Yale School of Medicine

Joint replacement surgery is a highly effective surgical procedure which restores movement and alleviates pain for hundreds of thousands of Americans each year. I love these operations because my team and I can really make a difference in the lives of our patients. But I predict we will be performing fewer such surgeries in the not too distant future. Why? The biologics are nearly here.

Most of my joint replacement colleagues donot embrace the opinions I will express here. They (and many hospital administrators) believe that the current state of 1M+ joint replacement surgeries a year in the United States will continue. After all, the population is aging and thus more arthritic. Moreover, the obesity epidemic has accelerated the development and progression of arthritis, particularly of the knee. And the data is clear: volumes for hip and knee replacement surgeries have steadily increased. Projections show further growth of 71% for hip replacements and 85% for knee replacements by 2030. Shocking statistics.

I don’t believe these projections will come to pass. I am old enough to have performed many joint replacements on patients with rheumatoid arthritis. Then came the biologics—Enbrel was the first in 1998 and now there are other such transformative drugs. These medications modify the actual disease of rheumatoid arthritis, thus preventing damage to the joint. The literature shows an actual decline for some types of joint replacement surgery, or a relative decline for other joint replacement surgery types in these patients. I have not done joint replacement, or seen my partners do so, on a patient with rheumatoid arthritis in years. Yes, years. This is good for patients.

Osteoarthritis is next. Currently joint replacement surgeries arean important service line for hospitals. A busy joint replacement surgeon can generate millions of dollars of revenue for a hospital. Companies create and sell products to make joint replacement surgery better. Robotic technology has been introduced, at high cost to hospitals, without clear evidence of clinical improvement. Custom made implants are now available and may be promising. Right now, joint replacement surgery is the best we have to offer patients with severe joint disease. Some of my most grateful patients have had hip or knee replacements.

But the disrupter is at the gate. Headlines state a $10B market for orthobiologics in 2025, exceeding the claim for the hip and knee replacement global market of $6.6B by 2023. While some of these orthobiologic costs are bone graft products used in surgery, others are therapies which show great promise at modifying the progression of osteoarthritis. A recent clinical trial which involved injecting a biological product into knee joints with osteoarthritis completed enrollment ahead of schedule. Another upcoming clinical trial involves gene therapy to modify the inflammatory aspect of the disease. Searching clinicaltrials.gov for knee osteoarthritis and biologics shows 194 clinical trials, some of which have been completed. Furthermore, I have been involved in landmark research showing that injecting bone marrow aspirate concentrate into arthritic knees can improve symptoms. Patients come to me asking for “stem cell” therapy to avoid joint replacement surgery. The interest is extremely strong.

Joint replacement surgery is not the only type of surgery which will be impacted by the rise of biologics. Biologicals will dramatically impact sports medicine and spine surgeries as well. Spinal disc degeneration can be delayed with injection of a biological product. Biological scaffolds show promise in supporting the healing of tendons, which previously were treated by reconstruction (e.g., anterior cruciate ligament tears). Research is progressing with biologics which support healing of tissues which previously were surgically treated (e.g., tears to the rotator cuff of the shoulder, the shoulder labrum or the knee menisci). Musculoskeletal sports medicine will shift to biological outpatient therapies which can be provided by non-surgeon physicians.

So, the question inmy mind is not if, but when, these biological therapies will transform musculoskeletal care. While my crystal ball is not always clear, I estimate these transformative therapies will come into clinical practice in the next 5-8 years. That is the blink of an eye. Yes, there will be a lag in impact on surgical volume, but that will only be a few years. In my opinion, many healthcare systems will not be ready for this transformation, as they are anchored to their traditional elective orthopaedic and spine operative service lines. But what is good for patients willprevail, as it should.

Actively anticipating the stealth disruptors in medicine is essential for our health system leaders. Patients want new, effective, lower-risk therapies that these orthobiologics will offer. However, patients also need vibrant local hospitals and cutting-edge tertiary facilities for urgent and life-threatening conditions. Let’s hope our health systems are ready for the challenge.