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Arthroplasty Register Data: Outcomes ofKnee Arthroplasty inYounger Patients
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Scott CEH, Bugler KE, Clement ND etal (2016) Patient expecta-
tions of arthroplasty of the hip and knee. Bone Joint J 98-B(12):
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Street BD, Wong W, Rotondi M, Gage W (2013) Younger patients
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knee joint replacement. J Orthop Sports Phys Ther 43(9):
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Swedish Knee Arthroplasty Register (2019) Annual Report. 2019.
researchgate. net
Thorsteinsson H, Hedstrom M, Robertsson O et al (2019)
Manipulation under anesthesia after primary knee arthroplasty
in Sweden: incidence, patient characteristics and risk of revision.
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Weber M, Craiovan B, Woerner ML et al (2018) Predictors of
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Wennergren D, Bergdahl C, Ekelund J etal (2018) Epidemiology
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Williams DP, Price AJ, Beard DJ etal (2013) The effects of age on
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Wilson I, Bohm E, Lübbeke A et al (2019) Orthopaedic registries
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Economics
Contents
Chapter 41 Economics ofSurgical Treatment
ofKnee Arthritis– AUS Perspective – 475
J. Parker Chapman, David P. Hagan,
and Chancellor F. Gray
Chapter 42 Conceptualizing theProblem ofCost inCemented Total
Knee Arthroplasty – 487
Kenoma Anighoro and Kevin J. Bozic
VIII
Economics ofSurgical
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Treatment ofKnee
Arthritis– AUS Perspective
J.ParkerChapman, DavidP.Hagan, andChancellorF.Gray
Contents
41.1 Introduction – 476
41.2 Economic Burden ofKnee Arthritis – 476
41.2.1 Non-TKA Treatments – 476
41.2.2 Health-Related Quality ofLife andSocietal Benets ofTKA – 477
41.3 Economic Considerations ofTKA – 478
41.3.1 Preoperative Considerations andPatient Selection – 478
41.3.2 Postoperative andDischarge Considerations – 479
41.3.3 Revision TKA – 480
475
41
41.4 Reimbursement – 480
41.4.1 Payment Models – 480
41.4.2 Limitations ofNew Payment Models – 481
41.4.3 Gainsharing – 482
41.5 Big Data inTKA – 482
41.6 TKA Implants – 482
41.7 Cemented TKA – 482
41.7.1 Cementing Technique – 483
41.7.2 Antibiotics inBone Cement – 483
41.8 Surgeons andtheEconomic Future ofTKA – 483
References – 484
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_41
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J. P. Chapman et al.
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41.1 Introduction
Symptomatic osteoarthritis of the knee is a common
condition for which patients seek treatment. A Swedish
study from 2012 reported a prevalence of 13.8% among
persons >45years of age of a large sample population
with symptomatic osteoarthritis of the knee with a predicted increase to 15.2% by the year 2032 (Turkiewicz
et al. 2014). The most complete current literature for
prevalence of symptomatic radiographic osteoarthritis of the knee in the United States (US) is from the
NHANES III cohort. Within the cohort of 2394 patients
greater than age 60 surveyed between 1991 and 1994,
12.1% reported symptoms in addition to having radiographic evidence of osteoarthritis (Dillon et al. 2006).
This data is antiquated, includes only patients >60years
of age and the percentage of affected persons is likely
under-reported as radiographic evaluation only included
an anterior-posterior (AP) view. It can be assumed that
the prevalence of symptomatic osteoarthritis of the
knee in the United States exceeds the 12.1% observed
in 1991–1994 including persons younger than 60 with
symptomatic osteoarthritis, population growth over the
last 25 years, and the current obesity epidemic. While
conservative management has a role and a nancial
impact on the treatment of symptomatic knee osteoarthritis, the majority of the economic impact and utilization of healthcare resources involves surgical treatment
(Bedard etal. 2017).
