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Shoulder replacement surgery is entering a transformative phase, driven by advancements in implant technology and surgical techniques. THE ORTHOPAEDIC INDUSTRY ANNUAL REPORT published by ORTHOWORLD noted that growing demand for shoulder arthroplasty helped spur orthopedic sales in the extremity joint replacement segment to $2.7 billion in 2022 — 7% more than the previous year. The burgeoning reverse shoulder replacement segment is an $800 million market that’s showing double-digit growth, according to the report.
Orthopedic companies are taking notice. Established players and ambitious startups are vying for a share of the market by developing personalized implants and enabling technology that help surgeons replace damaged and diseased bone with added precision.
Anatomically Aligned Implants
One of the key trends shaping the shoulder replacement market is the continuing development of anatomically designed implants. In the past, the design differential between implants used for reverse and anatomic shoulder replacements was considerable, said Zachary Leitze, M.D., an orthopedic surgeon at Intermountain Healthcare and consultant for Catalyst OrthoScience. The conventional wisdom rested on distinct design philosophies: anatomical implants mimicked natural joint anatomy, while reverse implants altered the joint’s articulation.
To challenge these design concepts and drive clinical improvements, Catalyst has taken a more refined approach to implant design. The company’s CSR Total Shoulder System centers around bone preservation and the restoration of anatomical integrity to provide a better range of motion in the joint. This philosophy has influenced every design aspect of the system, from the stemless humeral component to the angled instrumentation and all-poly glenoid.
Garrett Campbell, Senior Director of U.S. Marketing at Catalyst, explained that the Catalyst CSR system preserves more bone compared to other stemless or stemmed implants because the multi-planar osteotomy technique firmly anchors the implant in the dense, subchondral bone of the humeral head.
A secondary benefit of this bone-sparing design becomes apparent when patients who undergo a primary replacement require conversion to reverse total shoulder replacement due to a deficient rotator cuff. In such cases, surgeons have significantly more native bone to work with along with an untouched humeral canal, enabling a more successful, efficient and effective procedure.
Minimizing or eliminating stems in shoulder implants is another growing trend. Dr. Leitze noted that Catalyst’s undersized reverse stem allows for personalized cup placement, mirroring the concept of preserving the natural anatomy of the joint. This metaphyseal-fixated cup-centric philosophy aligns with the goal of establishing the center of the joint’s rotation as accurately as possible.
The longevity of shoulder implants is a key concern for orthopedic manufacturers, noted Robert Ball, CEO of Shoulder Innovations. Loosening of the glenoid implant is a common concern.
To address this issue, Shoulder Innovations created the InSet System, which not only provides better fixation but also allows surgeons to reconstruct the shoulder anatomy to a more natural position. Unlike traditional implants that are placed on top of the glenoid surface, InSet’s device is set within the most supportive bone of the glenoid. This significantly reduces the stress that contributes to loosening, Ball noted.
“Shoulder replacement outcomes are based on complications, joint function and postoperative pain,” Ball said. “When surgeons position anatomy more naturally, the likelihood of complications and post-op pain is reduced, and range of motion is increased.”
The focus on restoring the natural anatomy of the shoulder is also driving Exactech’s approach to product development. The company’s Equinoxe Shoulder System allows surgeons to adjust retroversion, neck angle and medial and posterior offset of the humeral head — without the need for trials or back table assembly.
Many companies, including Exactech, are developing implants that better conform to the patient’s joint anatomy. The Equinoxe anatomic system allows surgeons to replicate a patient’s unique anatomy by independently adjusting the system’s parameters during surgery.
“The designs of anatomic shoulder systems continue to evolve,” said Emery Patton, Exactech’s Vice President of Extremities Marketing. “One example of this movement is our stemless shoulder, which was one of the first of its kind in the U.S. The stemless prosthesis is placed in the center of the humeral head resection instead of in the intermedullary canal of the humerus.”
This feature allows surgeons to recreate each patient’s unique anatomy on the humeral and glenoid side of the joint, according to Patton. Although improved clinical outcomes are driving implant design decisions, surgical efficiency is also a key consideration in the development of new products.
