Source: PearlDiver Patient Records Database, 2004-2006
Third most replaced joint after Knees and Hips
It ain’t a hip joint, but that shoulder is, increasingly, where the action is in orthopedics!
The human shoulder is the third most replaced joint in the United States. That simple fact should cause most orthopedic suppliers to take notice. And with baby boomers increasingly complaining of shoulder pain, shoulder repair and/or replacement is becoming an actual growth market.
According to PearlDiver data, patients in the baby boomer age cohort account for the highest frequency of shoulder injuries and arthritis of any single group. Looking at the national database derived from the United States Department of Health and Human services that includes MedPAR data, we do find the aging population (45 years and above) to have a higher percentage of arthritis-related injuries―not just in shoulders but in other extremities, too. The table below shows the top five diagnoses in shoulder-related injuries for the 45- to 64-year-old age group. The table clearly indicates that the baby boomer population is getting diagnosed significantly more often than any other age range. PearlDiver’s patient data is derived from a consortium of insurance companies and is HIPAA-compliant. The data is private payor data and does not include Medicare data.
Table 1: Top Five Shoulder-Related Diagnoses and the Baby Boomer Population
Source: PearlDiver Patient Records Database, 2004-2006
The good news for surgeons, as we detail later in this article, is that the instruments, implants, and technical procedures have improved significantly in recent years. Today, a total shoulder replacement is becoming almost as routine as the gold standard of orthopedic surgeries—the hip or knee arthroplasty.
According to the PearlDiver database, total shoulder replacement (ICD-9-P-81.80) is one of the most commonly performed inpatient extremity procedures. The database lists just over 15,000 inpatient extremity cases (4.3 million outpatient and physician office extremity cases), of which 6,000 had some sort of shoulder-related repair and/or replacement surgery. Our database indicates that the number of patients aged 45-64 years represents 70% of the entire inpatient shoulder-related extremity cases.
Clearly, inpatient extremity cases are rare. That is changing—in part due to the aging of the population but also due to increasingly complex and successful implants—like shoulder replacement. According to other sources like the AAOS and the U.S. Department of Health and Human Services, around 12 million to 14 million patients a year complain of shoulder pain to their physicians. Of those patients, less than 1% are hospitalized. The vast majority from that 1% are over the age of 65.
According to the U.S. Department of Health and Human Services, between the years 1997 and 2005 the number of shoulder arthroplasties or total shoulder replacements increased by 145%. The number of patients of all ages who underwent total shoulder replacement in 2004, 2005 and 2006 was 15,400, 16,500 and 18,300, respectively. We are forecasting that the growth rate will continue, and we estimate that the number of patients increased to 20,300 in 2007. By the end of 2020, we expect the market to see the total number of patients undergoing shoulder replacement increase to around 63,500. The baby boomer or aging population cohort should drive the market extensively in the next 10 years (10% estimated growth rate) and then gradually slow down and become a consistent growth sector thereafter (we forecast a constant 7% growth rate). Chart 1 below illustrates the growth of total shoulder replacement from 2004 to 2006 and estimates the growth for 2007 to 2020 in accordance with the general population as well as the aging population.
Chart 1: Forecast of Shoulder Replacement Hospitalizations Based on General and Aging Populations
Source: PearlDiver Analyst, public sources and PearlDiver Patient Records Database, 2004-2006
The number of shoulder replacement surgeries appears to be growing at a record pace. This observation is supported by the research website of the American Academy of Orthopaedic Surgeons (AAOS), which shows that there has been an increasing trend for total shoulder replacement since 2001 (click here to view). In effect, aging baby boomers are driving a 5% annual growth rate in shoulder cases, according to Dr. Joseph Lipman of the Hospital for Special Surgery based in New York (http://hss.edu/newsroom_11306.asp).
Shoulder joint replacement has been performed regularly since the early 1970s and is regarded as one of the most important surgical advances of the last century. The first recorded shoulder replacement occurred in 1892 and was performed on a patient with severe shoulder arthritis. The first generation of shoulder implants, called “Monoblock,” were introduced to surgeons in 1953 and consisted of only a single piece—the head of the humerus could not be moved. The second generation of shoulder implant, called “Modular Prosthesis,” was more adaptive to the patient as it had an independent head and stem parts. The third generation of shoulder implant, called “Anatomical,” was more adaptive to the shoulder anatomy. Today’s shoulder replacements are similar in design to the ball and socket anatomy of the actual shoulder. One of the more important innovations in shoulder repair was the development in the 1980s of the reverse shoulder arthroplasty. Reverse shoulder arthroplasty was introduced for patients with shoulder arthritis and a severe rotator cuff tear or a complex shoulder problem that had not healed when applying the regular shoulder replacement procedure.
