The Biologic Future of Joint Replacement with Antonia Chen, MD, FAOA

Robotics emerges as another transformative force. While many surgeons remain skeptical, Dr. Chen makes a compelling case for why robotics will eventually become standard.

Perhaps most exciting is the potential to address periprosthetic joint infection (PJI)—what Dr. Chen calls "the holy grail" challenge in joint replacement. From implant coatings that prevent bacterial adhesion to novel technologies that disrupt biofilm formation, the future may include treatments that can eliminate infections without removing well-fixed implants.

Transcript

Introduction to Dr. Antonia Chen

UNKNOWN 0:00

Thank you.

SPEAKER_00 0:20

Welcome to the AOA Future in Orthopedic Surgery podcast series. This AOA podcast series will focus on the future in orthopedic surgery and the impact on leaders in our profession. These podcasts will focus on the vast spectrum of change that will occur as the future reveals itself. We will consider changes as they occur in the domains of culture, employment, technology, scope of practice, compensation, and other areas. My name is Doug Lundy host for this podcast series. Joining us today is Dr. Antonia Chen. Dr. Chen is a professor and the Dr. Charles F. Gregory Distinguished Chair in Orthopedic Surgery of the Department of Orthopedic Surgery at University of Texas Southwestern Medical Center. She specializes in primary and revision total hip and total knee reconstruction as well as management of infected total joint replacements. Dr. Chen earned her medical degree at Rutgers Robert Wood Johnson Medical School in New Jersey. She also earned her master's in business administration at the Rutgers Business School and then completed her residency in orthopedic surgery at the University of Pittsburgh and her adult reconstruction fellowship at the Rothman Institute in Philadelphia. She joined UT Southwestern in 2024, but she had previously served as an associate professor at Harvard Medical School and was chief of arthroplasty and joint reconstruction and the director of research for the arthroplasty service at Brigham and Women's Hospital in Boston. She has significant editorial roles in several academic journals and sits on the editorial boards of the Journal of Arthroplasty, the Journal of Bone and Joint Infection, Journal of Orthopedic Research, and is a deputy editor for the Journal of Bone and Joint Surgery and an associate editor for Arthroplasty Today and holds multiple leadership positions within the AOS, AUKUS, and is currently Currently second vice president of AUKUS and also a bit intimidating to me. Dr. Chen has her own podcast series that she does with the Journal of Bone and Joint Surgery that y'all should also listen to. So Antonia, my friend, thank you for being on the podcast.

SPEAKER_01 2:37

Thank you for that wonderful introduction. I appreciate it. And thank you for having me. It's always a pleasure to talk to you.

SPEAKER_00 2:43

And like I was saying, because you have your own podcast series, this is a little bit of like, oh, I'm talking to somebody who does this as well. So here we go.

SPEAKER_01 2:50

Very different type of podcast. That's for

SPEAKER_00 2:52

sure. It is. It is that. It is that. I enjoy your podcast. It's a lot of fun listening to the things that y'all talk about on JBJS there. Now, we were talking a bit ahead of time about the future in orthopedic surgery. We've been going through different things like compensation and the workforce and many other kind of total domain issues that affects everybody. But one thing that kept kind of coming out in our talks with folks was the specifics that were limited to the individual specialties within orthopedic surgery. And I thought this would be a great opportunity to talk with you specifically on where is total hip and total knee reconstruction going. And the next, if we could be so bold, 15 years, if not, we can pick a shorter timeline. If you feel even bolder, you can go further than that. And there's so many things, right? We could talk about access issues for folks that need it. We could talk about components and component design. We could talk about workforce in terms of the number of joint replacement surgeons we're making. Is this going to change in terms of who's doing total joints? We could talk for hours about this. There's just so many things that are coming down the pike that are affecting the delivery of total joint arthroplasty to the nation. So what do you think? Where do you see the future as we progress with total joints?

SPEAKER_01 4:15

So I've cleared my schedule for the next 15 years to talk to you about this. There we go. like in 15 years.

SPEAKER_00 4:21

Let me call for some Uber Eats real quick.

