Overview of Orthopedic Joint Replacement Market in India PDF

Overview of Orthopedic Joint
Replacement Market in India
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March 2011
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Table of Contents
Executive Summary
11
Research Aim and Key Deliverables
12
Market Segmentation and Scope of the Study
13
Current Market Size and Growth Trends
14
Key Market Drivers and Restraints
15
Future Growth Potential by Segment
16
Competitive Scenario and Conclusion
17
Research Methodology
18-20
Research Scope and Definitions
21
Scope of the Study
22
Definitions
23
Common Indications for Joint Replacement
24
Types of Joint Replacement Surgeries
25-27
Material Used for Prosthesis
28
Abbreviations
29
Total Orthopedic Joint Replacement Market
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30
Overview
31-32
Market Segmentation
33
Table of Contents (Contd)

Market Engineering Measurements
34
Industry Challenges
35-37
Key Market Drivers
38
Market Drivers
39-44
Key Market Restraints
45
Market Restraints
46-49
Revenue Forecasts
50-51
52
Life Cycle Analysis
53
Competitive Forces (Porters 5 Forces Model)
54-58
SWOT Analysis
59
Competitive Structure
60
Market Share Analysis
61
Factors Considered for the Selection of an Implant
62
Important Factors for the Selection of an Implant
63-66
Knee Joint Replacement Market

Overview
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67
68

69
Revenue Forecasts and Procedure Forecasts
70-72
73
Hip Joint Replacement Market
74
Overview
75
76
Revenue Forecasts and Procedure Forecasts
77-79
80
Recent Mergers and Acquisitions

Mergers and Acquisitions
Recommendations and Conclusion
82-85
86
Recommendations
87-90
Conclusion
91
Company Profiles
92
Leading Companies in the Total Indian Orthopedic Joint Replacement Market
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81
93

DePuy Medical Pty. Ltd (Johnson & Johnson)
94
Zimmer India Pvt Ltd.
95
Stryker India Pvt Ltd
96
Smith & Nephew
97
About Frost & Sullivan
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98-102
List of Figures
Total Orthopedic Joint Replacement Market: Abbreviations (India), 2010
29
Total Orthopedic Joint Replacement Market: Impact of Top Three Industry Challenges (India), 2011-2017
35
Total Orthopedic Joint Replacement Market: Market Drivers Ranked in Order of Impact (India), 2011-2017
39
Total Orthopedic Joint Replacement Market: Market Restraints Ranked in Order of Impact (India), 2011-2017
46
Total Orthopedic Joint Replacement Market: Revenue Forecasts (India), 2011-2017
50
Total Orthopedic Joint Replacement Market: Competitive Structure (India), 2010
60
Knee Joint Replacement Market: Revenue Forecasts (India), 2011-2017
70
Hip Joint Replacement Market: Revenue Forecasts (India), 2011-2017
77
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List of Charts
Total Orthopaedic Joint Replacement Market: Market Size and Growth Trends (India), 2010 and 2017
14
Total Orthopedic Joint Replacement Market: Key Drivers and Restraints (India), 2011-2017
15
Total Orthopedic Joint Replacement Market: Future Growth Potential by Segment (India), 2011-2017
16
Total Orthopaedic Joint Replacement Market: Competitive Landscape (India), 2010
17
Total Orthopedic Joint Replacement Market :Segmentation by Type of Joint replacement (India), 2010
33
Total Orthopedic Joint Replacement Market: Market Engineering Measurements (India), 2010
34
Total Orthopedic Joint Replacement Market: Key Market Drivers (India), 2011-2017
38
Total Orthopedic Joint Replacement Market: Key Market Restraints (India), 2011-2017
45
51
Total Orthopedic Joint Replacement Market: Future Growth Potential by Segment (India), 2011 -2017
52
Total Orthopedic Joint Replacement Market: Life Cycle Analysis (India), 2011-2017
53
Total Orthopedic Joint Replacement Market: Competitive Forces (India), 2011-2017
54-58
Total Orthopedic Joint Replacement Market: SWOT Analysis (India), 2011-2017
59
Total Orthopedic Joint Replacement Market: Company Market Share by Revenues (India), 2010
61
Total Orthopedic Joint Replacement Market: Important Criteria for the Selection of an Implant (India), 2010
63
Knee Joint Replacement Market: Market Engineering Measurements (India), 2010
69
71
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List of Charts (Contd)

Knee Joint Replacement Market: Procedure Forecasts (India), 2010 and 2017
72
Knee Joint Replacement Market: Company Market Share by Revenues (India), 2010
73
Hip Joint Replacement Market: Market Engineering Measurements (India), 2010
76
78
Hip Joint Replacement Market: Procedure Forecasts (India), 2010 and 2017
79
Hip Joint Replacement Market: Company Market Share by Revenues (India), 2010
80
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10
Executive Summary
11
Research Aim and Key Deliverables
The aim of this research service is to present an analysis of the joint replacement market in India.
The deliverables in this research service include:
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Quantifying the size and growth forecasts of the Indian joint replacements market from 2010 to 2017
by product segments
Providing insight into the industry challenges, market drivers, and market restraints during the
forecast period
Identifying key participants of the market and quantifying company market shares by product
segments
Providing further insight into the competitive environment through a Porters analysis (Analyzing the
impact of the 5 forces namely Bargaining power of suppliers, bargaining power of customers, threat
of new entrants, threat of generic products and intensity of competition on the joint replacement
market in India)
Highlighting the orthopedic surgeons perspective on factors influencing selection of an implant
Identifying opportunities and providing recommendations to current and new market participants
based on a strength, weakness, opportunities, and threats (SWOT) analysis
12
Market Segmentation and Scope of the Study

Market Segmentation
Indian Orthopedic Joint
Replacement Market
Knee Joint
Replacement Market
Shoulder and Ankle Joint

Replacement Market
Hip Joint
Replacement Market
Scope of the Study

In this research service, only the knee and hip joint replacement markets are covered. The shoulder and
ankle joint replacement market has not been covered in this study, as it does not make a significant
contribution to the total orthopedic joint replacement market in India. This research service also does not
include replacement market for trauma cases.
Time frame Details
Study period 2008-2017
Base year 2010
Forecast period 2011-2017
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13
Current Market Size and Growth Trends
The joint replacements market in India is in a high

growth stage, projected to grow at a rate over 25-30
percent over the next five to seven years.
The total Indian orthopedic joint replacement market

was valued at $80.4 million in 2010.
The demand is growing due to a combination of

factors such as increase in aging population (with its
majority suffering from arthritis), fast and sedentary
lifestyle making the younger generation susceptible
to orthopedic ailments requiring joint replacement,
booming economy leading to growing middle class
with substantial disposable income, and gradual
opening up of the insurance sector.
In terms of revenues, over 75 percent of the total

market is contributed by knee replacement
segment, about 20 to 25 percent is by hip
replacement segment and less than 5 percent is
contributed by shoulder and ankle replacement
segment.
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Total Orthopedic Joint Replacement Market: Market Size and

Growth Trends (India), 2010 and 2017
Over $400
Million
$80.4
Million
Next 5-7 Years
2010
2017
Over 65,000
Knee and Hip
Replacements
Over 350,000
Knee and Hip
Replacements
Note: All figures are rounded; the base year is 2010.

Source: Frost & Sullivan
14
Key Market Drivers and Restraints

Total Orthopedic Joint Replacement Market: Key Drivers and Restraints (India), 2011-2017
Word of mouth on
success of joint
replacement
surgeries
Key Drivers
Huge population
affected by arthritis
and other painful joint
diseases
Expensive surgery
and lack of
affordability
Booming economy
and improving
healthcare
infrastructure
Limited access to
orthopedic joint
replacement surgeries
Patient
apprehensions and
lack of awareness
Key Restraints
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15

Current Market Size($)
High
Shoulder and Ankle Replacement
Hip
Replacement
Knee
Replacement
Low
High
Low
Note: Size of bubble indicates market size ($) of segment
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Long Term Growth Potential

16
Competitive Scenario and Conclusion
In 2010, over 95 percent of the market was

occupied by major international companies such
as Depuy Companies (Johnson & Johnson),
Zimmer, Inc., Stryker, Smith & Nephew,
Exactech, Inc., B Braun, and Maxx Orthopedics,
Inc.
Others included a mix of international and local
companies such as Synthes GmbH, Biomet,
Inc., Endolite India Limited, Anthrex, Inc., Indus
Orthopedics, Inor Orthopedics, and Sushrut
Surgicals, and so on.
Total Orthopedic Joint Replacement Market: Competitive

Landscape (India), 2010
Others
5%
International
Companies
95%

With a huge population requiring joint replacement, and increase in awareness about the impact
of joint-related problems on the lives of patients and the importance of surgical treatment
process for them, the market for orthopedic implants is likely to become one of the most rapidly
growing segments in the Indian medical device market.
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17
18
Secondary Research
The research team conducted a comprehensive review of secondary information sources, including Frost &
Sullivan in-house databases, previous research services, online databases, trade journals, and the Internet. The
team then drew up a research plan on the basis of the research objectives and resources allotted. The research
plan primarily consisted of the following.
Research Instruments
The best research instrument suitable for this project was identified as an open-ended questionnaire, developed
separately for different types of target candidates, namely manufacturers, distributors, end users, and industry
experts. These instruments were made and checked for clarity, thoroughness, and to find if they motivated the
candidates to respond. Duplication and overlaps allowed corroboration and cross-checking of data.
Primary Research
Frost & Sullivan obtained primary data directly from industry participants. The analysts' finely honed interviewing
skills enabled the team to elicit valuable strategic information from industry participants. Using Frost & Sullivan's
uniquely designed research techniques, the analysts were able to obtain information invaluable for identifying
trends, threats, and opportunities in the marketplace. Primary research is focused on interviewing key personnel
of relevant companies and organizations. In addition, the research team interviewed end users and industry
experts from government and trade associations.
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19
Research Methodology (Contd)

