With 16 surgeons performing more than 3,100 surgical procedures annually in our two-OR orthopedic ASC, we have reached capacity. So, we are planning to add two new ORs, and we want to take this opportunity to offer more services - like pain management, 23-hour post-op care and more complex procedures like single-level cervical discectomies, lumbar discectomies, unicompartmental knee arthroplasties and, possibly, hip arthroplasty. With this in mind, I recently headed off to the American Academy of Orthopedic Surgeons (AAOS) Annual Meeting in San Francisco to evaluate the newest orthopedic surgical products. I focused my efforts on big-ticket items that I think will be important for our new center - namely, autoclavable scopes and cameras and integrated digital OR suites. Here's what I discovered.

Autoclavable scopes and cameras
Our volume of arthroscopic procedures is likely to double, and autoclavable scopes and cameras can save processing and set-up time. I evaluated four features of these systems: Compatibility with existing equipment, image quality, user-friendliness and warranty coverage. Although I do not outline the detailed terms of each system's warranty in this article, I recommend taking a close look at the terms before you buy. I learned that autoclavable scope and camera technology is still approximately five years "young," and factors like sudden temperature changes and steam in the camera head can significantly hinder optics. In addition, warranties may become void if you do not comply with the manufacturer's user instructions, so check to be sure the instructions are practical for your facility. In addition, in their instructions, some manufacturers recommend limiting the number of autoclave cycles.

Many of these manufacturers are integrating new imaging technologies into their autoclavable systems, so it's not just a matter of evaluating durability, reliability and user requirements. It's also a matter of evaluating image quality and determining if the improvements offer value to your surgeons. For example, manufacturers say state-of-the-art digital cameras produce a digital signal and send that signal across the cables to the monitor providing a clearer high-resolution picture. Other newer cameras convert analog signals into digital output, which is also an improvement.

Here's a brief rundown of what I learned from some makers of these systems.

• Smith & Nephew. Offers autoclavable camera heads, scopes and scope couplers that must be autoclaved separately. The system is "backward-compatible" in that users of older-model Smith & Nephew cameras can interchange analog camera heads with the new, autoclavable scopes and scope couplers - letting users stage upgrades without running into equipment incompatibility issues. However, not until existing users replace their analog camera heads with the newer, autoclavable heads can they take advantage of the firm's "three-chip, high-definition progressive scan" technology, which the manufacturer says processes superior images very quickly. The new camera heads are under warranty for two years, and the cables are under warranty for one year. The manufacturer also offers custom service agreements, forward-compatibility with future systems, and three different digital outputs, depending on your needs.
• Richard Wolf Medical Instruments Corporation. Offers camera heads, scopes, cables and scope couplers that can be autoclaved simultaneously, either assembled or disassembled. The system is not backward-compatible, meaning users must purchase all new equipment at a system price ranging from $11,000 and $15,000. The camera offers single-chip technology. A company representative emphasizes the durability of its autoclavable system and says it is "designed to last forever." The standard warranty lasts one year and covers any autoclave damage, according to the firm. Buyers can also purchase an extended three-year warranty.
• Arthrex. The vendor of Olympus orthopedic optical and video products, Arthrex offers autoclavable camera heads, scopes, light cables and associated hardware. The firm touts the system's durability even when processed under demanding flash sterilization (recommended for emergency use only), saying it's built for "rugged reuse." The system is backward- and forward- compatible. Arthrex and Olympus say that the limiting factor in image quality of an optical chain is the scope itself, and their Visera multi-specialty digital imaging platform is designed to optimize image quality obtained through the scope. The True View II arthroscope comes with a five-year autoclave guarantee. The firm also offers a three-year full-service contract for this period; all other components are warranteed for one year. Arthrex touts its "built-on-demand" service, which allows users to scale equipment options to their needs (entry-, medium- or high-level). The firm says it helps buyers cost-justify purchases as part of its 3C (Comprehensive Cost Containment) program. The item list prices are $13,995 for the processor, $11,495 for the camera head and $3,940 per scope. Arthrex also offers a digital information management system that allows real-time digital storage of patient data to a DVD, hard drive or network.
• Linvatec Corporation. Offers scopes, cameras and light guides that can be autoclaved together, as they require the same autoclave settings. The system offers three-chip cameras and the same one-year warranty as the non-autoclavable system, as well as a three-year extended warranty. Durability and reliability are key features, according to the firm, which has been making autoclavable systems since 1997 and is on its second-generation product. The Linvatec system is designed for repeated autoclaving, with a titanium capsule and plastic casing housing the optics to protect them against sudden temperature changes. A company representatives says one facility has used the system for 1,700 procedures with no problems and that the camera can be dropped from 40 inches without damage. The firm says backward- and forward compatibility makes sense as long as it's technically feasible, but won't make this a priority over the design and performance of a system. Like many others, the firm installs equipment free of charge when users agree under certain contract terms to use their disposables. List price of the camera controller is $14,000 and the camera head is $10,000; discounts are negotiable.

