The first database search identified 3,598 studies. Once duplicates were removed, a total of 2,168 records were available for screening. Title and abstract screening excluded 2,130 studies that were not related to the research question. Of the 38 records sought for retrieval, 7 records were not retrieved as a full-text version was not available. Full-text review of the remaining 31 studies resulted in the further exclusion of 27. In total, four studies were included in our analysis. Grey literature searching identified 3,371 studies. Screening excluded all identified studies as they did not meet the eligibility criteria for inclusion. The updated database search resulted in an additional 404 title and abstract reports for screening, from which 19 full-text records were assessed for eligibility. The updated grey literature search identified 4,548 records. Assessment of eligible records from the updated database and grey literature search excluded all identified studies as they did not meet the eligibility criteria for inclusion. These results at the time of the final literature search are summarized in the PRISMA diagram (Fig. 1).
Across the four included studies, the stated factors influencing prosthesis selection were categorised under six domains:
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Patient advantage – perceived patient-to-prosthesis fit, or patient outcomes
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Surgeon-related factors – surgeons’ willingness to try new implant/s, and impact of familiarity on perceived user-friendliness
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Prosthesis quality – aspects of the implant itself such as type of material or technology, longevity, or safety
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Vendor or service-related factors – pertaining to the service provided including training, and likeability or knowledge of the sales representative
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Cost – pertaining to the cost of the implant and subsequent implant choice
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Information source – relates to the process of obtaining information on implants to inform decision making
Three of the four included studies used surveys to elicit key information around what drives orthopaedic surgeons’ decision-making for prosthesis selection but had quite different foci. Burns et al focused exclusively on implant and vendor characteristics (20). Sharkey et al focused predominantly on what drove a change in implant choice, and the impact of cost and cost mitigation strategies employed by hospitals (15). Vertullo et al investigated what surgeons valued in a prosthesis and the drivers/barriers for changing their prosthesis choice, but only examined total knee arthroplasties (21). Gagliardi et al used interviews to understand surgeon decision-making and found five key themes which influenced surgeon choice: evidence on implant performance, patient factors, physician factors, organisational factors, and market factors (22). Three of the four studies were completed in North America (2 USA, 1 Canada) (15, 20, 22), with the fourth completed in Australia (21).
Table 3
Factors influencing decisions
| Factors Influencing Decisions |
Lead Author (Year), Country | Patient advantage | Surgeon-related | Prosthesis quality | Vendor / Service-related | Cost / Financial Considerations |
Burns (2018), USA | X | X | X | X | X |
Gagliardi (2017), Canada | X | X | X | | X |
Sharkey (1999), USA | X | X | X | | X |
Vertullo (2017), Australia | X | X | X | X | X |
Patient advantage
Across all included studies, an important consideration was the perceived clinical result in terms of outcomes and suitability for each patient, taking into consideration individual anatomy and pathology (15, 20–22). Whilst “best fit” was highlighted as a key consideration, none of the studies outlined which patient factors, such as age, weight, or reason for arthroplasty, were most often included in the decision-making process. Patient outcomes such as functionality, lower risk of complications, or need for revision were noted in two studies as a consideration (20, 21). Only one study discussed patient involvement in prosthesis selection, and reported that surgeons believed that patients would not have sufficient knowledge to engage in the selection process (22).
Surgeon familiarity
Study participants varied in their stated preference for experimentation with new prostheses. The most common preference stated in the included papers was continuing to use the same prostheses on which they were trained, with participants in one paper referring to themselves as “late adopters” and suggesting that familiarity with the nuances of the prosthesis may be associated with optimal patient outcomes (15, 21, 22). Barriers noted relate to the “learning curve”, including difficulty to learn a new technique, the time required to perform the surgery, prosthesis complexity, and relative ease of implantation (15, 20, 21). Conversely, one paper referenced a “philosophy” of acquiring proficiency in a range of prostheses so that choice of the prosthesis could be tailored to patient needs, thereby optimizing outcomes (22), whilst other participants expressed interest in new prostheses as they were “cutting edge” or the basis for academic research (22).