According to research conducted by a team led by Edward McFarland, M.D., Director of the Division of Adult Orthopedics at The Johns Hopkins Hospital (Johns Hopkins Medical Institutions (2007, March 27), “Shoulder Replacement No More Risky Than the Replacement Of Other Joints”), 99% of the patients who have a shoulder replacement for arthritis report pain relief and a high degree of satisfaction in their treatment. The study was a retrospective study and analyzed patient information provided by the Maryland Health Services Cost Review Commission, the state’s hospital rate-regulator. The study looked at 625 shoulder arthroplasties and compared them to 15,414 hip surgeries and 34,471 knee operations performed in Maryland from 1994 to 2001.
Their study showed that patients who undergo shoulder arthroplasty experience relief from chronic pain and gain mobility. According to the study, 7.5% reported postoperative complications after shoulder surgery, compared to 15.5% reporting complications after hip surgery and 14.4% after knee surgery. The study also concluded that shoulder arthroplasty was comparatively safer than any other joint replacement. According to the study, there were no fatalities associated with shoulder replacement compared to 27 deaths among hip replacement patients and 54 deaths among knee arthroplasty patients. The study also reported that the hospitalization time for shoulder patients was around two and half days compared to four or more days for both hip and knee arthroplasty patients. Even though the study’s numbers for shoulder replacement are small compared to hips and knees, the researchers found that mortality rates for this procedure were not statistically different from the rates for any other arthroplasty.
In terms of charges, shoulder replacement is catching up to hip or knee replacement. The typical charge for a total hip replacement or a total knee replacement (as listed in the PearlDiver database) is between $43,000 and $48,000, while the charge for a total shoulder replacement is around $33,000 to $38,000. The average length of stay is 3.5 days for either a hip or knee replacement, while total shoulder replacement patients usually stay for 1.5 days to 2 days. PearlDiver’s database shows osteoarthrosis in the shoulder region as the most common associated diagnosis with total shoulder replacement procedures. The following chart illustrates the top five diagnoses that are associated with total shoulder replacement.
Chart 2: Top Five Associated Diagnoses
Source: PearlDiver Patient Records Database, 2004-2006
The diagnosis most commonly associated with shoulder arthroplasty is localized osteoarthrosis (primary or secondary) in shoulder region (ICD-9-D-715.31), followed by unspecified hypertension (ICD-9-D-401.9), localized osteoarthrosis (primary) in shoulder region (ICD-9-D-715.11), rheumatoid arthritis (ICD-9-D-714.0), and diabetes mellitus (ICD-9-D-250.00), as shown in the chart above. Usually these diagnoses are treated in an outpatient setting.
In 2005 – 2007, there were more than 20 products approved by the FDA for shoulder replacement. They were:
Recently, Zimmer Holdings reported an astounding 30% increase in extremities revenues for the 4Q07 as compared to the same period in the prior year. One key driver of that growth was Zimmer’s new Anatomical Shoulder Inverse/Reverse System and its Bigliani/Flatow® Shoulder System. Exactech, too, had a big year with its new Equinoxe Reverse Shoulder System, which helped fuel the company’s strong sales report for 2007 (132% year-over-year growth for 4Q07).
In conclusion, while shoulder replacement surgery is still not in the same league with regard to procedure volume as knee or hip arthroplasty, the trend to treat severe shoulder pain with shoulder replacement is increasing. If patients realize that shoulder replacement surgery is consistent and delivers better outcomes and mobility restoration, then this surgery will continue to grow just like hips and knees—particularly as the population ages. Certainly, companies such as Zimmer, Tornier, Exactech, and DePuy are already on the shoulder bandwagon. With the continuous innovation and surgical technique improvement in shoulder repair, products for total shoulder repair procedures should become part of every major orthopedic supplier’s product offering.