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This BCC Research report covers the global joint reconstruction and replacement market, procedures, key growth areas, and quantitative market projections for technologies and devices through 2018. Increasing prevalence and rising patient concern about their health are boosting the joint reconstruction market. In addition to looking at current and future markets, the study also analyzes technological, demographic and economic developments that may have a long-term impact on the size and structure of the joint reconstruction and replacement market for services and products.

Use this report to:
- Learn about the the global market for joint reconstruction and replacement materials and technologies.
- Identify and segment the major orthopedic categories of joint reconstruction and replacement and the relevant disease population.
- Forecast the potential market based on the pipeline, taking into account the estimated probability that they will be commercialized.
- Assess the long-term outlook for the joint reconstruction and replacement market, taking into account market opportunities, as well as technological, financial and economic factors.

Highlights
- The global market for joint reconstruction and replacement was worth nearly $13.2 billion in 2013. This market is expected to increase to nearly $16.2 billion by 2018, registering a compound annual growth rate (CAGR) of 4.2% from 2013 through 2018.
- The U.S. market is projected to increase from $8.1 billion in 2013 to $10.3 billion by 2018, with a CAGR of 5.1% for the period of 2013 to 2018.
- The market in Europe is projected to increase from $3.8 billion in 2013 to $4.5 billion by 2018, with a CAGR of 3.3% for the period of 2013 to 2018.

INTRODUCTION
JOINT RECONSTRUCTION AND REPLACEMENT
The joint reconstruction and replacement market is the largest segment within the orthopedic market and contributes more than 40% in terms of sales revenue.
Osteoarthritis (OA) and rheumatoid arthritis (RA) are key joint disorders. Osteoporosis is another disease that affects the joints, especially in women (i.e., postmenopausal
osteoporosis), and leads to serious bone fractures. This market comprises bone cement and devices intended for the reconstruction and replacement of joints such as hip,
knee, shoulder and small joints (e.g., wrist, ankle, elbow and digits). Hip and knee devices account for more than 85% of the joint reconstruction and replacement market
in terms of sales revenue.

The ever-increasing aging population and the introduction of improved devices and technologies (e.g., minimally invasive techniques) are the key drivers of this market.
The U.S. and Europe lead the global joint reconstruction and replacement market followed by the rest of the world.

STUDY BACKGROUND
Osteoarthritis is the most common type of arthritis, characterized by the degeneration of articular cartilage, enlargement of bones at margins and deterioration of the synovial membrane. It causes chronic inflammation, resulting in the gradual wear of the cartilage covering the bone. The condition restricts the smooth motion of bones
and causes pain. It is common in the population aged 50 to 60 years. Weight bearing joints such as the hips, knees and spine are the joints most affected by OA with
increasing age.

Rheumatoid arthritis is another disabling type of arthritis. It is a chronic (long-term) disease that causes pain, stiffness, swelling and limited motion and function of many
joints. Although the disease can affect any joint, small joints in the hands and feet tend to be involved most often in this condition. Inflammation sometimes can affect organs
such as the eyes and lungs as well. In addition to the key disorders, OA and RA, osteoporosis is also a common bone disease that reduces the amount and quality of the bones, leading to fractures (broken bones). Osteoporosis does not cause pain or other symptoms unless a fracture has occurred.

Although drugs and other pharmacologic treatments slow down these diseases and related pain, in severe cases surgery is recommended. Since there is a large symptomatic patient pool worldwide, there is a pressing need to develop an up-to-date base of market information to better understand the dynamics of the joint reconstruction and replacement: materials, technologies and global markets. This report is the first edition of in-depth report to cover the joint reconstruction and replacement market, procedures, key growth areas, and quantitative market projections for technologies and devices. Increasing prevalence and rising patient concern about their health are boosting the joint reconstruction market. This study attempts to provide those involved in the industry with the information and analysis they need to address these challenges.

STUDY GOALS AND OBJECTIVES
This study, Joint Reconstruction and Replacement: Materials, Technologies and Global Markets, provides an overview of the products included in this market, and detailed
analyses of markets and competitive environments. This area covers a wide variety of products. It also covers the conditions that lead to joint disorders and injuries. The
study includes information about significant products, players, issues and trends, and other information affecting the orthopedic (joint replacement) industry. This study meets these needs by analyzing global markets for joint reconstruction and replacement (see the section “Scope” for a definition of these terms) in light of the most currently available information. In addition to looking at current and future markets, the study analyzes technological, demographic and economic developments that may have a long-term impact on the size and structure of the joint reconstruction and replacement market for services and products. The future of joint reconstruction also will be discussed with forecasts of each segment.

More specific objectives are to:
- Identify and segment the major orthopedic categories of joint reconstruction and replacement and the relevant disease population.
- Analyze the historical and current population under treatment by geographic markets.
- Identify and evaluate the impact of demographic, economic and other factors that will drive future demand for the joint reconstruction and replacement market..
- Forecast the disease population targeted for treatment by the probabilities that future demand will be higher or lower than the baseline forecast.
- Identify promising new devices, materials and technologies still in the development and testing stage, and assess the probability that they will be commercialized
successfully in the next five years.
- Forecast the potential market based on the pipeline, taking into account the estimated probability that they will be commercialized.
- Identify leading implant manufacturers and analyze the structure of the joint reconstruction and replacement market within the orthopedic industry (e.g., market
shares, concentration, and recent merger and acquisition activity).
- Assess the long-term outlook for the joint reconstruction and replacement market, taking into account market opportunities, as well as technological, financial and
economic factors.

Ongoing patient management studies will increase the number of indications. Keeping in touch with these applications for the various products is good business practice. This
study will provide the reader with the knowledge to adequately view and assess the joint surgery market and provide insights into market potential.