41.2 Economic Burden ofKnee Arthritis
There are multiple surgical options, but the most efcacious procedure for the treatment of global advanced
(tricompartmental) osteoarthritis of the knee is total
knee arthroplasty (TKA). TKA is one of the most common elective surgeries in the developed world, owing to
multiple factors: an aging population with expectations
of preserved activity, and increasingly safe and effective
knee arthroplasty procedures. The United States boasts
the highest utilization rate of TKA implants among
industrialized countries with projections for exponential growth over the next decade in the number of TKA
cases performed (Pabinger etal. 2015).
> The economic impact from a cost perspective will be
signicant. It is projected that the rate of primary
TKA will increase as much as 673% and revision
TKA by 601% by the year 2030 (Kurtz etal. 2007).
Orthopedic implants, operating room utilization, as well
as postoperative hospital stay and follow-up are all signicant contributors to the joint replacement expense.
With the projected exponential increases the amount
of total joint replacement surgeries to be performed
over the next decade, the cost and quality of delivery
of this modality will become increasingly important. In
order to address this nancial burden, changes to reimbursement in the US healthcare system have already
developed (via bundled payments and other alternative
payment models), and are likely to continue to grow in
prevalence (Kurtz etal. 2007).
A goal of all parties involved is to create a sustainable model that decreases cost, increases quality, and
does not limit access to TKA for those with comorbidities leading to higher operative risks or for those without
private insurance. Creating a system that accomplishes
these things will require delicate balancing of these factors.
> Although there is potential for difculty through this
transition, if done properly, benet could be seen by
each player via improved quality, streamlined pay-
ment models for hospitals and surgeons, and increased
value to the population.
41.2.1 Non-TKA Treatments
Depending on the stage of knee OA, there are alternatives available prior to TKA (. Fig. 41.1). Typically,
TKA is reserved for moderate to severe arthritis
(Kellgren and Lawrence stage III or IV) with heavy
burden of symptoms, signicantly impacting quality
of life. The onus of proper patient selection falls on the
treating surgeon, and there are no absolute guidelines
for operative vs. non-operative management outside of
an individual surgeon’s clinical judgment. Part of a surgeon’s responsibility to the patient and healthcare as a
whole is the value a modality provides for the patient–
whether surgical or non-surgical– and its overall costeffectiveness.
Historically, prior to any surgical intervention, it has
been important to have adequate trials and documentation of a step-wise progression through the available
non-operative management options. While there are a
multitude of non-operative modalities, it is important to
discuss the efcacy of a modality and its role within current practice guidelines. The AAOS clinical practice
guidelines are a culmination of evidence-based treatment
recommendations for orthopedic pathologies. Regarding
non-operative modalities, only physical therapy (lowimpact aerobic activity, strengthening exercises, neuromuscular education, etc.) and the use of NSAIDs and
tramadol received a recommendation strength of strong
(American Academy of Orthopaedic Surgeons 2013).
Few studies report on the cost- effectiveness of non-oper-
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Knee
Lifestyle
modification
. Fig. 41.1 Stage-dependent treatment of knee OA
Antiinflammatory
agents
injections:
-Steroid
-Hyaluronic
acid
-Stem cell
ative management before surgical intervention. A metaanalysis from 2012 queried the available literature
investigating the cost- effectiveness of non-surgical and
non-pharmacologic modalities as interventions for hip
and knee osteoarthritis. Their conclusion was that exercise-based programs appear to offer the best value for
money when quality-adjusted life years (QALY) are used
as the outcome of interest (Pinto etal. 2012). Using this
measure, 0.022–0.045 additional QALY are added for
$769–$796 of cost to the healthcare system, a number
which is considered cost-effective.
> It is important to note that the evidence included in
the analysis is limited, not standardized regarding
outcome measures, and at high risk of bias.