Most systems also offer optional voice-, touch-screen and/or hand-held controls, as well as centralized panels in which users store each surgeon's preferences to expedite set-up. I see both of these technologies, which add to the cost of the systems, as potentially useful for busy facilities, especially those with staffing limitations. For example, the circulator could be completing other patient care or documentation tasks while the surgeon controls the equipment using voice-activation. In addition, the centralized controls could allow staff to automatically adjust settings for the surgeon and procedure, a potentially valuable tool for busy multi-specialty facilities that perform back-to-back knee surgeries and laparoscopies, for example. For our facility, these high-end options may not be justified. Finally, many systems offer an internal automated system that adjusts light intensity to the procedure and specific light conditions, thereby optimizing visibility.

Orthopedic integrated digital OR suites
Integrated digital OR suites will be very important for us because they can substantially improve efficiency. Here are some examples. Surgeon pre-sets may save five to ten minutes that we now spend setting up equipment for each case. Digital image capture, archive and transfer will enable us to transfer pre-op images like CTs, MRI scans and X-rays to the OR suite, display the images on a monitor, capture new images and transfer everything back to the physicians' offices simply by touching the buttons. This would obviate the need to physically chase down and transport images back and forth while ensuring that we capture and keep the images we need. Voice activation and touch-screen controls will allow surgeons to zoom cameras, control shavers, take pictures, tweak the tables and lights, and even dictate operative notes while closing the patient. Overhead cameras in the OR routed outside will allow the control nurse to monitor cases and know when to send for patients without having to call into the OR for updates. Integrated digital OR suites will also allow surgeons to transfer images to other doctors for conferencing or consultation and allow us to broadcast procedures via the Internet or teleconference for educational purposes.

At the AAOS meeting, I evaluated these systems' digital transfer capabilities, purchasing options, user-friendliness, support and training services and reliability. I was especially concerned about reliability and technical support because, with so much technology at our fingertips, we will need technical support to assist with trouble-shooting or provide back-up in case of equipment failure. Here's a rundown of what I discovered:

• The Olympus ALPHA OR, according to the manufacturer, is designed with the "highest quality infrastructure available" and the firm says it designs back-up cabling into the ceiling and boom structures to ensure reliability. The firm says its system offers several features that make it easy to use - including real-time diagnostics and troubleshooting, and large bright display panels. The ALPHA OR offers voice control inside or outside of the sterile field, as well as touch-screen controls in the sterile field and at the nurses' station. The firm offers technical experts in 18 locations across the country, as well as nurse consultants and other specialists.
• Smith & Nephew's integrated digital OR relies on broadcast technologies that, says a company representative, are used widely and proven reliable. The firm says its equipment is designed to be user-friendly and takes just "a few cases" to master. Technical support includes the local rep, on-site training and a technical support line that is open from 7 a.m. to 8 p.m. EST. List prices vary widely - from $75,000 to $250,000 per room - because the suites are highly customized. The firm takes into account disposable usage when negotiating prices.
• Richard Wolf Medical Instruments Corporation offers an integrated digital OR that is Windows-based and, says the firm, "very stable." The manufacturer says users can fully operate the system after the first few cases because it is intuitive. The most significant learning involves understanding the function of each screen and how to locate the screens you need. For example, for endoscopic procedures, the camera controller and light source are integrated into the same touch-screen menu, and you can simply touch the screen to adjust brightness. System prices are negotiable based on disposable use, and contracts can last up to three years. The firm offers a two-week training program and an on-site rep as well as an extended warranty.

ConMed and Stryker also offer digital integrated OR suites, and all five firms provide a team of experts to help create a plan and install the system. Services include engineering, architecture, construction and training. I recommend choosing your firm early and getting this team involved with your own planners. For example, we are not yet sure if we will opt for the integrated electronic boom set-up - in which the electronics and cables are all neatly housed within the boom - but we will install the steel ceiling frames, cable conduits and other structural necessities during construction so we don't have to undergo an expensive retrofitting process in the future.

While evaluating integrated digital OR suites, ask potential vendors to take you, your surgeons and other key staff members to facilities in which their equipment is in use. Don't hesitate to ask lots of questions. One of my particular concerns, for example, is how easy (or difficult) it is to make repairs when an electronic-boom system loses power or components need replacement. Unlike conventional cart systems, these integrated boom systems can't be moved from the OR for service. For our center, versatility will be key, as we want to move equipment from room to room if needed.

Since manufacturers predicate the cost of a digital integrated OR suite - which can start at $100,000 and exceed $500,000 with all the bells and whistles - on your commitment to use their disposables, the cost and quality of disposables can become the deciding factor, especially if you find that equipment quality, user-friendliness and service are comparable between two or more vendors. If you're as dependent as we are on supplies like irrigation set-ups, pump tubing, insufflation tubing, shavers and ablation probes, I recommend paying close attention to these contracts. Some factor in consumable upcharges and/or minimum usage levels. Avoid getting locked into a long-term contract that commits you to products your physicians may not prefer, or breaks your disposable supply budget for the next three to five years. Finally, go with a company committed to technological advances and product improvements, since the contracts will lock you in for as many as five years.

So much more
At the AAOS this year, I also explored many of the other staple products we will need, like OR lights, orthopedic tables, equipment booms and orthopedic C-arms. I began the exciting process of planning the equipment needs for our expanded center. Thanks to this experience, I have come to believe that investing in many of the new high-technology products - like autoclavable arthroscopes and integrated OR suites - will make our facility more productive than ever.