Are New Surgical Gadgets Really Better Than ‘Old’ Technologies?

I recently returned from the Windy City Podiatry Conference in Chicago, which was co-hosted by the Podiatry Institute and the Illinois Podiatric Medical Association. Marking the first collaborative effort between these two organizations, the meeting had an exceptional turnout and was among the best I have attended in many years. I was honored to be part of an exceptional faculty who taught me so much in just two short days.

To me, the conference illustrated that many new surgical technologies being marketed in the podiatric profession show little advantage over longstanding techniques. The astounding costs of these new technologies should make any podiatric surgeon step back and evaluate the cost to benefit ratio for the patient. Three esteemed clinicians opened my eyes and made me reconsider my own current use of “new” technologies.

Jeffrey Boberg, DPM, is a well-respected faculty member of the Podiatry Institute. At the conference, he presented a compelling argument against using fancy fixation compression screws for distal osteotomies of the first metatarsal. Dr. Boberg witnessed numerous malunions and nonunions from cannulated screws and compression plates in comparison to standard K-wire fixation. Therefore, he and his colleagues set out to compare surgical outcomes with popular fixation techniques for distal first metatarsal osteotomies.

Dr. Boberg presented the results of this prospective study at the conference. According to his results, there is no advantage of using compression screws in comparison to threaded K-wire fixation for distal first metatarsal osteotomies. The cost comparison, however, was less than $5 for the K-wire versus up to $300 for a cannulated screw.

Thomas Smith, DPM, another respected Podiatry Institute faculty member, presented a beautiful overview of the history of staple fixation for foot and ankle surgery. He demonstrated that simple staples can act in the same method as locking plates, fixation screws or standard compression plates. Dr. Smith presented a multitude of applications for simple staples. When properly applied, staples can provide reliable fixation for hindfoot fusion, fracture fixation and first metatarsal osteotomies. Again, the cost comparison of staples versus locking plates shows a significant difference in favor of simple staples.

Finally, Jack Schuberth, DPM, presented a very pointed criticism of new bone graft substitutes for foot and ankle surgery. Dr. Schuberth is a widely recognized expert in ankle trauma as well as reconstructive surgery of the foot and ankle, and is never hesitant to voice a strong opinion. He presented compelling evidence that we have little reason to use exorbitant bioengineered bone graft technologies. Podiatrists can easily obtain a simple autograft from patients while working within the podiatric scope of practice. Dr. Schuberth showed a simple step-by-step approach to obtain either a calcaneal autograft or a distal tibial autograft, which will solve the needs of 90 percent of podiatric surgeries with minimal patient disability.

Rethinking My Approach To New Surgical Technologies

I have been an avid consumer of many new surgical technologies over the past 10 years. Following this conference, I have begun to pause and reflect on my previous surgical experience using simpler yet more cost effective hardware or techniques. I realize there is nothing wrong with using a threaded K-wire on a standard chevron osteotomy for bunion correction. In certain applications, a simple staple can achieve the same type of fixation as a locking plate. If I need bone to fill a defect or repair a nonunion, the best option is an autograft, which I can easily obtain with minimal cost and disability for the patient.

When I attend surgical lectures at our major scientific meetings, new technologies often inspire me. Many times, I fail to step back and re-examine if any of these gadgets or bioengineered materials are in fact superior to traditional solutions. Instead, there is a curiosity and sense of adventure, which leads me to try out new things and often forget previous techniques that were working fine.

The podiatric community has made great advances in foot and ankle surgery in the past two decades. This is due in part to the willingness of investigators and companies taking a chance in developing new technologies that make a difference. Our challenge is proceeding with caution as we embrace these technologies. We must remember that many of the things we did in the past remain useful. We need to constantly evaluate whether any new technology can justify its cost. Most importantly, we must assess whether it truly improves surgical outcomes and quality of life for our patients.



Ron Raducanu, DPMsays: December 23, 2011 at 9:46 am

Very interesting blog Dr. Richie.

I would very much like to read these studies. In my training, I was exposed to various sorts of fixation. I presently use what I feel works best in my hands and also what I feel to be the most appropriate in the given situation.

My experience with staple fixation has not been positive. Many of the staples cause gapping distally when compression is applied and also leave very large defects if they need to be removed. There is also no alternative if the staple fails while applying due to the large holes required to get the staple into the bone themselves. These are all glaring negatives to that fixation method in my opinion.

I would hate to have to remove a threaded k-wire in any situation. Been there, done that. Not fun.

I think looking at cost is prudent but shouldn't sway our use one way or the other necessarily. I have no vested interest in any of the facilities I perform surgery out of (unfortunately) and, once again, use what I feel is appropriate for the given situation.

Would I use a threaded K-Wire or staple fixation for a procedure performed on a family member? No and no.

As far as harvesting autografts are concerned, I also think there are many situations when an allograft is more appropriate. Many of the patients that require grafting are less than healthy individuals. Do I need to make another incision to get an autograft from a diabetic I'm doing a Charcot reconstruction on? What is the morbidity of the harvest site? These are all important questions to consider.

Good blog! Much to think about.

Reply to this comment »
Doug Richiesays: December 30, 2011 at 11:25 am

Ron,
Your concerns were all addressed by the speakers mentioned at this meeting. Quite frankly, the issues you raise are not really well founded. I would question the concern about "large defects' when staples are removed? How different is the defect of the "hole" created by staple compared to the multiple holes necessary for a locking plate?

Overall, I would suggest you question if allograft is really equivalent to autograft, if any study shows that screws give better outcome for Austin type bunionectomies and if staples can work as well as locking plates ( in certain situations). Simply forming a bias or opinion without looking for scientific evidence that validates a new technology is a flawed approach, in my opinion.

Anyway, I was hoping to stimulate some discussion and controversy and always appreciate your willingness to dive in and provide an opinion. Please continue to do so!

Doug

Reply to this comment »
Dr. Ron Raducanusays: December 31, 2011 at 7:59 pm

I appreciate your feedback Doug.

What I've used is my previous experience as the basis of what I've said. Unfortunately, there is very little literature to support either of our claims. We use a good bit of conjecture in what we do.

My other issues with staples are that they rarely provide uniform compression across the entire fusion site, but once again, there is little in the way of literature proving or disproving this.

I have been trying to stimulate interest in getting real compression/pressure studies done using various forms of fixation (K-Wire, screws, plates, synthes, headless screws...etc), and using micro force plates in cadaveric samples across proposed fusion soies, but have not been able to find any company willing to fund such an endeavor.

In reality, there is just not enough solid research being done to really tell us what is best in some of these situations.

As far as allograft vs autograft, there is a clear advantage to using autograft in most every situation. We know this. But few studies help distinguish the other factors that could lead to other morbidities in certain patient populations.

I love good discussion. It always gives food for thought and sometimes even shifts the paradigm of what we do. Kudos Doug!

Reply to this comment »
Vladimir Gertsik DPMsays: December 27, 2011 at 6:23 am

I think depending on expensive and complex devices may actually limit surgical thinking.
There was an article mentioning a simple ex fix made from a plastic syringe and k-wires.
Ilizarov used bicycle wires in his original ex fix.

The most important instrument is the surgeon.

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