Alexander T. Bradley MD MBA, Robert A. Burnett MD, Philo Hall JD, Joshua Kerr MA, Adam J. Rana MD

The Journal of Arthroplasty, November 2025

Abstract

The financial sustainability of orthopaedic private practices is under major threat due to continuous reductions in Medicare physician reimbursement, particularly for hip and knee arthroplasty procedures. These cuts, driven by healthcare policy over the last few decades, have had dramatic effects on joint arthroplasty surgeons, resulting in an 18% decrease in real dollar reimbursement between 2020 and 2026, and a 43% decrease in real dollar reimbursement from 1994 to 2026. As professional fees fall and inflation-adjusted practice costs rise, surgeons face mounting pressure from increasing overhead expenses, regulatory burdens, and administrative demands. This squeeze with reduced revenue and increased costs has accelerated consolidation trends across the orthopaedic field, shifting practice models from independent and small groups toward hospital employment, multispecialty mergers, and private equity-backed organizations. The resulting healthcare consolidation has major downstream effects, including increased healthcare costs to the broader system, reduced patient access, potential declines in care quality, and ultimately a loss of physician autonomy. Recent mergers and acquisitions illustrate a national trend toward a concentrated orthopaedic market, as shown by the rising Herfindahl-Hirschman Index (HHI). Advocacy efforts by the American Association of Hip and Knee Surgeons (AAHKS) aim to address these systemic issues by pushing for inflation-adjusted reimbursement, site-neutral payments, and other initiatives, with a goal of preserving physician autonomy. Without meaningful reform, arthroplasty surgeons risk losing control over clinical decision-making, and patient access to high-quality, efficient healthcare stands to be compromised.

Catherine M. Call MD, Zoë A. Walsh MPH, Diane Jeselskis BSN, Ryan J. Mountjoy MD, Brian J. McGrory MD, MS, Adam J. Rana MD

Arthroplasty Today, October 2025

Abstract

Background

Minimizing postoperative opioids remaining after total hip arthroplasty (THA) is important for patient outcomes and community safety. The purpose of this study was to investigate whether completion of one preoperative patient education class prior to THA was associated with reduced opioid consumption at 2 weeks postoperatively. Secondary goals included evaluating whether satisfaction scores and postoperative healthcare utilization were impacted by class attendance, and whether demographic characteristics varied between groups that may highlight care disparities for our practice to address.

Methods

Patients undergoing primary THA between January 2022 and December 2024 at a single large academic institution were retrospectively evaluated for inclusion, identifying 372 patients who completed the education class and 30 patients who did not. All patients received a multimodal perioperative pain management protocol standardized at our institution.

Results

The number of morphine milligram equivalents (MMEs) consumed in the 2 weeks following THA was significantly lower among the class completion group (84.60 vs 127.30 MMEs; P = .04). On multivariable analysis, patients who attended the preoperative education class consumed 41.57 fewer MMEs compared to those who do not attend (95% confidence interval: −75.87 to −7.27; P = .018). No differences in complications, 2-week refill requests, emergency department visits, or readmission were noted. Functional outcome and satisfaction scores were high among both groups.

Conclusions

THA patients who completed an education class preoperatively consumed significantly fewer prescribed opioids as measured at the 2-week mark following surgery compared to those who did receive education. Our results support the role of patient education in reducing opioid use following arthroplasty.

Full Text: Preoperative Patient Education as a Tool for Reducing Postoperative Opioid Use Following Primary Total Hip Arthroplasty: One Institution’s Experience

Catherine M. Call BA, Mary Noyes BA, Kamli N.W. Faour BA, Diane Jeselskis BSN, Adam J. Rana MD

Arthroplasty Today, August 2025

Abstract

Opioid overprescribing is a concern within the field of arthroplasty, and a growing body of evidence suggests surgeons can prescribe smaller quantities of opioids for orthopaedic postoperative pain management without compromising patient care. Current literature indicates prescribing trends in arthroplasty are shifting in response. Our institution has prioritized quality improvement projects focused on multimodal pain control for patients undergoing total joint arthroplasty procedures in an active attempt to reduce postoperative narcotic use. We highlight tips for instituting similar initiatives based on our institution’s experience, including communication strategies, the importance of establishing the expectation for postoperative pain management by the orthopaedic surgery team, and the role for postoperative pill counts. Future initiatives aimed to facilitate these changes, including the upcoming legislation the Nonopioids Prevent Addiction in the Nation Act, are discussed.