Biological Future of Joint Replacements

SPEAKER_01 4:25

Stat. We'll need some hydration as well too. So it's one of those things where I'll start with the joints themselves. That's probably where I see it. It's one of those interesting things where I remember being as a resident or as a medical student being asked, what are you interested in? Why? And what do you think it'll be like in the future? And I truly do think that 15, 20 years from now, maybe longer, maybe shorter, it'd be more biologic in nature, right? I've been doing hip and knee hip metal and plastic for years, and it's been going on for decades. But in decades from now, I don't think we'll be putting in metal and plastic. We'll be putting in more cartilage-like substitutes. We'll be putting more biological substances. I think with our technology improving, we're going to decrease our complication rates, right? We're going to decrease the number of infections that we have. We're going to be doing preventative techniques such as, you know, biofilm, electric impedance, or alternating magnetic fields, and that's going to keep biofilm from forming. And those technologies are actually here now, but they're not widely used and not used in all cases. I foresee that as we use more biological substances, we'll obviously still need surgeons to put them in, but the world between sports and joints will become more blurred with time. It's going to be, will you be able to put some of these things arthroscopically? Possibly. That's probably further down the future, you know, where you like produce a parachute maybe and stick it on the end of a cap of a femur, something like that. But anyway, biological fixation, I think is going to be much more common in the future than it is now. And there were a bunch of forays into cartilage, and we just haven't hit the holy grail of cartilage yet, but that will come. So that's what I think in the long-term future. In the here and now, I think a few things that are going to be relevant to joints will be technology. It's already becoming more relevant right now, but technology is still a little bit cumbersome, a little bit clunky, and only aids our procedures to some degree. Will it come to the point where it becomes the gold standard? Will it be that I think we'll have predictive analytics where, you know, you get a knee replacement, I get a knee replacement, and because of our morphology, activity level, age, whatever it is, we get different type knees or different implants or different something. And so with the amount of data that we have, we should be able to predict more in terms of what does everyone need and what's the best outcome for a patient. You know, right now I do a pretty similar joint for every person and they tend to do well, you know, but how can we refine it? How can we make it better? How can we keep it so that every single hip patient is happy, every single knee patient is happy. That's where I foresee that from a technology and metal and plastic and biological aspect.

SPEAKER_00 7:01

That was, that was a really good foray into it. So my gosh, you're right. We might take 15 years. How about implant design? I think you kind of, so in the short run, it seems as a knuckle dragging trauma surgeon that y'all are putting in the same things that I pounded in a few years ago as residents, how much has implant design really materially changed rather than what the reps are yelling at us over the last 10, 15 years? Have they changed? significantly or has it been kind of like, yeah, shut up, save a thing?

SPEAKER_01 7:35

So the biggest change I think is surface.

SPEAKER_00 7:38

So

Evolution of Implant Design Philosophy

SPEAKER_01 7:38

they finally created a cementless implant in the knee. The cementless hips have been around for ages now, but cementless knees that have better longevity. It's orthopedics is all cyclical, right? We've seen it over and over again. You know, some trends come and they go and trends come and go and they don't last because they fail. Well, in this case, this has not failed. The cementless knee trend has, I think is here to stay. So that's probably the biggest change. Little things like anatomic changes are actually really interesting. So how we understand how the knee works has changed over time. It was the four bar ligament diagram that we all learned as residents. We were tested on the OITE. And now that's being called into question. So for example, there's the medial pivot knee. It used to be that we want the medial lateral side to be nice and balanced. Well, over time, people are like, actually, the native knee is tighter medially. So we should make it so that it's tighter medially when we do a total knee. And that's not something I learned as a resident. That's what I did as an attending and it has taken off. And alignment is another big area. So people have, there's so many terms, kinematic alignment, restricted kinematic alignment, functional alignment, all these different terms to tell you how the legs should be aligned after surgery. And I think the answer is not just one alignment for every single person. You know, the kinematic alignment, people will be like, this is the only way to do knee replacements. And then people who, you know, been doing knee replacements for 50 years or mechanical alignment is the only way to do, because I've been doing that for the last 50 years. And I think the answer is somewhere in between is, you know, again, you and me, we both get different knee replacements. We both need different type of alignment techniques. So that has changed. The philosophy of knee replacement has changed, which has been really interesting to see because the philosophy hadn't changed for decades. And finally, there's a new philosophy that's probably more confusing than anything else, but if anything, it teaches us the whole individuality of medicine. And I think in orthopedics, we hadn't been really privy to that. And most of the times we individualize medicine And it's mostly because the patient is osteoporotic and you want to do a different fixation to make their bone, you know, because their bone's not as strong, they can do that. Or like different fracture patterns. Like that's how we've done the individualization of orthopedics. But here we're saying, no, based on your anatomy, morphology, activity expectation, whatever it is, we can actually tailor that a little bit differently to give you a more natural joint. And that's where I think the goal is to become more natural in what we do for our patients.