For moderate arthritis (stage II, III), therapy typically
progresses through the ever-increasing array of knee
injection options. Corticosteroid, hyaluronic acid, platelet-rich plasma, and, most recently, stem cell injections
have all been utilized in non-operative management of
knee OA.The AAOS clinical practice guidelines consensus is inconclusive regarding steroid injections and
platelet-rich plasma and cannot make a recommendation for or against the use of these modalities. While
there is no consensus regarding the use of steroid injections, they continue to be used as a treatment modality
and can offer temporary pain relief that in some cases
may delay TKA.A recommendation of strong was given
against the use of hyaluronic injections for symptomatic
arthritis based on a meta-analysis of 14 studies (3 high
strength and 11 moderate strength) that demonstrated
no appreciable number of patients achieving a clinically
relevant benet in outcome scores.
Biologics remain a source of confusion. Though the
AAOS has formally created a committee to investigate
the science behind biologic therapies for musculoskeletal
care, the American Academy of Hip and Knee Surgeons
(AAHKS) has stated: “It is our position that biologic
therapies, including stem cell and PRP injections, cannot
currently be recommended for the treatment of advanced
… knee arthritis.”(American Academy of Hip and Knee
Surgeons 2019)
> At this time, the authors cannot advocate for the use
of biologics in the spectrum of knee arthritis treat-
ment from a cost or efcacy standpoint.
Alternate operations:
Unicompartmental
knee arthroplasty
-High tibial
osteotomy
Total knee
arthroplasty
Revision total
knee
arthroplasty
The limited use of arthroscopy has been found to provide benet for mechanical symptoms in OA; otherwise,
there is limited evidence that arthroscopy provides a
clinically signicant improvement in symptoms or outcome measures (Hutt et al. 2015). Although each of
these forms of conservative management has been used
with varying efcacy in mild to moderate arthritis, it has
been shown that in end-stage knee OA (stage IV), a decision for TKA is of greatest benet in most cases.
In addition, the surgical alternatives to TKA should
be noted (. Fig.41.1). High tibial osteotomy (HTO) as
well as unicompartmental knee arthroplasty (UKA)
have been utilized in select scenarios. HTO is benecial
in younger patients (<50years, typically) with isolated
medial compartment disease, varus deformity, and
intact ligamentous stability (Smith etal. 2017). UKA is
also benecial under these circumstances but additionally can be appropriate in patients of more advanced age
(Fabre-Aubrespy etal. 2016).
> Though these interventions are able to preserve more
of the native anatomy, the index costs are similar and
the potential need for conversion to a TKA exists,
along with the associated costs.
41.2.2 Health-Related Quality ofLife
andSocietal Benets ofTKA
As mentioned above, TKA has been targeted for cost
reduction because it represents a signicant expense in
the budget of any health insurer– this situation reects
both its high utilization rate and high cost. The intervention continues to be highly utilized because it is effective,
and it continues to be reimbursed for the same reason.
By any standard, TKA adds cost-effective value to a
patient’s life. QALYs are currently the standard for
determination of an intervention’s value to the patient
within a population. QALYs effectively reect both the
quantity of time added to a patient’s life as well as the
quality of that time. For example, 1 year lived in perfect
health is represented by one QALY. Otherwise, the
QALY is calculated using a utility value based on the
patient’s state of health along with the time spent in that
state of health (Wu etal. 2014). Utility values are based
on factors such as pain, functional level, and ability to
perform activities of daily living (ADLs). Governing
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. Fig. 41.2 Quality-adjusted
life years (QALY). QALYs
consider both the quantity of life
years gained and the quality of
health during those years, and
assigns an associated cost to
recoup the additional time and
quality of life. Perfect health is
assigned a value of 1, while death
has a value of 0
1
Recovered QALY with TKA
0.75
41
Reduced QALY
bodies navigate this ethically and economically challenging area to set the value for a QALY.In the United
States, the addition of each QALY has been valued anywhere between $50,000 and $150,000.
> Although TKA raises the lifetime cost of treatment
for knee OA (average cost of TKA approximately
$50,000 with wide range), the associated increase in
QALYs outweighs this cost and is well within the currently accepted range of cost per QALY (.
Fig.41.2).