INTENDED AUDIENCE
The report has been written for the orthopedic market community with a focus on the joint reconstruction and replacement segment, but is especially tailored for readers
with an interest in the marketing and management dimensions of current market and technological trends within joint reconstruction and replacement, and global markets.

This especially includes readers in the:
- Pharmaceutical and medical device industry.
- Medical research institutions.
- Investment community.
- Financial and analyst community.

SCOPE OF THE REPORT
This report is an analytical business tool whose primary purpose is to describe the thorough evaluation of the global market for joint reconstruction and replacement
materials and technologies. The format of the study is organized around the following topics:
- Detailed study around joint disorders and key indications, including OA, RA and osteoporosis.
- Disease incidence and prevalence.
- Regulatory structure.
- Market characterization, unmet need, market size and segmentation.
- Market drivers and restraints.
- Detailed market projections through 2018.
- Competition and market shares.
- Pricing and reimbursement.
- Marketed and pipeline (R&D) products along with a description, regulatory status and clinical trials.
- Market strategy with an overview of key mergers and acquisitions.
- Observations and conclusions regarding the future market of joint reconstruction and replacement, materials and technologies.
- Profiles of market participants and associations.

METHODOLOGY AND INFORMATION SOURCES
The findings and conclusions of this report are based on information gathered through primary and secondary data collection methods. Primary methods included interviews
with key executives, product managers, clinical specialists and other related key personnel involved in the orthopedic industry. Secondary sources included published
literature, investment reports, trade publications, trade associations, government sources (diseases and demographics), joint registries, company literature and online
databases and various business journals that have an emphasis on joint disorders and injuries and related areas to produce the market estimates contained in this report.
The base year for analysis and projection is 2013. At the time this report was prepared (early 2014), year-end data for 2013 were not yet universally available.

With 2013 as a baseline, market projections were developed for 2013 to 2018. These projections are based on a consensus of primary contacts combined with BCC Research’s understanding of the key market drivers and their impact from a historical and analytical perspective. The analytical methodologies used to generate the market estimates are described in detail in the section on “Detailed Market Projections.” All dollar projections presented in this report are in 2013 constant dollars.

Table Of Contents

Joint Reconstruction and Replacement: Materials, Technologies, and Global Markets
TABLE OF CONTENTS

CHAPTER 1 INTRODUCTION 2
JOINT RECONSTRUCTION AND REPLACEMENT 2
STUDY BACKGROUND 2
STUDY GOALS AND OBJECTIVES 3
INTENDED AUDIENCE 4
SCOPE OF THE REPORT 4
METHODOLOGY AND INFORMATION SOURCES 4
ANALYST'S CREDENTIALS 5
RELATED BCC RESEARCH REPORTS 5
BCC RESEARCH WEBSITE 5
DISCLAIMER 6

CHAPTER 2 SUMMARY 8
EXECUTIVE SUMMARY 8
SUMMARY TABLE A GLOBAL MARKET FOR JOINT RECONSTRUCTION AND
REPLACEMENT, THROUGH 2018 ($ MILLIONS) 8
SUMMARY FIGURE A GLOBAL MARKET FOR JOINT RECONSTRUCTION AND
REPLACEMENT, 2012-2018 ($ MILLIONS) 8
SUMMARY TABLE B GLOBAL JOINT RECONSTRUCTION AND REPLACEMENT MARKET
BY SEGMENT TYPE, THROUGH 2018 ($ MILLIONS) 9
SUMMARY FIGURE B GLOBAL JOINT RECONSTRUCTION AND REPLACEMENT
MARKET BY SEGMENT TYPE, 2012-2018 ($ MILLIONS) 9

CHAPTER 3 CLINICAL OVERVIEW OF BONES AND JOINTS 12
CLINICAL OVERVIEW AND ROLE OF BONES IN BODY MOVEMENT 12
BONE STRUCTURE 12
CELLULAR STRUCTURE 12
Osteogenic Cells 13
Osteoblasts 13
Osteocytes 13
Osteoclasts 13
Organic Matrix 13
Collagen 13
Cartilage 14
BONE MODELING 14
BONE REMODELING 14
BONE MATERIAL 14
COMPACT BONE 14
SPONGY BONE 15
BONE MARROW 15
LIGAMENTS AND TENDONS 15
JOINT STRUCTURE, FUNCTION AND DEFINITIONS 15
HIP JOINT 16
KNEE JOINT 16
SHOULDER JOINT 16
SMALL JOINTS 16
Foot and Ankle 17
Hand and Wrist 17
Elbow 17
Digits 18

