Faculty Bibliography

BACKGROUND:Physicians may choose to opt out of accepting reimbursements through the Medicare program. There is limited information on arthroplasty surgeons who elect to opt out of Medicare. METHODS:The public Centers for Medicare & Medicaid Services (CMS) Opt-Out Affidavits Dataset was used to identify individual orthopaedic surgeons performing hip and knee arthroplasty who had opted out of Medicare as of February 2024. Publicly available internet pages were used to investigate individual surgeon characteristics and evaluate trends among those surgeons who opted out of Medicare over time. RESULTS:Of the 308 orthopaedic surgeons who did not accept Medicare, 85 performed hip and/or knee arthroplasty. Of these surgeons, 37% practiced in or near New York City, while 27% practiced in the Southwest United States. All practiced in urban areas. At the time of opt out, physicians had an average time in practice of 21.3 years and a median of 20 years (range, five to 46). Surgeons had an average H-index of 17.6 and a median of six (range, zero to 82). Approximately half of the surgeons were fellowship-trained in arthroplasty. Of these, 39% completed their training at the same institution. Surgeons received a mean of $377,178 and a median of $2,520 (range, zero to $10,631,606) from industry payments in the most recent year. This includes 47 (56%) who received less than $5,000 and nine (11%) who received over $1,000,000. In addition, 53% accepted insurance plans other than Medicare, and 25% had ownership of outpatient surgery centers. Also, the annual incidence of arthroplasty surgeon opt outs was higher in 2023 than in any year previously. CONCLUSION/CONCLUSIONS:Arthroplasty surgeons who opt out of Medicare have diverse demographic, academic, and financial characteristics. Features commonly shared were geographic location and fellowship institution, while other characteristics vary substantially.

The American Joint Replacement Registry continues to grow, as represented by the 4.3 million hip and knee arthroplasties analyzed in the 2024 American Joint Replacement Registry Annual report. Highlights of this report are found in the following article. We encourage readers to access the full report at https://www.aaos.org/registries/publications/ajrr-annual-report/.

BACKGROUND:Patients with Medicaid insurance are at an increased risk of postoperative complications following total knee arthroplasty and total hip arthroplasty (TJA); however, their outcomes following revision TJA for periprosthetic joint infection (PJI) requires further study. METHODS:A retrospective query was conducted for adult patients undergoing implant explantation and antibiotic spacer placement for TJA PJI from the Premier Healthcare Database between December 1, 2016, and December 31, 2021. Patients were then grouped by Medicaid or non-Medicaid insurance status and were age matched through exact caliper matching. Multivariable regression models addressed potential confounding. Adjusted risks of 90-day postoperative complications were reported. RESULTS:Of the 40,346 patients identified, 2,711 Medicaid patients were matched to 10,844 non-Medicaid patients on age (56.1 vs. 56.1 years, P = 1.000). Patients with Medicaid experienced higher risk of sepsis (adjusted odds ratio [aOR] = 1.20, P = 0.010), readmission (aOR = 1.12, P = 0.022), being discharged to a skilled nursing facility (aOR = 1.13, P = 0.031), and had longer length of stay (9.48 vs. 6.67 days, P < 0.001), compared with patients with non-Medicaid. Medicaid patients had a higher rate of inpatient mortality (0.81% vs. 0.48%, P = 0.038); however, the risk was similar after accounting for differences in comorbidities. CONCLUSION/CONCLUSIONS:Following revision TJA for PJI, patients with Medicaid were at an increased risk for postoperative complication, including sepsis and readmission. They experienced a higher rate of inpatient mortality that may be driven by differences in comorbidities. Insurers and policy makers should consider this information to develop risk stratification-based payment strategies that take into account the healthcare burden of this high-risk patient population. LEVEL OF EVIDENCE/METHODS:IV.

INTRODUCTION/BACKGROUND:The relationship between surgeon volume and risk of dislocation after total hip arthroplasty (THA) is debated. This study sought to characterize this association and assess patient outcomes using a nationwide patient and surgeon registry. METHODS:The Premier Healthcare Database was queried for adult primary elective THA patients from January 1, 2016, to December 31, 2019. Annual surgeon volume and 90-day risk of dislocation were modeled using multivariable logistic regression with restricted cubic splines. Bootstrap analysis identified a threshold annual case volume, corresponding to the maximum decrease in dislocation risk. Surgeons with an annual volume greater than the threshold were deemed high volume, and those with an annual volume less than the threshold were low volume. Each surgeon within a given year was treated as a unique entity (surgeon-year unit). 90-day complications of patients treated by high-volume and low-volume surgeons were compared. RESULTS:From 2016 to 2019, 352,131 THAs were performed by 5,106 surgeons. The restricted cubic spline model demonstrated an inverse relationship between risk of dislocation and surgeon volume (threshold: 109 cases per year). A total of 9,967 (87.8%) low-volume surgeon-year units had individual dislocation rates lower than the average of the entire surgeon cohort. Patients treated by high-volume surgeons had decreased risk of dislocation (adjusted odds ratio [aOR], 0.60; 95% CI, 0.54 to 0.67), periprosthetic fracture (aOR, 0.87; 95% CI, 0.76 to 0.99), periprosthetic joint infection (aOR, 0.63; 95% CI, 0.56 to 0.69), readmission (aOR, 0.70; 95% CI, 0.67 to 0.73), and in-hospital death (aOR, 0.60; 95% CI, 0.46 to 0.80). CONCLUSION/CONCLUSIONS:While most of the low-volume surgeons had dislocation rates lower than the cohort average, increasing annual surgeon case volume was associated with a reduction in risk of dislocation after primary elective THA. THERAPEUTIC LEVEL OF EVIDENCE/UNASSIGNED:Level IV.

