switched to triple stem, triple taper stem. The feedback is always is, man, this is so easy to put in. And I, I [00:14:00] think this is something that we hear and George, when we got to meeting, we hear this all the time, it's like, oh wow, that this is, it's almost like natural because it, it really hugs that medial calca.

It slides down and, and when it fits and it follows anatomy, there's something about this. Stem design that, that makes it, I think, beneficial for the surgeon as well as for the, for the patient. And I think that's why I think a powered impacter there with this, because all it does, the, the canal is providing the, the template and the power impacter it just put it down until it sits.

So I think that combination may be a winning combination. Yeah. So I think I, I think that's what I have to add to this. Yeah, I, I agree with what's been said, and I think it's also important to note that there are potential downsides to cementing, especially if it's not done well. One of my least favourite revisions is a loose cemented stem where I'm, you know, trying to fish out cement from a soft canal that's easy to perforate.

And I would love [00:15:00] to see less of that. Sure. So Molly, if I maybe stick with yourself and we'll move on from sort of stem design and then and look on a bit about the approaches being used for both prior and hip and revision hip surgery. You know, what are your thoughts on the role and potential benefits of the direct anterior approach for, for, for these types of surgeries?

Well, so the direct anterior approach, you know, we know it's getting more popular every year at ORCAS in the polling data. It, it becomes a more widely utilised approach. And I think, you know, part of that is that there is, some data shunt. There are some benefits to it. It's something that patients are aware of and are asking for more and more.

And I, I also think that since the time that I was applying to and going into fellowship, it's become more commonly taught. So. I don't think that it's going anywhere. I think it's here to stay. And I also think that as more and more surgeons use it as their primary workhorse approach and get more comfortable with it, that we're gonna see more people doing revisions from the front as [00:16:00] well.

Data on whether or not that's beneficial. Is not really there. It's been shown essentially to be not inferior to posterior approach revisions. Although the indications for anterior revision tend to be a little bit more narrow for most surgeons, like if a well fixed stem needs to come out, very few surgeons are gonna do that from the front currently.

But for me, I think it's. You know, it's my most comfortable approach, and so I'm gonna use it almost everywhere that I can. And it has the added benefit of using fluoro, having the table be your assistant instead of another human being. And so I do think that there are some, some benefits to it. That's interesting

Molly. Thorsten yourself? Any experience with it and your thoughts on it? Yeah, so Andrew, as you may know, I trained at the institution that, that Molly is right now, so I. Did a lot of anterior approaches coming out of training and, then kind of my practice evolved from, from a DA to anterior based muscle sparing, to returning to posterior, [00:17:00] and now doing a a STAR approach, which is just a minimally invasive posterior hip approach.

So, so I, I think the debate about approach is you gotta acknowledge a, that about 50 to 60% in the US of the hip surgeons are doing a hip through a DA approach. There are advantages to it. I don't think it is vastly superior to a posterior hip approach. I think a, a well done posterior hip approach, you can have equal outcomes.

The benefits of a DA approach is certainly in the, in the, in the short term, but, but not in the long term. And I haven't seen any convincing data to, to make me believe that that is truly superior. Absolutely. And George, anything you'd add to that? Yeah, I think I agree with all the comments. There's no data that shows it's better in any long-term parameter, nor do I think there will be, because if you put in a hip correctly, it probably doesn't matter what approach you gotta look at, you know, the early benefits and also the risk profile, right?

So DA [00:18:00] has clear benefits in the literature about early. Discharge earlier return to getting rid of gait aids. And that's particularly useful if you're sending patients home. Or keeping them very short stay. And then the other thing is the market forces are massive. The standing joke in Florida is if you're not a DA surgeon and you're a knee surgeon.

You're just, everybody does DA. It is literally every surgeon I know in the city. It has become by far the dominant approach 'cause patients want it and I've done all the approaches and in my hands it's the easiest approach to send them home from. Sure you could do that with a mini posterior. But I think just me being able to inject the field and give 'em some pain relief with some ropivacaine and how they do they clinically, when they come back to the office, you know, they.

Look phenomenal. A lot of 'em forget their gait aids and they're moving really well. And that's particularly impactful if, you know, over the last 25 years have done all the approaches. So I think there's a huge advantage in the marketing. You give the people what they want and the earlier. Return of function is clear, but there's no long-term difference.

And then [00:19:00] your risk profile, you know, you're balancing femoral fracture or complication versus dislocation. Yes, they're rare, but those are big deals. Both of those are big deals. Yeah, absolutely. George and Jonathan, just to finish up on this topic, you know, what, what are your sort of thoughts on it? And, you know, we've touched on it a bit but.

There probably won't be ever be any real literature that says one is superior to the other 'cause. Correct me if I'm wrong. From what you are saying, I think it's what you feel most comfortable doing, isn't it really? And what you are good at.