'Bottom-up' Approach
Frost & Sullivan used a 'bottom-up' methodology to assess the market, where each final market measurement
represents the sum of many detailed, bottom-rung measurements. Frost & Sullivan calculated the market size by
interviewing each market competitor and deriving their revenues, average selling price, and unit volume. To
calculate total market size, the analyst team first cross-verified all measurements and then added them to derive
the final measurement of the total market
'Bottom-up' versus 'Top-down' Approach

The 'top-down' approach is to ask a few participants to estimate the total size of the market, assess its growth
rate, and make a forecast. These numbers are then averaged to make a final projection. This methodology is
commonly used, but it is highly imprecise and can lead to serious problems when used to make strategic
decisions. This approach assumes that the average market participant has a strong perception of measurements
of an entire market segment or industry. Frost & Sullivan has found that it is often not so. It is very rare for a
spokesperson to accurately portray the intricacies of his/her own company, let alone gauge the entire market
segment or industry. Frost & Sullivan has, thus, chosen a 'bottom-up' approach to market measurement.
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Research Scope and Definitions
21
Scope of the Study

Market Scope
This study analyzes the hip and knee joint replacement markets in India from 2008 to 2017.
This research service does not include the analysis of shoulder and ankle joint replacement market.
It also does not include the analysis of trauma, or minimally invasive surgeries.
Base Year and Forecast Period
The base year for this research service is 2010, and the historic period is 2008-2009. The forecast period
is 2011-2017.
The forecasts are based on the estimates of future capacity additions and market conditions. They are
calculated based on the impacts of industry challenges and market drivers and restraints.
Market information for this period was collected through both primary and secondary research. Key trends
and information on market share, market size, and other variables are based on the discussions with end
users and manufacturers.
Exchange Rate
$1 =
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INR 46.0
All revenue estimates were calculated in INR and then converted to USD using the above-mentioned
exchange rate (unless mentioned otherwise).
22
Definitions
Arthritis: Arthritis is inflammation of a joint.
Rheumatoid Arthritis: This is a chronic inflammatory disease of one or multiple joints.
Osteoarthritis/Degenerative Arthritis: This is a 'wear-and-tear arthritis affecting any joint.
Durability: Durability is the characteristic of a material or object referring to its long-lasting strength and
function.
Arthoplasty of the Hip: This is the process of reconstruction of joint surfaces in the hip by replacing the
femoral head and acetabulum with a plastic or metallic prosthesis.
Arthoplasty of the Knee: It is the reconstruction of joint surfaces in the knee by replacing the femoral
condyles and tibial plateau with a metallic or plastic prosthesis.
Unicompartmental Knee Arthoplasty: This process requires the removal of damaged parts, using
minimally invasive surgeries
Osteolysis: This is lysis of bone caused by disease, infection or inadequate blood supply.
Minimally Invasive Surgery (MIS): MIS is a surgical procedure carried out by allowing the surgical
equipment to enter the body through the skin or through a body cavity or anatomical opening, thus
allowing minimal damage to the body
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Common Indications for Joint Replacements

Following are the common indications associated with the joints that might require replacement:
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For patients above the age of 55 to 60 years, secondary osteoarthritis or rheumatoid arthritis in the
knee joint is the most common indication.
Incongruence of knee or hip joints after a traumatic surgery is another indication.
Fractures resulting from avascular necrosis (resulting in secondary arthritis) in patients aged above
60 years and traumatic fractures damaging acetabulum for the younger ones are the most common
indications for the hip joints that require replacement surgery. Total replacement is performed in
India only in case of avascular necrosis.
Tumor is one of the rare indications. In case of tumor, a surgeon needs to order an implant designed
according to the patients requirements.
Joint problems can be experienced even by young people. At present, several people aged below 40
years are suffering from arthritis due to fast-paced, sedentary city life.
24
Types of Joint Replacement Surgeries
During a replacement surgery, either an entire joint or a part of it is replaced with an artificial implant
known as prosthesis to improve and enhance the functioning of the joint.
Total Replacement Surgery
Total Replacement Surgery The surgical procedure to replace a joint entirely with an artificial
prosthesis is called as total replacement surgery. The total replacement prosthesis looks exactly like
the human body joint.
Two types of replacement surgeries can be performed based on the type of implant used, as
discussed below.
Cemented - In the total cemented replacement surgery, artificial implants
metal part is fixed on to bone by a type of epoxy cement called polymethyl
methacrylate (PMMA).
Cementless - The uncemented joint is a porous implant. After the surgery,
the bone is expected to grow into and through the pores in the implant,
thereby securing the implant.
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Types of Joint Replacement Surgeries (Contd)

Partial Replacement Surgery
Partial Replacement Surgery- Partial replacement surgery is performed when the damage is
restricted to a single compartment of a joint. In such cases, the damaged area is shaved off and is
replaced with an appropriate artificial component. This technique is less complicated and less
invasive, and it enables a patient to perform the regular activities and recover much faster, even within
six weeks. Artificial component used in this surgery can be either of the following two types, based on
whether the surgery is done to the hip or knee joint.
Unicompartmental Knee Arthroplasty (UKA) Prosthesis- This type of
prosthesis is used when any one of the three compartments (medial, lateral,
and patellofemoral) of a knee needs to be replaced. This type of prosthesis is
called as uni-spacer, which is a metal disc in the form of an articular condyle.
During surgery, the damaged bone is resected and resurfaced. The uni-spacer
is then placed within the damaged bone to unload the diseased compartment.
Bipolar Hip Joint Replacement Prosthesis - In this type of prosthesis, the set
consists of two balls. The external ball matches the size of acetabulum, while
the internal one matches that of femur head. The femoral component (internal
ball) is fixed into bone, but the acetabular component (external ball) is not
fixed in the acetabulum, thus allowing the cup to move freely in the socket.
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Types of Joint Replacement Surgeries (Contd)

Revision Replacement Surgery
Revision Replacement Surgery Usually, implants have a shelf life of 15 to 20 years. Hence, when a
replacement surgery is done in younger patients, there are chances for the prosthesis to deteriorate.
In such cases a revision surgery is done to replace a worn out prosthesis. This procedure is also called
revision arthroplasty. Revision joint replacement surgery is often more complicated, with less predictable
results.
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Materials Used for Prosthesis
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The orthopedic prosthesis are made of different materials, mostly metal, plastic, and ceramic.
Selection of a material depends on its qualities such as strength (weight-bearing capacity),
biocompatibility, and wearing rate.
Metal on Plastic
This is one of the most commonly used types of prosthesis. In this prosthesis,
head and stem of a joint are made up of metal, while the cup is made of plastic.
The metals used include titanium, stainless steel, and cobalt chrome. The plastic
is cross-linked polyethylene. Such implants can be used for both cemented as
well as non-cemented replacement surgeries.
Metal on Metal
Both the bearing surfaces (the ball and cup component) on the metal-on-metal
prosthesis are made of metal. These implants are more resistant than the metalon-plastic ones. Despite the low wear rates, metal-on-metal implants will not last
longer. There are also concerns about the wear debris generated by these
implants
Ceramic on
Ceramic
Ceramic-on-ceramic implants have the lowest wearing rate and are scratch
resistant. These are also smoother than the metal-on-metal ones. Commonly
used ceramics are alumina or zirconia ceramics. These implants are designed to
be the most resistant among all available replacement implants. However, no
long-term data are available on how well these implants work over time.
28
Abbreviations
Total Orthopedic Joint Replacement Market: Abbreviations (India), 2010
Abbreviations
Expansions
UKA
Unicompartmental knee arthroplasty
CAS
Computer-assisted surgery
CAGR
Compound annual growth rate
R&D
Research and development
FDA
Food and Drug Administration
CNC
Computed numerically controlled
RFP
Rotating platform flexion
BPL
Below poverty line
INR
Indian Rupee
Pvt
Private
Ltd
Limited
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29
Total Orthopedic Joint Replacement Market
30
Overview
According to international statistics, joint-related diseases account for about half of all chronic conditions
in people aged 60 years and more. Moreover, experts predict that the number of individuals aged above
50 years is expected to increase two-fold between 1990 and 2020, which will have a significant bearing
on the burden of orthopedic diseases.
It is estimated that more than 150.0 million Indians are suffering from joint-related problems. A study
done in 2005 revealed that 22 to 39 percent of the Indian population seems to suffer from painful
osteoarthritis, and about 50 percent of them feel that it has a significant impact on their life, work, and
finances1.
Despite this, orthopedic conditions do not receive the attention they deserve, both from the patient as
well as doctors. "The lack of attention by the medical profession, policy-makers and the media is due to
the perception that orthopedic diseases are less serious. Unlike cardiovascular disease, AIDS and
cancer, they are largely chronic, non-fatal conditions and tend to be seen as an inevitable consequence
of ageing says Professor Lars Lidgren, Department of Orthopedics, Lund University Hospital, Sweden
and Chairman of the International Steering Committee, Bone and Joint Decade.
Rise in aged population may be one of the reasons for increasing orthopedic diseases, but it is not the
only reason; an active lifestyle and high life expectancy also result in increased wear of joints.
1: A Mahajan et. Al, July 2005, Osteoarthritis, JAPI, Vol. 53, pg. 1
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Overview (Contd)
The advancements in the field of orthopedics treatment in India are in the same pace of that in other
developed countries. The latest techniques and equipment to handle this probable epidemic are also
available in India, and today/at present, world-renowned surgeons are practicing the latest surgery
techniques in our hometown/the country.
India is expected to be the forerunner in terms of research, treatment options, and revenue generation in
the orthopedic segment, in the time to come.
The orthopedics market in India has witnessed a major boon, mainly due to the increased spending
capacity of the Indian population.
On the surgical front, main revolution is minimal invasive approach aided by computer guided surgery,
which means less morbidity and lesser hospital stay for patients. Dr. Parag Sancheti, Medical Director,
Sancheti Institute of Orthopedics and Rehabilitation, Pune, says The accuracy in surgery can be
increased by using computer navigation and longevity is increased by using better metals and
polyethylene for prosthesis. Minimally invasive techniques are being used to improve the surgery
outcome and also to enable the patient to return to work early.
There is a growing trend among patients and family members to seek alternate opinions and ask specific
product-related queries to their surgeons prior to decision-making. The task for orthopedic implant
suppliers and healthcare service providers is, therefore, to create awareness and make patient-surgeon
communication effective.
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Market Segmentation
Total Orthopedic Joint Replacement Market: Segmentation by Type of Joint Replacement (India), 2010
Indian Orthopedic
Replacement Market
Knee Joint
Replacement Market
Primary
Revision
Shoulder and Ankle Joint

