Dev Joshi
January 15, 2008
Rotator cuff repair market
Rotator cuff sprain (ICD-9 Code# 840.4) and the complete rupture of the rotator cuff (ICD-9 Code# 727.61) count as two of the top five reported shoulder diagnoses in the PearlDiver database. Out of 3.7 million distinct patient counts that reside in our extremities database, the top five reported diagnoses in the shoulder region accumulate to 1.6 million distinct patients. ICD-9 Code# 840.4 accounts for 164,793 patients, while ICD-9 Code# 727.61 diagnoses totaled 56,653 patients. With the number of patients receiving these diagnoses increasing every year, the market for rotator cuff repair products has shown a rising trend as well.
According to an article published in the Encyclopedia of Surgery (“Rotator Cuff Repair” Mark Mitchell, 2004: l), a website created by various experts in the field of surgery for healthcare students and researchers, 5% to 10% of the general population has rotator cuff sprains and males experience these diagnoses more frequently than females. The article also suggests that most rotator cuff injuries are associated with athletic activities where the arms are repeatedly lifted over the head such as baseball, tennis, weight lifting, and swimming. Our PearlDiver database also shows males being diagnosed at higher rates than females. Out of the 6.1 million distinct patients whose records reside in the PearlDiver database (which includes all the orthopedics patients from extremities to spine to trauma and hips and knees), rotator cuff sprain and rupture accounts for almost 4.2%, which is close to the Encyclopedia of Surgery’s estimates. Table 1 below presents a demographic breakdown for both rotator cuff sprain and rupture of the rotator cuff for the years ending 2005 and 2006.
Table 1 – Demographic Breakdown for 2005 and 2006
Source: PearlDiver Patient Records Database 2004-2006
As Table 1 illustrates, roughly three times as many patients are diagnosed with rotator cuff sprains as are diagnosed with a complete rupture of the rotator cuff. The age ranges that usually are affected by rotator cuff injuries are 40 years and above. Table 2 illustrates the age range for these diagnoses and also sorts those results by gender. Most patients with these diagnoses range in age from 40 to 64 (PearlDiver data does not include MEDPAR data and is primarily focused on patient data under the age of 65).
Table 2 – Age% Breakdown for 2005 and 2006
Source: PearlDiver Patient Records Database 2004-2006
According to the PearlDiver database, most extremities procedures occur on an outpatient basis. That is also the case with treatments for rotator cuff sprains as well as for complete rupture. Most patients suffering from rotator cuff sprain or complete rupture are treated with either arthroscopic procedures with partial acromioplasty (CPT Code # 29826) or rotator cuff repair (CPT Code # 29827). We thought it was particularly notable that these two procedures are among the top five procedures performed in the shoulder region. In addition, the PearlDiver database shows that inpatient rotator cuff repair (ICD -9 Procedure Code# 83.63) is being used increasingly and now represents a significant number of patients.
The most common procedure to treat shoulder pain is an arthroscopy procedure. And one of the most common of those is the partial acromioplasty, which entails making two or three small incisions around the shoulder joints through which the physician operates.
Most typically, an arthroscopic shoulder surgical procedure with acromioplasty is performed on patients with small or medium-sized tears of the rotator cuff. If the diagnosis is a complete rupture, then a more involved surgical procedure for rotator cuff repair is typically recommended. Not surprisingly, since it occurs earlier in the continuum of care, the numbers of patients undergoing arthroscopic procedures are significantly higher than the numbers undergoing surgery for rotator cuff repair. This relationship is abundantly evident in the PearlDiver data tables, which show that patients diagnosed with rotator cuff sprain are a population that is three times larger that those patients undergoing the complete rupture of the rotator cuff diagnosis.
In the clinical study record, there have been some questions raised regarding acromioplasty. A study conducted at the Panam Clinic in Winnipeg, Canada, pointed out that arthroscopic surgery for rotator cuff repair provided a better treatment outcome than surgery with just acromioplasty. In an article published in the Journal of Bone and Joint Surgery (“Surgical Repair of Chronic Rotator Cuff Tears” Jan 2001; Volume 83: 71), a prospective long-term study done by Robert H. Cofield, M.D., Javad Parvizi, M.D., and other researchers, suggested that arthroscopy with anterior acromioplasty can produce consistent and lasting pain relief and improvement in range of motion. Despite the ongoing debate, PearlDiver data does show that the number of patients undergoing acromioplasty is increasing every year.
Rotator cuff problems, of course, are also treated on an inpatient basis—although it is rare. Extremities inpatient procedures account for less than 2% of procedures in the PearlDiver database, and they are usually performed at what would otherwise be considered an “outpatient site of care.” However, rotator cuff repair is one of the few procedures that has been performed frequently and is one of the top performed surgical procedures in the extremities region in the inpatient site of care. Chart 1 below shows how often these three procedures are performed for treatment of both the diagnoses.
Chart 1 – Shoulder Surgical Procedures 2005-2006
Source: PearlDiver Patient Records Database 2004-2006
Chart 1 above clearly shows that the number of arthroscopic procedures, when combined with a partial acromioplasty, is the largest sector of the shoulder repair market. Arthroscopy with rotator cuff repair is principally used when there is a complete rupture, and our database shows that the diagnosis of complete rupture occurs three times less often than the diagnosis of regular sprain on the rotator cuff.
As far as the charges go, inpatient procedures are a relatively higher expense than are outpatient procedures. Typical outpatient charges for shoulder repair are usually under $2,000. The inpatient charges for shoulder repair average just under $20,000. The Healthcare Cost and Utilization Project by the Agency of Healthcare Research and Quality, based in Rockville, Maryland, also estimated costs of shoulder repair and they calculated that the national average was $16,000.
Chart 2 – Average Charges by Site of Care 2005-2006
Source: PearlDiver Patient Records Database 2004-2006
The range of new products to treat rotator cuff tears and ruptures is expanding and a number of companies, most notably Wright Medical, ArthroCare, CONMED, Tornier, Smith & Nephew, Zimmer, DePuy, and Biomet, are making important contributions.
Among the fastest growing shoulder repair companies is ArthroCare. In the third quarter of 2007, the company reported a 24% year-over-year revenue growth rate in its extremities line, and a major contributor to that was the firm’s Opus™ Collection of suture anchors. The Opus Collection contains mostly shoulder-related products and consists of the Magnum™ AutoCuff® System, which has revolutionized the arthroscopic repair of rotator cuff and also fixes labral repair. The Opus Collection market revenue primarily consists of the AutoCuff System. CONMED’s Super Revo® Rotator Cuff Repair System offers a simple and reproducible technique for arthroscopic or mini-open rotator cuff repair. CONMED’s arthroscopy product line, as well as the company’s powered surgical instruments, had combined sales growth of 8.1% over the third quarter of 2006.
Other manufacturers with prominent shoulder repair products include Smith & Nephew with its KINSA RC 5.5 Suture Anchor, which is designed to provide secure repair of shoulder injuries stemming from tears to the rotator cuff. Exactech’s Equinoxe® Shoulder System has also been getting good reviews and the firm’s growing revenues prove it. Also in the market is Zimmer’s® Collagen Repair (ZCR) Patch. The ZCR Patch is durable and is resistant to degradation and enzymatic attack.
Within the large and rapidly evolving extremities market, rotator cuff tears and ruptures are not only increasingly frequent diagnoses, but they are also the source of rising rates of product innovation. Yet another example of this is Wright Medical’s GRAFTJACKET®. With nearly 250,000 rotator cuff repairs performed annually in the United States, the potential for significant expansion of this market as the baby boomers age is truly impressive.