Big Trend Towards Small Bone Plating

Consider it a natural evolution, of sorts.
 
The planet’s extremities market, long ignored by major orthopedic device manufacturers, is finally commanding respect as companies attempt to counterbalance sluggish growth in the saturated, maturing hip and knee replacement sectors. Fueled by an aging world population, more youth-related sports injuries, and rising rates of obesity, osteoarthritis, and osteoporosis, the global extremities market is projected to be worth $15.9 billion by 2024, according to Research and Markets data. Internal fixation devices such as plates and screws have dominated the sector in recent years due to the early functionality, abbreviated hospital stays, minimal scarring, and reduced non-union risk associated with these products. Acumed LLC has particularly benefited from the high demand for internal fixation, having sold 500,000 wrist fixation implants (Acu-Loc and Acu-Loc 2) in just two years.
 
Such promise, of course, is garnering interest among major orthopedic companies that traditional have overlooked the sector in favor of the more lucrative large-joint sector. ODT’s May/June feature story “Going to Extremes” examines the trends and challenges driving the extremities market as well as some of the latest technologies available to patients. John Clausen, vice president of trauma and extremities marketing at Smith & Nephew plc, was among the 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?
John Clausen: We are still seeing a big trend towards small bone plating, especially in the distal radius segment, and there has also been a push by companies with new shoulder prostheses and total ankle replacements. There has not been as much emphasis as in the past on hammer toe devices. We are also seeing increased emphasis in the mini rail systems in recent years.
 
Barbella: What challenges face companies in the small joint (extremities) sector, and how are these challenges different than those faced by companies manufacturing large joints – i.e., hips and knees? How can companies in the extremities sector overcome these challenges?
Clausen: When benchmarked against large joint replacement, many of the small joint procedures struggle to reach the same level of clinical success. Most large joint surgeries have very high satisfaction scores and very low rates of reoperation at 10 years. Innovative companies are looking for ways to improve outcomes and long term success rates for small joint procedures.
 
Barbella: What new technologies are on the horizon? What kinds of implants hold the most potential for patients and for market growth? 
Clausen: We will probably see additional innovation in the Total Ankle Replacement (TAR) segment and may soon see bioresorbables or carbon fiber technology make a successful entrance into the small bone segment. These technologies have not yet been proven effective in the larger bone segments but may be useful in extremities. Implants with the most potential for patient and market growth are probably in TAR and in hammer toe segments. Both can be extremely painful for patients and outcomes can likely be improved upon. We have seen some advanced innovation in the hammer toe segment with products like the Smith & Nephew HAT-TRICK Lessor Toe Repair System.

Innovation comes from close interaction with surgeons, having a good overview of the technology landscape and having superior engineering talent to develop products and commercial solutions that address real needs. Smith & Nephew has always prided itself on innovation, as evidenced by our rich intramedullary nail (IM) history, TRIGEN IM Nails and SURESHOT for Distal Targeting, INTERTAN for Hip Fractures and OXINIUM technology in our Joint Reconstruction business. We find that partnering with thought-leading surgeons to identify key needs and evaluate solutions to be extremely valuable. Smith & Nephew arguably has some of the best engineering talent in the industry and when paired with surgeon thought-leaders has given us a proven formula for innovation success.
 
Barbella: Aside from the implants, how does the extremities market differ from large joints, or spine?
Clausen: Surgical specialization is a challenge in extremities. There are a large number of DPMs (Doctor of Podiatric Medicine) that now perform extremity surgery as well as the hand and foot specialists that may practice at hospitals or surgery centers. This is a slightly different call pattern than the traumatologist who also performs extremity surgery in the trauma centers. Each of these surgeons has different philosophy in treatment and different customer needs that need to be met.
 
Barbella: How do the technological/physiological demands of small joints differ from other orthopedic markets?
Clausen: Small joint issues cause extreme pain for the patient and can significantly alter their lifestyle. Surgery for small joints tends to be somewhat more painful than something like a total hip procedure. It is very frustrating for a patient when a toe, finger, ankle, or shoulder needs an operation because the recovery time can be long. Small joints can be a very demanding environment for the implant with relatively high loads and mobility.
 
Barbella: Where do the extremities and trauma markets overlap? How do they differ?
Clausen: Extremities and trauma markets overlap the most in the areas of plates and screw fixation. There are a significant number of trauma surgeons that perform hand and wrist as well as foot and ankle surgery which can overlap with the hand and wrist specialist, foot and ankle specialists, and DPM surgeons. It is common to find a differing of philosophies among these specialties.
 
Barbella: Where do you see the extremities market five years from now? 
Clausen: The extremity market is ready for continued innovation to improve mobility, reduce pain, and increase patient satisfaction. This can be seen with such products as Smith & Nephew HAT-TRICK and VLP MINI-MOD. We are just starting to see the large joint companies switch their engineering focus to extremity solutions. This competition will spur the smaller companies to increase their innovation strength as well. With this much focus on small joints, we are entering into a very exciting time to see some unique product innovations which will benefit patients.