More specically, with TKA, lifetime costs rose from
$37,100 (no TKA) to $57,900 after TKA.Nonetheless
cost-effectiveness ratios remained favorable at $18,300
per QALY for low-risk patients and $28,100 per QALY
for high-risk patients (Losina etal. 2009).
Additionally, there are economic advantages in
returning patients to the workforce. For instance, for a
50-year old with symptomatic knee OA, TKA would be
expected to save society nearly $70,000 over a lifetime
compared to non-operative management. These cost
benets are realized quickly and are preserved throughout a lifetime (Bedair etal. 2014).
> Due to such favorable economics, TKA will continue
to be the standard of care in end-stage knee OA for
the foreseeable future.
Years
Years
41.3 Economic Considerations ofTKA
Economic considerations of TKA must account for
factors from before the patient with knee osteoarthritis enters the clinic door to when the patient exits the
90-day postoperative period and beyond. Each stage
carries intricacies that play into the economic viability
of TKA in a population.
41.3.1 Preoperative Considerations
andPatient Selection
When selecting patients for primary TKA, the surgeon
must consider each patient’s medical comorbidities
along with other factors in determining who can safely
undergo surgery and experience the greatest benet. It
is well known that certain diseases such as obesity and
diabetes mellitus (DM) increase the risk for postoperative infection and other postoperative complications. A
personal or family history of thromboembolic disease
or other prothrombotic states increases the risk of postoperative pulmonary embolism (PE) or deep venous
thrombosis (DVT), and often requires more aggressive
anticoagulation therapy, though acetyl salicylic acid
(ASA) has been shown to be cost-effective for the majority of patients undergoing TKA (Parvizi etal. 2017).
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> It is also important to account for lifestyle factors
such as smoking status, alcohol consumption, and the
use of any recreational drugs which can lead to any
number of adverse effects.
Complications lead to increased cost to orthopedic practices, the hospital, the healthcare system, patients, and
society as a whole; potentially avoidable complications
must be minimized through optimization wherever possible. Preoperatively, a thorough medical history should
be gathered for each patient along with identication and
characterization of all comorbidities (Santaguida et al.
2008). Once identied, each risk factor should be opti-
mized with assistance from the appropriate providers (i.e.,
anesthesia, cardiology) prior to operative intervention.
The Charlson comorbidity index (CCI), which accounts
for age, heart disease, vascular disease, endocrine disease (DM), lung disease (COPD), renal disease, etc., is
a commonly used tool in preoperative evaluation and in
studies evaluating outcomes in the total joint replacement literature (Baumgartner etal. 2018). Patient screening and selection techniques among surgeons display a
wide range of variability. In general, despite increased
risks with advanced age and multiple comorbidities, it
has been shown that the benet of TKA outweighs these
risks for much of the population even when considering
the increased cost. Patient- specic care will need to be
addressed in payment models to prevent access limitations for patients with increased risk factors.
An innovative use of big data and machine learning
could provide a solution for creating patient-specic
reimbursement models through a tiered system– when
more complex patients are encountered, the reimbursement would reect this complexity (Navarro etal. 2018).
At present, CMS makes a minimal distinction between
the vast majority of patients and those with “major
medical comorbidities”, which make up very few total
knee replacement episodes (around 6% nationally)
(Vizient Inc 2020). This lack of granularity in risk creates disincentive to manage complex cases.
> Future work in this area will help to ensure that sur-
geons are able to provide TKA to patients despite
increased comorbidities and the associated increase in
nancial burden due to an increased rate of postop-
erative complications.
When a TKA patient requires inpatient management
postoperatively, costs begin to increase and frequently
exceed the reimbursement in standard bundled payment
models and Center for Medicare and Medicaid Services
(CMS) standards. This is especially true for patients
with postoperative PE or DVT, intensive care unit (ICU)
admission, and other medical/psychiatric consultations
(Baumgartner etal. 2018).
