Trends in Reimbursement for One- versus Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection

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.

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 (total hip arthroplasty or total knee arthroplasty), insurance status (Medicare or private), and Current Procedural Terminology 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.

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 Current Procedural Terminology codes 27487/27,488 and 27,091/27,134, 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.

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.