Replacement Market*
Unicompartmental
Primary
Hip Joint
Replacement Market
Revision
Partial/ Bipolar
*The
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shoulder and ankle joint replacement market is not analyzed in this study as it forms less than 5 percent of the total market.
33

Total Orthopedic Joint Replacement Market: Market Engineering Measurements (India), 2010
Measurement Name
Measurement
Trend
Market age
Growth stage
Increasing
Revenues
$80.4 million
Increasing
Potential revenues (maximum future market size)
$426.2 million
Increasing
Base year market growth rate
25.0%
Increasing
26.7%
Increasing
High
Increasing
Around 30
Increasing
About 80.4%
Decreasing
Degree of competition
Increasing
Customer loyalty
Stable
15-20 years
Stable
Price sensitivity
Competitors (active market competitors in base year)
Market concentration (percent of base year market controlled
by top 4 competitors)
Units shelf life
Note: All figures are rounded; the base year is 2010. Source: Frost & Sullivan
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34
Industry Challenges
Total Orthopedic Joint Replacement Market: Impact of Top Three Industry Challenges (India), 2011-2017
Challenge
1-2 Years
3-4 Years
5-7 Years
Lack of awareness about joint replacement surgeries
High
High
Medium-High
Patient apprehensions slow market penetration of joint replacement

procedures
High
High
Medium-High
Medium-High
Medium-High
Medium-High
Brand loyalty and client relationships
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Industry Challenges (Contd)
Lack of Awareness about

Joint Replacement
Surgeries
Patient Apprehensions
Slow Market Penetration
of Joint Replacement
Procedures
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The awareness about joint replacement surgery is very low in India.

Many people approach doctors only at an advanced stage of when the
bones would have incurred most damages. A few small surveys
conducted in urban areas reveal that, only about 10 percent of people are
aware about detection and prevention of joint related problems such as
osteoporosis. In Tier II, Tier III cities and rural areas the awareness level
is much low.
Low awareness is also a concern within the medical fraternity itself.
Physicians and specialists often neglect the signs at the initial stage
rather than immediately recommending the patient to an orthopedic
surgeon.
Arthritis generally affects people aged 55 years and above. It is one of
the leading causes of disability among those people. However, not many
people are willing to undergo surgery for treatment of arthritis, mainly due
to their fear of whether the surgery will be successful, the risks involved,
and prolonged recovery period. Most patients prefer alternative treatment
methods or other non-surgical procedures such as physiotherapy,
exercises, or yoga. As a result, the penetration of joint replacement
products in the market is limited.
36
Industry Challenges (Contd)
Patient Apprehensions
Slow Market Penetration
of Joint Replacement
Procedures (Contd)
Brand Loyalty and Client

Relationships
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Joint replacement surgery is believed to be associated with

complications, including infections. Many patients are unconvinced to
undergo this surgery because of the risk of implant failure. Any foreign
material that is implanted into the body has a chance of being rejected by
the patients body. There have been cases in which a knee implant
recipient developed blood clots in the leg vein. This can prove to be
dangerous, as it blocks blood flow in leg. For this reason as well, the
patients opt for other non-surgical procedures such as physiotherapy,
exercises, or yoga. This reduces the number of patients undergoing the
joint replacement surgery.
Surgeons decisions play an important role in purchase of an implant.
They are usually loyal to a specific brand of implant primarily due to their
familiarity with it. This helps them to deal with any complication during a
surgery. Client relationships between joint replacement suppliers and
surgeons also play a crucial role in product loyalty and preference in the
market. This can be a challenge for new companies seeking to gain a
foothold in this market.
37
Key Market Drivers

Total Orthopedic Joint Replacement Market: Key Market Drivers (India), 2011-2017
Revision joint
replacement
surgeries
Increase in the
coverage of
insurance
policies
Advancements in
Surgery
Note: Size of bubble indicates the level of impact

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Increasing
medical
tourism
Word of mouth on
success of joint
replacement
surgeries
Huge population
affected by arthritis
and other painful
joint diseases
Booming economy
and improving
healthcare
infrastructure

38
Market Drivers
Total Orthopedic Joint Replacement Market: Market Drivers Ranked in Order of Impact (India), 2011-2017
Rank
Driver
1-2 Years
3-4 Years
5-7 Years
Booming economy and improving healthcare infrastructure
Very High
Very High
Very High
Huge population affected by arthritis and other painful joint

diseases
Very High
Very High
Very High
Word of mouth on the success of joint replacement surgeries
Very High
Very High
Very High
Advancements in surgery
Very High
Very High
Very High
Increase in the coverage of insurance policies
High
Very High
Very High
Revision joint replacement surgeries
High
High
High
Increasing medical tourism
Medium-High
Medium-High
Medium-High
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39
Market Drivers (Contd)
Booming Economy and

Improving Healthcare
Infrastructure
While the huge population base is the single largest driver of the
orthopedic joint replacement market in India, the underpenetrated
silver age population (aged less than 55 years) which constitutes 7 to
12 percent of the total population, represents the scope for growth in
the market. Indias growing economy is driving urbanization and
creating an expanding middle class, with more disposable income to
spend on healthcare. As a result, demand for improved health
services and surgical expertise has been growing rapidly in the
country.
Healthcare infrastructure in the metros and Tier I cities is rapidly
increasing, with major corporate hospital groups such as Sterling,
Apollo and Wockhardt among others, making significant investments
in setting up state-of-the-art hospitals in major cities which also
include orthopedic specialties.
Though the government has not taken sufficient steps to cater to the
huge population of arthritis needing joint replacements, the only
positive step is to help indigenous manufacture of consumables and
implants is the import duty waiver for manufacture of orthopedic
implants.
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Huge Population Affected

by Arthritis and Other
Painful Joint Diseases
Word of Mouth on the

Success of Joint
Replacement Surgeries
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An significant part of the Indian population is either suffering from or

are susceptible to arthritis and other painful joint-related diseases. An
estimated 150.0 million Indians, comprising about 15 percent of the
country's population, suffer from arthritis. This figure was projected at
the Madras Institute Of Trauma in the meeting held in conjunction with
World Arthritis Day in 2005; this number is on rise. Some of the major
reasons for such rapid spread of these diseases include increase in
aging population (above 55 to 60 years) susceptible to arthritis,
younger age group (40 years and above) with fast and sedentary
lifestyle, which includes imbalance in the diet, rest, and exercise, and
side effects of unprescribed drugs.
Companies and surgeons are increasingly taking efforts to conduct
programs to increase the awareness about the very existence and
benefits of the joint replacement surgeries. Word of mouth on the
success of these surgeries and pain-free life after surgery influences
more people to undergo these surgeries. Increase in awareness about
benefits of joint replacement surgeries especially among the urban
population in metros and Tier I cities is likely to drive this market.
41
Advancements in
Surgery
Growing number of Indians have started realizing the importance of a

surgical treatment as an approach to cure knee and hip joint problems.
Advancements in surgical techniques are also one of the main reasons
for the same, especially the minimal invasive approach aided by
computer guided surgery, which means less morbidity and lesser
hospital stay for patients. Says Dr. Parag Sancheti, Medical Director,
Sancheti Institute of Orthopaedics and Rehabilitation, Pune, "The
accuracy in surgery can be increased by using computer navigation and
longevity is increased by using better metals and polyethylene for
prosthesis. Minimally invasive techniques are being used to improve the
surgery outcome and also to enable the patient to return to work early.
With the availability of networking systems that link operating room (OR)
facilities at different locations, supported with a range of integrated
surgical equipment and lights, offers novel experience to the operating
surgeons. These systems are useful as they can exchange MRIs, Xrays, live pictures and other kinds of information between ORs, doctor's
offices, and teaching institutions located anywhere in the world.
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42
Increase in the Coverage

of Insurance Policies
Revision joint
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The insurance sector in India is poised for tremendous expansion. Its

growth in the recent years has been significant. In 2007, the health
insurance market was worth $680.0 million (INR 33.00 billion) with
over 4.0 million policies, and it is expected to grow at a rate of 25 to 35
percent in the next five years. The State and Central Government run
insurance schemes and most importantly, private insurance schemes
are significantly increasing the affordability for orthopedics implants, in
turn driving the market.
Artificial joint replacements do not last lifelong. As a result, patients

with joint replacements need to revisit their treatment options, and
recipients of artificial implants in the last few years will be in need of
revision surgeries in the next few years. The revision joint replacement
market is expected to grow at a rate of over 20 percent in the next five
to seven years.
43
Increasing Medical
Tourism
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India is emerging as a hub for medical tourism, which is one of the

major external drivers for growth in the Indian healthcare sector.
According to a study, Indian medical tourism was valued at $350.0
million in 2006. The market is growing by 30% a year and has the
potential to grow into a (approximately over) $2.00 billion industry by
2012. The growing recognition of the competence and skills of Indian
surgeons as well as the emergence of world-class hospitals in the
corporate sector has provided a stimulus to medical tourism.
44
Key Market Restraints