Yeah. I mean, I think the most important thing George said was that. Choose your approach and do it well. Right? If you do it well, you're gonna have good outcomes. And maybe there's certain scenarios where you need to do something differently because of a risk profile. So I think that's really important.

But if, you know, if I haven't done DA in 10 years, I'm. There is definitely a learning curve to these approaches, right? The learning curve can be 50, a hundred, 150 cases. Where there's true, you know, each blip on the learning curve is a human being, so you have to be mindful of that as you're going through it.

And that's why there's now, you know, Anterior Hip Foundation, different companies all have, [00:20:00] training programmes to help surgeons adopt and do these approaches more safely. And I think combining with powered stems that decrease fracture rates may help. You know, the powered impactors may help in terms of preparing the bony envelopes technology to help in terms of putting the parts in in the right spots.

All these helps will evolve and make this approach conversation kind of moot because, you know, just do it correctly. And more, more interestingly, you know, George, you do a lot of trauma and you Andrew as well an extended anterior approach for big revisions, right? That's just an old iliofemoral approach.

And from my understanding, that was always very plagued with a lot of complications. But, so I don't know. I think smaller revisions through anterior cups, some stems, but doing huge GTOs, big whacks down the thigh. I don't know what, if that's useful or not. Yeah, I agree with you, Jonathan. At the, the old EIF approach we use for old acetabular fractures is very destructive, right?

Very high rate of limp and HO. So I agree with moly. I think for mostly [00:21:00] acetabular revisions, DA is gonna become just another way to do it. But anything extensive on a femoral side, I have yet to see a logical femoral osteotomy from the extended DA approach. It makes biologic sense to my brain compared to standard sagittal Paprosky from the back where I'm not damaging any muscle.

Everything else looks like dead planks of bone to me. So I'm a little worried about where the chips are gonna fall and that whole philosophy. Yeah, that, that makes total sense. I agree, George. So, so guys maybe sort of drawing a bit of this all together sort of maybe looking at, at all the things we've looked at and I'm probably ask you each in turn this question, your overall thoughts on what you think the potential benefits may be of some of the things we've discussed here today.

If you draw these all together in terms really, first of all, in the cost savings. To the healthcare systems, you know, which is a big important driver now, and also improving outcomes. Thorsten maybe I'll start with yourself. Yeah, yeah. So to summarize with this, I, I, I think we're gonna start with this. We are gonna get paid more if we do the. The joint replacement in an [00:22:00] inpatient setting than an outpatient setting. So we really have more constraints doing joints in an ambulatory surgery centre.

So cost matters. There's two ways to bring cost down. A, you increase your productivity, so that means efficiency. B, cost savings through implant savings. Through savings and cost of goods that we use, and that includes dressings and, and other materials. So there's two ways to balance this. So technology comes at a price, right?

Luckily the impactors is that we see the companies give us to for free, which is really nice. So you don't have any added cost there, but you have a benefit of efficiency because they're time saving. But then you look at, at. The trend that we're seeing in triple taper stems, there are still, because it's a newer stem design, they come at an upcharge to more traditional or more proven stems.

So you lose some of the efficiency and, and cost savings that you have potentially with an impactor there, right there. And then [00:23:00] approaches George is right. A, a, a DA approach is, is the prime approach for, for outpatient surgery. The patients have no issues going home. But are you doing this off table? Are you doing this on a Hana table?

You have the cost of the Hana tables. Most of of us run two rooms. So you need two tables. DA approaches require flouro the, those are cost factors. I think there's so many things that need, we need to weigh in, and it has to do with the settings that you work in. I, I think the key at this time is, is really one tray.

Efficiency, you gotta be efficient in the operating room, delivering a good product. And then the rest is, is negotiating with vendors and insurance companies to make their survival enterprise that. That's a really nice overview Thorsten, is there anything you'd add to that George Yeah. I think the other thing, when we look at costs, you know, we always focus on little things on, you know, how we could save on a surgical sponge or use less, you know, gloves and all, but big picture, if you could decrease [00:24:00] complications, improve outcomes, right?

So less patients get readmitted. Less patients have a periprosthetic fracture, which is an operative intervention. Now you're putting in a several thousand dollar long stem fluted cables, the whole thing, you know? So if you could even decrease your rate of periprosthetic fracture, dislocation, or infection by a little bit.

I think the impact on overall cost of care will be massive compared to the other interventions. But I agree with Thorsten and the one, one case, one tray philosophy. I mean, you need to do more cases per hour in your facility. 'cause a lot of the costs are fixed. The CRM is plugged in in a hallway just sitting there, so it doesn't really add too much.

But if you can do seven cases in that room instead of six over the course of a year with all the surgeons in your group. Because you don't have to open as many trays or an autoclave, too many things, or SPD isn't just buried because you have all these unused trays. If you could in increase efficiency and decrease complications, I think you're, you're winning on both ends of the spectrum.

Absolutely, George, that makes a lot of sense. And Molly, would you agree that, that that concept that George is [00:25:00] talking about in terms of all these things, reducing that complication rate, which really is such a big driver of cost as well, isn't it?