CHAPTER 4 JOINT DISORDERS 20
GENERAL OVERVIEW OF JOINT PAIN AND RELATED DISORDERS 20
OSTEOARTHRITIS 20
DISEASE OVERVIEW 20
ETIOLOGY 21
EPIDEMIOLOGY AND MARKET BURDEN 21
TABLE 1 GLOBAL PREVALENCE OF OSTEOARTHRITIS (SYMPTOMATIC) BY
GEOGRAPHIC REGION, THROUGH 2018 (MILLIONS) 22
FIGURE 1 GLOBAL PREVALENCE OF OSTEOARTHRITIS (SYMPTOMATIC) BY
GEOGRAPHIC REGION, 2012-2018 ($ MILLIONS) 22
DISEASE SYMPTOMS AND RISK FACTORS 23
Disease Symptoms 23
Risk Factors 23
DIAGNOSIS AND TREATMENT 24
Diagnosis 24
Treatment 24
Non-pharmacological Treatment 24
Pharmacological Treatment 25
Intra-articular Treatment 25
Surgical Treatment 25
Reducing the Risk of Osteoarthritis 26
RHEUMATOID ARTHRITIS 27
OVERVIEW 27
ETIOLOGY 27
EPIDEMIOLOGY AND ECONOMIC BURDEN 28
TABLE 2 GLOBAL PREVALENCE OF RHEUMATOID ARTHRITIS (SYMPTOMATIC) BY
REGION, THROUGH 2018 (MILLIONS) 28
FIGURE 2 GLOBAL PREVALENCE OF RHEUMATOID ARTHRITIS (SYMPTOMATIC) BY
REGION, 2012-2018 ($ MILLIONS) 29
DISEASE SYMPTOMS AND RISK FACTORS 29
Disease Symptoms 29
Risk factors 29
DIAGNOSIS AND TREATMENT 30
Diagnosis 30
Treatment 30
Non-pharmacological Treatment 30
Pharmacological Treatment 31
Surgical Treatment 32
REDUCING THE RISK OF RHEUMATOID ARTHRITIS 32
POSTTRAUMATIC ARTHRITIS 33
DISEASE OVERVIEW 33
ETIOLOGY 33
EPIDEMIOLOGY AND MARKET BURDEN 33
TABLE 3 POST-TRAUMATIC ARTHRITIS AND INCIDENCE OF KNEE FRACTURES BY
GEOGRAPHIC REGION, THROUGH 2018 (ACTUAL) (MILLIONS) 34
FIGURE 3 POST-TRAUMATIC ARTHRITIS AND GLOBAL INCIDENCE OF KNEE
FRACTURES BY REGION, 2012-2018 ($ MILLIONS) 34
DISEASE SYMPTOMS AND RISK FACTORS 34
DIAGNOSIS AND TREATMENT 35
Diagnosis 35
Treatment 35
REDUCING THE RISK OF POST-TRAUMATIC ARTHRITIS 35
OSTEOPOROSIS 36
DISEASE OVERVIEW 36
ETIOLOGY 37
EPIDEMIOLOGY AND ECONOMIC BURDEN 37
TABLE 4 GLOBAL PREVALENCE OF OSTEOPOROSIS BY REGION, THROUGH 2018
(MILLIONS) 38
FIGURE 4 GLOBAL PREVALENCE OF OSTEOPOROSIS BY REGION, 2012-2018 ($
MILLIONS) 38
DISEASE SYMPTOMS AND RISK FACTORS 39
Disease Symptoms 39
Fractures 39
Spinal Deformities 39
Pain 39
Risk Factors 39
DIAGNOSIS AND TREATMENT 41
Diagnosis 41
Treatment 41
REDUCING THE RISK OF OSTEOPOROSIS 42
JOINT DISORDERS AND ECONOMIC BURDEN ON THE U.S. HEALTHCARE SYSTEM 43
HISTORICAL BACKGROUND OF ORTHOPEDIC MARKET 43

CHAPTER 5 JOINT IMPLANTS, MATERIALS AND ASSOCIATED ISSUES 46
JOINT IMPLANTS 46
HIP IMPLANTS 46
KNEE IMPLANTS 46
SHOULDER IMPLANTS 46
SMALL JOINT IMPLANTS 46
Elbow Implants 46
Foot and Ankle Implants 46
Hand Wrist Implants 47
Digit Implants 47
IMPLANT MATERIALS 47
HISTORICAL BACKGROUND 47
CURRENT MATERIALS 48
Titanium 48
Cobalt-Chrome 48
Tantalum 48
Foam Metal Implants 48
Polyetheretherketone 48
Allograft Prosthesis 49
Innovative Ceramics 49
ISSUES ASSOCIATED WITH CURRENT MATERIALS 49
JOINT REPLACEMENT PROCEDURES 50
OPEN PROCEDURE 50
MINIMALLY INVASIVE PROCEDURE 50
IMPLANT FIXATION 50
IMPLANTS BY BEARING TYPE 51
FIXED BEARING IMPLANTS 51
MOBILE BEARING IMPLANTS 51