Total Orthopedic Joint Replacement Market: Key Market Restraints (India), 2011-2017
Expensive surgical
procedures and
lack of affordability
Limited access to
orthopedic joint
replacement
surgeries
Price war bringing

down cost of
implants
Unregulated
market
scenario
Note: Size of bubble indicates the level of impact
P54D-54

45
Market Restraints
Total Orthopedic Joint Replacement Market: Market Restraints Ranked in Order of Impact (India), 2011-2017
Rank
Restraint
1-2 Years
3-4 Years
5-7 Years
Expensive surgical procedures and lack of affordability
High
High
Medium-High
Limited access to orthopedic joint replacement surgeries
High
Medium-High
Medium
Price war bringing down cost of implants
Medium-High
Medium-High
Medium-High
Unregulated market scenario
Low-Medium
Low-Medium
Low
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46
Market Restraints (Contd)
Expensive Surgical
Procedures and Lack of
Affordability
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Affordability of joint replacement surgeries continues to be hurdle. Total

cost of a joint replacement surgery includes hospital expenses such as
expenses of operation, stay, and many other charges apart from the
implant. The minimum cost of any replacement surgery is above $4500 to
$5,000. Indias per capital income is $1,030 and the country is ranked
139th in the world.
Though the insurance sector is fast growing, current penetration of health
insurance is very moderate; at present the patients need to bear such
medical expenses by themselves. Moreover, there is a wide variation in
surgical costs across hospitals, because there is no fixed price in the
private sector and most medical aid schemes do not cover the total
costs.
47
Limited Access to
Orthopedic Joint
Price War Bringing Down

Cost of Implants
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Though healthcare infrastructure in India is growing at a fast pace, the

penetration of orthopaedic joint replacement surgeries is limited to
tertiary care and super-speciality hospitals in metros and Tier I cities.
These facilities are still not accessible to a large section of the
population living Tier II-Tier III cities and rural areas. Moreover,
currently, there are only about 750 to 850 surgeons in the country who
perform joint replacement surgeries.
About 10 to 15 years ago, only a few companies offered orthopedic
implants. However, at present several international and indigenous
companies are offering a wide variety of implants, which increases
the bargaining power of customers which include not only the private
hospitals and super-specialties, but also the Government hospitals as
well. Therefore, companies are forced to reduce their prices, thus
allowing a lower profit margin. Moreover, this is a customer driven
market and works more on relationship with hospitals & surgeons.
48
Unregulated Market
Scenario
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India does not have a well-developed laboratory for certifying these

implants nor regulatory guidelines for manufacturing or quality check
laboratories for orthopedic products. On the contrary, by an
amendment to the Drug and Cosmetic Act of 1940, orthopedic
implants are currently classified as drugs. As a result, the
manufacturers and importers at present need to register orthopedic
implants with the Office of the Drug Controller General of India, prior
to import, manufacture, or sale in the Indian market.
Lack of approvals such as the Food and Drug Administration or
European Conformity mark allows domestic participants to sell lowquality implants at a price that is less than half of the price of goodquality implants manufactured by international participants. This
hampers the market for good quality implant manufacturers, and may
also increase the fear and apprehension among the users once those
low-quality products do not yield expected results.
49
Revenue Forecasts
Year
Revenues
($ Million)
Revenue
Growth Rate
(%)
2008
51.6
--
2009
64.3
24.6
2010
80.4
25.0
2011
100.9
25.4
2012
127.0
25.9
2013
160.5
26.4
2014
203.6
26.9
2015
259.3
27.4
2016
331.6
27.9
2017
426.2
28.5
Compound Annual Growth Rate (2011-2017): 26.7%

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50
Revenue Forecasts (Contd)
About 76.8 percent of the total market share was

held by knee replacement and the rest by hip
replacement.
This market is expected to grow at a CAGR of 26.7

as per the figure in the previous slide percent from
2010 to 2017.
Currently, more than 90 percent of the total
customers for this market are the private corporate
hospitals and superspeciality hospitals. Less than 10
percent of the total market is Government or Public
hospitals.
With private insurance segment experiencing rapid
growth and the various state and central Government
reimbursement schemes for below poverty line
families, the huge unaddressed arthritis population
becomes potential target for the orthopedic implant
manufacturing companies.
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Total Orthopedic Joint Replacement Market: Revenue

Forecasts (India), 2011-2017
450.0
400.0
29.0
CAGR (2010-2017): 26.7%
28.0
350.0
300.0
27.0
250.0
26.0
200.0
25.0
150.0
100.0
24.0
23.0
50.0
0.0
Revenue Growth Rate (%)
The total orthopedic joint replacement market in India

Revenues ($ Million)
22.0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Year
Revenues ($ Million)
Revenue Growth Rate (%)

51

Current Market Size($)
High
Hip
Knee
Replacement Replacement
Shoulder and Ankle Replacement
Low
High
Low
Long Term Growth Potential
Note: Size of bubble indicates the comparative size of the segment in terms of revenues generated
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52
Life Cycle Analysis
Market Value
Total Orthopedic Joint Replacement Market: Life Cycle Analysis (India), 2011-2017
The knee joint replacement market in India is in a high

growth phase. It was valued $61.8 million in 2010, and is
likely to grow at a CAGR of 28.2 percent from 2010 to 2017.
Opportunity for growth is high due to a significant population
being aged above 55 years , active life style of the younger
population, increased confidence in procedures due to more
successful clinical results after operations and the growth of
insurance sector.
The hip joint replacement market in India was valued at

about $18.3 million in 2010, and is expected to grow at a
CAGR of 20.7 percent from 2010 to 2017. The market is
shifting focus from cemented to uncemented hip implants
due to better results.
Shoulder and ankle replacement formed less than 5 percent

of the total market and is at a very nascent stage of
development.
Knee Replacement
Hip Replacement
Shoulder and Ankle

Replacement
Development
Growth
Maturity
Decline
Time

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53
Competitive Forces (Porters 5 Forces Model)

The bargaining power of customers in the

Indian joint replacement market is very high.
Threat
of
Substitutes
During the past 10 to 15 years, the number of

companies offering a wide range of implants
at different price ranges has increased
rapidly.
Moreover, penetration of insurance being
moderate, patients have to pay out of pocket
for these surgeries, which not only include
the cost of the implants but also the cost of
hospital stay and other expenses.
Furthermore, insurance schemes do not
cover the total cost of prostheses; patients
have to pay the difference of more than 40
percent of the cost of surgery or sometimes
even more.
The affordability of these products for these
customers determines the ability of suppliers
to market them. Therefore, suppliers may
modify their prices to retain their positions in
the market.
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Low
Medium
High
Intensity of
Competition
Bargaining
Power
of
Suppliers
Bargaining
Power
of
Customers
Threat
of New
Entrants
54
Competitive Forces (Porters 5 Forces Model) (Contd)

The threat of new entrants in the Indian

orthopedic joint replacement market is high.
This market has a huge untapped potential.
In the past five years, several notable
companies have entered this market and
made their presence felt; a few prominent
companies include Smith & Nephew,
Exactech and Maxx Orthopaedics.
With the market expected to grow at a rate
over 20 to 25 percent in the years to come,
many major international giants companies
such as Biomet and Wright Medical are
planning to enter this market in a huge way.
The new entrants need not necessarily take
away the share of the existing market
participants; they could create their own
market or customer base without dislodging
the existing established participants, as the
market provides sufficient scope of growth.
Threat
of
Substitutes
Intensity of
Competition
Bargaining
Power
of
Suppliers
Bargaining
Power
of
Customers
Low
Threat
of New
Entrants
Medium
High
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55

The bargaining power of suppliers in the

Indian orthopedic joint replacement market is
low.
Currently, the major buyers or customers of
these implants are the corporate hospitals
and the private superspeciality hospitals.
With several companies offering implants of
different types and costs, hospitals and
surgeons have a wide variety of options to
select the best available implant the market
which matches their expectation in terms of
both quality and price. The competition being
intense, companies often need to reduce the
prices to sustain in the market.
In the public sector, the Government
determines
the
purchasing
and
reimbursement terms of the joint replacement
products for their market. The supplier that
meets these standards will be awarded the
contract for product provision. This
environment inhibits the bargaining power of
suppliers.
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Threat
of
Substitutes
Intensity of
Competition
Bargaining
Power
of
Suppliers
Bargaining
Power
of
Customers
Low
Medium
High
Threat
of New
Entrants
56