41.3.2 Postoperative andDischarge
Considerations
Since the adoption of bundled payment models, the goal
of the arthroplasty surgeon has been to manage the whole
episode of care associated with the arthroplasty, and to
minimize low value but expensive care practices (Gray
etal. 2018). One such opportunity is in post- discharge
planning. Discharge home, in most cases, either with or
without home-care is an increasingly favored option,
improving outcomes and cost (Keswani etal. 2016). The
alternatives including discharge to skilled nursing or
subacute rehab quickly increase episode costs for TKA
and generally lead to worse outcomes.
The “risk assessment and prediction tool” (RAPT) is
a frequently used assessment tool shown to be useful in
predicting length of stay (LOS) requirements for patients
undergoing TKA. RAPT accounts for
5 Age
5 Gender
5 Ambulatory distance capability
5 Level of assistance required for ambulation
5 Level of community support
5 Level of home support (Dibra etal. 2019)
It predicts whether patients will be appropriate for home
discharge vs. requiring extended rehabilitation. Certain patients are unable to effectively discharge home
due to their social support and functional status, and
future reimbursement models will need to take this into
account.
For TKA, there is emerging evidence that, for most
patients, there is little difference in complications or readmission rates for patients undergoing outpatient surgery vs. those who have a short-stay surgery (Courtney
et al. 2015; Bovonratwet et al. 2019; Gogineni et al.
2019). With similar outcomes, and substantially
decreased costs, outpatient surgery has become a favorable pathway for optimizing value with TKA care for
many patients. An increasing number of patients and
surgeons are electing to proceed with outpatient surgery
with promising outlook.
> Of note, hospitals and surgeons with a clearly dened
care pathway postoperatively are associated with
reduced costs and utilization compared to those with-
out clearly dened pathways (Tessier etal. 2016).
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Re-admission post-discharge after TKA has been shown
to occur at a rate of approximately 4–10% (Gray etal.
2018; Keswani et al. 2016; Iorio et al. 2016); these re-
admissions can be due to surgical or medical complications and greatly increase costs (Clair etal. 2016). One
large academic center studied re-admission rates and
associated cost status post TKA and discovered an 8%
re-admission rate with a total average cost of $27,979
(range $4790–$40,774) for surgical complications (infection, wound complications, post-surgical pain) and average cost of $11,682 (range $3306–$24,076) for medical
complications (Clair etal. 2016). Additionally, approximately 4% of TKA patients require manipulation. The
most common surgical complications include infection
and periprosthetic fracture while the most common
medical complications are cardiovascular or pulmonaryrelated (Luzzi etal. 2018).
41.3.3 Revision TKA
Revision TKA will continue to increase in frequency
and complexity for the next several decades. The most
common diagnosis associated with revision TKA is
prosthetic joint infection (PJI), followed by mechanical loosening, implant failure or breakage, and other
mechanical complications of the prosthetic joint
(Postler etal. 2018). Re-admission for revision TKA is
also a signicant cost. A recent study demonstrated that
all- cause complication rate in a large cohort for patient’s
undergoing revision TKA was 37.2% compared to 2.5%
for patient’s undergoing primary TKA; the most common complication was infection (24.1%). Additionally,
it was noted that index hospital cost for re-admission
was approximately $7000 higher per episode of care for
revision TKA re-admission when compared to primary
TKA re-admission (Nichols and Vose 2016).
ated separate payments (with the notable exception of
the global period for physician services which excludes
follow-up services from additional billing for 90days).
Traditional fee-for-service models create a situation
where healthcare delivery is prioritized over provision of
health– thus there is little nancial incentive to improve
outcomes or reduce costs as each complication or readmission generated even more revenue for a hospital
system. Care coordination was uncommon in this setting. Similarly, there was no attention paid toward the
use of post-acute care facilities, which billed independently of the physician practice. These trends have
shifted since the onset of alternative payment models
(APMs) and bundled payments with an increased
emphasis on coordination of care between each provider and facility that takes care of the patient during a
TKA care episode, including the surgeon, anesthesiologist, physical and occupational therapists, and nursing
staff in both home nursing and inpatient settings (Rozell
etal. 2016).