CHAPTER 6 HIP REPLACEMENT 54
OVERVIEW OF HIP REPLACEMENT 54
HIP FRACTURES 55
TABLE 5 GLOBAL INCIDENCE OF HIP FRACTURES BY REGION, THROUGH 2018
(THOUSANDS) 55
FIGURE 5 GLOBAL INCIDENCE OF HIP FRACTURES BY REGION, 2012-2018
(THOUSANDS) 56
HIP IMPLANT TYPES 56
MODULAR VS NON-MODULAR IMPLANTS 56
CEMENTED VERSUS PRESS-FIT (CEMENTLESS) IMPLANTS 57
BEARING SURFACES 57
Metal-on-Polyethylene 57
Ceramic-on-Ceramic 57
Metal-on-Metal 58
CROSS-LINKED POLYETHYLENE 58
BIPOLAR IMPLANTS 59
GENDER SPECIFIC HIP IMPLANTS 59
HIP REPLACEMENT BY TYPE 59
PRIMARY/TOTAL HIP REPLACEMENT 59
Indications for Total Hip Replacement 59
Cemented Hip Implants 60
Cementless Hip Implants (Press-Fit) 60
Hybrid Hip Implants 61
HIP RESURFACING 61
Birmingham Hip Resurfacing (BHR) 61
Indications for Hip Resurfacing 62
REVISION HIP REPLACEMENT 62
HEMIARTHROPLASTY 62
MINIMALLY INVASIVE HIP ARTHROPLASTY 63
Anterior Hip Replacement Surgery 63
NAVIGATION SYSTEMS 63
Robotic Hip Surgery 64
HIP REPLACEMENT PROCEDURES BY REGION 64
TABLE 6 GLOBAL HIP REPLACEMENT PROCEDURES VS TOTAL JOINT
RECONSTRUCTION PROCEDURES, THROUGH 2018 (THOUSANDS) 64
FIGURE 6 GLOBAL HIP REPLACEMENT PROCEDURES VS TOTAL JOINT
RECONSTRUCTION PROCEDURES, 2012-2018 (THOUSANDS) 64
TABLE 7 GLOBAL HIP REPLACEMENT PROCEDURES BY REGION, THROUGH 2018
(THOUSANDS) 65
FIGURE 7 GLOBAL HIP REPLACEMENT PROCEDURES BY REGION, 2012-2018
(THOUSANDS) 65
BENEFITS, RISK FACTORS AND COMPLICATIONS ASSOCIATED WITH HIP
REPLACEMENT 66
CHAPTER 7 KNEE REPLACEMENT 69
OVERVIEW OF KNEE REPLACEMENT 69
KNEE IMPLANT TYPES 70
FIXED BEARING KNEE IMPLANT 70
MOBILE BEARING KNEE IMPLANT 70
MEDIAL PIVOT KNEE IMPLANT 71
GENDER SPECIFIC KNEE IMPLANTS 71
PATIENT-SPECIFIC/CUSTOMIZED IMPLANTS 71
KNEE REPLACEMENT TYPES 72
PRIMARY/TOTAL KNEE REPLACEMENT 72
Indications for Total Knee Replacement 72
Posterior Stabilized/Cruciate Retaining 72
Cemented Knee Prostheses 73
Cementless Knee Prostheses 73
Hybrid Knee Fixation 73
KNEE RESURFACING 74
REVISION KNEE REPLACEMENT 74
Indications for Revision Knee 74
UNICONDYLAR KNEE REPLACEMENT 74
NAVIGATION SYSTEMS 75
Robotic Knee Surgery 75
NAVIGATION SYSTEMS 76
Computer-Guided Robotic Shoulder Replacement Surgery 76
MINIMALLY INVASIVE SURGERY 76
KNEE REPLACEMENT PROCEDURES BY REGION 76
TABLE 8 GLOBAL KNEE REPLACEMENT PROCEDURES VS TOTAL JOINT
RECONSTRUCTION PROCEDURES, THROUGH 2018 (THOUSANDS) 77
FIGURE 8 GLOBAL KNEE REPLACEMENT PROCEDURES VS TOTAL JOINT
RECONSTRUCTION PROCEDURES, 2012-2018 (THOUSANDS) 77
TABLE 9 GLOBAL KNEE REPLACEMENT PROCEDURES BY REGION, THROUGH 2018
(THOUSANDS) 78
FIGURE 9 GLOBAL KNEE REPLACEMENT PROCEDURES BY REGION, 2012-2018
(THOUSANDS) 78
BENEFITS, RISK FACTORS AND COMPLICATIONS OF KNEE REPLACEMENT
PROCEDURES 78

CHAPTER 8 SHOULDER REPLACEMENT 81
OVERVIEW OF SHOULDER REPLACEMENT 81
SHOULDER IMPLANT MATERIALS AND TYPES 81
SHOULDER REPLACEMENT TYPES 82
PRIMARY/TOTAL SHOULDER REPLACEMENT 82
REVERSE SHOULDER ARTHROPLASTY 83
SHOULDER HEMIARTHROPLASTY/PARTIAL SHOULDER REPLACEMENT 83
SHOULDER RESURFACING 84
REVISION SHOULDER REPLACEMENT 84
MINIMALLY INVASIVE SHOULDER REPLACEMENT 84
SHOULDER REPLACEMENT PROCEDURES BY REGION 85
TABLE 10 GLOBAL SHOULDER REPLACEMENT PROCEDURES VS TOTAL JOINT
RECONSTRUCTION PROCEDURES, THROUGH 2018 (THOUSANDS) 85
FIGURE 10 GLOBAL SHOULDER REPLACEMENT PROCEDURES VS TOTAL JOINT
RECONSTRUCTION PROCEDURES, 2012-2018 (THOUSANDS) 85
TABLE 11 GLOBAL SHOULDER REPLACEMENT PROCEDURES BY REGION, THROUGH
2018 (THOUSANDS) 86
FIGURE 11 GLOBAL SHOULDER REPLACEMENT PROCEDURES BY REGION,
2012-2018 (THOUSANDS) 86
BENEFITS, RISK FACTORS AND COMPLICATIONS OF SHOULDER REPLACEMENT
PROCEDURES 87

CHAPTER 9 SMALL JOINT REPLACEMENT 89
OVERVIEW OF SMALL JOINT REPLACEMENT 89
SMALL JOINT REPLACEMENT TYPES 90
ANKLE REPLACEMENT 90
Mobile Bearing 91
Fixed Bearing 91
ELBOW REPLACEMENT 91
Total Elbow Arthroplasty 91
Constrained Arthroplasty 92
Semiconstrained Arthroplasty 92
Unconstrained Arthroplasty 92
Radial Head Arthroplasty 92
Metal and Pyrocarbon 93
Silicone 93
HAND WRIST REPLACEMENT 93
DIGITS REPLACEMENT 93
Finger Replacement 94
Toe Replacement 94
Thumb Replacement 94
ARTHROSCOPIC (MINIMALLY INVASIVE) SMALL JOINT SURGERY 94
Ankle Arthroscopy 95
Elbow Arthroscopy 95
Wrist Arthroscopy 95
SMALL JOINT REPLACEMENT PROCEDURES BY REGION 95
TABLE 12 GLOBAL SMALL JOINT REPLACEMENT PROCEDURES VS TOTAL JOINT
RECONSTRUCTION PROCEDURES, THROUGH 2018 (THOUSANDS) 96
FIGURE 12 GLOBAL SMALL JOINT REPLACEMENT PROCEDURES VS TOTAL JOINT
RECONSTRUCTION PROCEDURES, 2012-2018 (THOUSANDS) 96
TABLE 13 GLOBAL SMALL JOINT REPLACEMENT PROCEDURES BY REGION,
THROUGH 2018 (THOUSANDS) 97
FIGURE 13 GLOBAL SMALL JOINT REPLACEMENT PROCEDURES BY REGION,
2012-2018 (THOUSANDS) 97
BENEFITS, RISK FACTORS AND COMPLICATIONS OF SMALL JOINT REPLACEMENT
PROCEDURES 97