The threat of indigenous unapproved product

in the Indian orthopedic joint replacement
market is medium.
These products that have been manufactured
either locally or imported from other markets
are thriving due to the absence of medical
device regulation. Therefore, they constitute
a threat to better quality, higher-cost
products.
The reason behind the threat of generic
products being classified as medium and not
as high is that most orthopedic specialists
tend to opt for high-quality and branded
products.
A few companies manufacture devices
without registration and do not follow
regulatory codes of conduct. Low price of
generic products is one of the major reasons
for these products to persist in the market.
Low
Medium
Threat
of indigenous
Products
High
Intensity of
Competition
Bargaining
Power
of
Suppliers
Bargaining
Power
of
Customers
Threat
of New
Entrants
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57

The intensity of competition in the Indian

orthopedic joint replacement market is high..
Threat
of indigenous
Products
In India, more than 150.0 million people are

suffering from arthritis and only about 70,000
joint replacements are done every year.
Therefore, a substantial portion of the market
continues to remain untapped.
Companies are using various means and
strategies to tap this huge untapped potential,
such as by creating awareness among people
and surgeons on the importance and benefits
of joint replacement surgeries. Relationship
with the hospitals and surgeons also plays an
important role in this market.
With the private insurance sector opening up
and
the
Governments
reimbursement
packages for families below poverty line,
intense competition is expected between the
companies, not only among the existing ones
but also the companies planning to enter.
Low
Medium
High
Intensity of
Competition
Bargaining
Power
of
Suppliers
Bargaining
Power
of
Customers
Threat
of New
Entrants
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58
SWOT Analysis
Total Orthopedic Joint Replacement Market: SWOT Analysis (India), 2011-2017
Strengths
Weakness
Booming economy and increasing middle class

population with substantial disposable income
Lack of availability of trained surgeons

performing joint replacement surgeries
Increasing awareness
replacement surgeries
Facilities performing orthopedic joint replacement

surgeries concentrated in metros, Tier I cities,
and a few Tier II cities
on
benefits
of
joint
Innovations are constantly introduced into the

market; specialists follow innovations closely
Waiver of Customs Duty for import of implants
Low rate of implementation of Government

reimbursement schemes; lack of affordability
among lower middle income group living in Tier
II-Tier II cities and rural areas
Opportunities
Huge arthritis population
Opening up of private insurance sector
The expansion of age group of patients susceptible
to orthopedic ailments requiring joint replacement
surgery to include the population aged about 40
years, due to their fast and sedentary lifestyle
Threat
Decreasing
profitability
prices
affecting
companies
Orthopedic joint replacement surgeries often

being done by surgeons in certain areas without
receiving proper training and infrastructure.
Huge potential for revision surgery market

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59
Competitive Structure
Total Orthopedic Joint Replacement Market: Competitive Structure (India), 2010
Number of Companies in the Market
Around 30
Key International Companies
DePuy Companies, Zimmer, Inc , Stryker, Smith & Nephew,

Exactech, Inc., B Braun, and Maxx Orthopedics, Inc.y,
Zimmer, Stryker, Smith & Nephew, Exactech, and B Braun
Type of Competitors
Approximately 90 to 95 percent dominated by the

international companies
Distribution Structure
Distribution is done mostly through distributors and dealers;

less than 5 percent of the hospitals buy implant in bulk
directly from the manufacturer
Tiers of Competition
Tier 1 DePuy Companies and Zimmer

Tier 2 Stryker, Smith & Nephew, Exactech and B Braun
Tier 3 - Other companies (Local and international)
Key End-user Groups
Private hospitals and clinics

Public hospitals
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60
The total Indian orthopedic joint replacement market Total Orthopedic Joint Replacement Market: Company
Market Share by Revenues (India), 2010
DePuy, the orthopedic division of Johnson &

Johnson Ltd., led the market in 2010 with 48.1
percent market share. Established in the Indian
market for a very long time, its aggressive marketing
and strong relationship built with surgeons and
hospitals are some of its key success factors.
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The second largest participant in 2010 was Zimmer

with a market share of 21.4 percent, followed by
Stryker with 10.0 percent.
Smith & Nephew that held nearly 8.1 percent market
share in 2010, had grown almost three times from
2009; some of the key state Government deals were
won by this company in 2010.
Other notable international companies include
Exactech and B Braun with a cumulative market
share of 8.4 percent in the same year.
Revenues - $80.4 million

4.6% 3.8%
4.0%
8.1%
48.1%
10.0%
21.4%
Depuy
Zimmer
Stryker
Exactech
Smith & Nephew

B Braun
Others
Note: Others includes international and domestic companies such
as Synthes GmbH, Biomet, Inc., Endolite India Limited,
Anthrex, Inc., Indus Orthopedics, Inor Orthopedics and so on

61
Factors Considered for the Selection of an Implant

Parameters for the Selection of an Implant
Technology, design, and type of an implant, its cost, patients need, product delivery, durability of a product,
training offered, previous experience, and brand reputation are the parameters considered while selecting
an implant.
Calculations (for One Modality)
Every respondent was asked to rate the above-mentioned parameters on a scale of 1-8, depending on the
importance given to them while purchasing an implant. (1 stands for the least important criteria, while 8
stands for the most important criteria.)
For every criteria, percent of response for each rating was calculated. For example, out of 15 respondents,
31 percent gave patients need a rating of 6.
For a particular criterion, the rating given by a majority of respondents was considered and plotted on the
spider chart. For example, product delivery was given a rating of 5 by a majority of respondents (42.0
percent). Hence, it was given a rating of 5.
Sample Size For the purpose of this study, about 15 orthopedic surgeons (who perform joint replacement
surgeries) across India were interviewed.
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62
Important Factors for the Selection of an Implant (Contd)

About 73.0 percent of the respondents rated technology, design, and type of implant as the most important
criterion. Cost of an implant and patients need followed it.
Total Orthopedic Joint Replacement Market: Important Criteria for the Selection of an Implant (India), 2010
Maximum Response
Technology, Design and Type of

Implant
73.0%
73.0% respondents rated it as
most important criteria
Cost of an Implant
53.0%
Brand Reputation
42.0%
8
7
6
5
4
3
2
1
0
Patient's Need
31.0%
Previous Experience
42.0%
Training Offered
58.0%
Durability of a Product
32.0%
Product Delivery
42.0%
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63

Technology, Design, and Type of an Implant
Technology, design, and type are the most important factors considered while selecting an implant. Some
implants are complicated, while the others are very easy to use. Hence, selection also depends on the
surgeons level of comfort with an implant. For instance, a cemented implant is not suitable for younger
patients, as the chances of cement wearing out are high. Hence, it is used mostly for older patients who
perform less activities. Uncemented implants can be easily replaced through the revision surgery; hence,
they are used for younger patients.
Cost of an Implant
Cost of an implant is the second-most important criterion according to surgeons. Adopting new technology
becomes difficult, especially when its cost is very high when compared to the existing one.
Uncemented implants are more expensive than the cemented ones, hence are preferred by medium to
high income group of patients. Though patients are less involved in the process of selecting an implant,
their affordability also determines the type of implants.
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64

Patients Need
The next important factor is the patients need. Any implant is selected after the patients physical
examination based on the extent of damage caused to the bone and age. For example, uncemented
implants are selected depending on the bone strength of a patient. If the bones are strong, which is
mostly the case with younger patients, uncemented implant is preferred over the cemented one.
Product Delivery
Speedy product delivery is another criterion considered during selection. An implant is expected to be
delivered within 24 hours. Speedy delivery is important especially in trauma cases. A surgery in this case
is not planned, hence, an implant is expected to arrive as early as possible.
Durability of a Product
The quality of an implant is also considered while selecting an implant. Quality includes the grade of
material used and its finishing; the material used should wear less. A good-quality implant should have a
shelf life of 15 to 20 years.
Training Offered
Training for new technologies, in the form of live demo or whole model training, helps a surgeon to
become familiar with them. This, to some extent, influences the decision regarding the selection of an
implant. Some companies offer cadaver trainings abroad.
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65

Previous Experience
Previous experience with a vendor influences the decision of purchase of an implant. Most of the
surgeons become comfortable with an implant while being trained on its usage. For example, DePuy was
the first orthopedic implant company to be established in India. It trained many surgeons to use its
implants; hence, they are accustomed to them. This results in them being loyal to the company.
Brand Reputation
According to the surgeons (42.0 percent), brand reputation is a less important criteria when compared to
the other factors listed during the selection of an implant. Most of the companies provide references either
from a previous case study or a renowned surgeon or hospital.
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66
Knee Joint Replacement Market
67
Overview
Knee replacement surgery, also known as knee

arthroplasty, can help relieve pain and restore
function in severely diseased knee joints. During
knee replacement, a surgeon cuts away
damaged bone and cartilage from the thighbone,
shinbone, and kneecap and replaces those with
an artificial joint (prosthesis) made of metal
alloys, high-grade plastics, and polymers.
Knee replacement can improve knee problems
associated with osteoarthritis, rheumatoid
arthritis, and other degenerative conditions, such
as avascular necrosis, a condition in which
obstructed blood flow causes the death of bone
tissue.
Knee arthroplasty procedures are

categorized as primary or revision.
Primary and revision surgeries

unicompartmental (partial) or total.
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are
Knee Joint
Replacement Market
Primary Knee Replacement

