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Simplify to Succeed: Instrument Reduction in the OR

Sacher adds that from a surgeon perspective, they could be performing four to six surgeries per day while leveraging fewer instruments. That not only drives cost out of the system but potentially creates additional revenue, too.

DJO Surgical
The Exprt Revision Knee was inspired by feedback. Surgeons were complaining to DJO representatives that the knee revision segment had grown overly-complex. Operating inefficiencies abounded, causing an increase in cost components. Kristin Barnebey, Senior Director, Global Marketing of DJO Surgical says that no one had taken a step back and asked whether the process could be simplified.

“As surgeons get more experience doing revision knees, and build upon that competency, they use fewer and fewer instruments,” Barnebey says. “The problem is that companies are still largely providing that erector tray of instruments that typically coincide with revision knee surgery.”

Barnebey says that DJO’s inspiration for the two-tray Exprt system came from surgeons who were already simplifying their own revision knee procedures. OR staff were only bringing in the instruments they would need to use for the procedure, making abundantly clear what the excess instrumentation was.

DJO consulted with surgeons to identify which instruments were necessary and which were, in fact, excess in a revision knee. During the evaluation, erector trays of instruments were set in front of the surgeons. In response, the surgeons were literally plucking instruments from trays and hurling them over their shoulders.

“They knew what they were doing,” Barnebey says. “We wanted to mimic what they were doing; we wanted to capture that efficiency. The average selling price for revision knees is between $13,000 and $15,000; some are as high as $30,000. That’s a significant burden to the system.”

The advent of bundled payments also spurred DJO’s Exprt. Barnebey says that while bundles haven’t impacted revision knees yet, she’s anticipating that payment model will become increasingly common versus fee-for-service.

“Continued price pressure and transparency is being dictated by hospitals. People are taking notice of cost,” she says. “We saw an opportunity with overall pricing. We wanted to reduce our burden on the healthcare system.”

According to Barnebey, the Exprt is 50% to 75% less costly than competitive traditional knees. That said, Exprt will not replace all of its competition. Barnebey readily admits that the system has limited indications.

Previously, DJO did not have a presence in the revision knee space. Some would view that as a disadvantage, but Barnebey says that her company viewed it as an opportunity to approach a problem with a clean slate.

“We were able to really listen to the surgeons when they said that the surgery had become too complex,” she says. “There were inefficiencies everywhere. The sterilization costs alone were quite high. A traditional revision knee set can be eight to ten trays. You have to look at the cost and the impact of all of that.”

DJO wanted to shake up the market and jar loose some of those inefficiencies, making the segment leaner as a whole and less burdensome on the healthcare system. Instead of merely targeting the C-Suite, DJO sought to build a grassroots, surgeon-backed marketing strategy.

“The market has changed so dramatically, and surgeons have changed their employment relationships with providers, so that surgeons now care more deeply about the cost of their implants. They have a vested interest in making a cost difference,” Barnebey says.

As the industry lurches forward, she says that every manufacturer will have to become cognizant of the value-added component of their products and services. The strategy of offering competitive systems with fewer instruments will become more common, she adds.

“Surgeons understand the price component better than they ever have,” says Barnebey. “When you continue to increase instrumentation options, what does that do to the price? Everyone is looking to drive inefficiencies out of their process, especially as we move toward outpatient joint replacement settings.”

United Orthopedic Corporation (UOC) USA
Making surgery simpler is not a new trend. It’s just that companies are paying more heed to the tenets of cost-savings and value-added products as orthopaedics continues to feel the twin pincers of regulatory scrutiny and price pressure. The question of how companies respond to those factors is more prominent.

Patient specific instrumentation (PSI) has been one strategy. The issue with PSI is lead time and, potentially, cost. Calvin Lin, President of United Orthopedic Corporation USA (UOC), notes that PSI requires the patient to receive an MRI or CT scan. He adds that once the order is placed, it can take up to four months for a surgeon to receive the instruments.

UOC isn’t currently pursuing opportunities in PSI at this time. Lin says they have their own system.


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