CHAPTER 10 JOINT RECONSTRUCTION AND REPLACEMENT MARKET ASSESSMENT 100
JOINT RECONSTRUCTION AND REPLACEMENT MARKET 100
GLOBAL MARKET 100
Global Market by Region 100
TABLE 14 GLOBAL JOINT RECONSTRUCTION AND REPLACEMENT MARKET BY
REGION, THROUGH 2018 ($ MILLIONS) 100
FIGURE 14 GLOBAL JOINT RECONSTRUCTION AND REPLACEMENT MARKET BY
REGION, 2012-2018 ($ BILLIONS) 100
Global Market by Segments 101
TABLE 15 GLOBAL JOINT RECONSTRUCTION AND REPLACEMENT MARKET BY
SEGMENT, THROUGH 2018 ($ MILLIONS) 102
FIGURE 15 GLOBAL JOINT RECONSTRUCTION AND REPLACEMENT MARKET BY
SEGMENT, 2012-2018 ($ MILLIONS) 102
FIGURE 16 JOINT RECONSTRUCTION AND REPLACEMENT MARKET BY SEGMENT
TYPE, 2013 (% OF TOTAL MARKET) 102
JOINT RECONSTRUCTION AND REPLACEMENT MARKET BY SEGMENTS 103
HIP REPLACEMENT 103
Hip Replacement by Region 103
TABLE 16 GLOBAL HIP REPLACEMENT MARKET BY REGION, THROUGH 2018 ($
MILLIONS) 104
FIGURE 17 GLOBAL HIP REPLACEMENT MARKET BY REGION, 2012-2018 ($
MILLIONS) 104
Hip Replacement by Type 104
TABLE 17 GLOBAL HIP REPLACEMENT MARKET BY PROCEDURE, THROUGH 2018 ($
MILLIONS) 105
FIGURE 18 GLOBAL HIP REPLACEMENT MARKET BY PROCEDURE, 2012-2018 ($
MILLIONS) 105
KNEE REPLACEMENT 106
Knee Replacement by Region 106
TABLE 18 GLOBAL KNEE REPLACEMENT MARKET BY REGION, THROUGH 2018 ($
MILLIONS) 106
FIGURE 19 GLOBAL KNEE REPLACEMENT MARKET BY REGION, 2012-2018 ($
MILLIONS) 106
Knee Replacement by Type 107
TABLE 19 GLOBAL KNEE REPLACEMENT MARKET BY PROCEDURE, THROUGH 2018
($ MILLIONS) 107
FIGURE 20 GLOBAL KNEE REPLACEMENT MARKET BY PROCEDURE, 2012-2018 ($
MILLIONS) 107
SHOULDER REPLACEMENT 108
TABLE 20 GLOBAL SHOULDER REPLACEMENT MARKET BY REGION, THROUGH 2018
($ MILLIONS) 108
FIGURE 21 GLOBAL SHOULDER REPLACEMENT MARKET BY REGION, 2012-2018 ($
MILLIONS) 108
SMALL JOINT REPLACEMENT 109
TABLE 21 GLOBAL SMALL JOINT REPLACEMENT MARKET BY REGION, THROUGH
2018 ($ MILLIONS) 109
FIGURE 22 GLOBAL SMALL JOINT REPLACEMENT MARKET BY REGION, 2012-2018 ($
MILLIONS) 110
BONE CEMENT 110
TABLE 22 GLOBAL BONE CEMENT MARKET BY REGION, THROUGH 2018 ($
MILLIONS) 111
FIGURE 23 GLOBAL BONE CEMENT SMALL JOINT REPLACEMENT MARKET BY
REGION, 2012-2018 ($ MILLIONS) 111
MARKET GROWTH DRIVERS AND RESTRAINTS 112
GROWTH DRIVERS 112
Growing Aged Population 112
Baby Boom Population Reaching Retirement 112
Increasing Awareness 112
Active Younger Patients Seeking Surgery 112
Increasing Demand for Joint Replacement Surgery 112
Development and Adoption of Newer Implant Materials and
Techniques 113
Constant Innovations in Implant Design 113
Increased Adoption of Minimally Invasive Surgery 113
Increased Adoption of Computer Guided (Robotic) Surgery 113
Direct-to-Customer Marketing 113
Favorable Reimbursement for Procedure Growth 114
Medical Tourism 114
GROWTH RESTRAINTS 114
Downward Pricing Pressure and Increasing Material Cost 114
Increasing Competition and Decreasing Profit Margins 114
Risk of Failure Rates of Newer Implant Materials 114
Increasing Research and Development Costs 115
Regulatory Hurdles and Product Recalls 115
Shorter Product Life Cycles 115
Risk and Complications 115
Alternative Treatment Options 115