Unicompartmental Knee
Replacement
Revision Knee Replacement
broadly
either
68

Knee Joint Replacement Market: Market Engineering Measurements (India), 2010
Measurement Name
Measurement
Trend
Market age
Growth stage
Increasing
Revenues
$61.8 million
Increasing
Potential revenues (maximum future market growth)
$355.5 million
Increasing
27.2%
Increasing
28.2%
Increasing
High
High
About 30
Increasing
About 79.5%
Decreasing
Increasing
Customer loyalty
Stable
15-20 years
Stable
Price sensitivity
Competitors (active market competitors in base year)
Market concentration (percent of base year market controlled by top
3 competitors)
Units shelf life
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69
Revenue Forecasts
Year
Revenues
($ Million)
Revenue
Growth Rate
(%)
2008
38.3
--
2009
48.6
26.9
2010
61.8
27.2
2011
78.8
27.4
2012
100.6
27.7
2013
128.8
28.0
2014
165.3
28.3
2015
212.7
28.7
2016
274.5
29.1
2017
355.5
29.5
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70
Over 50,000 knee replacement were performed in

2010 of which, 85 to 90 percent were total knee
replacement; 9 to 10 percent were revision knee
replacement, and less than 2.0 percent were
unicompartmental knee replacement.
At present, almost all the types of knee

replacements in India performed are cemented
ones; the cementless types are yet to penetrate the
market. The Indian knee joint replacement market
is expected to grow at a CAGR of 28.2 percent
from 2010 to 2017.
New materials used for bearing surfaces are
rapidly changing the average age of patients who
undergo knee replacement surgeries, with younger
patients becoming more common. As a result, a 40
to 50 years old patient can enjoy the benefits of
improved implant longevity.
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Knee Joint Replacement Market: Revenue Forecasts (India),

2011-2017
360
30.0
CAGR (2010-2017): 28.2%
320
280
29.5
29.0
240
28.5
200
160
28.0
27.5
120
80
40
27.0
26.0
26.5
RevenueGrowth
GrowthRate
Rate(%)
(%)
Revenue
Revenue
Growth
Rate
(%)
The Indian knee joint replacement market was

valued at $61.8 million in 2010.
Revenues
Million)
Revenues
($Million)
Million)
Revenue ($($
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Year
Year
Year
Revenue ($Million)
Revenue Grow th Rate (%)

71
Procedure Forecasts
Of the over 50,000 knee procedures done in. The

total knee replacement segment accounted for
approximately 88.0 percent share in 2010, and is
expected to grow to about five to six times from
2010 to 2017. The revision knee replacement
segment is also expected to grow at an equally
high rate to attain 17.0 percent market share in
2017 from 10.0 percent in 2010.
The Indian unicompartmental knee replacement
segment is at a very nascent stage of growth. In
India, people generally go to the physician at a
very late stage of the disease. By then, their
ailment would have crossed the stage of partial
knee replacement. Therefore, the potential for
growth of this market is moderate.
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Knee Joint Replacement Market: Procedure Forecasts

(India), 2010 and 2017
Number of Knee Procedures
1.7%
9.9%
88.4%
2010
Primary Knee Replacement
3.0%
17.0%
80.0%
2017
Revision Knee Replacement
Unicompartmental Knee Repalcement

72
The Indian knee joint replacement market was valued

at $61.8 million in 2010.
In 2010, DePuy Companies dominated this market

with 47.5 percent share, followed by Zimmer, Inc. and
Stryker with a market share of 22.1 and 10.5 percent,
respectively.
Smith & Nephew had increased its market share to

8.4 percent in 2010, acquiring the shares of a few
other companies. Alignment of human resources,
products, and pricing are some of the reasons for this
growth.
Exactech with a share of 4.9 percent and B Braun with
a share of 2.8 percent in the same year were some of
the other prominent international participants.
Due to the high volume of potential population
requiring knee joint replacement in India, more
international and local companies concentrate on this
market as compared to those on the hip joint
replacement market.
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Knee Joint Replacement Market: Company Market Share

by Revenues (India), 2010
Revenues - $61.8 million
8.4%
4.9%
2.8%
3.8%
47.5%
10.5%
22.1%
Depuy
Stryker
Exactech
Others
Zimmer
Smith & Nephew
B Braun
Note: Others include international and domestic companies such as

Synthes GmbH, Biomet, Inc., Endolite India Limited, Anthrex,
Inc., Indus Orthopedics, Inor Orthopedics and so on

73
Hip Joint Replacement Market
74
Overview
Hip joint replacements are essential when the hip joints

degenerate. It is the surgical process of replacing the
existing ball and socket joint with artificial ones.
Hip joint replacement is usually considered only when
other therapies, such as pain medications, have failed.
There are three types of procedures for hip
replacements: primary, partial, and revision.
Primary hip joint implants include an array of
components that replace the ball and socket hip joint.
Manufacturers supply these parts as individual pieces or
as a complete hip system.
Revision hip prosthetics are endowed with design
features to augment the fixation of the implant in an
increasingly bone-deficient environment. When a
primary total hip arthroplasty loosens, the orthopedic
surgeon is likely to consider the removal of the
prosthesis and its replacement with a new prosthesis.
Hip Joint
Replacement Market
Primary Hip Replacement

Partial Hip Replacement*
Revision Hip Replacement
*Partial Hip Replacement Market is not considered as a part of this

study. This is a highly fragmented market with a lot of local
manufacturers and distributors.
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Hip Joint Replacement Market: Market Engineering Measurements (India), 2010
Measurement Name
Measurement
Trend
Market age
Growth stage
Increasing
Revenues
$18.6 million
Increasing
Potential revenues (maximum future market size)
$70.7 million
Increasing
18.4%
Increasing
20.7%
Increasing
High
High
About 30
Increasing
About 78.6%
Decreasing
Increasing
Customer loyalty
Stable
15-20 years
Stable
Price sensitivity
Competitors
Market Concentration (percent of base year market controlled
by top 3 competitors)
Units shelf life
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76
Revenue Forecasts
Year
Revenues
($ Million)
Revenue
Growth Rate
(%)
2008
13.3
--
2009
15.7
18.0
2010
18.6
18.4
2011
22.1
18.9
2012
26.4
19.4
2013
31.7
20.1
2014
38.3
20.8
2015
46.6
21.7
2016
57.1
22.7
2017
70.7
23.7

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Of the total 15,000 to 20,000 hip replacements

performed in India during 2010, cemented hip
replacements formed about 44 to 45 percent,
while uncemented formed about 49 to 50
percent ; the rest 6 to 7 percent were revision
hip replacements.
The Indian hip joint replacement market is

expected to grow at a CAGR of 20.7 percent
from 2010 to 2017.
The hip replacement cases in India are low as

compared to the knee replacement cases.
Uncemented hip replacements are growing at a

faster rate when compared to cemented hips
due to better results and shorter recovery time.
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Hip Joint Replacement Market: Revenue Forecasts (India),

2011-2017
80.0
24.0
CAGR (2010-2017): 20.7 %
70.0
23.0
60.0
22.0
50.0
21.0
40.0
20.0
30.0
19.0
20.0
18.0
10.0
17.0
-0.0
Revenue
Growth
Rate
(%)
Revenue
Growth
Rate
(%)
The Indian hip joint replacement market was

Revenue
($ Million)
Revenues
($ Million)
16.0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Year
Year
Revenue ($ Million)
Revenue Grow th Rate (%)

78
Procedure Forecasts
Of the total 15,000 to 20,000 hip replacement procedures

a in 2010, the type of uncemented implant constituted
49.0 percent and is expected to increase to 60.0 percent
in 2017.
The uncemented implants is gaining popularity and their
share is expected to increase due to benefits like
increased longevity, shorter operation time (there is no
need to wait for bone cement to dry), and an easier
revision process in the future.
Cemented replacement is likely to experience a decline in
usage from 44.0 percent in 2010 to 25.0 percent in 2017.
However, it will still hold a substantial portion of the
market, because cemented replacements are preferred
over cementless ones for older, less active people and
people with weak bones, such as those who have
osteoporosis.
Hip Joint Replacement Market: Procedure Forecasts

(India), 2010 and 2017
Number of Hip Replacement Procedures
6.4%
15.0%
47.6%
60.0%
46.0%
25.0%
2010
Cemented Hip Repalcement
2017
Uncemented Hip Replacement
Revision Hip Replacement

Revision surgeries are expected to grow from 7.0 percent

in 2010 to 15.0 percent in 2017, as most of the patients
who underwent replacement surgery 10 to 15 years back
will need revision surgery and same is the case in future.
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The Indian hip joint replacement market was Hip Joint Replacement Market: Company Market Share by
Revenues (India), 2010
Revenue - $18.6 Million
DePuy led this market with a share of 50.3 percent

in 2010, followed by Zimmer, Inc. with 18.7 percent.
DePuys metal-on-metal hip implants, ASR, were
recalled from the market last year due to their
failure and several complaints from patients. This
affected the companys share globally in the hip
replacement market.
Stryker with a share of 8.2 percent was the third

largest participant in this market in 2010.
Smith & Nephew and B Braun both held 7.0

percent share each in that year.
Exactech, Inc. which is not present in the cemented

knee implant segment, held a market share of 3.5
percent in that year.
5.3%
7.0%
3.5%
7.0%
50.3%
8.2%
18.7%
Depuy
Stryker
Exactech
Others
Zimmer
Smith & Nephew
B Braun
Note: Others include international and domestic companies such as

Synthes GmbH, Biomet, Inc., Endolite India Limited, Anthrex,
Inc., Indus Orthopedics, Inor Orthopedics and so on.