I, I absolutely agree, and I think that, you know, the things that we've talked about today, including approaches, stem designs, impactors, things like that, they're all designed to have better outcomes for these patients. You know, we're trying to figure out ways to, to do it better, to do it faster. You know, the only thing that's frustrating is that there, you know, there's a lot of work that goes into these optimisations and then on the back end, it's.

It's like, oh, well it looks easy. Maybe we shouldn't be paying these people as much. That's a whole other topic. But you know, the innovation and the, and the preoperative work, which is substantial. And it's, you know, we know it's better to get these patients out of the hospital earlier, but that doesn't mean that we're doing less work.

We're just doing it on the front end. So, you know, I hope people can keep that in mind. Maybe just to finish up, I'll come to George first, and I'm gonna come to you, Jonathan, if that's okay. Just to wrap this all up and give us an overview. But George, maybe going full circle and, and taking, bringing this all together, you know, taking it back to [00:26:00] our, for our listeners, some of the things that we discussed in episode one, of the series.

Now you know, about personalised treatment plans tailored to individual patients and their anatomy and the benefits with ease and how this applies to patient selection. You know, site of care selection we've talked about today. Other factors, you know. This is how all this with technology can really drive things forward.

Do, don't you think? Yeah. So a little bit of a multilayer question, I'll try to simplify it for myself in my answer, but I think the patient specific planning pre-op I think the reason that I. Improves a lot of things along the course is number one, you can trial before you do the operation. You basically do it on your brain on a screen.

You know that you're gonna need a size five with a 56 cup. And when you're in the OR, it makes it much more efficient. I think the importance of the overall episode of care is occasionally you'll see somebody has very unusual anatomy. Maybe it'll need a few different stems on backup or there's an offset issue, or there's some problems that may require.

A little bit more equipment for that case. Now, if you know that and they [00:27:00] already opened those trays for you, you can be way more efficient and say, oh my God, this stem doesn't fit. We need to get a, a whole set of ML taper. Or this stem's too big or it's just too small. Or I need a 80 millimeter cup.

'cause this patient's a huge so preoperatively planning this. It can make you more efficient in the OR. And then the reps can bring less things they don't have to open in some cases reamers that go up to 76 for giant patients or bring the, for example, the 46 cup, 'cause the patient's tiny and you didn't anticipate that.

So I think the whole pre-op. Planning is a lot more sophisticated now. Yeah. And then with modern navigation, small footprint navigation, you can hit your targets and be extremely efficient in the or. Yeah. So it's helped my practice a lot, the pre-op planning and individual individualisation. And if you think about it, you're spending less time in the OR trialing 'cause you've already simulated that.

So you know that if you hit your target, you're gonna be clear of impingement and you know your offset. You don't have to guess, put in a standard offset and go high offset. So the whole process of. [00:28:00] Implantation, you're just executing in the, OR you're not checking everything 5, 6, 7 times. 'cause you already did it.

Perhaps maybe one trial and you go. That's, that's a really nice overview there. George and Jonathan, maybe I finish up with yourself. You know, there that previous question I asked, but also the question that we sort of mentioned a few times on these is that you know. Moving forward, you know you know, in sort of, you know, rationed healthcare systems, particularly like in the NHS proving that all these interventions actually have cost effective A and b actually give benefits is gonna be difficult, isn't it?

Because, you know, we're trying to improve a very good operation at baseline. Well. It comes down to a couple things, right? Then we, we hit on a lot of this. The payers are looking at 90 day complication rates, when in reality we should be looking at 2, 3, 5 years, right? If we look at all the revision surgeries that we do for hip replacement, and we published on this, almost 50% of them were avoidable.

Had you just done the first one correctly? So cost savings wise, we looked at [00:29:00] the economics of this. We're looking at hundreds and hundreds of millions of dollars of savings. If you prevent. These complications, readmissions, right? Periprosthetic fracture. That's. 40, $50,000 in a hospital stay in implants.

You know, infection needs to be solved because that's 50 to a hundred thousand dollars spent after you spent, you know, 15 or 20,000 on their primary surgery only. So in a rationed healthcare system, the prevention of complications through preoperative imaging, understanding patient specific risk factors and doing something differently, doing the surgery better is where we're gonna see the tremendous amount of cost savings over the long run for these big health systems.

And from the surgery standpoint, if you do all that and you become more efficient, do more cases per day, your hospital will, will also be profitable and not be fighting against revenue margins. That's a really, really good point. Jonathan, I think a really nice way to sum up everything that we've discussed here today.

Well, team, I think that's all we have time for. So thank you all for taking the time to join us. It was a [00:30:00] really great discussion and some great insights there for our listeners. It was great to have you all with us. And to our listeners, we hope you've enjoyed our special edition podcast. Feel free to be in touch with us about anything we've discussed here today.

And thanks again for joining us. Take care, everyone.