CHAPTER 11 COMPETITION AND MARKET SHARES 117
COMPETITIVE LANDSCAPE 117
TABLE 23 GLOBAL JOINT RECONSTRUCTION AND REPLACEMENT MARKET SHARES,
2013 ($ MILLIONS/%) 117
FIGURE 24 GLOBAL JOINT RECONSTRUCTION AND REPLACEMENT MARKET
LEADERS, 2012 (% OF TOTAL MARKET) 117
MARKET SEGMENT COVERAGE BY COMPANY 119
TABLE 24 ORTHOPEDIC COMPANIES JOINT RECONSTRUCTION PRODUCT SEGMENT
COVERAGE MATRIX 119

CHAPTER 12 MARKET STRATEGY 122
JOINT RECONSTRUCTION AND REPLACEMENT MARKET STRATEGY 122
KEY STRATEGIC EVENTS IN LAST 10 YEARS 122
TABLE 25 JOINT RECONSTRUCTION AND REPLACEMENT MARKET, KEY
MERGERS/ACQUISITIONS 123
MICROPORT SCIENTIFIC'S ACQUISITION OF ORTHORECON BUSINESS OF
WRIGHT MEDICAL 124
STRYKER'S ACQUISITION OF MAKO SURGICAL 124
ZIMMER'S ACQUISITION OF NORMED MEDIZIN-TECHNIK 124
SMITH and NEPHEW'S ACQUISITION OF SUSHRUT SURGICALS 124
ZIMMER'S ACQUISITION OF KNEE CREATIONS 125
STRYKER'S ACQUISITION OF TRAUSON 125
JOHNSON and JOHNSON'S ACQUISITION OF SYNTHES 125
MEDTRONIC'S ACQUISITION OF CHINA KANGHUI HOLDINGS 126
TORNIER'S ACQUISITION OF ORTHOHELIX SURGICAL DESIGNS 126
INTEGRA LIFESCIENCES' ACQUISITION OF ASCENSION ORTHOPEDICS 126
STRYKER'S ACQUISITION OF ORTHOVITA 126
EXACTECH'S ACQUISITION OF BRIGHTON PARTNERS 126
ZIMMER HOLDINGS' ACQUISITION OF BEIJING MONTAGNE MEDICAL DEVICE 126
ORTHOPEDIC SYNERGY'S ACQUISITION OF PRAXIM 127
SMALL BONE INNOVATIONS' ACQUISITION OF LINK AMERICA 127
DEPUY ORTHOPEDICS' ACQUISITION OF FINSBURY ORTHOPAEDICS 127
WRIGHT MEDICAL'S ACQUISITION OF INBONE TECHNOLOGIES 127
SMITH and NEPHEW'S ACQUISITION OF PLUS ORTHOPAEDICS 128
TORNIER'S ACQUISITION OF NEXA ORTHOPAEDICS 128
SMITH and NEPHEW'S ACQUISITION OF OSTEOBIOLOGICS 128
SMALL BONE INNOVATIONS ACQUISITION OF AVANTA ORTHOPAEDICS 128
ZIMMER'S ACQUISITION OF IMPLEX 128
ZIMMER'S ACQUISITION OF CENTERPULSE 129

CHAPTER 13 MARKETED AND PIPELINE PRODUCTS 131
MARKETED PRODUCTS 131
HIP RECONSTRUCTION AND REPLACEMENT 131
Key Products from Leading Companies 131
DePuy Synthes (Johnson and Johnson) 131
Zimmer 132
Stryker 132
Biomet 133
Smith and Nephew 133
Exactech 133
Key Device Approvals by the FDA 134
TABLE 26 HIP RECONSTRUCTION AND REPLACEMENT: LIST OF KEY DEVICE
APPROVALS BY THE FDA, 2005-2014 134
Key Premarket Approvals in the U.S. 137
DePuy Ceramax Ceramic Total Hip System (P070026) 137
Pinnacle CoMplete Acetabular Hip System (P090002) 137
KNEE RECONSTRUCTION AND REPLACEMENT 137
Key Products from Leading Companies 137
DePuy Synthes (Johnson and Johnson) 137
Zimmer 138
Stryker 138
Biomet 139
Smith and Nephew 139
Exactech 139
Key Device Approvals by the FDA 140
TABLE 27 KNEE RECONSTRUCTION AND REPLACEMENT, LIST OF KEY DEVICE
APPROVALS BY THE FDA, 2005-2014 140
SHOULDER RECONSTRUCTION AND REPLACEMENT 143
Key Products from Leading Companies 143
DePuy Synthes (Johnson and Johnson) 143
Zimmer 144
Stryker 144
Biomet 144
Exactech 145
Key Device Approvals by the FDA 145
TABLE 28 SHOULDER RECONSTRUCTION AND REPLACEMENT, LIST OF KEY DEVICE
APPROVALS BY FDA, 2005-2014 145
SMALL JOINT RECONSTRUCTION AND REPLACEMENT 147
Key Products from Leading Companies 147
DePuy Synthes (Johnson and Johnson) 147
Zimmer 147
Stryker 147
Biomet 147
Wright Medical 148
Key Device Approvals by the FDA 148
TABLE 29 SMALL JOINT RECONSTRUCTION AND REPLACEMENT, LIST OF KEY
DEVICE APPROVALS BY THE FDA, 2005-2014 148
KEY PIPELINE PRODUCTS 149
HIP RECONSTRUCTION AND REPLACEMENT 149
ReCap Total Hip Resurfacing System 149
TABLE 30 HIP RECONSTRUCTION AND REPLACEMENT, LIST OF KEY PIPELINE
DEVICES 149
Trinity BIOLOX delta Ceramic-on-Ceramic Total Hip System 150
Element Proportional Neck Stems 150
NovoHip: Total Hip System 151
DePuy Silent Hip 151
Reflection FSO V Total Hip Replacement 151
KNEE RECONSTRUCTION AND REPLACEMENT 152
TABLE 31 KNEE RECONSTRUCTION AND REPLACEMENT, LIST OF KEY PIPELINE
DEVICES 152
Alpina Unicompartmental Knee 152
Uniglide Mobile Bearing Unicondylar Knee System 152
NovoKnee Total Knee System 153
BiPhasic Cartilage Repair Implant 153
GEM Total Knee System 153
HemiCAP Femoral Condyle 153
Exactech GPS Guided Personalized Surgery 154
Optetrak Logic RBK 154
SHOULDER AND OTHER SMALL JOINT RECONSTRUCTION AND
REPLACEMENT 154
TABLE 32 SHOULDER AND OTHER SMALL JOINT RECONSTRUCTION AND
REPLACEMENT, LIST OF KEY PIPELINE DEVICES 154
Simpliciti Shoulder 155
aSpire Total Shoulder Arthroplasty System 155
Luna Stemless Humeral Prosthesis 155
AFT Proximal Humerus Fracture Prosthesis 155
Reverse Shoulder Implant 156
Reverse Shoulder Implant 156
Pyrohemi Implant 156
Akilos Total Ankle System 156