SPEAKER_00 10:01

Right. What do you specifically mean when you say philosophy of the knee or the

SPEAKER_01 10:07

hip? So for example, the father of the total knee is John Insull. And his philosophy was in both flexion and extension, you'd want to create a rectangular box. You want the medial and the lateral side, both in flexion extension to be balanced all around. And that's going to feel good for your knee. And that was a philosophy because to do so, you have to cut a certain amount and cut it equally and things like that. And you cut it parallel to the tibia so it's a zero degree cut and then to the femur you cut it at five or six degrees of valgus and that was the idea that you're reconstituting because the normal femur is like nine degrees and the tibia is three degrees so six degrees is the happy medium and that's what i grew up learning well now with the kinematic alignment for example it's a caliper so how much you cut off the distal end of the femur is no longer uniform and that and how you do things like if i look at an x-ray of what i did as a resident where it was like every was parallel to one another and that was considered a really good joint well now everything's oblique you know and oblique is okay it's not abnormal or there's asymmetric polyethylenes so it's a really different way of thinking that's what i mean by philosophy and that like how i used to think about knees is totally different how i do knees now is also different than how i did it as a resident so i had to learn um all these new things and um it's been it's been good i think what we're doing is better for patients um but it's a different way of thinking

SPEAKER_00 11:31

so Next thing I was going to ask you about is the more recent and more near-term future things in terms of coating implants. But thinking through that, you're going to coat your implants different than I coat mine. Mine will be coated with growth factors and other things where you're going to be coating with anything to prevent PJI. I can just tell that you're going to go there. What

SPEAKER_01 11:57

if I do the in-growth one on the base surface of my cementless implant and And then the infected stuff on the top part.

Robotics in Total Joint Arthroplasty

SPEAKER_00 12:03

However, I was at a conference and Dan Murray was talking about the vast frontier for total joint arthroplasty was PJI. And he made such a compelling argument for that. I was thinking, you know, if I was 30 years old again and I was going into this, I might say that's going to be my frontier I'm going to focus on. You would hate to be known as the PJI surgeon, but on the other hand. But before we get to that, before we get there, we could talk about periprostatic fractures. That'd be fun. Before we get to that, let me stir up the pot here. I have very good friends of mine who are total joint surgeons who are absolute apologists, cannot say enough good things about Mako, Phyllis, you name it, and other surgeons that swear it's the work of the devil. I'm going to put you in a little bit in there, but where does the future look like in terms of robotics? Is it going to take off and be the standard of care is it always going to be the surgeon's choice thing is it going to be well for these cases that it's indicated and for the rest of it's not will it just be you'll have some people that are passionate about and other ones that won't will the robot actually be so materially better that it becomes standard of care in the future