Source is Frost & Sullivan
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Recent Mergers and Acquisitions
81
Mergers and Acquisitions

DePuy Orthopedics Acquisition of Finsbury Orthopedics
In December 2009, DePuy Orthopedics acquired Finsbury Orthopedics, which is a manufacturer of

orthopedic devices. With this acquisition, DePuy strengthened its position in the hip and knee joint
replacement markets by gaining proprietary, advanced high-performance hip bearings, and products
with the ceramic-on-ceramic and metal-on-metal bearing technologies.
Zimmer Acquired Chinese Orthopedic Implant Company Beijing Montagne Medical Device Co., Ltd.
In December 2010, Zimmer completed acquisition of Beijing Montagne Medical Device Co., Ltd. The
acquisition will provide an expanded product line in hips, knees, and powered surgical instruments
designed according to the Chinese market. This move is expected to provide Zimmer with an access
to additional research, development, and manufacturing capabilities in China.
Zimmer Announced Acquisition of SoPlus Orthopaedic Surgical Power Tools Company
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In December 2010, Zimmer announced acquisition of Sodem Diffusion S.A., the manufacturer of
SoPlus Orthopaedic Surgical Power Tools based in Geneva, Switzerland. The company will be
renamed Zimmer Surgical, S.A., and will be a part of Zimmer Surgical, headquartered in Dover, Ohio.
Adding SoPlus's innovative small and large bone product lines to Zimmers portfolio is expected to
expand Zimmers offerings in the orthopedic power equipment market.
82
Mergers and Acquisitions (Contd)

Zimmers Acquisition of Endius Inc.
In early 2007, Zimmer acquired Endius Inc., which is a Massachusetts-based company and a
leading developer of minimally invasive instrument kits and associated implants for spinal fusion.
Endius Inc. is at present wholly owned by Zimmer. This acquisition has helped Zimmer to broaden
its product line by incorporating the minimally invasive technology, which has increased the
companys revenues in the growing spine replacement markets.
Zimmers Acquisition of ORTHOsoft Inc
In November 2007, Zimmer acquired ORTHOsoft Inc, which is a developer of medical software,
instruments, and computerized systems. This acquisition added the FDA-approved, patented
navigation software solutions of ORTHOsoft Inc to Zimmers computer-assisted surgery (CAS)
product line. CAS has gained popularity in India, and this acquisition has helped Zimmer to hold a
stronger position in this segment.
Strykers Acquisition of OstiMed
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In November 2009, Stryker completed its acquisition of OstiMed, which is a CAS softwaremanufacturing company. These software help surgeons to achieve better alignment during
replacements. This acquisition will allow Stryker to include CAS software in its product line as well
as enhance its existing knee joint replacement product line. It is likely to enhance Strykers growth,
as CAS is becoming popular in India.
83

Exactech Announces Acquisition of Brighton Partners, Inc
In May 2010, Exactech announced acquisition of Brighton Partners, Inc., the sole source supplier of
the direct compression molded polyethylene bearings used exclusively in Exactechs flagship product,
the Optetrak knee replacement system. Direct compression molded polyethylene bearings are a key
component of Exactechs knee replacement system. By this acquisition, Exactech aims to protect this
proprietary technology, that represented more than $75.0 million of its total 2009 revenues.
Exactech Acquires VertiFlex, Inc
In August 2010, Exactech announced acquisition of VertiFlex, Inc., a developer of minimally invasive
and motion preserving spinal surgery technologies. With this acquisition Exactech aims to tap the
spine industry with products implanted through a surgical approach designed to reduce the length of
hospital stays and shorten overall patient rehabilitation time.
Exactechs acquisition of Altiva Corporation
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In January 2008, Exactech announced acquisition of Altiva Corporation Orthopedics Altiva, which
offers a spinal fusion product line with implants and instrumentation that address major spinal
pathologies. Altiva has multiple development projects underway, most notably a collaboration with a
leading group of spinal surgeons focused on the rapidly emerging motion preservation market.
84

Exactech Acquires of France Medica SAS
In April 2008, Exactech, Inc., announced the acquisition of the stock and assets of France Medica
SAS, a French importer and distributor of orthopedic products and surgical supplies. This is expected
to enable the establishment of a direct sales operation in France and strengthen its competitive
position, improve service to its customers in France and to grow its European business.
Biomets Acquisition of Cartilix
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In 2009, Biomet (which develops solutions for knee disorders) acquired Cartilix, which develops
cartilage repair and regeneration solutions and products, including a proprietary cartilage
regeneration technology for the repair of knee cartilage (yet to be launched). This acquisition allowed
Biomet to increase its sports medicines portfolio.
85
Recommendations and Conclusion
86
Recommendations
Product Differentiation and Customization
Companies should align their products to cater to the demand of different sections of the society (such as
the very premium end, the mediocre and not so affordable class of population) as well as to a larger
section of the population. With fierce competition in the market compelling participants to bring down the
prices of implants, it can be difficult for the international companies to offer the products below a certain
price to realise the bottom line.
Reducing Manufacturing Costs
Products should be customized to meet the needs of Indian patients without compromising on the
quality. All these factors may call for bringing down the cost of manufacturing an implant in order to
realise the margin of profit. Therefore, with raw material cost being fixed, to reduce the overhead cost
of manufacturing, some companies are in process and a few are planning to open manufacturing
centres in countries such as China where labour cost is low.
Joint Venture Agreements
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Alternatively, another solution can be to seek joint venture agreements or acquisition of a local or
indigenous manufacturer, who meets the ISO/GMP/international standards. The global leaders will
require local market knowledge and distribution networks and will also be attracted by lower
manufacturing costs. Reduced price of implants could increase the reach to various classes and
sections of the population, thereby creating an opportunity for a wider customer base.
87
Recommendations (Contd)
Educating the Users
A large section of the population is either unaware of the problem and seriousness of jointrelated
diseases or is reluctant to undergo joint replacement surgery due to fear of surgery and the postsurgery
trauma.
There is a need to raise awareness of arthritis in all its forms among the medical community, arthritic
patients, and the general public. Increasing the awareness about the disease and educating patients on
the various treatment options available will significantly help in fighting this severe disabling disease as
well as will drive the orthopedic joint replacement market.
Conferences and meetings should be held were people suffering or even not suffering from arthritis are
invited to spread awareness/knowledge regarding arthritis, its prevention and management.
This is to ensure all people with arthritis and their caregivers are aware of the vast support network
available to them.
Operated patients with joint replacement should be made to interact with those affected with arthritis.
This builds confidence and positive attitude toward the treatment process. This can help millions of
patients who suffer acutely and lose hope of becoming well and enjoying life.
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Training Surgeons
About 800 850 orthopedic surgeons, who can perform replacement surgeries, serve the entire
population of India. This is because there is less opportunity for orthopedic training in India; most
surgeons go overseas to learn, and many of them do not return.
Surgeons need to be trained on the new products in the market. Most of the young and experienced
surgeons should be trained through seminars and conferences arranged by a company; live telecast of a
surgery and dry bone exercise could also be arranged.
The trainings should start right from the time the medical schools and should be a part off college
curriculum. For post graduate students, special courses should be offered. Level of these trainings can
vary at different orthopedic joint replacement centers.
Relationship with the surgeons forms a very important decision making criteria while purchasing an
implant. These trainings allow a manufacturer to interact with surgeons and change their perception about
a particular implant. Younger surgeons and post graduates should be awarded with special training.
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Promotional Activities and Advertising Channels
Updating the surgeons on the latest advancements frequently on the new technologies through
advertising channels such as journals, conferences, seminars, Webinars, medical newsletters, portals,
and so on, is necessary. This will help the companies to strengthen the relationship with the surgeons
who are one of the most important decision makers while purchasing an implant.
Conferences or seminars may allow a platform for surgeons to get their queries clarified such as success
rate, results, previous references, and so on. These activities may also help a company to change a
surgeons preference for a particular implant.
Strong distribution Network
An implant is usually chosen by a surgeon according to the surgeons comfort, the requirement of a
surgery, and cost of the device.
Hospitals and surgeons prefer to buy implants from distributors. This provides them the advantage of
having to pay only for the used component. Distribution networks in India are extremely dense, layered,
and difficult to penetrate without connections and experience. Therefore, finding the right partner is
essential, and lack of due diligence can significantly affect the distribution process.
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Conclusion
The total market for orthopedic joint replacement market in India was valued at $80.4 million. Of this, over
75 percent contribution was from knee replacement market, about 20 to 25 percent was from hip
replacement market and less than 5 percent of the total market revenues were contributed by shoulder and
ankle replacement market.
For the manufacturers of orthopedic implants, the Budget 2010-11 has proposed an exemption of specified
inputs for the manufacture of implants from import duty. These incentives will drive the already fastemerging medical devices and equipment sector in India.
India has one of the fastest growing medical devices market. In the coming years, healthcare may be the
largest user of technology and also the largest employer. The growth rate of the orthopedic implants is
estimated to be over 25 percent per annum at least for the next five to six years.
Growth of the Indian joint replacement market is likely to be driven by a combination of factors such as
increasing affordability of the middle class population with substantial disposable income, spreading word
of mouth on successful joint replacements, and opening up of the insurance sector, among others.
Currently, over 70,000 hip and knee replacements are performed every year. A significant percent of the
Indian population is either suffering from or susceptible to orthopedic joint ailments, requiring replacement
surgeries. With a large potential population requiring joint replacement and increase in awareness about
the impact of joint problems on the lives of patients and the importance of a surgical treatment approach to
cure it, the market for orthopedic implants is likely to become one of the most profitable segments in the
Indian medical device market.
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Company Profiles
92
Leading Companies in the Total Indian Orthopedic Joint

