Towards global integration: China's evolving role in joint replacement and sports medicine

In recent decades, China has been increasingly engaged in the shared evolution of orthopaedic practice, reflecting a broader trend towards global integration. With a rapidly aging population, a growing prevalence of osteoarthritis, and rising sports injuries, the demand for high-quality musculoskeletal care has positioned China as one of the most dynamic centres for the advancement of arthroplasty and sports medicine. In this editorial, we aim to provide an overview of the current landscape of joint replacement and sports medicine in China, highlighting its historical evolution, epidemiological features, clinical outcomes and future directions, as part of a broader discussion on how China is aligning with—and contributing to—the global development of orthopaedics and sports medicine. China began exploring total hip arthroplasty (THA) in the 1970s, with rapid expansion in the 1990s following the introduction of bone cement techniques. In parallel with THA, total knee arthroplasty (TKA) has developed rapidly since the early 2000s in China. National registry and multicenter reports highlight a sharp rise in TKA utilisation for end-stage osteoarthritis, with survival rates of TKA exceeding 90% at 10 years, comparable to international benchmarks. Professional societies accelerated this progress: the Chinese Orthopaedic Association (COA), founded in 1980, provided a national platform for training and research. The Joint Surgery Group under the Orthopaedics Branch of the Chinese Medical Association, established in 1989 and later expanded into hip and knee committees in 2013, promoted subspecialty standardisation. The Chinese Association of Orthopaedic Surgeons (CAOS), formed in the mid-2000s, advanced continuing education through annual congresses. Supported by these institutions, clinical adoption accelerated sharply. By 1990, national estimates suggested fewer than 10,000 joint replacement procedures had been performed annually, highlighting the very early stage of development [19]. A 2005 nationwide reported 1275 hospitals performing 34,395 joint replacements; and by 2012, volumes had reached roughly 200,000 THAs and 80,000 TKAs, marking the transition from an exploratory phase to large-scale practice. By 2019, this figure had risen dramatically, with nearly 952,000 hip and knee replacements performed nationwide, reflecting both the expansion of surgical capacity and rapid uptake of Enhanced Recovery After Surgery (ERAS)-driven perioperative protocols [3, 14]. A significant recent development is the establishment and rapid growth of day surgery for hip and knee arthroplasty in China. By 2022, the annual volume of hip and knee replacements reached approximately 1.75 million procedures, sustaining a growth rate of 25%–30% [2]. This expansion has been facilitated by the formalisation of day surgery protocols, as detailed in the 2023 Chinese Expert Consensus on Perioperative Management of Day Surgery for Hip and Knee Arthroplasty [2]. The consensus outlines standardised pathways enabling selected patients to be safely admitted and discharged within 24–48 h, representing a major advance in applying ERAS principles to high-volume joint replacement practice [2]. Driven by the ERAS concepts, joint replacement in China has entered a phase of accelerated growth. In 2019, the total annual number of hip replacements (excluding uni-compartmental procedures) reached 951,986, over four times the 221,920 recorded in 2011 [3]. The average annual growth rate of approximately 20% demonstrates a remarkable development momentum. The implementation of day surgery arthroplasty is now a key component of joint replacement services in China. This model has been demonstrated to safely reduce hospital stays and optimise resource utilisation without compromising outcomes [2]. The development reflects a maturation of Chinese joint arthroplasty services, integrating specialised clinical pathways, refined anaesthesia and analgesia protocols, and structured postdischarge follow-up to support early discharge. The aetiological spectrum of joint replacement in China differs markedly from that in Western countries. A single-centre cohort of 1037 primary THAs demonstrated that osteonecrosis of the femoral head and femoral neck fracture accounted for 31% and 28.4% of cases, respectively, while primary osteoarthritis contributed to only 12.4%. In contrast, TKA indications are dominated by primary osteoarthritis (>80%), followed by rheumatoid arthritis and posttraumatic sequelae [11, 19]. These differences strongly influence surgical strategies and implant choice. Notably, the prevalence of developmental dysplasia of the hip (DDH) in China is significantly higher than in Western countries, with reported rates of approximately 1.52% in Chinese populations compared to only 0.1%–0.3% internationally [17]. This high prevalence presents unique technical challenges for Chinese arthroplasty surgeons, who must frequently address complex anatomical abnormalities including acetabular bone