41.4.1 Payment Models
The comprehensive care for joint replacement (CJR)
model was initiated by CMS in April 2016 and has been
used in metropolitan statistical areas (MSAs) across
the United States (Center for Medicare and Medicaid
Innovation 2016). In addition, the CMS bundled payments for care improvement (BPCI) initiative has dened
4 categories of bundled payments (Bundled Payments
for Care Improvement (BPCI) Initiative 2013). BPCI
has many models, but model 2 is the most commonly
used form (as described in . Fig.41.3) which includes
Model 1: Inpatient acute hospital stay
41
41.4 Reimbursement
> Healthcare in the United States is expensive, compris-
ing close to 18% of the gross domestic product (GDP)
expenditures (Papanicolas etal. 2018). A large part of
this increase is due to the aging population and
increasingly complex healthcare options.
Due to the age of the patient population undergoing
TKA, CMS remains the primary payer for these surgeries. Traditionally, in the United States, surgical procedures have fallen into the fee-for-service model, in which
each provider service, as well as any follow-up, gener-
Model 2: Inpatient acute hospital and all
Bundled payments
for care
improvement
. Fig. 41.3 a, b BPCI models. a The 4 versions of the BPCI model;
care model 2 is the most commonly used option among total knee
surgeons 35. b In a BPCI model 2 for TKA, billing and care are delivered as usual, with a post-hoc analysis of the spending. Participants
are eligible for a repayment or a penalty based on performance
throughout the program year 27
post-acute care (90 days)
Model 3: post-acute care beginning at
hospital discharge
Model 4: Pre-determined bundled
payment for entire inpatient stay
b
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Claim from hospital
triggers a bundle
All providers bill Medicare
as normal
If it is LOWER than the target,
the awardee will receive a check
. Fig. 41.3 (continued)
for the difference
Patient is flagged by
CMS
CMS pays all providers
as normal
Any patient having surgery at pilot
hospital for one of the MS-DRGs is
by default a part of the bundle;
it is not physician-specific
Retrospectively the sum of claims is
reconciled against the target price
If it is HIGHER than the target, the
awardee has to repay CMS
both upside and downside risk from the acute care episode and the post-acute phase of care.
Bundled payments have proven benecial to all key
players including the patient. They have helped to reduce
costs via reduction of postoperative hospital LOS as
well as the number of re-admissions. The physician’s
ability to effectively select patients for TKA and plan for
their postoperative needs has been enhanced. As a
result, overall cost has decreased and the relative value
of TKA to the population has increased.
> Of note, TKA has been removed from the CMS
inpatient- only (IPO) list effective January 2018, and
site-neutral reimbursement is slated to begin in 2020
(Bundled Payments for Care Improvement (BPCI)
Initiative 2013). These changes will have profound
impact on and health systems alike as joint replace-
ment surgery moves into the outpatient setting.
have largely mitigated this concern by demonstrating
that quality does not suffer under the bundled payment
model (Gray etal.
2018; Iorio etal. 2016; Dummit etal.
2016). As mentioned previously, a continued concern is
that bundled payments may limit patient access due to
increasingly stringent patient selection factors, a practice
sometimes referred to as “cherry-picking” and “lemondropping” (Luzzi etal. 2018).
The two largest of these models, the BPCI and CJR,
have variable nancial risks to physician practices and
hospitals, and it is unclear which of these mechanisms
will sustain the longest-term increase in value of care.
> One may presume that a model that is voluntary and
empowers physician decision-making and leadership,
as in BPCI, would engender more successful long-
term changes, though only time will tell.
There is no doubt that such mechanisms will drive down
costs, but will they also endanger the autonomy of the
41.4.2 Limitations ofNew Payment Models
orthopedic surgeon (as well as innovation and risktaking)? Will the effect on value-based care be lasting?