Replacement Market
The total Indian orthopedic joint replacement market is growing at a high rate and has a number of
participants that provide a variety of products. However, it is dominated by international participants.
Some of the active international participants include Zimmer, Inc., Stryker, DePuy Companies (Johnson &
Johnson), Smith & Nephew, Exactech, Inc., B. Braun and Maxx Orthopaedics. These are wellestablished companies with a wide range of products, and they account for a major share of the market
revenues.
Some local implant manufacturers such as Indus and Inor are also well-known companies that have a
prominent presence in the total Indian orthopedic joint replacement market. Many other companies export
implants to small-scale prosthesis manufacturers of unknown quality as well.
Indian surgeons prefer imported prosthesis over the ones manufactured in India. About 95 percent of the
joint replacement implants used by Indian surgeons are imported, because of their superior quality and
instrumentation.
In comparison to international countries, Indian manufacturers use semi-Computed numerically controlled

(CNC) based machinery, which means that certain manufacturing procedures are operated manually,
while others are automated.
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DePuy Medical Pty. Ltd (Johnson & Johnson)

Web site - http://www.depuy.com/
Headquarters - DePuy Orthopedics, Inc. 700, Orthopedic Drive, Warsaw, IN 46582
Local Headquarters - DePuy India, DePuy Medical Private Limited, 30 Forjett Street, Mumbai 400 036,
Tel: + 91 22 2386 1431
Established in 1895 as DePuy and later acquired by Johnson & Johnson in 1998, DePuy Orthopedics
was the first commercial orthopedics company to enter the Indian market. The company conducts
business virtually in all countries across the world through its dense network of dealers.
DePuy imports orthopedic products from Europe and the United States for the Indian market. In India, it
offers products such as innovative orthopedic implants for hip, knee, and shoulder joint replacement.
DePuy offers a number of products for hip and knee joint replacement, including total knee and hip joint
replacement systems, CAS products, cemented and uncemented hip systems, partial knee joint
replacement systems, and revision hip and knee systems.
The recent product launches further extend its product line in the hip joint replacement, knee joint
replacement, and navigation system segments. These products are likely to drive the companys growth
in the Indian market, as they have novel technologies.
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Zimmer India Pvt Ltd.

Web site - http://www.zimmerindia.com/z/ctl/op/global/action/1/id/9016/template/CP
Headquarters - P.O. Box 708 , 1800 West Center Street, Warsaw, IN 46581-0708 , Tel: +1-800-613-6131
Local headquarters - Vanijya Nikunj, 7th Floor, EnkayTowers, Udyog Vihar, Phase V, Gurgaon,
Haryana 122 016, INDIA.
Founded in 1927, Zimmer Holdings, Inc. (Zimmer) designs, develops, manufactures, and markets reconstructive
orthopedic implants, including joint and dental, spinal implants, trauma products, and related orthopedic surgical
products. It operates in more than 25 countries around the world and sells products in more than 100 countries.
By the company's estimates in 2007, it was the leader in the global hip and knee joint replacement markets with
revenue shares of 26 percent ($1.30 billion) and 28 percent ($1.60 billion), respectively.
In 2009, Zimmers global sales were $4.10 billion; its revenues in the Asia Pacific knee and hip joint replacement
markets were $230.0 million and $214.0 million, respectively. In 2010, the company expects its revenues to
increase by 3 to 5 percent globally.
Zimmers product line includes total knee and hip joint replacement systems, cemented and uncemented hip
systems, and revision knee and hip systems.
The company recently launched gender-specific implants systems, which are likely to gain high popularity in the
Indian market.
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Stryker India Pvt Ltd.

Web site - http://www.stryker.com/en-us/index.htm
Headquarters - 2825, Airview Boulevard, Kalamazoo, MI 49002, The United States.
Local Headquarters - Stryker India, Vatika Towers, Block A, 1st Floor, Golf Course Road, Sector 54,
Gurgaon
Established in 1941, Stryker is the 12th-largest medical technology company in the world. The company's
products include implants used in the joint replacement, trauma, craniomaxillofacial, and spinal surgeries,
surgical, neurologic, ear, nose, and throat, and interventional pain equipment, endoscopic, surgical
navigation, communications, and digital imaging systems. It is known for a variety of innovative, highquality products and services.
Stryker is active in the hip as well as knee joint replacement segments.
The companys global revenues were $6,723.0 million, and its orthopedic products yielded approximately
$3,570.0 million, in 2006.
According to the companys reports, its orthopedic implants sales reported 15.0 percent growth in 2007.
The sales of hip and knee implants grew by 9 and 16 percent, respectively.
Strykers product line includes total knee and hip joint replacement systems, cemented hip systems, and
revision knee and hip joint replacement systems.
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Smith & Nephew

Web site - http://global.smith-nephew.com/master/india_19530.htm
Headquarters - Smith & Nephew Surgical, 19-25 Khartoum Rd, North Ryde NSW 2113
Tel: +61 2 9857 3999
Local Headquarters - Smith & Nephew Healthcare Pvt. Ltd, B-203, Dynasty Business Park, J. B. Nagar,
Andheri Kurla Road, Andheri East, Mumbai - 400 059, Tel: + 91 22 2386 1431
For over 150 years, Smith & Nephew has been developing advanced medical devices for healthcare
professionals around the world. The company operates in 32 countries and offers a wide range of
orthopedic joint reconstruction services. It manufactures products in three global business units to cater to
the orthopedics sector reconstruction, trauma, and clinical therapies.
In 2009, the company generated a profit of $503.0 million in the global orthopedics sector and witnessed a
growth rate of 2 percent. The revenues generated from the hip and knee joint reconstruction segments
were $176.0 million and $158.0 million, respectively. The knee and shoulder repair products sales grew by
12.0 percent.
Smith & Nephew is active in the hip and knee joint replacement segments, and it offers products for total
hip and knee joint replacement, partial hip joint replacement, and revision knee joint replacement.
The recent launches of the next generation of existing products are likely to drive Smith & Nephew's
growth in the Indian market.
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About Frost & Sullivan
98
Who is Frost & Sullivan

The Growth Consulting Company
Founded in 1961, Frost & Sullivan has over 45 years of assisting clients with their decisionmaking and growth issues
Over 1,700 Growth Consultants and Industry Analysts across 32 global locations
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Developers of the Growth Excellence Matrix industry leading growth positioning tool for
corporate executives
Developers of T.E.A.M. Methodology, proprietary process to ensure that clients receive a
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360 perspective of technology, markets and growth opportunities
Three core services: Growth Partnership Services, Growth Consulting and Career Best
Practices
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What Makes Us Unique
Exclusively Focused on Growth
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Proprietary T.E.A.M.
all 6 critical research methodologies to
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addressing client growth strategies and plans
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360o Perspective
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Overview of Orthopedic Joint

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Research Aim and Key Deliverables

Market Segmentation and Scope of the Study

Current Market Size and Growth Trends

Key Market Drivers and Restraints

Future Growth Potential by Segment

Competitive Scenario and Conclusion

Research Scope and Definitions

Scope of the Study

Common Indications for Joint Replacement

Types of Joint Replacement Surgeries

Material Used for Prosthesis

Total Orthopedic Joint Replacement Market

Table of Contents (Contd)

Key Market Drivers

Key Market Restraints

Future Growth Potential by Segment

Life Cycle Analysis

Competitive Forces (Porters 5 Forces Model)

Market Share Analysis

Factors Considered for the Selection of an Implant

Important Factors for the Selection of an Implant

Knee Joint Replacement Market

Table of Contents (Contd)

Revenue Forecasts and Procedure Forecasts

Market Share Analysis

Hip Joint Replacement Market

Market Engineering Measurements

Revenue Forecasts and Procedure Forecasts

Market Share Analysis

Recent Mergers and Acquisitions

Leading Companies in the Total Indian Orthopedic Joint Replacement Market

Table of Contents (Contd)

Zimmer India Pvt Ltd.

Stryker India Pvt Ltd

Smith & Nephew

About Frost & Sullivan

Total Orthopedic Joint Replacement Market: Revenue Forecasts (India), 2011-2017

Total Orthopedic Joint Replacement Market: Competitive Structure (India), 2010

Knee Joint Replacement Market: Revenue Forecasts (India), 2011-2017

Hip Joint Replacement Market: Revenue Forecasts (India), 2011-2017

Total Orthopaedic Joint Replacement Market: Competitive Landscape (India), 2010

Total Orthopedic Joint Replacement Market: Revenue Forecasts (India), 2011-2017

Total Orthopedic Joint Replacement Market: Competitive Forces (India), 2011-2017

Total Orthopedic Joint Replacement Market: SWOT Analysis (India), 2011-2017

Knee Joint Replacement Market: Market Engineering Measurements (India), 2010

Knee Joint Replacement Market: Revenue Forecasts (India), 2011-2017

List of Charts (Contd)

Hip Joint Replacement Market: Market Engineering Measurements (India), 2010

Hip Joint Replacement Market: Revenue Forecasts (India), 2011-2017

Research Aim and Key Deliverables

The deliverables in this research service include:

Highlighting the orthopedic surgeons perspective on factors influencing selection of an implant

Market Segmentation and Scope of the Study

Shoulder and Ankle Joint

Scope of the Study

Study period 2008-2017

Base year 2010

Forecast period 2011-2017

Current Market Size and Growth Trends

The joint replacements market in India is in a high