SPEAKER_01 13:24

The short answer is yes. I had to be polarizing right off the bat. I can't

SPEAKER_00 13:29

be on the

SPEAKER_01 13:34

Dr. Lundy show and not be controversial, right? My real reasoning for saying that is because at some point in time, we're going to say that person A phenotype should have this method of surgery, person B phenotype, person C phenotype, and you can have who knows how many phenotypes. Well, how are you going to execute those phenotypes? We're reliably. And I don't think our manual instrumentation right now can reliably say, this person should have a two degree varus on their femur, but this person should have a four degree varus on their femur, or something like that, right? I'm just throwing out numbers, of course, there are, you know, for the tibia, this person should have zero degrees of varus, but this one should have three degrees of varus. Now zero to three degrees, maybe can dial that in, but I'm human, I can't dial in, you know, three versus four degrees, or two versus three degrees. Now, some might argue makes no difference. But we don't know the answer to that. And so if I want to precisely execute exactly what I want to give the best outcome to my patients, I'm going to have to use some sort of technology to do so because I'm not good enough as a human to do that. So that's where I think robotic technology will work. Now, I will say manual instrumentation works. A lot of our patients are really happy with manual instrumentation. So will it become the gold standard to use robotics? Will you have to use robotics? I don't think you have to use robotics. But if you want to execute what you plan to do for that particular patient to give them the best outcome, I think you will need robotics or some sort of technology to do so.

Preventing Periprosthetic Joint Infections

SPEAKER_00 15:00

Very good. All right, let's get back to PJI then. So where do you see, can we talk about coding? Are they going to start coding total knees, total hips with microtubules slowly releasing? I heard Josh Jacobs talk about this, about slowly releasing antibiotics or how are we going to attack this PJI thing? What's the future look like for that?

SPEAKER_01 15:23

So the funny thing is as a resident, I got interested in PJI because someone just gave me a project and I started doing PJSF. And

SPEAKER_00 15:29

I guess in fairness, we should define PJI. It was my fault. I used it. Can you define it? So I'm sure folks out there, what are you talking

SPEAKER_01 15:36

about? Periprosthetic joint infections, infections from around joints. I mean, of course, this is not just hip and knee. That's the specialty that I'm interested in, but that's shoulder, you know, ankles, elbows, all sorts of things around the joint infections, but particularly around implants related infections, which are very different than, for example, you know, fractures infection, related infection. The infection is not only an infection, right? And that's what's hard about joints is the second you put metal in there, bacteria preferentially stick to it and it becomes so much harder to eradicate the infection if the metal is present. And I think that's the key factors, exactly as you're saying right now, whether it's coatings, whether it's irrigation solutions, whether it's other stuff, the second you put metal in there, that is going to be a predisposition as a foreign material for bacteria to adhere to it. And every time we do surgery, bacteria is going to go into the wound and it's going to stick to this metal. And that's true for plates, for anything like that. But again, this is the periprosthetic environment. The difference with synovial fluid, though, that changes the milieu of how the bacteria works. And for example, there's things like clumping. So the bacteria can clump together and they're harder to eradicate when they're in a clumped format. And again, that's a synovial fluid thing, not a, like in the, you know, the bloodstream or things like that, where you'll have more fracture care and things like that. So when it comes are really, when it comes to preventing infection, the few factors that are really relevant are one is the patient, right? What is the patient status? And those are things that we can optimize through medical stuff. But are there other things that we can do to optimize a patient's milieu? For example, is there an injection that you can put into the synovial fluid that's going to actually kill any bacteria that come into contact with it? Because we know there's bacteria is going to come in from the skin. That's absolutely a given, right? So you put it in there. And then at As you're closing, you inject it in there like we do our tranexamic acid, and that's going to kill any bacteria that comes present because the first 24, 36 hours are the most prevalent when it comes to bacteria formation. Coatings are good. The thing we have to always be careful about coating is to make sure it doesn't interfere with biological fixation. So more important, the hip than the knee for looking at cementless implants. But coatings were created actually in the European market. They created an antibiotic coating, but then there were issues with it and have not really been commercialized. So it hasn't really taken off. The other thing too, is people were looking at antibiotic coatings, but they were implant specific. Ideally, what you want is something in the back table where you dip your implant, it becomes covalently bonded or something. And then it has bactericidal effects, meaning it kills the bacteria that comes in contact with that metal. And in theory, you can use it on any surface, right? Metal, plastic, you know, screw heads, like plates, everything like that. That would be a really nice way of doing it. There've been basic science studies that have shown this, but the problem is kill time, right? How long does it kill for? Does it only kill for 24 hours to 36 hours? You want this to last ideally like a year, right? It's something that's going to elude it, but not elude it immediately afterwards, like antibiotic cement, right? You want it to last over a long period of time. You don't want it to be sheared off by walking, for example. You put this coating at the end of a femur or, you know, proximal tibia and you lock in a poly in the knee replacement and you walk and it comes right off. And then that defeats the purpose as well, too. There's other technologies that are really neat when it comes to infection because PGI really is the holy grail. I was told not to study PGI because that would mean all my patients would come in with infection. They're not wrong. I can't say that for sure that it's definitely that people have found me for that reason and referred to me for that reason. But I will say the cool part about that is that there are things like I was talking about, like alternating magnetic fields, you know, so then now you're heating the implant and that's breaking up the biofilming with antibiotics that kills bacteria They're ones that have like developed like a sonication, like ultrasound like device. And that also keeps the biofilm from forming. And can we do that on a more regular basis to prevent infection? So, you know, instead of giving an antibiotic, you use this treatment or use something else, or, you know, do you take up a capsule? It's a probiotic or not antibiotic, but antimicrobial. And you take this capsule and you swallow it and it goes preferentially to your metal and then kills everything around it. You know, do you do this as you're like, you know, once a your, hey, let's prevent this infection. Let's keep this going. Something like that would be kind of neat. Another way to do, I would love to say is like, I would love to treat infections in the clinic. You know, if a patient comes in that are infected, I put in, I inject something into their joint. It kills all the bacteria. You don't have to do anything. As long as the implants are well fixed, you're good to go. So I think the morbidity of PJI or periprosthetic joint infection is when you take everything out. And that is a very hard recovery for patients. You're putting new stuff in either immediately or later. Either way, it's a very big thing. If we can keep from having to even open them up surgically would be great. And if we can keep them to just removing, let's say, exchanging the plastic part or the head and the plastic part for a hip, that would be really nice.

