After severely injuring his left ankle celebrating an ace at the Masters 2018 Par-3 contest, the 28-year-old professional golfer will likely think twice (or more) before attempting another backwards run on the golf course.
Fortunately, the extent of Finau’s injury was limited to soft tissue damage and torn ligaments (a sprain). An overnight regimen of ice packs and anti-inflammatory drugs, along with a cold/compression treatment device and heavy taping, enabled Finau to return to the course and participate in the Masters Tournament in early April (he eventually finished tied for 10th place).
Though his injury wasn’t severe, Finau’s ankle sprain could have long-term consequences. Not only is the strapping 6-foot 4-inch golfer prone to re-injury, prolonged symptoms, and limited activity, he also is at greater risk for developing ankle osteoarthritis—a condition that is expected to help fuel the global extremities market over the next half-dozen years.
ODT’s May/June feature story “Shouldering Growth” details the shoulder and ankle technologies that are driving growth in the worldwide extremities reconstructive devices market. Steve Vankoski, senior director of Global Marketing, Extremities, for Zimmer Biomet Holdings Inc., was among several experts interviewed for the feature; his full input is provided in the following Q&A.
Michael Barbella: Please discuss the trends in the extremities market. What trends have you noticed this year and how do they differ (if at all) from past trends?
Steve Vankoski: There are three leading trends that we continue to experience in the extremities market:
- We continue to see increasing adoption of stemless shoulder implants. Zimmer Biomet introduced the Sidus Stem-Free Shoulder system into the U.S. market earlier this year and we expect that will continue to drive adoption in that market as companies prepare to introduce their stemless solutions as well. The stemless shoulder market is comparatively mature in Europe and Canada, with a 25 percent market penetration for primary shoulder arthroplasty. Within the next few years, we expect the U.S. to approach a similar level of penetration.
- Another noteworthy trend this year is the increasing use of augmented glenoid solutions for reverse shoulder arthroplasty. A primary benefit of augmented versus non-augmented baseplates is that they are intended to better match a patient’s deformity. Rather than having to remove more of the patient’s bone to accommodate for the baseplate to fit, augmented baseplates fit more closely match the patient’s deformity to yield the potential for greater bone preservation. Additionally, these solutions are being introduced to the global market nearly simultaneously, leading to adoption and market presence in Europe, Canada and the U.S.
- An increased acceptance and adoption of advanced 3D planning for arthroplasties. The 3D visualization enables surgeons to virtually plan their surgeries in advance and allows them to accommodate the individual morphology of each patient with the goal of optimizing implant position and potentially improving clinical outcomes.
Vankoski: From a market standpoint, a lack of predicates in the elbow, hand and wrist markets makes it more challenging to obtain regulatory clearance into certain markets. In these instances, to gain entry into the market, a company must conduct a clinical trial which is expensive, time consuming and riskier. In addition, some markets demand post market clinical data which can be a challenge for some smaller joint procedures where procedure volume may be less concentrated and less consistent.
Another challenge for the extremities sector is the variety of customers that exist compared to the hip and joint market. Surgeons with different backgrounds and disciplines specializing in a wide range of areas—hand, shoulder, elbow, sports medicine, trauma, etc. all perform extremities procedures. Our sales force and downstream teams need to understand and be able to expertly support a number of different joints performed by this varied customer base. We may continue to see increasing sales force specialization to meet the challenge that this market poses.
Barbella: What new technologies are on the horizon? What kinds of implants hold the most potential for patients? For market growth?
Vankoski: Over the next five years, we can expect to see advancements in the materials and solutions used in joint surgeries. As the number of surgeries on younger patients increases, we may see the need for more advanced materials to ensure the longevity of the joint replacement. In terms of solutions, I expect we will see increasing adoption of vitamin E polyethylene bearing surfaces as patients get younger and place more demands on their joint. Additionally, we’ll see some incremental advancements, like the stemless shoulders, and again, increased use of 3D imaging prior to surgeries.
Barbella: Where does innovation come from in the extremities market? How does Zimmer Biomet stay innovative?
Vankoski: Innovation in the extremities markets can arise from adjacent spaces. For example, dental colleagues are investigating and developing solutions for small implants. Leveraging these breakthrough technologies from the dental space holds much promise, especially within the hand and wrist. Additionally, many clinicians within the small joint space have an innovative mindset, and oftentimes advancements come from that community collectively thinking on how we can make things better for surgeons and patients.
Barbella: Aside from the implants, how does the extremities market differ from large joints, or spine? What makes extremities implants a design challenge?
Vankoski: In the extremities market, there are many more small players that focus on just one area compared to the large joint market. These smaller companies are focused and nimble with an ability to innovate at a faster pace compared to some of the larger organizations.
Barbella: How do the technological/physiological demands of small joints differ from other orthopedic markets?
Vankoski: In joints like the hip and knee, there are mature technological and testing requirements that need to be met in order to introduce a new product into the market. For extremities, like the finger and wrist for example, the testing requirements may not be as clear. Testing itself is still evolving in small joints.
Barbella: Where do the extremities and trauma markets overlap? How do they differ?
Vankoski: There is overlap in all joints, especially in shoulder fractures. Whereas trauma seeks to repair, shoulder reconstructive seeks to replace. There are good discussions and varying philosophies on the treatment algorithms depending on the joint. For example, for shoulder fractures, the trauma market tends to skew towards the younger patient and the arthroplasty market is biased to the older population; however, there are no cookie cutter solutions and a lot of gray area based on patient age, activity level and other health factors. For the wrist, finger and thumb, most seek to repair or fusion but this could be an area where replacement may become more acceptable with advancements in implant technology. For the elbow, whether to repair (which requires a plate) or replace depends on the surgeon’s background and patient’s clinical situation.
Barbella: Where do you see the extremities market five years from now?
Vankoski: We expect the market to mature and will see a continued migration towards smaller implants, less metal and increased convertibility of implants, particularly on the glenoid side which has lagged the humeral side in terms of clinical success. There is an opportunity for a company to offer good a convertible glenoid solution. Additionally, we expect to see continuous advancements in 3D pre-operative planning and range of motion assessments, burgeoning application of sensor technologies, leveling of the elbow market, and advancements in hand and wrist solutions in the U.S.