JOA - 2026-05-28 - Journal Article
Trends in Reimbursement for One- Versus Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection.
Forlenza EM, Serino J, Hietpas K, Fehring KA, Della Valle CJ, Fehring TK
Topics
Key Takeaway
Two-stage exchange reimbursement exceeds one-stage by 28% ($4,342 vs $3,382, p<0.001), though a 43-minute operative time savings per case may equalize cumulative surgeon revenue across 10 cases.
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Summary
This study analyzed reimbursement data from 199 patients enrolled in an RCT comparing one- versus two-stage exchange for PJI between 2016 and 2022, converting all values to 2022 inflation-adjusted dollars. Two-stage exchange yielded significantly higher mean reimbursement ($4,342 vs $3,382, p<0.001) across both THA and TKA and across Medicare and private payers. An opportunity cost analysis demonstrated that the 43-minute operative time advantage of one-stage exchange could theoretically allow additional primary arthroplasties, potentially equalizing total surgeon reimbursement across a 10-case cohort.
Key Limitation
The opportunity cost model is purely theoretical and does not account for real-world OR scheduling constraints, anesthesia availability, or the higher complexity and complication risk of one-stage exchange that may offset time savings.
Original Abstract
BACKGROUND
Emerging evidence suggests similar efficacy of one- and two-stage revision for periprosthetic joint infection (PJI). However, there is concern that extended surgical time and lower reimbursement for one-stage exchange may disincentivize surgeons from performing this procedure.
METHODS
Reimbursement data from 200 patients enrolled in a randomized controlled trial evaluating one- versus two-stage exchange for PJI between 2016 and 2022 was collected. The final cohort consisted of 98 patients undergoing one-stage exchange and 101 patients undergoing two-stage exchange. There was one patient excluded from the final analysis due to incomplete reimbursement data. Reimbursements were converted to 2022 inflation-adjusted dollars. The mean reimbursements for one- and two-stage exchanges were compared, and subgroup analyses based on procedure type (THA or TKA), insurance status (Medicare or private), and Current Procedural Terminology (CPT) codes were performed. A separate opportunity cost analysis was performed to determine the theoretical cumulative reimbursement surgeons could expect after treating 10 cases of PJI via either one- or two-stage exchange.
RESULTS
The mean combined reimbursement for a two-stage exchange was significantly greater than for a one-stage exchange ($4,342.40 versus $3,382.40; P < 0.001). The CPT codes 27487/27488 and 27091/27134 when billed together consistently yielded the greatest reimbursement for one-stage exchange knee and hip procedures, respectively. Total operative time of a one-stage exchange was lower by 43 minutes, potentially allowing surgeons to perform more primary arthroplasties, equalizing total surgeon reimbursement.
CONCLUSION
Reimbursement for a one-stage exchange is lagging behind a two-stage exchange; however, the efficiency of performing one procedure rather than two could lead to an equalization of total reimbursement. In an era of decreased surgical fees, a 28% discrepancy in reimbursement could conceivably discourage the usage of a potentially superior evidence-based treatment.