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International sales have been a key growth driver for some of the largest orthopedic companies in the last several years. While results can always be a little choppy from quarter to quarter, the early portion of 2026 has brought a new sense of volatility to OUS markets.
Below we take a look at emerging headwinds like physician strikes, opportunities to take hip replacement share and the next round of volume-based procurement in China.
Multiple Headwinds Emerge, Especially in Europe
While it is impossible to make sweeping statements about the varied markets around the globe, it is fair to say the early portion of 2026 brought volatility to worldwide orthopedics.
Since 2020 it seems like there’s always some geopolitical crisis that is confounding global shipping. Now it is the war in Iran and chaos in the Straight of Hormuz.
While orthopedics is mostly done with volume-based procurement in China, there’s still looming tenders that will impact the industry’s sports medicine players (more on that below).
The markets of Europe, which have served as a growth engine for orthopedic’s largest players in recent years, is facing numerous headwinds.
MDR has caused frustrating delays for orthopedic players to get their newest, most innovative implants and technologies approved for patients in Europe. Stryker CEO Kevin Lobo said overaction to isolated issues is “stunting innovation” in Europe and impacting the entire industry.
Furthermore, healthcare strikes are sweeping across Europe as doctors demand improved pay and working conditions. Resident physicians in the United Kingdom plan to stage a four-day walk out starting June 15th. A doctor strike in Spain is slated for the same days. The healthcare labor situation is also tenuous in Portugal and Germany.
“It was definitely a slower start to the year compared with our Q4 momentum,” said Enovis CEO Damien McDonald. “There’s a lot of market volatility. There are doctor strikes, nurse strikes, pharmacy strikes, and waiting list increases. And still with all of that, we outgrew the market. I’d say the team executed really well in a very dynamic market situation.”
International Hip Replacement Share Up for Grabs
Zimmer Biomet, Stryker and DePuy Synthes are the largest joint replacement players by far. While each has varying degrees of penetration in OUS markets, they have unmatched reach and scale.
As expected, Zimmer Biomet is still the undisputed leader in large joint replacement outside the United States. Its OUS knee replacement sales in 2025 were more than Stryker and DePuy Synthes combined. But the gap in hip replacement is closing.
Big 3 OUS Knee Replacement Sales
Big 3 OUS Hip Replacement Sales
In knee replacement, Stryker has been underrepresented compared to its peers. It generated a 10-year CAGR of 6.9% for OUS knee replacement sales, growing from $403 million in 2016 to $734 million in 2025. DePuy’s CAGR over than span was 1.5% while Zimmer Biomet turned in a respectable 3.5%.
The Mako robotic system has been a big driver of Stryker’s international growth. At the end of 4Q25, Stryker reported it had more than 3,000 Mako installs worldwide and had begun to crack some of the tougher OUS markets.
“We’re seeing it start to take off in international markets, Japan being the most important one where it took a while, first of all, to get the regulatory approval,” said Stryker CEO Kevin Lobo. “They’re obviously very data-conscious there. But now Japan is really starting to take off. In fact, other countries in Asia Pacific are starting to really drive the incremental growth. We’re very bullish.”
Zimmer Biomet’s lead in OUS hip replacement is far less pronounced and its 10-year CAGR is just 1.4%. Stryker’s CAGR of 4.7% has helped it bypass DePuy Synthes (0.6% CAGR) and close the gap with Zimmer Biomet.
In 2016, Zimmer Biomet’s OUS hip replacement sales were 84% larger than Stryker’s. By 2025, that lead had shrunk to 37%.
Zimmer Biomet has worked hard to differentiate its hip offering with its Z1, OrthoGrid and HAMMR triple play. It also recently launched its iodine-coated hip implant which is seeing rapid adoption in Japan, Zimmer Biomet’s second largest market.
New Sports Med Tender Delayed in China
Like its globalized peers, Smith+Nephew has dealt with volume-based procurement headwinds in China for years. We estimate the company’s sales in China amounted to about $135 million in 2025, or about 2% of total group sales.
The most recent VBP headwind came with the 2024 introduction of tenders on sports medicine joint repair products. By the second quarter of 2025, the company had weathered the worst of VBP’s headwinds.
“Excluding China, emerging markets grew by 12.2%,” said Smith+Nephew CEO Deepak Nath. “We have passed the peak of the China impacts, and we expect these to continue to ease through the second half as distributor destocking in Orthopaedics reduces and as we lap the effects of Joint Repair VBP.”
Additional tenders for sports medicine enabling technologies (and ENT) are slated for 2026. Smith+Nephew has less exposure this time, given the mix of its sports medicine business (62% joint repair products).
Smith+Nephew Sports Medicine Sales
The company also got a bit of reprieve on timing, with the enabling tech tender being delayed by a few months. That led to increased demand for Smith+Nephew’s sports medicine products in the first quarter. While VBP will hit in the second half, 2026 will likely be the first time in years that the company’s sales in China are neutral.
International sales have been a key growth driver for some of the largest orthopedic companies in the last several years. While results can always be a little choppy from quarter to quarter, the early portion of 2026 has brought a new sense of volatility to OUS markets.
Below we take a look at emerging headwinds like physician strikes,...
