The Economics of Revision Arthroplasty for Periprosthetic Joint Infection

Hip and knee arthritis is a prevalent and debilitating disease projected to affect over 78 million adults in the United States by 2040 [[1]Hootman J.M. Helmick C.G. Barbour K.E. Theis K.A. Boring M.A. Updated projected prevalence of self-reported doctor-diagnosed arthritis and arthritis-attributable activity limitation among US adults, 2015–2040.Arthritis Rheumatol. 2016; 68: 1582-1587https://doi.org/10.1002/art.39692Google Scholar]. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures provide definitive care for this life-altering pathology and allow patients to live their lives with reduced pain and increased function. Despite the efficacy of these interventions, it is important to recognize that revision THA (rTHA) and revision TKA (rTKA) procedures are also on the rise [2Schwartz A.M. Farley K.X. Guild G.N. Bradbury T.L.J. Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2030.J Arthroplasty. 2020; 35: S79-S85https://doi.org/10.1016/j.arth.2020.02.030Google Scholar, 3Shichman I. Roof M. Askew N. Nherera L. Rozell J.C. Seyler T.M. et al.Projections and epidemiology of primary hip and knee arthroplasty in medicare patients to 2040-2060.JB JS Open Access. 2023; 8e22.00112https://doi.org/10.2106/JBJS.OA.22.00112Google Scholar, 4Shichman I. Askew N. Habibi A. Nherera L. Macaulay W. Seyler T. et al.Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2040-2060.Arthroplast Today. 2023; 21101152https://doi.org/10.1016/j.artd.2023.101152Google Scholar]. Revision procedures are more technically demanding and generally longer than primary THA (pTHA) and primary TKA (pTKA), as they often require removal of some or all components, irrigation and debridement, management of bone loss, and complex wound closures. Revisions for septic reasons may also require the placement of antibiotic spacers, multiple trips to the operating room for staged procedures, and prolonged intravenous antibiotic therapy. For these reasons, septic revisions pose an enormous financial burden on the healthcare system: Morcos et al. looked at 73 patients who underwent two-stage revision and found a higher overall cost with a mean cost of $35,500 for revision TKA performed for infection compared to $6800 for primary TKA [[5]Morcos M.W. Kooner P. Marsh J. Howard J. Lanting B. Vasarhelyi E. The economic impact of periprosthetic infection in total knee arthroplasty.Can J Surg. 2021; 64: E144-E148https://doi.org/10.1503/cjs.012519Google Scholar]. The cost of a debridement, antibiotics, and implant retention (DAIR) procedure is estimated to be roughly $15,000, with initial procedure costs of $10,000 and failure-related additional treatment costs of $22,000 [[6]Haddad F.S. Ngu A. Negus J.J. Prosthetic joint infections and cost analysis? BT - a modern approach to biofilm-related orthopaedic implant infections.Adv Exp Med Biol. 2017; 5: 93-100https://doi.org/10.1007/5584_2016_155Google Scholar]. Given the complexity and cost, one may imagine that surgeons are compensated accordingly for the increased time and effort required to perform these cases; however, in practice, the complexity does not correlate with reimbursement rates [[7]Patel A. Oladipo V.A. Kerzner B. McGlothlin J.D. Levine B.R. A retrospective review of relative value units in revision total knee arthroplasty: a dichotomy between surgical complexity and reimbursement.J Arthroplasty. 2022; 37: S44-S49https://doi.org/10.1016/j.arth.2022.02.033Google Scholar,[8]Quan T. Best M.J. Gu A. Stake S. Golladay G.J. Thakkar S.C. Septic revision total hip arthroplasty is not adequately compensated by work relative value units.J Arthroplasty. 2021; 36: 1496-1501https://doi.org/10.1016/j.arth.2020.11.034Google Scholar]. Patel et al. examined the relationship between case difficulty and relative value units (RVU) compensation for rTHA and rTKA. When compared to the pTHA cohort, every revision type, except for modular component head/liner exchange, reimbursed less per minute, and every revision type reimbursed less per RVU [[9]Patel A. Oladipo V. Kerzner B. McGlothlin J.D. Levine B.R. A retrospective review of reimbursement in revision total hip arthroplasty: a disparity between case complexity and RVU compensation.J Arthroplasty. 