BACKGROUND/UNASSIGNED:Electronic medical record portals enable real-time communication between patients and surgeons after total knee arthroplasty (TKA). This study evaluated the impact of message timing and frequency on postoperative outcomes and patient-reported outcome measures (PROMs). MATERIALS AND METHODS/UNASSIGNED:We retrospectively reviewed 9,353 primary TKAs performed at a single academic institution. Of these, 1,219 patients sent messages within 2 weeks of surgery (early), 507 sent messages between 2 and 8 weeks (late), and 7,627 did not message. RESULTS/UNASSIGNED:< .001). There was no difference in PROMs regardless of message timing, and there was no association between the number of messages sent and perioperative outcomes or PROMs. CONCLUSION/UNASSIGNED:Older age and longer LOS were associated with less patient-initiated contact after TKA. Older patients may be less familiar with digital platforms and less likely to send messages. Early messaging may reflect heightened recognition of postoperative issues, enabling counseling or intervention and reducing readmissions. These findings underscore the importance of preoperative education and equitable access, though long-term effects of messaging warrant further study.

BACKGROUND/UNASSIGNED:The increased emphasis on reimbursement, diversity, and burnout in hip and knee arthroplasty necessitates a foundational understanding of the surgeon workforce. The purpose of the study was to cross sectionally survey a representative sample of the AAHKS surgeon membership on the subject of salary, practice patterns, and demographic factors to establish a baseline framework for future advocacy efforts and initiatives. METHODS/UNASSIGNED:An online survey was sent to AAHKS members between December 20, 2022 and January 19, 2023. Surgeon demographic data, experience, practice geography and type, and annual case volume were solicited. Univariate and multivariate analyses were performed to describe the association of respondent characteristics with reported salary directly from patient care, as well as indirect revenue streams. RESULTS/UNASSIGNED:A total of 730 AAHKS members responded to the survey. The largest proportion of surgeons performed 251-400 cases annually (36%); 81% (n = 592) and 93% (n = 679) of respondents identified as white and male, respectively. Case volume was the primary determinant for surgeon salary, followed by practice type, years in practice, and gender. After controlling for confounding variables, multivariate analyses revealed the direct salary of women surgeons was 14.4% less than men [95% confidence interval, 0.4%-28.3%]. When considering indirect revenue, the gender pay gap widened. Salary was not associated with reported hours worked per week, geographic location, or ethnicity. CONCLUSIONS/UNASSIGNED:Salary is an important but underdiscussed subject that reflects the realities of our culture and value system in medicine. A direct relationship between salary and modifiable variables like case volume is clear. However, after controlling for confounders, women arthroplasty surgeons still earn 86 cents on the dollar compared to their male colleagues from direct surgical revenue.

BACKGROUND:There is increasing appreciation of the distinction between gender and sex as well as the importance of accurately reporting these constructs. Given recent attention regarding transgender and gender nonconforming (TGNC) and intersex identities, it is more necessary than ever to understand how to describe these identities in research. This study sought to investigate the use of gender- and sex-based terminology in arthroplasty research. METHODS:The 5 leading orthopaedic journals publishing arthroplasty research were reviewed to identify the first twenty primary clinical research articles on an arthroplasty topic published after January 1, 2022. Use of gender- or sex-based terminology, whether use was discriminate, and whether stratification or adjustment based on gender or sex was performed, were recorded. RESULTS:There were 98 of 100 articles that measured a construct of gender or sex. Of these, 15 articles used gender-based terminology, 45 used sex-based terminology, and 38 used a combination of gender- and sex-based terminology. Of the 38 articles using a combination of terminology, none did so discriminately. All articles presented gender and sex as binary variables, and 2 attempted to explicitly define how gender or sex were defined. Of the 98 articles, 31 used these variables for statistical adjustments, though only 6 reported stratified results. CONCLUSIONS:Arthroplasty articles infrequently describe how gender or sex was measured, and frequently use this terminology interchangeably. Additionally, these articles rarely offer more than 2 options for capturing variation in sex and gender. Future research should be more precise in the treatment of these variables to improve the quality of results and ensure findings are patient-centered and inclusive.

BACKGROUND/UNASSIGNED:There are high reported rates of burnout and job turnover among orthopedic surgeons. The purpose of this study was to investigate the prevalence of job change among early-career adult reconstruction surgeons and to examine which demographic or practice factors influenced job change. METHODS/UNASSIGNED:An electronic survey was distributed to all practicing surgeon members of the American Association of Hip and Knee Surgeons Young Arthroplasty Group. The survey included questions about practice type, demographics, job change, and a validated burnout questionnaire. Survey responses were collected using a secure database. Statistical analysis was performed to examine relationships between respondent characteristics and job change. RESULTS/UNASSIGNED: = .007). CONCLUSIONS/UNASSIGNED:Surgeons changing jobs cited social factors such as workplace culture as reasons for leaving. Burnout symptoms were higher in surgeons considering changing jobs but improved in those who had already changed jobs. It is important to identify factors that lead to job change to guide young surgeons in job selection and improve retention.