defects, excessive anteversion and leg length discrepancies. These complex cases often require specialised surgical techniques, including acetabular reconstruction and the use of specialised implants, making the procedures substantially more demanding than primary arthroplasty for standard osteoarthritis. Long-term outcomes remain encouraging: survival rates exceed 90% for both uncemented THA and TKA at >10 years, aligning with international experience. Yet, cemented fixation remains underutilized—less than 40% of THAs employ cement, and adoption of key third-generation cementing tools (e.g., pulsatile lavage) is inconsistent. Antibiotic-loaded bone cement is used in only ~12% of primary THAs, suggesting opportunities to enhance infection prophylaxis [20]. For TKA, several large-centre series have demonstrated 10–15-year survival rates above 95% and average implant longevity approaching 20 years, though many reports still feature modest follow-up rates and sample sizes [11, 19]. Unicompartmental knee arthroplasty (UKA) is increasingly performed for isolated compartment disease with intact anterior cruciate ligaments (ACLs) and minimal deformity, yet its nationwide uptake remains limited and long-term data relatively sparse [19, 20]. Since the early 2000s, several Chinese centres have actively explored minimally invasive surgical (MIS) approaches and computer-assisted or robotic technologies. MIS initially gained attention for its smaller incision and faster recovery, but enthusiasm has waned due to its steep learning curve and uncertain long-term benefit. More recently, targeted approaches such as the direct anterior approach (DAA), modified Watson–Jones, and Hardinge have gained popularity in high-volume academic hospitals seeking to balance soft-tissue preservation with adequate exposure [20]. The DAA now accounts for 20%–30% of primary THAs in leading centres, though national rates remain lower [14, 20]. Robotic-assisted joint replacement represents the next frontier. China has become one of the most active countries globally in robotic total joint arthroplasty (TJA) research, and its domestic market is expanding rapidly. By 2028, the number of orthopaedic surgical robots in China is projected to approach 500 units, with 90,000–210,000 robot-assisted joint replacements expected [5]. Early systems such as MAKO, CORI and ROSA paved the way for over ten domestically developed platforms since 2020—including SkyWalker™, KunWu and Arthrobot—approved by the National Medical Products Administration (NMPA), some of which have entered international markets [13]. As software-hardware ecosystems and standardised training evolve, these platforms are transforming from high-end tools into intelligent surgical partners. With the rapid rise in primary procedures, revision arthroplasty has also increased. Domestic data indicate that aseptic loosening (≈65%) remains the leading cause of hip revision, followed by infection (9.9%) and periprosthetic fracture (8.7%) [19]. For TKA, infection predominates, with staged revision as the mainstay approach. These findings underscore the urgent need to strengthen infection prevention and revision strategies across high-volume centres. In 2023, approximately 160 million people in China were affected by sports-related musculoskeletal conditions, including more than 20 million with acute or chronic sports injuries. Against this backdrop, sports medicine, integrating physical training science and clinical medicine—has emerged as a critical field for both athletic performance and population health. The origins of Chinese sports medicine trace back to the 1950s, with the establishment of the Medical Sports Physician Supervision Teaching and Research Group and the Department of Medical Sports, marking the inception of the discipline. In 1978, the Chinese Society of Sports Medicine was officially founded, and in 1980 China joined the International Federation of Sports Medicine (FIMS), a milestone marking its entrance onto the global stage. The founding of the Sports Medicine Branch under the Chinese Medical Association in 2007 further accelerated professionalisation, research and innovation. The 2008 Beijing Olympic Games served as a powerful catalyst, focusing national attention and resources on sports medicine and inspiring a new generation of clinicians and researchers [1, 15]. Technological advances followed. Knee arthroscopy, first introduced in the 1980s for meniscectomy and patellar stabilisation, laid the foundation for multijoint arthroscopic applications. In the 1990s, arthroscopic techniques extended to ACL reconstruction using autografts such as the iliotibial tract and bone-patellar tendon-bone (BPTB), while the artificial ligament technique was also gradually adopted [9]. A landmark was achieved in 2001 with the world's first report of arthroscopic release of gluteal muscle contracture, an innovative soft-tissue application of arthroscopy [12]. In 2005, China issued the first national standard for Cryopreserved Human Meniscal Allografts (YZB/National 0828-2005), followed in 2006 by the first successful