Why fewer people are getting knee replacements right now, and why it probably won't last

What the companies reported

Knee replacement has been one of the steadiest businesses in medicine for decades. An aging population and more active older adults pushed volumes up almost every year. That made this fall's earnings reports stand out.

• Stryker cut its 2026 organic growth forecast to 6.5% to 7%, down from 8.3% to 9.3% in July. Its knee sales grew just 1.1% in the quarter.¹ CEO Kevin Lobo told investors it was "now clear that there is a market slowdown" in hips and knees.²
• Smith+Nephew saw US knee implant sales fall 7.3% and lowered its full-year revenue growth forecast from 4% to about 3%. It expects the weakness in US orthopedics to continue through the fourth quarter.³
• Zimmer Biomet, the largest knee company, reported global knee sales down 3.1%, with US knees down 2.0%. The company still raised its overall outlook because hips, sports medicine and technology grew, but it told investors to expect continued pressure on knees in the near term.^4,5
• Johnson & Johnson reported medical device sales below analyst expectations and said it's on track to spin off its orthopedics business, DePuy Synthes, by mid-2027.¹³

Not every company's weakness has the same cause. Zimmer Biomet blamed part of its US knee decline on a sales force reorganization and competition, and China was its biggest international drag.⁵ But when several companies point at the same soft US market in the same month, the market itself has changed.

Reason one: patients are paying more and waiting

Stryker's CEO pinned the slowdown on affordability, pointing to higher insurance premiums and deductibles.² Hospital companies said the same thing in their own earnings calls a week earlier.

• The enhanced Affordable Care Act subsidies expired at the end of 2025. KFF projected that subsidized enrollees' average yearly premium payments would more than double, from $888 to $1,904.⁶
• HCA Healthcare named lost coverage as the main reason for softer volume. Its admissions of patients with marketplace insurance fell about 19%, with most of those patients becoming uninsured.⁶
• In a KFF poll from October, about 28% of adults said they had skipped or postponed care in the past year because of cost.⁶

The deductible calendar matters too. Someone who hasn't met this year's deductible by fall often waits for January, when the new plan year starts. That shifts surgery into the next year without ending the need for it. A Community Health Systems executive made exactly that argument: joint replacement demand gets delayed, not lost.⁶

Reason two: approvals are harder to get

After Stryker's report, analysts at Truist flagged tougher insurance approvals alongside softer demand.⁷ Prior authorization, where the insurer must approve surgery in advance, now applies to nearly every high-cost procedure.

The evidence that it saves money in joint replacement is thin. In a study of about 3,900 commercially insured hip replacement patients presented at the 2025 AAOS meeting, prior authorization didn't lower costs. Patients who needed it had worse hip scores before surgery and waited longer.⁸ Insurers pledged in 2025 to simplify the process. By an April 2026 survey, participating insurers had cut about 11% of requirements.¹⁶ That's progress, but it's slow progress for someone who can't walk across a parking lot.

Reason three: surgeons are being squeezed

This is the part that worries me most, because it doesn't fix itself when the economy improves.

Medicare cut surgeon payment for total knee and hip replacement by about 7.5% in 2026.⁹ In its final 2027 rule, released November 4, CMS cut the work value of the knee replacement code again, from 19.11 to 16.70 units. That's about a 13% cut, smaller than the roughly 20% it first proposed.⁹ The overall Medicare conversion factor also drops 2.31% in 2027.¹⁰ Surgeon groups say payment for these procedures has fallen sharply over three decades once you adjust for inflation.¹²

The workforce is shrinking at the same time. Bureau of Labor Statistics data show about 14,100 orthopedic surgeons practicing in 2025, down from 16,260 in 2021.¹¹ A senior joint replacement surgeon at Rothman Orthopaedics told Becker's he's considering opting out of Medicare, and that several colleagues are weighing the same move.¹²

Opting out has been rare in orthopedics. If it becomes common, the people who feel it first will be Medicare patients in places that already have few surgeons. Longer waits for a knee replacement aren't harmless. Patients lose mobility and conditioning while they wait, and some arrive at surgery in worse shape.

Reason four: where surgery happens is moving

Medicare's mandatory TEAM bundled payment model started January 1, 2026, at roughly 740 hospitals. It makes hospitals financially responsible for the cost and quality of a joint replacement from surgery through 30 days after discharge.¹⁴ A broader mandatory bundle, CJR-X, starts in 2028 for more than 2,000 hospitals.¹⁵

These programs push healthy patients toward outpatient surgery and surgery centers. Medicare will raise surgery center payment for total knee about 4% in 2027, faster than the overall update.¹⁰ The shift is visible already. Tenet's surgery center division grew total joint replacements 12.8% in the quarter, even as HCA's surgery center procedures fell.⁶ When cases move between settings, some of the year-over-year comparisons get noisy.