CHAPTER 14 REGULATORY STRUCTURE 158
REGULATORY STRUCTURE 158
U.S. 158
EUROPEAN UNION 160
TABLE 33 DIFFERENCES IN REGULATORY APPROVALS: U.S. VS EUROPE 162
JAPAN 162
OTHER ASIA 163
China 163
Hong Kong 164
Taiwan 164
India 164

CHAPTER 15 PRICING AND REIMBURSEMENT 166
REIMBURSEMENT STRUCTURE 166
U.S. 166
ICD-9-CM 167
TABLE 34 HIP AND KNEE REPLACEMENT, INTERNATIONAL CLASSIFICATION OF
DISEASES, NINTH REVISION (ICD-9) CODES 168
ICD-10 168
Insurance and Reimbursement 169
TABLE 35 CENTERS FOR MEDICARE and MEDICAID SERVICES, MEDPAR INPATIENT
HOSPITAL NATIONAL DATA FOR FISCAL YEAR 2011 ($) 169
EUROPE 171
JAPAN 172
OTHER ASIA 172
MEDICAL DEVICE PRICING TRENDS 173
CHAPTER 16 CONCLUSIONS: OUTLOOK FOR JOINT RECONSTRUCTION AND
REPLACEMENT 175
MAJOR DEVELOPMENTS TO INFLUENCE JOINT RECONSTRUCTION AND
REPLACEMENT MARKET 175
TECHNOLOGICAL DEVELOPMENTS 175
Adaptation of Minimally Invasive Techniques to New Types of
Surgical Procedures 175
Future Materials and Implants Technologies 175
DEMOGRAPHIC AND ECONOMIC TRENDS 176
Increasing Aging Population 176
TABLE 36 ESTIMATED WORLD POPULATION AND ANNUAL GROWTH BY SELECTED
AGE GROUP AND SELECTED YEARS, THROUGH 2030 (MILLIONS) 177
FIGURE 25 ESTIMATED WORLD POPULATION BY SELECTED AGE GROUP AND
SELECTED YEARS, 2000-2030 (MILLIONS) 177
TABLE 37 WORLD POPULATION BY SELECTED GEOGRAPHIC REGIONS, THROUGH
2020 (MILLIONS) 178
FIGURE 26 WORLD POPULATION BY SELECTED COUNTRIES, 2000-2030 (MILLIONS) 178
U.S. Demographics 179
TABLE 38 U.S. POPULATION ESTIMATES AND PROJECTIONS BY AGE GROUP,
THROUGH 2030 (MILLIONS) 179
FIGURE 27 U.S. POPULATION ESTIMATES AND PROJECTIONS BY AGE GROUP,
2000-2030 (MILLIONS) 179
FIGURE 28 DISTRIBUTION OF TYPES OF JOINT SURGERIES PERFORMED GLOBALLY
AMONG THE TOTAL GENERAL POPULATION, AGED 65 YEARS AND ABOVE, 2013 (%) 180
U.S: Gender, Age and Life Expectancy 181
TABLE 39 ESTIMATES OF ANTICIPATED U.S. LIFE EXPECTANCY AT BIRTH AND
PROJECTIONS BY GENDER, 2005-2020 (YEARS) 181
FIGURE 29 ESTIMATES OF ANTICIPATED U.S. LIFE EXPECTANCY AT BIRTH AND
PROJECTIONS BY GENDER, 2005-2020 (YEARS) 181
European Demographics 182
TABLE 40 EUROPEAN POPULATION ESTIMATES AND PROJECTIONS BY AGE GROUP,
THROUGH 2030 (MILLIONS) 182
FIGURE 30 EUROPEAN POPULATION ESTIMATES AND PROJECTIONS BY AGE GROUP,
2000-2030 (THOUSANDS) 182
Japanese Demographics 183
TABLE 41 JAPANESE POPULATION ESTIMATES AND PROJECTIONS BY AGE GROUP,
THROUGH 2030 (MILLIONS) 183
FIGURE 31 JAPANESE POPULATION ESTIMATES AND PROJECTIONS BY AGE GROUP,
2000-2030 (MILLIONS) 183
Income Growth in Developing Markets 184
TABLE 42 PROJECTED TRENDS IN PER CAPITA REAL GDP GROWTH BY REGION,
2000-2030 (ANNUAL AVERAGE PERCENTAGE CHANGE) 185
CHANGING STRUCTURE OF THE HEALTHCARE INDUSTRY 185
Hospital Consolidation 185
Medical Tourism 185
Health Insurance Developments 186
FUTURE OUTLOOK 186
CONSISTENT GROWTH TO CONTINUE IN A MATURE MARKET 186
MARKET GROWTH WILL BE DRIVEN BY PROCEDURE VOLUME RATHER
THAN THE PRICE OF IMPLANTS 187
YOUNGER AND BROADENING PATIENT BASE TO DRIVE SHORT- AND
MEDIUM-TERM GROWTH 187
"BABY BOOM" POPULATION SET TO DRIVE LONG-TERM GROWTH 187
REVISION AND PARTIAL REPLACEMENT TO DRIVE MARKET SEGMENT
GROWTH 187
MINIMALLY INVASIVE SURGERY 188
DEVELOPMENT BIOLOGICAL IMPLANTS 188