SPEAKER_00 20:36

Wow. A lot of stuff in there. Anything before we get off, let's, let's finish up metal before we get to the other cool stuff that you were brought up initially. Is there anything else in terms of metal or poly?

SPEAKER_01 20:50

In terms of like, so in terms

SPEAKER_00 20:52

of, yeah.

SPEAKER_01 20:53

So actually my colleagues at MGH have developed a antibiotic tethered polyethylene and it's not in commercial use yet or anything like that, but the idea is really cool. Why not use what we're putting into the joint as a delivery device and not just for antibiotics, but they also attach things like bupivacaine. So reduce the amount of pain that you have at a joint. So use the surfaces that we have to do. So I will say metal is becoming less in favor. There's metal allergies, people are sensitive to it, things like that. So if you can use something else instead of metal. So an example is there's some companies who are coming out with peak implants. And that's what our spine surgeons have been using a very, very hard substance, but it's not metal. Could that have better wear characteristics over time? Possibly. Could it feel more like a natural knee? Possibly. You know, one of the things that we talk about is thigh pain because the titanium we put in for hip replacement is good. The elasticity of modulus is pretty close to bone, but not the quality of bone. Can we do it so it's closer to bone? What if we put in these implants that are more bone-like, right? So that they feel more natural and they grow in better to the bone or things like that. So we've always used metal and plastic, but again, I don't think we're going to use metal and plastic forever

SPEAKER_00 22:07

that kind of leads us into the articular cartilage talk that you brought up initially because you know when you think of adult recon you your mind obviously goes to the cobalt chrome and the poly stuff that you guys put in all the time and it's really a natural progression to cartilage type surgery when that technology presents itself and as soon as you said it, I thought, are the sports surgeons going to say, wait, that's mine? And you laid it all out there. Unfortunately, this is going to roll out slow enough that people will be able to adjust their practices. I'm sure there'll be new fellowships out there that will look very different from your fellowship. What are your thoughts on how does this all roll out? What does this look like in your mind?