arthroscopic meniscal transplantation [16]. These milestones reflect China's early integration of arthroscopy, tissue engineering and regenerative medicine. Knee surgery remains the cornerstone of Chinese sports medicine and the largest field of arthroscopic activity. By 2019, approximately 1.5 million arthroscopic procedures were performed nationwide, a number expected to double by 2025, with over 60% involving the knee joint. In ligament reconstruction, graft selection has become increasingly diverse. Autografts—particularly hamstring tendons and BPTB—remain the standard for ACL reconstruction, offering excellent biocompatibility and outcomes. Synthetic ligaments, notably the ligament advanced reinforcement system (LARS), initially garnered significant attention for their mechanical advantages. They subsequently achieved remarkable market growth in China, making it the world's largest user [6]. However, similar to experiences in Europe, early synthetic grafts were associated with notable complications, which tempered their adoption globally. In response, Chinese teams have identified failure mechanisms of synthetic grafts and developed domestic alternatives tailored to Asian anatomy [7], improving biomechanical performance and host integration. Meniscal surgery has similarly evolved, from partial meniscectomy to routine inside-out, outside-in and all-inside repair techniques, including root repair. Meniscal transplantation remains limited by donor availability and cost, but artificial meniscal implants are under active development, with several clinically approved domestic products. Complex reconstructions, such as multiligament or osteochondral transplantation, are now routine in major centres, reflecting strong innovation in both technique and biomaterials. Shoulder arthroscopy in China has expanded rapidly. Procedures for long-head biceps pathology, labral tears, rotator cuff injuries and Bankart lesions are now common. The market for shoulder arthroscopy instruments grew from approximately $112–$140 million in 2019 to a projected $280 million by 2025. The domestically pioneered ‘Chinese Way’ of using the long head of the biceps for superior capsular reconstruction [4] has gained international recognition for its strong fixation and adaptability. Similarly, the Limited Osteotomy Elastic Fixation Latarjet (LUtarjet) technique [8], an evolution of the traditional Latarjet, offers simplified procedures, reduced complications and has been adopted in >1000 cases nationwide. Hip and ankle arthroscopy, though relatively new, are advancing quickly. Hip arthroscopy is routinely applied for femoro-acetabular impingement, labral tears and chondral lesions, with several Chinese centres meeting international standards. Robotic assistance, refined capsular management and minimally invasive fixation have further improved outcomes [18]. Ankle arthroscopy is one of the fastest-growing subspecialties, applied to chronic instability, chondral lesions and synovial disorders, supported by improved ligament reconstruction techniques [10]. Elbow and wrist arthroscopy remain in earlier stages, currently limited to impingement, lateral epicondylitis and carpal tunnel syndrome. Continued development of guidelines and international collaborations will likely accelerate upper-limb minimally invasive surgery. National registry system: Establishing a comprehensive arthroplasty database to enhance long-term surveillance and complication management. Localisation and accessibility: Promoting cost-effective, implants tailored to the anatomical characteristics of the Chinese population. Digitalisation integrated with ERAS: Leveraging robotic and navigation technologies within day-case and rapid-recovery frameworks to achieve high precision with low cost. Infection prevention and revision strategies: Addressing the challenges of infection and revision in the context of high surgical volumes. In summary, China's joint replacement and sports medicine sectors have entered a stage characterised by both rapid growth and continuous quality improvement. While opportunities abound, challenges persist, particularly in registry establishment, infection control and equitable technology dissemination. China's trajectory exemplifies how national innovation, institutional support and international collaboration can converge to transform orthopaedic care. As global partnerships deepen, such shared progress will continue to shape the next era of musculoskeletal health worldwide. This study was funded by Natural Science Foundation of Chongqing, China (CSTB2025NS CQ-GPX1148), The Science and Technology Research Program of Chongqing Municipal Education Commission (No. KJQN202300403), the National Natural Science Foundation of China (No. 81902293), Postdoc Research Funding (No. 2022CQBSHTB3016), China Postdoctoral Science Foundation (No. 2022M702604), Chongqing medical scientific research project (Joint project of Chongqing Health Commission and Science and Technology Bureau) (No. 2025GDRC009). The authors declare no conflicts of interest. The authors have nothing to report.