2022; 37: S807-S813https://doi.org/10.1016/j.arth.2022.03.025Google Scholar]. For the TKA group, tibial component, all-component, and spacer revisions were reimbursed significantly less dollars per minute as compared to pTKA. Modular component/DAIR and all-component revisions had fewer dollars per RVU than primary TKA [[7]Patel A. Oladipo V.A. Kerzner B. McGlothlin J.D. Levine B.R. A retrospective review of relative value units in revision total knee arthroplasty: a dichotomy between surgical complexity and reimbursement.J Arthroplasty. 2022; 37: S44-S49https://doi.org/10.1016/j.arth.2022.02.033Google Scholar]. Quan et al. also had similar findings when comparing RVU per minute between aseptic and septic rTHA: aseptic rTHA cases were valued higher, at $9.28 per minute, whereas septic rTHA cases were valued at $7.65 per minute [[8]Quan T. Best M.J. Gu A. Stake S. Golladay G.J. Thakkar S.C. Septic revision total hip arthroplasty is not adequately compensated by work relative value units.J Arthroplasty. 2021; 36: 1496-1501https://doi.org/10.1016/j.arth.2020.11.034Google Scholar]. Numerous studies have investigated the efficacy of DAIR and two-stage exchange for the eradication of periprosthetic joint infection (PJI). More recent studies have shown eradication rates following DAIR ranging from 49% to 84% [10Qu G.-X. Zhang C.-H. Yan S.-G. Cai X.-Z. Debridement, antibiotics, and implant retention for periprosthetic knee infections: a pooling analysis of 1266 cases.J Orthop Surg Res. 2019; 14: 358https://doi.org/10.1186/s13018-019-1378-4Google Scholar, 11Iza K. Foruria X. Moreta J. Uriarte I. Loroño A. Aguirre U. et al.DAIR (Debridement, Antibiotics and Implant Retention) less effective in hematogenous total knee arthroplasty infections.J Orthop Surg Res. 2019; 14: 278https://doi.org/10.1186/s13018-019-1324-5Google Scholar, 12Leta T.H. Lygre S.H.L. Schrama J.C. Hallan G. Gjertsen J.-E. Dale H. et al.Outcome of revision surgery for infection after total knee arthroplasty: results of 3 surgical strategies.JBJS Rev. 2019; 7: e4https://doi.org/10.2106/JBJS.RVW.18.00084Google Scholar, 13Urish K.L. Bullock A.G. Kreger A.M. Shah N.B. Jeong K. Rothenberger S.D. A multicenter study of irrigation and debridement in total knee arthroplasty periprosthetic joint infection: treatment failure is high.J Arthroplasty. 2018; 33: 1154-1159https://doi.org/10.1016/j.arth.2017.11.029Google Scholar, 14Narayanan R. Anoushiravani A.A. Elbuluk A.M. Chen K.K. Adler E.M. Schwarzkopf R. Irrigation and debridement for early periprosthetic knee infection: is it effective?.J Arthroplasty. 2018; 33: 1872-1878https://doi.org/10.1016/j.arth.2017.12.039Google Scholar, 15Kim K. Zhu M. Cavadino A. Munro J.T. Young S.W. Failed debridement and implant retention does not compromise the success of subsequent staged revision in infected total knee arthroplasty.J Arthroplasty. 2019; 34: 1214-1220.e1https://doi.org/10.1016/j.arth.2019.01.066Google Scholar, 16Bene N. Li X. Nandi S. Factors affecting failure of irrigation and debridement with liner exchange in total knee arthroplasty infection.Knee. 2018; 25: 932-938https://doi.org/10.1016/j.knee.2018.07.003Google Scholar, 17Dx Duffy S. Ahearn N. Darley E.S. Porteous A.J. Murray J.R. Howells N.R. Analysis of the KLIC-score; an outcome predictor tool for prosthetic joint infections treated with debridement, antibiotics and implant retention.J Bone Jt Infect. 2018; 3: 150-155https://doi.org/10.7150/jbji.21846Google Scholar, 18Weston J.T. Watts C.D. Mabry T.M. Hanssen A.D. Berry D.J. Abdel M.P. Irrigation and debridement with chronic antibiotic suppression for the management of infected total knee arthroplasty: a Contemporary Analysis.Bone Joint J. 2018; 100-B: 1471-1476https://doi.org/10.1302/0301-620X.100B11.BJJ-2018-0515.R1Google Scholar, 19Son W.S. Shon O.-J. Lee D.-C. Park S.-J. Yang H.S. Efficacy of open debridement and polyethylene exchange in strictly selected patients with infection after total knee arthroplasty.Knee Surg Relat Res. 2017; 29: 172-179https://doi.org/10.5792/ksrr.16.040Google Scholar, 20Chang M.J. Lee S.A. Kang S.-B. Hwang K.M. Park H.J. Lee K.H. et al.A retrospective comparative study of infection control rate and clinical outcome between open debridement using antibiotic-impregnated cement beads and a two-stage revision in acute periprosthetic knee joint infection.Medicine (Baltimore). 2020; 99e18891https://doi.org/10.1097/MD.0000000000018891Google Scholar]. Two-stage exchange for both hip and knee PJI has been estimated to have a success rate ranging between 54% and 100% [21Cochran A.R. Ong K.L. Lau E. Mont M.A. Malkani A.L. Risk of reinfection after treatment of infected total knee arthroplasty.J Arthroplasty. 