Bundled payments have, however, not been without
their concerns. An initial concern was that bundled
payments may allow for continued reimbursement
reductions affecting compensation and possibly lead to
decreasing quality, though multiple comparison studies
of bundled payments and traditional payment models
These are questions that will be answered in the coming
years as bundled payments (will likely) become the standard across the United States. Expansion of bundled
payments to smaller hospitals and less dense metropolitan statistical areas (MSAs) will likely require modications as these “micropolitan” areas are unable to bear
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the nancial risks of bundled payment models (Bundled
Payments for Care Improvement (BPCI) Initiative 2013).
Policy makers will need to take this risk into account
when expanding bundle payment standards to smaller
community hospitals with more diverse cases and less
sub-specialization.
As previously discussed, most TKA operations are
performed on patients over 60years of age; as a result,
Medicare is the primary payer for the lion’s share of
these procedures. It will be interesting to see the direction that private payers take over the coming years with
relation to bundle payments. Although not as likely to
have a large inuence on total joint replacement, private
payers are acutely interested in bundled payments
involving younger populations such as in the maternity
model (George 2018).
41.4.3 Gainsharing
Gainsharing, achieved through the identication and
alignment of key stakeholders, will be essential to the
success of a bundled payment model (Bosco etal. 2018).
Cost savings must be shared across spheres to maintain
adequate incentive for continued improvement. The
nancial risks must be acceptable to healthcare organizations of various sizes and revenue streams must
remain steady. Hospitals cannot keep their doors open
unless an adequate stream of revenue persists.
41.5 Big Data inTKA
In the world of big data, medicine must not be left
behind. High-volume operations such as TKA require
robust data collection that will be used in generating
continued improvement for years to come. Not only will
data be useful for continued improvement, it will also
allow for necessary checks and balances in a system that,
if too broadly applied, could lead to decreased availability of joint replacement (Navarro etal. 2018). Highly
powered studies have already been used to demonstrate
ndings such as a decreased revision rate of TKA performed at high-volume centers compared to low-volume
centers (Jeschke et al. 2017). Such studies have also
shown that TKA performed at low volume centers will
carry an increased risk of short-term complications. The
collection of data from multiple studies is necessary for
the publication of meta-analyses and level I evidence
with translation for clinical practice. Easy access to
this data is essential for continued production of highquality evidence.
41.6 TKA Implants
The “Big 4” implant manufacturing companies– Stryker,
Zimmer-Biomet, DePuy-Synthes, Smith & Nephew –
have the majority of the market share in the world of
total knee replacement implants. In an implant- driven
subspecialty, it can be difcult to decipher outcomes
data, oftentimes conveniently aligned with a company’s
marketing.
> Objective studies by third-party organizations are
essential to an unbiased approach to implant characterization.
Commoditization
z
TKA implants comprise a signicant proportion of
total episode costs; in revision TKA there is yet higher
implant-associated cost. It has been found that in
America, implant costs vary widely; implant costs at
hospitals above the 90th percentile are approximately
double the implant costs of hospitals below the 10th
percentile (Haas and Kaplan 2017). Generic implants
have great potential for reducing costs. Much like the
affordability of generic aspirin or acetaminophen,
generic implants would allow for a more sustainable and affordable model for certain hospitals and
populations. It has been shown that when implants
are purchased from a less expensive physician-owned
dealership there was no signicant difference in outcomes or complications when compared to TKA with
higher-cost industry-supplied implants (Baumgarten
etal. 2019).
Unfortunately, there can be a drawback to commoditization. In the case of orthopedic joint replacement
implants, commoditization may lead to a reduction in
innovation and diminished funding for novel technologies in the treatment of end-stage osteoarthritis.
Nonetheless, analysis of data surrounding the efcacy
of generic TKA implants will be benecial in the changing climate of healthcare reimbursement.
41.7 Cemented TKA
> Despite recent advances in press-t, non-cemented
TKA, a cemented knee arthroplasty remains, as of
2020, the gold standard.
Although cemented, hybrid, and non-cemented TKA
all obtain similar patient-reported outcomes, noncemented knees may have higher rates of revision than
cemented based on currently available registry data
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