International sales have been a key growth driver for some of the largest orthopedic companies in the last several years. While results can always be a little choppy from quarter to quarter, the early portion of 2026 has brought a new sense of volatility to OUS markets.
Below we take a look at emerging headwinds like physician strikes, opportunities to take hip replacement share and the next round of volume-based procurement in China.
Multiple Headwinds Emerge, Especially in Europe
While it is impossible to make sweeping statements about the varied markets around the globe, it is fair to say the early portion of 2026 brought volatility to worldwide orthopedics.
Since 2020 it seems like there’s always some geopolitical crisis that is confounding global shipping. Now it is the war in Iran and chaos in the Straight of Hormuz.
While orthopedics is mostly done with volume-based procurement in China, there’s still looming tenders that will impact the industry’s sports medicine players (more on that below).
The markets of Europe, which have served as a growth engine for orthopedic’s largest players in recent years, is facing numerous headwinds.
MDR has caused frustrating delays for orthopedic players to get their newest, most innovative implants and technologies approved for patients in Europe. Stryker CEO Kevin Lobo said overaction to isolated issues is “stunting innovation” in Europe and impacting the entire industry.
Furthermore, healthcare strikes are sweeping across Europe as doctors demand improved pay and working conditions. Resident physicians in the United Kingdom plan to stage a four-day walk out starting June 15th. A doctor strike in Spain is slated for the same days. The healthcare labor situation is also tenuous in Portugal and Germany.
“It was definitely a slower start to the year compared with our Q4 momentum,” said Enovis CEO Damien McDonald. “There’s a lot of market volatility. There are doctor strikes, nurse strikes, pharmacy strikes, and waiting list increases. And still with all of that, we outgrew the market. I’d say the team executed really well in a very dynamic market situation.”
International Hip Replacement Share Up for Grabs
Zimmer Biomet, Stryker and DePuy Synthes are the largest joint replacement players by far. While each has varying degrees of penetration in OUS markets, they have unmatched reach and scale.
As expected, Zimmer Biomet is still the undisputed leader in large joint replacement outside the United States. Its OUS knee replacement sales in 2025 were more than Stryker and DePuy Synthes combined. But the gap in hip replacement is closing.
Big 3 OUS Knee Replacement Sales
Big 3 OUS Hip Replacement Sales
In knee replacement, Stryker has been underrepresented compared to its peers. It generated a 10-year CAGR of 6.9% for OUS knee replacement sales, growing from $403 million in 2016 to $734 million in 2025. DePuy’s CAGR over than span was 1.5% while Zimmer Biomet turned in a respectable 3.5%.
The Mako robotic system has been a big driver of Stryker’s international growth. At the end of 4Q25, Stryker reported it had more than 3,000 Mako installs worldwide and had begun to crack some of the tougher OUS markets.
“We’re seeing it start to take off in international markets, Japan being the most important one where it took a while, first of all, to get the regulatory approval,” said Stryker CEO Kevin Lobo. “They’re obviously very data-conscious there. But now Japan is really starting to take off. In fact, other countries in Asia Pacific are starting to really drive the incremental growth. We’re very bullish.”
Zimmer Biomet’s lead in OUS hip replacement is far less pronounced and its 10-year CAGR is just 1.4%. Stryker’s CAGR of 4.7% has helped it bypass DePuy Synthes (0.6% CAGR) and close the gap with Zimmer Biomet.
In 2016, Zimmer Biomet’s OUS hip replacement sales were 84% larger than Stryker’s. By 2025, that lead had shrunk to 37%.
Zimmer Biomet has worked hard to differentiate its hip offering with its Z1, OrthoGrid and HAMMR triple play. It also recently launched its iodine-coated hip implant which is seeing rapid adoption in Japan, Zimmer Biomet’s second largest market.
New Sports Med Tender Delayed in China
Like its globalized peers, Smith+Nephew has dealt with volume-based procurement headwinds in China for years. We estimate the company’s sales in China amounted to about $135 million in 2025, or about 2% of total group sales.
The most recent VBP headwind came with the 2024 introduction of tenders on sports medicine joint repair products. By the second quarter of 2025, the company had weathered the worst of VBP’s headwinds.
“Excluding China, emerging markets grew by 12.2%,” said Smith+Nephew CEO Deepak Nath. “We have passed the peak of the China impacts, and we expect these to continue to ease through the second half as distributor destocking in Orthopaedics reduces and as we lap the effects of Joint Repair VBP.”
Additional tenders for sports medicine enabling technologies (and ENT) are slated for 2026. Smith+Nephew has less exposure this time, given the mix of its sports medicine business (62% joint repair products).
Smith+Nephew Sports Medicine Sales
The company also got a bit of reprieve on timing, with the enabling tech tender being delayed by a few months. That led to increased demand for Smith+Nephew’s sports medicine products in the first quarter. While VBP will hit in the second half, 2026 will likely be the first time in years that the company’s sales in China are neutral.
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Mike Evers is a Senior Market Analyst and writer with over 15 years of experience in the medical industry, spanning cardiac rhythm management, ER coding and billing, and orthopedics. He joined ORTHOWORLD in 2018, where he provides market analysis and editorial coverage.