2016; 31: 156-161https://doi.org/10.1016/j.arth.2016.03.028Google Scholar, 22Claassen L. Plaass C. Daniilidis K. Calliess T. von Lewinski G. Two-stage revision total knee arthroplasty in cases of periprosthetic joint infection: an analysis of 50 cases.Open Orthop J. 2015; 9: 49-56https://doi.org/10.2174/1874325001509010049Google Scholar, 23Stammers J. Kahane S. Ranawat V. Miles J. Pollock R. Carrington R.W.J. et al.Outcomes of infected revision knee arthroplasty managed by two-stage revision in a tertiary referral centre.Knee. 2015; 22: 56-62https://doi.org/10.1016/j.knee.2014.10.005Google Scholar, 24Romanò C.L. Gala L. Logoluso N. Romanò D. Drago L. Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers.Knee Surg Sports Traumatol Arthrosc. 2012; 20: 2445-2453https://doi.org/10.1007/s00167-012-1885-xGoogle Scholar, 25Pangaud C. Ollivier M. Argenson J.-N. Outcome of single-stage versus two-stage exchange for revision knee arthroplasty for chronic periprosthetic infection.EFORT Open Rev. 2019; 4: 495-502https://doi.org/10.1302/2058-5241.4.190003Google Scholar, 26Hsieh P.-H. Shih C.-H. Chang Y.-H. Lee M.S. Shih H.-N. Yang W.-E. Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis.J Bone Joint Surg Am. 2004; 86: 1989-1997Google Scholar, 27Klouche S. Leonard P. Zeller V. Lhotellier L. Graff W. Leclerc P. et al.Infected total hip arthroplasty revision: one- or two-stage procedure?.Orthop Traumatol Surg Res. 2012; 98: 144-150https://doi.org/10.1016/j.otsr.2011.08.018Google Scholar, 28Silvestre A. Almeida F. Renovell P. Morante E. López R. Revision of infected total knee arthroplasty: two-stage reimplantation using an antibiotic-impregnated static spacer.Clin Orthop Surg. 2013; 5: 180-187https://doi.org/10.4055/cios.2013.5.3.180Google Scholar]. Studies directly comparing DAIR to two-stage exchange for the treatment of PJI have mixed outcomes: Zhang et al. showed a 70% success rate for DAIR compared to 75% in the two-stage group, although these differences did not reach statistical significance [[29]Zhang Y. Gao Z. Zhang T. Dong Y. Sheng Z. Zhang F. et al.A comparsion study between debridement, antibiotics, and implant retention and two-stage revision total knee arthroplasty for the management of periprosthetic joint infection occurring within 12 weeks from index total knee arthroplasty.J Orthop Surg Res. 2022; 17: 330https://doi.org/10.1186/s13018-022-03218-xGoogle Scholar]; Barry et al. showed DAIR to be as effective as two-stage exchange for preventing reoperation for infection and more effective for maintaining function [[30]Barry J.J. Geary M.B. Riesgo A.M. Odum S.M. Fehring T.K. Springer B.D. Irrigation and debridement with chronic antibiotic suppression is as effective as 2-stage exchange in revision total knee arthroplasty with extensive Instrumentation.J Bone Joint Surg Am. 2021; 103: 53-63Google Scholar]; Leta’s team compared DAIR, one-stage, and two-stage revisions and found a 19% (63/329), 13.9% (10/72), and 11.5% (28/243) re-revision rate for infection, respectively [[12]Leta T.H. Lygre S.H.L. Schrama J.C. Hallan G. Gjertsen J.-E. Dale H. et al.Outcome of revision surgery for infection after total knee arthroplasty: results of 3 surgical strategies.JBJS Rev. 2019; 7: e4https://doi.org/10.2106/JBJS.RVW.18.00084Google Scholar]. There are a few key factors inherent to rTHA and rTKA for infection that complicate these procedures when compared to DAIR. The 3 major factors are operative time, bone/soft tissue management, and unpredictability. DAIR procedures generally take 45-60 minutes, depending on how extensive a debridement is performed. Conversely, two-stage exchanges can often take multiple hours for each procedure. Since the implants are removed, careful time and effort are required during the implant extraction to minimize bone loss, and many of these patients, during the secondary reconstruction, require the use of metal, cement, or bony augments to recreate an appropriate surface on which to fix the revision implants. When combined with the soft tissue loss and, when needed, consultations with plastic and vascular surgery to ensure appropriate soft tissue coverage and blood supply to the wound, the unpredictability of these procedures further increases. The variable nature of rTKA and rTHA further affects the compensation of surgeons performing revision procedures. Feng et al. modeled dedicated rTHA and rTKA services (with 1 room to reflect the variability in case time and complexity, preventing