Dear Timothy, this a very actual but painful question at the same time.

In my opinion, this is a matter of medical ethics, personal and literature experience from evedence-based results and shared patient consent. All other aspects should be discussed on as a second line of importance. 

I agree that patients are vulnerable to the effects of economic pressures, political manoeuvring and also unfortunately the whims of the surgeons. “The best operation for the patient is the operation you do best” does apply to some extent. Choice of implant should have something to do with science over marketing and history over hypothesis.

In the UK, ‘state of the art’ implants are now introduced via Beyond Compliance, a system for regulating, testing and introducing new technologies.

Outside of this system, a review commissioned by the Department Of Health suggested that only a small number of implants with a proven track record should be used within the NHS for the majority of patients. The large number of available implants in the UK is unnecessary and results in huge financial wastage benefitting the implant companies.

The UK National Health Service has been restructured to allow private providers, via commissioning, to take on the financial risk (and opportunity) of joint replacement surgery. This has been introduced under the guise of ‘patient choice,’ but it may be neither the patient nor the surgeon choosing the implant. Accountability for joint replacement surgery in all settings in the UK is in the form of low mortality, low early revision rates and high patient satisfaction. Increasingly, the implant of choice is likely to be one which is ‘good enough’ and cheap enough.

I agree entirely with Dr. Arshad's considerations. Especially, with the statement that  'the best operation for the patient is the operation the surgeon does best'.And also with the idea that an implant should be 'good enough and cheap enough'. 

Homa and Panayot,

I have difficulty in the term good enough. What was good enough 10 - 15 years ago might not be good enough in today's high demand patient? I have spent 40 years trying to design and create the best possible implant with current understanding of todays materials, surgical technique and patient compliance.

I do not know any surgeon that uses the same surgical approach from 15 years ago, the same poly material, the same post rehab or the same medication. I must challenge the concept of good enough. I believe we must strive for doing the best at all levels of medical care not just good enough. Who is to say what is good enough?

While we are seeing health care systems reducing payments to surgeons and putting sever pressure on implant prices there is a shift in the economic scale to favor administrators and purchasing agents while impacting the health care worker. I have difficulty with non medical personnel making medical decisions.

Some devices work well for some surgeons based on they're training while the same devices does not with others because of they're training. I fear that the expectancy of good enough will stifle advancement.

Regards,

Tim

Dear Timothy, 

I understand the term good and cheap enough in the context of the fourth column of medical ethics: fair-minded distribution of financial resources in the health care system. And it is generally known that it is a matter of chronic insufficiency. 

On the other hand I agree entirely with your considerations mentioned in para 3 of your posting.Obviously, the participation of medical experts in making important decisions, incl. finances in health care should be more active.

Panayot,

This is a complex issue that needs debate and I appreciate all interaction. I am not sure that there is one right approach but certainly we need many more individuals that have a stake in this issue to enter the debate.

Warm regards,

Tim

indebted....