Distribution of Total Knee Arthroplasty Periprosthetic Infection Care in the United States: Reported from the American Joint Replacement Registry.

Abstract

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). 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. 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. 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.