SPEAKER_01 23:00

I think it's going to start in small segments, I would say. For example, artificial cartilage will probably not go to the toe joint yet It'll still go to the surgeons who are doing Macy, you know, which is the, you know, the artificial cartilage implantation, right? Or any sort of things where you're taking cartilage from another place and you're putting it into the place that has a defect. Well, instead of taking it from one place to another and borrowing it or growing it, you're going to actually take it from outside from a Petri dish and put it into a defect region because they need to show that it works. And you can't replace the entire cartilaginous surface of a needle, for example, or hip right off the bat because it'll wear, fail. and you'll be back there again. And then I'll be using metal and plastic for that. So I think it will start with our sports surgeons. I think the lesion sizes that they treat will get bigger and bigger. You know, they'll start with, you know, half a centimeter, they'll go to a centimeter. They will go bigger and bigger. And as they go bigger and bigger, what that will become is it will finally get to the entire surface. And when it gets the entire surface, for example, to start with a uni, right? So our sports surgeons do unis, our total joint surgeons do unis. Well, then our sports surgeons will say are doing unis with this cartilage replacement, then joint surgeons will start doing that. And then it'll go to the total knee and then it'll go to total hip and things like that. So I think it'll be in a very specific subset of the population because the reoperation rate will be unknown to begin with. So, you know, if I'm 80 and I'm getting a joint replacement or I need a joint replacement, I'm going to get a joint replacement. I'm not going for a cartilage replacement at that point in time because I want this to last 20, 25, 30 years. And there's a good track record with that already. I don't need to play with fire. But if I'm 50, that's young. I'm 50, I'm 60, that's young. I want to have a very active joint.

SPEAKER_00 25:06

I didn't say total joint replacement. So this new adult recon, I can see you saying it's a balance between sports and our conventional now total joint doctors. There may be a new one. Will the generalists have any way in it? Will the trauma surgeons be doing it? Or is this going to be, where's that going to end up?

SPEAKER_01 25:28

So it depends on how we do it. Now we're doing it where we're just literally resurfacing everything that's there. Then I think it can be general orthopedic surgeons, sports, anyone, trauma. But when it comes to patients who already have hip and knee replacements, the number of revisions are going to go up exponentially as well too. And so we're not getting rid of all metal and plastic because a lot of it's going in right now. So that's where I see the adult reconstruction specialists are really going to be specialized in are treating revisions. Most of the practices now, everyone's just cranking joints, trying to do a lot of primaries, et cetera, et cetera. I think in the future, there'll be a lot more revisions.

SPEAKER_00 26:06

So So along with that, and I know you've worked a lot on this with AUKUS and with the academy, let's talk about funding and governmental things like that. So the things that you've talked about are extremely expensive, right? I mean, these cartilage transplants are not going to be, they'll eventually, the price will come down as the access improves, but at first this will be extremely expensive. Medicare is not going to cover it. How, how does the funding for all these newer, more expensive, So the hardest

SPEAKER_01 26:45

part about this is I feel like there's two separate areas here. One, how much the federal government gives and the amount of reimbursement and everything like that has gone down. And two, R&D for developing these new implants. And if the money is going down, will these things be developed because implant companies are being like, why would we do that? Why would we spend money doing that? Because we're not going to get a return on investment. That's the biggest area. So I think there's two areas here. One is access to care, and that's with regards to even getting the surgery done, and that's a whole other one. I think with regards to these new implants, who pays for it? So in theory, the companies will pay for it, right? Whoever's developing and things like that, they're going to charge top shelf. I think there's going to be a certain subset of patients who are going to have to pay extra money to begin with to get this. I liken this to stem cells, right? For example, they say, hey, look, here's a new technology. If you want to replace your cartilage, come here and pay for it, and then you can do it. And then they gather some data and show that it works. Because I think the federal government won't put their money on it unless they show good outcomes for longer periods of time. When it comes to implant costs, I would say most hospital settings, probably yours, probably like mine, there's cap pricing, right? Where you say, well, we're going to give you X number of dollars for a knee replacement and X number of dollars for hip replacement. Well, if this cartilage replacement thing comes out and it's three times the cost, it's just not going to fly unless someone's willing to pay for it. And so that's where I see kind of like our weekend warriors or sports patients. We saw that PRP has taken off. Stem cells have taken off. People are willing to pay for this out of pocket, but that does create a disparity for our patients because not all patients can afford that. And there's unfair to them to not be able to get it. So hopefully what you can do is generate enough data, show that it's a good standard of care even, and then the government will start supporting it in that way. But that takes even longer because of the data you need to generate.