The wild card: weight-loss drugs

A large study published in June 2026 found that adults with knee arthritis who took semaglutide or tirzepatide for three years had about 4.7 fewer knee replacements per 100 people over eight years than similar patients who didn't.¹⁷ The study was observational, so it can't prove the drugs prevented surgery. Some of the effect may come from less pain rather than a healthier joint.

It's too early to see this in company sales. But if these drugs keep spreading, some people will delay surgery for years, and others will become safer surgical candidates after losing weight. Both effects could reshape demand over the next decade.

My take

Most of what showed up this quarter is a delay, not a disappearance. Knee arthritis gets worse, not better, and the population that needs knee replacement keeps growing. The procedures pushed out of 2026 will mostly come back.

What may not come back is the old growth rate. Lower surgeon pay, fewer surgeons, insurer gatekeeping and drugs that ease arthritis pain are structural. The companies are already adjusting, from DePuy Synthes becoming a standalone company to the push for robots and outpatient-friendly tools. The question for patients is simpler: can you get a good surgeon, on time, at a price you can manage?

If you're waiting for a knee replacement

• Don't let the calendar decide alone. If you've already met this year's deductible, scheduling before December 31 may cost less. If pain is starting to limit walking, sleep or work, tell your surgeon rather than waiting for January.
• Ask about approvals early. Ask the office how long your insurer usually takes and what records they need, so the process starts right away.
• On Medicare, ask about participation. Ask whether your surgeon plans to keep accepting Medicare in 2027.
• Ask about the setting. Ask whether you're a candidate for outpatient surgery or a surgery center, and how your costs compare.
• Use the wait well. Prehab, weight loss and good control of diabetes lower complication risk. See our guide to preparing for knee replacement.

This is an opinion piece based on public company reports, government rules and published studies as of the date above. It isn't financial or medical advice.

Sources

1. Stryker reports third quarter 2026 operating results. Stryker press release, October 29, 2026 morningstar.com; kalkine.ca
2. Stryker lowers 2026 guidance after slowdown in hip, knee procedures. MedTech Dive. October 2026. medtechdive.com
3. Smith+Nephew Third Quarter 2026 Trading Update. November 4, 2026. investegate.co.uk
4. Zimmer Biomet Announces Third Quarter 2026 Financial Results. Form 8-K exhibit, November 4, 2026. sec.gov; and "Zimmer Biomet's net sales surpass $2B in Q3." Becker's Spine Review. beckersspine.com
5. Zimmer Biomet Q3 2026 earnings call summary. tradingkey.com
6. Major U.S. hospital chains report patients delaying elective surgery over coverage and costs. Medical Daily. November 1, 2026. medicaldaily.com
7. Stryker's hip and knee slowdown spooked Wall Street. Finimize. November 2026. finimize.com
8. Abe E, Lizcano JD, Tarabichi S, Parikh N, Krueger CA, Courtney PM. Prior authorization does not reduce costs in patients undergoing primary total hip arthroplasty. Presented at AAOS 2025. Summary: aaos.org
9. What spine and orthopedic leaders need to know about CMS's final 2027 physician fee schedule. Becker's Spine Review. November 2026. beckersspine.com
10. 'They're angry': AAOS president says CMS cuts threaten access. Becker's Spine Review. November 2026. beckersspine.com
11. The orthopedic access crisis surgeons see coming. Becker's Spine Review. 2026. beckersspine.com
12. The 'hamster wheel' orthopedic surgeons can't outrun. Becker's Spine Review. 2026. beckersspine.com
13. J&J sets mid-2027 target for orthopedics spinoff, as Q3 medtech sales miss estimates. MassDevice. October 13, 2026. massdevice.com
14. Orthopedics owns the operation. Who owns everything around it? Becker's Spine Review. 2026. beckersspine.com
15. The CJR-X reckoning coming for 2,217 hospitals. Becker's Spine Review. 2026. beckersspine.com
16. 2027: A year of reckoning for payers? Becker's ASC Review. 2026. beckersasc.com
17. Carter V, Desverreaux E, Amin I, et al. Glucagon-like peptide 1 receptor agonist use and risk of arthroplasty for knee osteoarthritis: retrospective database analysis. Reg Anesth Pain Med. 2026. doi:10.1136/rapm-2026-107658