Prosthesis quality
All four studies included selection factors relating to the features of the prosthesis itself. These focused on prosthesis performance measures, including evidence of improved material technology, reproducibility of the outcome, prosthesis longevity, and product reputation (15, 20–22). Reported selection factors also included the practical elements of using the prosthesis, such as the prosthesis design (15, 20, 21). Interview participants from one study highlighted that, in some situations, there were minimal differences between the prostheses themselves in terms of quality, and decision-making may be limited to which models were available on the market. Similarly, some prosthesis components were considered comparable across companies, so clear advantages in terms of “ease of implantation or safety” would need to be demonstrated before switching products (22).
Vendor or service-related
When considering vendor characteristics and their relationship to a surgeon’s prosthesis preference, both sales and service, and the surgeon-vendor relationship, were important (20, 21). One included study focused exclusively on vendor and service-related factors and their influence on the prosthesis selection (20). Sales and service factors included: prosthesis training or education-focused events funded or delivered by the vendor; personal experience with this training; and the information available to patients on the internet about the prosthesis (20). Personal attributes of the salesperson were also highlighted, including: availability and likeability; the degree to which the salesperson engaged with the surgeon; knowledge relating to the prosthesis; and tenure (20). Vendor-specific factors were also raised, such as: vendors’ willingness to listen to surgeon suggestions for improving existing products; product innovations introduced by the vendor; reputation; and willingness to create specialized products to meet surgeons’ needs (20). Surgeons also considered whether another vendor made a similar prosthesis that performed the same function or whether it would be easy to switch to another vendor’s prosthesis (20).
Cost considerations
A common consideration across all studies was the cost of the implant. One study reported that the biggest deciding factor would be cost, not surgeon comfort, patient anatomy or track record of the prosthesis (22). However, no studies provided in-depth information on how costs affected surgeons’ decisions, for example, whether there was an acceptable range of implant costs. In one of the included studies, additional considerations such as the willingness of insurers to adequately reimburse the surgeon or hospital, and other consulting arrangements with the vendor were considered important (20).
Surgeons indicated that they had full control of prosthesis selection in some contexts, however, the alternative – no control or limited control over the selection, was also apparent (15). Two papers highlighted organisational mechanisms limiting prosthesis choice, including limited inventory available within a hospital, or specific hospital requirements (15, 22). Costs were commonly managed through purchasing group contracts with preferred vendors. In some instances, hospitals did not own or stock prostheses; instead, surgeons ordered prostheses from a set “menu” and they were delivered to the operating room by industry representatives (22). Surgeons’ views on accepted prosthesis lists varied considerably. Some noted that it was not always possible or even necessary to use the “latest and greatest” for every patient (22). However, others indicated that they believed group purchasing contracts constrained choice, leading to poor patient outcomes that would negate any cost savings (22).
Information source
One study indicated the complexity of decision-making around prosthesis selection and highlighted that multiple sources of data including medical literature, internet searches, registries, colleagues, professional meetings, and industry representatives all contributed to the final choice (22). Authors reported that colleagues were the most frequently consulted source of knowledge when considering a new prosthesis or learning from others’ experiences with the same prosthesis after experiencing an adverse event (22). Their definition of colleagues included mentors, experts, and local, national, or international orthopaedic surgeons (22). Sourcing information from colleagues was often informal and considered a quick and easy way to acquire trustworthy information, but also occurred on a more formal basis at various professional meetings (22). Further, the study found that apart from colleagues, surgeons often relied on industry representatives to provide information about prostheses (22). However, this was not always seen as beneficial, with some sales representatives/vendors reported to inconsistently share information about prosthesis warnings, requiring surgeons to double-check information or be forced to switch to other products upon experiencing a sub-optimal outcome (22).