Economic Challenges and Access to Care

SPEAKER_00 28:32

Now y'all can demonstrate the benefit to society for getting the 50-year-old with the worn-out knee, worn-out hip back to productive living in terms of generating within the economics of the society. Is there an argument there? Will Congress finally hear that? Or are they still going to say, no, I'm elected on a two-year, six-year basis and the clock's ticking. The only thing I care about is my two-year or my six-year window based on if I'm in the House or the Senate.

UNKNOWN 29:02

Yeah.

SPEAKER_01 29:02

That's a different political question that we can talk forever about for sure. I think the hard part about it is that with the data we have now, for example, we can say, look, patients do pretty well with plastic and metal. Why would I pay for something more if it's not better, right? And so I'll use stents as a great example, right? Stents for the longest time were not drug eluding. And so most of the time people were just like, oh, why do we care about paying a lot more for a drug looting stint. But then you saw the clot risk go down and patient mortality go down and all sorts of public health things that were actually better for the system and probably honestly cost the system less in the long run. And so you create a cartilage that is replaceable and that can last 50 years. That's an overestimate, of course. Then all of a sudden, quality of life, number of hospitalizations, number of things like that, then the of like, oh, this is prolonging a joint replacement more effectively than stem cells, PRP, whatever. While it costs a bunch to start off now, in the long run, that gives them, to your point, 30 more years of productivity in the workforce, not having to go to the hospital, not having to do physical therapy, not having to take NSAIDs, not taking opioids, that sort of stuff. Then the federal government says, now this is worth our time and money. But until it demonstrates that it is really hard because the outcomes after a total knee, after a total hip are both pretty good. And so don't necessarily justify the means of moving things to a different paradigm.

SPEAKER_00 30:42

So currently on the fee-for-service paradigm, you, me, get paid for the work that we do. And trauma, it's a little bit weirder because we don't necessarily, people don't plan on getting hurt most of the time. But if there is a capitated contract in the future where your group at UTC Southwestern is responsible for 50,000, 100,000 lives across the Texas area that you live in. The people running that contract are going to say, we need to cut total joint down as low as we can because it's an expensive procedure. How does the change from fee-for-service into a more capitated value-based model affect how you guys are going to be in the future and how you distribute this stuff?

Value-Based Care and the Future Model

SPEAKER_01 31:28

Well, the future is now according to Dr. Kevin Bozic.

SPEAKER_00 31:31

Yeah,

SPEAKER_01 31:32

it's true. They're only three hours away from us and they are truly doing value-based care, right? Patient comes in, you need PT, you need this, you need this. This is a multidisciplinary team. Every surgeon is salaried there. And that's the focus and care is all on the patient. And that's a great model. It works really well. It's a hard, I say mental switch, right? We're used to produce more, work harder, get rewarded for your work. And it's not a bad thing since there's a lot of baby boomers, a lot of People need joint replacements and we're helping people still. That's the benefit of it. But at some point in time, the system will not sustain it. And we will probably go from the fee for service. And they've tried over time, right? To go from fee for service to value-based care to say, well, if you hit these metrics, then you get paid or you do a bundle and you say you save all this money, then we're going to give you some of those savings. And that's been a race to the bottom, right? You save, let's say$10,000. And next time your amount drops down by$10,000, Then you can save$5,000. The next time you can only save$1,000. And then all of a sudden you can't save any more money. So that's sort of, I wouldn't say value-based care, but it's a different type of valuing our money to get the most out of it. I think what it's going to come down to is how can we get the best outcomes for our bucks? And CMS is trying to do that right now with regards to patient reported outcomes. They're having a So meaning me as a joint surgeon, for a patient that sees me now and sees me at the one-year follow-up, at least 50% of my patients, or greater than 50% of my patients need to fill them out. But there's no say right now on how well they have to do. That comes at a later point in time. Those are a significant clinical benefit. And there's certain point scales on certain patient-reported outcomes, specifically COOS and HOOS. And if you meet those metrics, then that will be indication to potentially get some sort of money or funding. Now, what I will say that's nice about is that it does drive a discussion more about how the patient does, as opposed to the number of cases you've done. So while you're still going to be getting paid fee for service, you're also getting incentivized to do other things. And you're incentivized to get a good patient outcome. So I love the BOSIC model. It's amazing. I just think it's really hard for all systems to implement that. In the future, could that be, you're talking about 15, 20 years down the road, it could be every single hospital is like that. And that's the model that we're going to go forward with. with because he's proving it to be quite successful and it's doing a good job. But I think for right now, I think we're going to do things from a value-based perspective to enhance the patient experience as opposed to just doing a ton of joints.