a surgeon from using 2 operating rooms) compared with a two-room primary service. For hips, revision surgeons lost 26% potential RVU per day compared to one-room service and 55% potential RVU per day compared to two-room service [[31]Feng J.E. Anoushiravani A.A. Schoof L.H. Gabor J.A. Padilla J. Slover J. et al.Barriers to revision total hip service lines: a surgeon’s perspective through a deterministic financial model.Clin Orthop Relat Res. 2020; 478: 1657-1666https://doi.org/10.1097/CORR.0000000000001273Google Scholar]. Similar findings were demonstrated in the knee group [[32]Gabor J.A. Padilla J.A. Feng J.E. Anoushiravani A.A. Slover J. Schwarzkopf R. A dedicated revision total knee service: a surgeon’s perspective.Bone Joint J. 2019; 101-B: 675-681https://doi.org/10.1302/0301-620X.101B6.BJJ-2018-1504.R1Google Scholar] and in other recently published studies [[33]Peterson J. Sodhi N. Khlopas A. Piuzzi N.S. Newman J.M. Sultan A.A. et al.A comparison of relative value units in primary versus revision total knee arthroplasty.J Arthroplasty. 2018; 33: S39-S42https://doi.org/10.1016/j.arth.2017.11.070Google Scholar]. The current reimbursement model, as well as the foregone revenue from the pTHA and pTKA that could have been performed instead of a rTHA or rTKA, disincentivize revision surgeons from performing these complex procedures. Additionally, these same factors may prompt surgeons to preferentially perform DAIR as compared to one- or two-stage revisions, which are currently considered the gold standard for chronic hip and knee PJI [[34]Lazic I. Scheele C. Pohlig F. von Eisenhart-Rothe R. Suren C. Treatment options in PJI - is two-stage still gold standard?.J Orthop. 2021; 23: 180-184https://doi.org/10.1016/j.jor.2020.12.021Google Scholar]. This may potentially incentivize multiple washouts being performed prior to referral to a tertiary care center for a two-stage revision, which may cause delays in definitive care and infection eradication [[12]Leta T.H. Lygre S.H.L. Schrama J.C. Hallan G. Gjertsen J.-E. Dale H. et al.Outcome of revision surgery for infection after total knee arthroplasty: results of 3 surgical strategies.JBJS Rev. 2019; 7: e4https://doi.org/10.2106/JBJS.RVW.18.00084Google Scholar]. A few strategies should be considered to better align monetary incentives with the standard of care and make the patient care process more efficient. First would be to increase the RVU compensation for rTKA and rTHA. This will provide direct incentive to perform these surgeries, as surgeons would be appropriately compensated for their time, effort, and foregone RVUs from pTHA and pTKA. Second would be to develop dedicated revision team service lines whose sole focus within the hospital system is performing rTKA and rTHA. These teams would encompass a range of providers and would be led by the orthopaedic surgeon who would work closely with infectious disease physicians to guide antibiotic therapy. Protocolizing patient hospital stays, such as standardizing the placement of a peripherally inserted central catheter on postoperative day 1, can help streamline safe and efficient discharge. Third would be to regionalize the care of patients with PJI to institutions of excellence specializing in the management of PJI. OrthoCarolina’s Periprosthetic Joint Infection Center and Duke University’s Dedicated Orthopedic Infectious Disease Service have already started to institute this strategy and will serve as important case studies to understand the effect that regionalization can have on outcomes following rTKA and rTHA for PJI. V. Aggarwal is a paid consultant and has received research support from Zimmer. R. Schwarzkopf receives royalties and research support from Smith & Nephew, is a paid consultant from Zimmer, Intellijoint, and Smith & Nephew, receives stock options from Gauss Surgical, Intellijoint, and PSI, is an editorial board member of Arthroplasty Today and Journal of Arthroplasty, and is a board/committee member of American Academy of Orthopaedic Surgeons and American Association of Hip and Knee Surgeons; the other author declares no potential conflicts of interest. For full disclosure statements refer to https://doi.org/10.1016/j.artd.2023.101213. Download .docx (.02 MB) Help with docx files Conflict of Interest Statement for Aggarwal Download .docx (.02 MB) Help with docx files Conflict of Interest Statement for Roof Download .docx (.02 MB) Help with docx files Conflict of Interest Statement for Schwarzkopf