The January 2020 issue of Orthopedic Network News (ONN) newsletter is concentrated on extremity joint replacements. These include joints other than hips or knees and include shoulders, ankles, elbows, digits, and wrists. Read below for an editorial on extremity joint replacement market trends for 2020.

Hospitals will most likely see an increase in shoulder replacements, which now number about 154,000 a year in the US and grew 8.2% last year, compared to the 647,000 hip replacements and 1.0 million knee replacements, according to data provided by iData Research.

The “Top 10” shoulder hospitals by Medicare volume include those most associated with hip and knee replacements: the Mayo Clinic, Hospital for Special Surgery, New England Baptist, among others. 

Physician payment from Medicare for joint replacements has largely remained the same based on the 2020 Medicare payment rules. Although specifics will vary based on geography and other factors, a physician will receive about $1,415 for a total hip replacement, $1,413 for a knee replacement, and $1,515 for a total shoulder from Medicare in 2020.

Although the data available to Orthopedic Network News for sports medicine is limited to the hospitals that report purchases of sports medicine products, there are two main segments: allograft tissue, such as Achilles tendons for transplant, and soft tissue anchors for repairing torn rotator cuffs and other ligaments. Arthrex dominates this segment with their soft tissue anchors.

The world-wide extremities market is led by Wright Medical, Zimmer Biomet, DePuy Synthes, and Stryker, which collectively have 59% of the world-wide market share, according to ORTHOWORLD. In the US, shoulders are led by Zimmer Biomet, DJO Surgical, Wright Medical, and Arthrex, which collectively accounted for about 84% of the reverse shoulder market and 78% of the entire shoulder market.

There are two major types of shoulder replacements: anatomic shoulders, which have a humeral head that mimics that of the natural anatomy, and reverse shoulders, in which the humeral head portion has been placed into the glenoid. Reverse shoulders were indicated for severe rotator cuff damage, and now account for about 66% of all shoulder replacements in the Curvo research network. Sporting an average selling price of $8,017 in 2019, they are significantly more expensive than total shoulders ($5,416). Partial shoulders, once accounting for as many as 32% of the shoulder cases in 2008, now account for about 2% of the shoulder cases.

Total and reverse shoulder replacements have gone through several “shake-outs” in surgical technique with various changes in implant design, adjuncts, and assistive devices for the surgeon. Bone screws, largely unneeded for total shoulders, now average about 4 for reverse shoulders. Soft tissue attachments have declined in reverse shoulders from over 10% of cases in 2014 to less than 5% in 2019. 

Another major innovation has been the use of “canal sparing” humeral stems which are smaller and sacrifice less humeral bone during the implant. Currently Wright Medical’s Simpliciti dominates this segment, but others including Zimmer Biomet’s Sidus, and others are coming onto the market. Also, “convertible” humeral stems have become more widespread. These stems allow the surgeon to use the same humeral stem in either a reverse shoulder or total shoulder procedure, thus reducing inventory and redundant implants and instrumentation.

ONN surveyed the total ankle market which has received boosts from Medicare by reassigning total ankle replacements to MS-DRG 469 with a substantially higher payment ($19,653) compared to that of hip or knee replacements (about $12,000). While the market is considerably smaller than that of hips, knees, or shoulders, it is expected to grow as more surgeons and patients embrace the ability to have an ankle that allows patients to bend or flex their foot. Previously, the treatment for severe arthritis of the ankle was to fuse the joint, which didn’t provide this flexibility. Wright Medical dominates this market.

Finally, Orthopedic Network News began surveying key issues in joint replacements that have a financial impact for hospitals. Although there are a large number of both clinical and financial issues relating to joint replacements, these are factors that are known to impact costs. For hip replacements, this includes the types of femoral stems, femoral head materials (ceramic or cobalt chrome), femoral head size, acetabular liner materials, acetabular shell materials and numbers of acetabular screws. 

For knees, the issues surveyed were the impact of “cementless” knees, types of materials used for tibial inserts, types and quantities of bone cement, and the use of tibial extension stems. 

Cervical and lumbar fusions examined the distribution in costs for metals, interbody fusion devices, and biologics for single level fusions. Orthopedic Network News also reported the number of levels fused over the last 10 years for both cervical and lumbar spinal fusions.

For detailed reports on the 2020 market trends in extremity joint replacement, sign up for the ONN Newsletter.