SPEAKER_00 34:14

And Kevin and Carl are doing more, instead of procedure-based bundles, they're working more into diagnostic bundles where they're doing knee pain rather than total knee arthroplasty. How do you, do you think we're heading that way as well?

SPEAKER_01 34:27

I think to some degree we are heading that way. Population-based medicine is a big thing. And, you know, while I love being right toe surgeon, you know, or you're like very, very specific, those days are probably gone. I don't do toes, by the way, I do hip and knee replacements. Thank goodness. To all my foot and ankle colleagues, go you, I just don't. So I wrapped that up and put it out of the way for that reason. I think we are probably moving towards that model where we see the continuum of care. And we're doing that in a small scale in orthopedics, I would say, right? My goal for every patient that comes in between the ages of you know 30 to 90 or 100 or whatever is they get to see a non-operative provider who then decides that they should go to sports or go to joints and that's a continuum of care sort of thing where you know you first work up a patient take good care of them and then eventually go to surgery you don't go to surgery right away I think it may become more systems based I think they'll be more integrated over time I think people say like the Mayo model is quite nice right let's say you get cancer you go in you get you see your oncologist you see your, you know, radiologist, radiology oncologist, you see your surgeon, you see all those people all at once. Well, if you have knee pain, well, you probably have hip pain and back pain and neck pain, you know, all sorts of areas. Can you kill two birds or multiple birds with one stone? Can you do one-stop shopping for your MSK in that way, right? Where, you know, you get a holistic team that sees you. So instead of the team seeing you, it's just for knee pain, you're seeing a team that addresses everything. You get a holistic view of it. You don't have to go wait and see someone else and go back and forth and back because everyone's so siloed. That could really change how we do population medicine and do one-stop shopping for our patients.

SPEAKER_00 36:14

Kind of hinging into that for my last question is, it sounds like all these things are going to improve access to the people who need your services.

SPEAKER_01 36:24

I hope so. That's the goal. On the flip side of things, you know, if not everyone switches to it, then maybe we're not going to attract enough people to do that. You know, I know of people who've gone to University of Austin, usually Texas and Austin, and that model just doesn't work for them, you know, and for some people that works really well for them. And so until we shift an entire society, there'll be other options, which, you know, may or may not limit care. And I will say, for example, I've seen it happen before, right, where Medicare reimbursement is going down and keeps getting cut more and more. People are limiting the amount of Medicare they see or the amount of Medicaid they see or don't see Medicaid. And so I do worry about that because I do think that patient access is obviously very, very important. But if we can holistically treat the patient, and I think the key factor is if we holistically treat the patient in a one-stop shopping manner and we show cost savings, then access to care improves because we know that it's better overall for people, patients, as well as the system.

SPEAKER_00 37:23

This has been an amazing buffet of the future and total joint orthopedic surgery, adult reconstruction in terms of implants, patient selection, patient optimization, PJI, funding, scope of practice, access. It's been fantastic. Thank you so much, Antonia. We really appreciate your insight and for you being on the podcast.

SPEAKER_01 37:47

I had a wonderful time talking to you as always. Thanks a lot.

SPEAKER_00 37:50

Thank you. And y'all stay tuned for more futures in orthopedic surgery and this podcast series.