The Pipeline

Minimally Invasive Total Hip Replacement: Justifying the Cost of a Hana Table

Recently, the Technology Insights team has fielded several questions about the Hana table, an expensive surgical table that facilitates minimally invasive procedures. Because of its role in facilitating these procedures, the question of the Hana table is completely tied to the question of minimally invasive hip replacement surgery--specifically the anterior approach. 

The table is considerably expensive relative to other OR tables (we tend to hear it quoted somewhere around $150,000). To justify such an outlay the technology would have to demonstrate a substantial improvement on current clinical practices, and within minimally invasive joint replacement, that does not appear to be the case at this time. Right now in orthopedics and spine, minimally invasiveness is still a moving target. There are countless approaches being developed and honed by many surgeons, but at this time none have emerged as a true standard.  Complicating matters is that in joint replacement and spine what constitutes "minimally-invasive" is subjective.  Still, it is an attractive term to patients, and the demand for minimally invasive procedures will grow.  There are a few major factors that will determine that rate of growth in hips:

  • Patient demand--Traditionally a total hip replacement has been an invasive procedure with a long recovery time lasting months. Not surprisingly, any improvement to this extended recovery time would be desirable to patients. Additionally the demographic of patients undergoing hip replacement is changing. Patients are often still employed full-time and express a desire to be back at work as soon as possible. Minimally invasive surgery affords the patient the advantage of a faster, less painful recovery. Cosmetic concerns of a large scar are also reduced with a minimally invasive approach.  For all these reasons, consumer demand will be a key factor in the growth of these procedures.
  • Additional research clarifying clinical benefit--Currently a review of the relevant literature finds few attempts to compare different approaches of minimally invasive surgery to each other. Although the benefits of muscle-sparing procedures have been established, the specific technique for accomplishing this goal is debatable. In addition to the clinical benefits associated with various approaches, a host of other concerns must be considered. The ideal minimally invasive surgical technique would be easily learned, use little if any specialized equipment, and require a short operating time. Many of the proposed approaches claim to fix one of these issues. Additional research and innovation will drive the selection of the optimal technique.
  • Demonstrated cost benefit to providers--An omnipresent concern for hospitals, cost strongly impacts the growth of new procedures especially those which require expensive supplies or technology. Ideally, total hip replacements would become such low-trauma procedures that they could be performed with minimal perioperative support and a very short length of stay. The evidence that these approaches deliver these advantages is anecdotal, and note demonstrated at a large scale. Minimally invasive surgery could save hospitals much needed supplies and increase throughput. Unfortunately, this shift is unlikely to occur on a large scale in the near future.

All those drivers are noted for minimally invasive hip procedures in general, and since the Hana table is specifically designed for only one approach, a provider runs the risk of betting on a technique that may not win out clinically in the long run, and in fact already has some data suggesting a higher complication rate (see the abstract here). We've also heard that the anterior approach has a substantially longer learning curve than other techniques.

For all these reasons, we've erred on the side of caution in investing in this table and tend to be conservative in recommending its adoption. That being said, there can always be unique circumstances that make the investment more appropriate for certain institutions, and the Technology Insights orthopedics team will happily investigate those circumstances on your behalf.