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The context of the trend toward minimally invasive procedures is wider than our other three businesses, because its beneficiaries lie with two broad population groups: Active, but aging, people who expect to remain active late into life, and athletes – professional, amateur or recreational – who seek minimally invasive treatment of joint injuries from overuse or trauma.

Global studies provide evidence that arthroscopic procedures deliver quality patient outcomes, and while this is important, economic considerations are gaining importance given the rising costs of healthcare.  Studies also show that arthroscopic procedures often cost less than open surgery. Additional studies also illustrate the growing awareness of, confidence in and as a result the demand for such procedures.

Research conducted by Orthopaedic surgeons at the Massachusetts General Hospital and Harvard Medical School, showed that patients who underwent surgery to repair shoulder instability saw comparable results whether they had open or arthroscopic surgery. The arthroscopic procedure took less time, cost less and resulted in fewer recurrent dislocations than open surgery, said the study, which was published in the journal Arthroscopy in October 2005. The key to its reduced cost was the lack of a hospital stay.

A second study, published in the German orthopaedics journal Orthopade in July 2003, showed similar results, based on a randomized study of two groups of 20 patients. This study showed that arthroscopic surgery cost significantly less – 2315 Euro compared with 2741 Euro for the open surgery – as did postoperative treatment – 1630 Euro for arthroscopic surgery compared with 2202 Euro for the open procedure.

A 2006 study, published in Arthroscopy in April 2007, showed that a vast majority of patients perceive multiple advantages of arthroscopic shoulder surgery. The study surveyed 202 shoulder surgery candidates at two orthopedic practices. Eighty-eight percent of the patients at one practice and 96 percent at a second said that they would prefer arthroscopy if asked to choose between open or arthroscopic surgery. An average of 20 percent of those patients said they would forego surgery altogether if an open procedure were the only option.

Other healthcare economic factors and considerations related to arthroscopy:

1. The adoption of minimally invasive surgical techniques as an accepted standard of care among both doctors (more efficient, fewer complications, better technology) and patients (reduced trauma, less rehabilitation, increasing media coverage).
   
   Example: Knee Arthroscopy - In the late 1970s and early 1980s, arthroscopic surgery became popular, especially in the sports world, as fiber-optic technology enabled surgeons to see inside the body using a small telescope, called an arthroscope.  During knee arthroscopy, the surgeon makes an incision about the width of a straw tip in the knee joint and inserts the arthroscope, which contains both lenses and a light source. A camera outside the joint captures this image and relays it to a monitor, enabling the surgeon to inspect the joint and locate the source of pain or injury, particularly those causes that might have been missed using an X-ray or MRI. Then, using instruments inserted through other small openings, or portals, the surgeon repairs the injury.
   
   Thanks to ongoing improvements made by technology leaders like Smith & Nephew, arthroscopic surgery is now accessible to more people than just professional athletes.



2. An increase in the number of surgical sites (including surgery centers and sites dedicated to outpatient procedures) and the number of surgeons trained in minimally invasive techniques. This is particularly so in the United States, where in 2006 there were about 3,700 ambulatory surgical centers (ASCs), compared with 275 in 1980 and 1,450 in 1990.
   
   The Ambulatory Surgery Centers Association forecasts 25 percent growth in orthopaedic ASCs between 2002 and 2025. In the US, increases in reimbursement levels for many arthroscopic procedures between 2008 and 2011 period will make those procedures more profitable for outpatient centers.



3. Product and technique evolution – in materials, product mechanics and operating room equipment – have the potential to increase our current market size.
   
   Example: The FOOTPRINT PK Suture Anchor for rotator cuff repair in the shoulder is designed to allow for suture tension to be adjusted even after the anchors have been implanted. An internal plug on the FOOTPRINT PK Anchor can be tightened or loosened to adjust the tension of suture bridges that result in more attachment points in the joint, resulting in a stronger repair. 
   
   This procedure delivers a repair equivalent to an early approach, which involved drilling tunnels through the humeral head and lacing suture through them. Smith & Nephew Endoscopy’s FOOTPRINT PK Suture Anchor delivers a Transosseous Equivalent (TOE) repair without the need for drilling transosseous bone tunnels.