RBC’s 5th Annual Extremities Survey Released

The Royal Bank of Canada (RBC), the 5th largest investment bank in North America and one of the most respected research houses on Wall Street, issued its 5th annual survey of the extremities market last week. This survey of 57 U.S. surgeons focused primarily on upper extremities (shoulders).The survey, aimed at the Wall Street crowd, pulled in some interesting insights for both surgeons and companies who supply them. Here are five excerpts from that report that caught our attention.

1. 65% of surveyed surgeons plan to increase their use of pre-operative planning software and patient specific cutting guides for shoulder replacement
   Several manufacturers offer pre-operative planning software for shoulder replacement surgeries. And a growing number of manufacturers including Stryker Corporation and Blue Belt Technologies are offering smart, robotic tools which actually help guide the surgeon’s movements for knee and hip surgery.
   Can these smarter, more software driven tools—whether with motors attached or not—improve the quality of musculoskeletal procedures while reducing complication rates? Apparently the vast majority of extremity surgeons believe so.
   The RBC survey found that nearly two-thirds of surveyed surgeons (approximately 65%) said they will be using pre-operative or intro-operative planning software for patient specific cutting guides in the coming year. As many as 11% of the surgeons said that they would use it on more than 40 procedures in the coming year.

   

2. S. Surgeons remain undecided about pyrocarbon bearing surfaces for shoulder implants
   Pyrolytic carbon surfaces promise better wear than other bearing surface materials in articulating implants. But U.S. surgeons remain undecided. Several journals have stepped into this knowledge gap and have accelerated their efforts to publish studies on these materials.
   A retrospective review of 51 implants in 36 patients was undertaken by a group of researchers from Wrightington Hospital in the UK led by David R. Dickson, BSc, MBBS. They collected demographics, complications, further surgery, and implant revision data. The objective measures they employed were grip strength, range of motion, and radiological assessment of alignment, loosening, and subsidence. They also collected a subjective outcome measure—the Patient Evaluation Measure, Quick Disabilities of the Arm, Shoulder and Hand score, and visual analog scores (0, best; 10, worst) for appearance, satisfaction, and pain.
   Their results were published in the August 2015 edition of the Journal of Hand Surgery. Average follow-up was 103 months (range, 60–172 months). The mean arc of motion was 54° (range, 20° to 80°).
   Conclusions: No difference in grip strength between operated and nonsurgical side. Six implants were revised, and three of these required additional surgery. The degree of loosening or subsidence did not correlate with outcome. Implant survival as assessed by Kaplan–Meier was 88% at 10 years. And the patients reported good pain relief, a functional range of motion, and high satisfaction.
   So, at this stage in the commercialization of pyrocarbon implants for extremity surgery, the RBC survey found that 54% of the surgeons surveyed did not believe that this new bearing material would prove to be superior to other materials for shoulder replacements.

   

3. Stemless shoulders will grab 10-20% of shoulder procedures in five years
   Earlier this year, Minnesota-based Tornier (soon to be acquired by Wright Medical Group, Inc.) introduced the first stemless shoulder implant in the U.S. Stemless shoulder systems have been available in Europe for years.
   Since the original Neer humeral replacement in the 1950s, the standard primary anatomic total shoulder arthroplasty design has evolved slowly. Recently that evolution has been to shorten stems progressively in order to reduce the risk of stem-related complications. Several companies have developed and now market a stemless humeral arthroplasty component in Europe.
   Of the stemless shoulder arthroplasty systems heading to U.S. surgeons, three are currently undergoing clinical trials in the U.S., of which, as we noted earlier, Tornier’s Simpliciti, received FDA clearance earlier this year following the successful conclusion of its 2011 clinical trial.
   Naples, Florida-based Arthrex, Inc.’s Eclipse clinical trial started in January 2013 and the company has stated that it hopes to complete the study in 2017.
   The Biomet Nano clinical trial began in October 2013 and also has a tentative completion date of 2017. Results for stemless shoulder arthroplasty indicate clinical outcomes are similar to standard stemmed shoulder arthroplasty. Radiographic analysis indicates implant stability without migration or subsidence at two- to three-year minimum follow-up.
   According to the RBC survey, surgeons are looking forward to this new Tornier implant. With more than 2, 700 Simpliciti cases performed outside the U.S., there is good reason for excitement about stemless implants. So far 16% of the U.S. surgeons have been trained on the Simpliciti implant. And feedback is positive.
   When surgeons were asked for what percentage of their patients would they consider using a stemless implant, the average answer was 20% within five years.

   

4. Patient specific instruments, planning software, new poly and stemless shoulders are technologies most likely to change practices in the next few years
   To a large extent innovation in orthopedics is migrating toward reducing clinical errors, improving patient outcomes by lowering complication rates and, in effect, standardizing excellence even in the face of patient anatomical diversity.
   Probably the predominant method that manufacturers are using to develop this avenue of innovation is a combination of new instrumentation, planning software, 3-D visualization software, and implant customization.
   When RBC asked surgeons about their reaction to specific product lines, these trends in innovation were apparent in the rankings. Extremity surgeons are clearly excited about the innovations coming their way.
   In what was probably the most interesting question in the survey, RBC asked surgeons about specific company products. Here, courtesy of RBC, is the result.

   

5. Surgery backlogs are growing in the U.S. and upper extremity surgeries should grow at high-single-digit year-over-year rates in 2015 and 2016
   RBC’s analysts, relying on data from Dalton Consulting in Warsaw, Indiana, are forecasting continued strong growth in sales of extremity products in the U.S. due to improved health care utilization; more surgeons trained on extremity procedures; innovative, new products which can expand the total market; and mix changes which can mitigate the effects of pricing pressure. As a result, RBC’s analysts are modeling approximately 9% year-over-year sales growth in 2016. Forming the basis for such a strong forecast is the message from the surgeons themselves that backlogs are strong and likely to grow in 2016.

   

Thanks to RBC Capital Markets and specifically Glenn Novarro, Brandon Henry, CFA and George Santo for allowing OTW to use portions of the Fifth Annual RBC Extremity Surgeon Survey for this article.