Catalyst’s proprietary set of instrumentation, designed for ease of use with the CSR system, further enhances its appeal to surgeons. The angled glenoid instrumentation minimizes retractor stress on surrounding tissues and streamlines the surgical process, even during complex cases.
Ball emphasized the importance of developing shoulder replacement systems with the ASC customer in mind. “Our platform includes seven shoulder arthroplasty products in two basic instrument trays,” he said. “That makes it easier for the surgical team to support the surgeon, resulting in simpler and shorter procedures.”
Reverse Shoulders on the Rise
A notable shift in the market is the growing popularity of reverse shoulder surgery. By reversing the orientation of the ball-and-socket joint, this procedure leverages different muscle groups to restore shoulder function and stability. Increased interest in reverse shoulder replacement, especially for patients with severe rotator cuff tears or cuff tear arthropathy, has prompted advancements in implant designs and ancillary technologies.
“Most of the recent changes and efforts to improve range of motion are seen in the biomechanical designs of reverse implants,” Ball said.
Campbell shared that the shoulder arthroplasty market has seen a surge in the popularity of indications for reverse shoulders. He said about 60% to 70% of the procedures performed today are reverse shoulders, so it is a priority for many companies to develop and refine their portfolios in this segment. Competition in the space is strong, and companies continue to examine unmet clinical needs and push the boundaries of what’s possible.
One such advancement is the Catalyst R1 Reverse System, which is a true single-tray system that allows for directed, precise and bone-sparing implant placement. “We wanted to design a modern yet simple-to-use reverse shoulder system,” Campbell said. “The R1 is purposefully designed with a versatile stem and baseplate and paired with streamlined instrumentation.”
The InSet Reverse Shoulder System from Shoulder Innovations provides added stability and optimized motion in the joint.
Shoulder Innovations’ InSet Reverse Shoulder System strengthens fixation and reduces complication risks. The comprehensive implant system lets surgeons tailor the fit of its components to the unique anatomy of individual patients. InSet’s titanium humeral stems include curved fins that provide increased stability and a porous titanium surface coating that promotes bone regeneration and bonding.
“Placing InSet devices on the reverse side of the shoulder so that the implants support the scapular and humeral sides of the joint provides excellent fixation and allows the surgeon to restore anatomy to a more natural position,” Ball said.
Exactech has also contributed to the evolution of reverse shoulder replacement. The company’s Equinoxe platform system was one of the first on the market to facilitate a smoother and more efficient conversion from a failed anatomic shoulder to a reverse replacement. Innovations like this reduce intraoperative complications, limit blood loss and contribute to shorter operative times.
Planning for Improved Outcomes
Robotic assistance and surgical navigation are set to usher in a new era of personalized surgical approaches. Zimmer Biomet and Stryker expect to introduce shoulder robotic platforms to the market in 2024.
Catalyst’s Archer 3D Targeting Software provides surgeons with a comprehensive toolset to visualize and plan procedures accurately. The planning software lets surgeons review and analyze 3D models of patients’ joints based on preoperative CT scans, providing crucial insights before they enter the operating room.
Preoperative planning software from Shoulder Innovations presents surgeons with 3D models of an individual patient’s shoulder anatomy that helps them optimize implant alignment.
Shoulder Innovations supports its InSet Shoulder System with PreView Shoulder Arthroscopy Planning Software, which converts CT scans of the shoulder joint into 3D anatomical models. Surgeons can review the model before surgery to plot out an effective surgical plan and optimize the implant size, placement and orientation.
Exactech’s ExactechGPS is a unique navigation technology that offers real-time visibility into the joint, enabling precise implant placement and contributing to better patient outcomes.
As major players continue to spearhead advancements in implant design and adopt enabling technology, the future of shoulder surgery looks promising. The introduction of innovative devices will redefine surgical precision, patient customization and overall joint health.
“I think we’re just scratching the surface of what’s possible,” Patton said. “Ten years from now, technology will play an even more important role in shoulder replacement outcomes.”
Ball believes that the future of shoulder replacement surgery will involve increased specialization and addressing the clinical needs of individual patients. “Companies will need to be highly flexible to provide a broad range of products to highly specialized surgeons who know exactly what they want to deliver the best possible care to their patients.”
