JOA - 2026-07-22 - Journal Article
Distribution of Total Knee Arthroplasty Periprosthetic Infection Care in the United States: Reported from the American Joint Replacement Registry.
Elmenawi KA, Zaniletti I, Poilvache H, Hannon CP, Abdel MP, Bedard NA
Topics
Key Takeaway
Only 4% of TKA-PJI cases in the US are managed by a high-volume surgeon (>11 cases/year) at a high-volume institution (>40 cases/year), with a median institutional annual volume of just 4 PJI cases.
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Summary
Using AJRR data from 2012–2022, this study characterized the distribution of TKA-PJI surgical volume across US institutions and surgeons to assess feasibility of PJI centers of excellence. Median annual institutional volume was 4 PJI cases and median surgeon volume was 2 cases; high-volume institutions and surgeons each performed only 15% and 10% of cases, respectively. Only 4% of TKA-PJIs were treated by a high-volume surgeon at a high-volume institution, and by 2022 these figures had not meaningfully improved.
Key Limitation
The absence of outcome data in the AJRR means the study cannot demonstrate that high-volume designation actually correlates with superior PJI eradication or survivorship, which is the foundational assumption underlying the centers-of-excellence argument.
Original Abstract
INTRODUCTION
There has been growing interest in establishing periprosthetic joint infection (PJI) centers of excellence in the United States (US). However, the current distribution of total knee arthroplasty (TKA) PJI surgeries in the US remains unknown. We aimed to evaluate the surgical volume of institutions and surgeons caring for knee PJI in the US using data from the American Joint Replacement Registry (AJRR).
METHODS
The AJRR was utilized to capture all TKAs performed between 2012 and 2022. This resulted in 1,779,422 primary and revision TKAs performed in 1,366 institutions by 8,658 surgeons. Out of these, 45,914 (3%) were for knee PJI (TKA-PJI). We established volume thresholds based on median annual volume groupings to identify high-, medium-, and low-volume surgeons and institutions caring for TKA-PJI. High-volume TKA-PJI threshold for institutions was greater than 40 TKA-PJIs/year, and the high-volume TKA-PJI threshold for surgeons was greater than 11 TKA-PJIs/year. The proportion of surgeries performed by low, medium, and high TKA-PJI volume institutions and surgeons was calculated.
RESULTS
The median institution annual TKA-PJI volume was four PJIs (range, two to 113), and the median surgeon annual TKA-PJI volume was two PJIs (range, one to 45). High TKA-PJI-volume institutions and surgeons performed 15 and 10% of TKA-PJIs, respectively. Only 4% of TKA-PJIs were cared for by a high-volume TKA-PJI surgeon at a high-volume TKA-PJI institution. In 2022, only 16% of TKA-PJI surgeries occurred at high TKA-PJI volume institutions, and only 12% were performed by high TKA-PJI-volume surgeons.
CONCLUSION
In the US, approximately one out of 25 TKA-PJIs were managed by a high-volume TKA-PJI surgeon at a high-volume TKA-PJI institution. These findings raise concern that PJI centers of excellence could restrict access for patients with knee PJI, as a 7-fold expansion in caseload at existing high-volume PJI institutions is not sustainable from a financial, physical, mental, or emotional perspective.