CHAPTER 17 APPENDIX A: ACRONYMS 190

CHAPTER 18 APPENDIX B: VENDOR PROFILES 194
AESCULAP INC. 194
ALLOSOURCE 194
ALPHATEC SPINE INC. 195
ANIKA THERAPEUTICS INC. 195
ARISTOTECH IMPLANT TECHNOLOGIES GMBH 196
ARTHREX INC. 196
ARTHROCARE CORP. 197
ARTHROSURFACE 197
ASCENSION ORTHOPEDIC 197
B. BRAUN MELSUNGEN AG 198
BIOMET INC. 199
BIOMIMEDICA INC. 199
BONOVO ORTHOPEDICS INC. 200
BRAINLAB AG 200
CERAVER 201
CONFORMIS INC. 201
CONSENSUS ORTHOPEDICS 201
CORENTEC CO. LTD. 202
CORIN GROUP 202
DEPUY (SUBSIDIARY OF JOHNSON and JOHNSON) 203
DJO INC. 203
ENCORE MEDICAL LP 204
ENZTEC LTD. 204
EXACTECH INC. 205
FH ORTHOPAEDICS 205
GLOBUS MEDICAL INC. 206
HOWMEDICA OSTEONICS 206
ICONACY ORTHOPEDIC IMPLANTS LLC 206
IMPLANTS INTERNATIONAL 207
INGEN ORTHOPEDICS 207
INTEGRA LIFE SCIENCES CORP. 207
JAPAN MEDICAL DYNAMIC MARKETING INC. 208
JRI ORTHOPEDICS LTD. 208
KINAMED INC. 208
LAFITT 209
LIMACORPORATE SPA 209
MAKO SURGICAL CORP. 209
MEDACTA INTERNATIONAL SA 210
MEDARTIS AG 210
MEDIN 211
MEDSHAPE INC. 211
MERETE MEDICAL GMBH 211
METRIMED 212
MICROPORT SCIENTIFIC CORP. 212
MOXIMED INC. 212
NOVOSOURCE INC. 213
NUVASIVE INC. 213
OMNI LIFE SCIENCE INC. 214
ORTHEON MEDICAL 214
ORTHO DEVELOPMENT CORP. 214
ORTHO SOLUTIONS 215
ORTHODYNAMICS PTY LTD. 215
ORTHOFIX INTERNATIONAL 215
ORTHOPAEDIC SYNERGY INC. 216
ORTHOPEDIC INNOVATION LTD. 216
ORTHOVITA INC. 217
OSTEOMED 217
PERMEDICA SPA 217
PIPELINE BIOMEDICAL 218
PIVOT MEDICAL 218
Q-MED 219
RENOVIS SURGICAL TECHNOLOGIES 219
RTI SURGICAL 219
SEIKAGAKU CORP. 220
SERF DEDIENNE SANTE 220
SHOULDER OPTIONS INC. 220
SIGNATURE ORTHOPAEDICS PTY LTD. 221
SKELETAL DYNAMICS 221
SMALL BONE INNOVATIONS 221
SMITH and NEPHEW 222
STANMORE IMPLANTS 223
STELKAST 223
STRYKER 224
SYNOVIS 225
SYNTHES INC. 225
TENDON TECHNOLOGY LTD. 226
THE ORTHOPAEDIC IMPLANT CO. 226
TORNIER INC. 226
TOTAL JOINT ORTHOPEDICS INC. 226
UandI CORP. 227
WALDEMAR LINK 227
WRIGHT MEDICAL TECHNOLOGY INC. 227
ZIMMER HOLDINGS 228

CHAPTER 19 APPENDIX C: INDUSTRY AND PROFESSIONAL ORGANIZATIONS 231
AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 231
AMERICAN ASSOCIATION OF HIP AND KNEE SURGEONS 231
AMERICAN JOINT REPLACEMENT REGISTRY 231
AMERICAN ORTHOPAEDIC ASSOCIATION 232
CENTERS FOR MEDICARE and MEDICAID SERVICES 232
CHINA'S MINISTRY OF SCIENCE AND TECHNOLOGY 232
DEPARTMENT OF HEALTH AND HUMAN SERVICES 233
EUROPEAN DATABANK ON MEDICAL DEVICES (EUDAMED) 233
FOOD AND DRUG ADMINISTRATION 233
HEALTHCARE COST AND UTILIZATION PROJECT 234
INTERNATIONAL FEDERATION OF PHARMACEUTICAL MANUFACTURERS AND
ASSOCIATIONS 234
INTERNATIONAL OSTEOPOROSIS FOUNDATION 234
NATIONAL CENTER FOR BIOTECHNOLOGY INFORMATION 235
NATIONAL INSTITUTE ON AGING (NIA) 235
NATIONAL JOINT REGISTRY 235
NATIONAL OSTEOPOROSIS FOUNDATION 236
NATIONAL RHEUMATOID ARTHRITIS SOCIETY 236
ORGANIZATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT 236
PHARMACEUTICAL AND MEDICAL DEVICE AGENCY (PMDA) 237

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