Full Text: Fewer Pills for Fewer Problems: Strategies for Reducing Postoperative Opioid Prescribing Following Total Joint Arthroplasty

Zachary C. Lum DO, R. Michael Meneghini MD, James I. Huddleston MD, Adam Rana MD

The Journal of Arthroplasty, October 2025

No abstract available

Mary L. Noyes BA, Kamli N.W. Faour BA, Zoë A. Walsh MPH, Catherine M. Call BA, Johanna A. Mackenzie MPH, Adam J. Rana MD

Arthroplasty Today, August 2025

Abstract

Background

Prescription opioids leftover following arthroplasty surgery pose risks to patients and communitys. The purpose of this study was to capture opioid utilization patterns following primary total hip arthroplasty before and after a targeted intervention to decrease postoperative opioid prescription quantity. We hypothesized that reducing discharge pill count would not impact pain or functional outcomes.

Methods

Primary total hip arthroplasties performed by a high-volume, fellowship-trained arthroplasty surgeon between October 2022 and January 2024 were retrospectively evaluated for study inclusion; 229 patients met inclusion criteria. Beginning in April 2023, the surgeon gradually implemented a 38% reduction in postoperative opioid prescribing from 40 to 24 pills. Opioid consumption was evaluated by patient-reported pill count at the first postoperative visit. Patients were sorted into 2 groups: “preintervention” (n = 157) and “postintervention” (poI) (n = 72). Preintervention patients received between 300 and 420 oral morphine equivalents and poI patients received between 240 and 299.99 oral morphine equivalents. Demographics, pill counts, refills, 30-day emergency department visits, function (Hip Disability and Osteoarthritis Outcome Score Joint Replacement), pain (visual analog scale), and satisfaction scores were analyzed.

Results

Proportion of discharge prescription remaining at 2-week postoperative visit did not differ significantly between intervention groups (P = .33). There were no differences in opioid refill requests (P = .82), function (P = .75), or satisfaction with functional improvement (P = .61). Patients in the poI group reported lower pain at 6 weeks postoperatively (P < .05). There were no differences in 30-day emergency department visits between groups (P = .57).

Conclusions

Results support that arthroplasty surgeons can prescribe smaller quantities of opioids without compromising care. Such interventions can help reduce the number of prescription opioids available for misuse and diversion.

Full Text: Toward Opioid-Free Total Hip Arthroplasty: A Retrospective Study of a Targeted Opioid Reduction Program in 229 Patients

Catherine M. Call MD, Zoë A. Walsh MPH, Aliyah A. Olaniyan MS, George Babikian MD, Brian J. McGrory MD, MS, Adam J. Rana MD

Arthroplasty Today, August 2025

Abstract

Background

The Centers for Medicare and Medicaid Services has mandated at least 50% institutional compliance of patient-reported outcome–based performance measures (PRO-PMs) for Medicare fee-for-service patients undergoing inpatient, elective total joint arthroplasty. The purpose of this study was to evaluate characteristics of patients undergoing primary total hip arthroplasty to identify risk factors for patient-reported outcome measures (PROMs) noncompletion using the Hip Dysfunction and Osteoarthritis Joint Replacement Outcome Score as a marker PROM.

Methods

A retrospective review was performed of patients undergoing primary total hip arthroplasty at a single large academic center between January 2013 and August 2020. Demographics, operative variables, hospital outcomes, and PROMs were compared between patients achieving and not achieving PRO-PM requirements and multivariable analysis was performed.

Results

A total of 5691 patients were included; 2547 patients did not complete either PROM, 2201 completed the preoperative PROM within 90 days of surgery, and 943 completed the PROM preoperatively and at 365 ± 60 days postoperatively. Demographics and outcomes between groups varied; patients not completing the PROM more often had a length of stay >48 hours (P < .001) and any complication (q = 0.07); these associations remained significant with adjusted multivariable analyses.

Conclusions

PRO-PM completion is necessary for compliance with the new Centers for Medicare and Medicaid Services mandate. We report on the characteristics of patients completing and not completing a marker PROM as well as risk factors for noncompletion from the era before this mandate, before substantial efforts were undertaken to increase response rate, to provide an organic overview of the patients at risk for noncompletion to guide further initiatives.

Full Text: Who is Completing Patient-Reported Outcome Measures following Total Hip Arthroplasty? An Investigation of Completion Characteristics to Inform the Age of Mandatory Reporting Rates

Robert A. Burnett MD, Omar Shalakhti MS, James I. Huddleston MD, Adam J. Rana MD

The Journal of Arthroplasty, October 2025

No abstract available

Catherine M Call, Aliyah A Olaniyan, Zoë A Walsh, George M Babikian, Adam J Rana, Brian J McGrory

The Journal of Arthroplasty, July 2025

Abstract

Background

Centers for Medicare and Medicaid Services (CMS) began mandating at least 50% institutional compliance of patient-reported outcome-based performance measures for Medicare fee-for-service patients undergoing inpatient, elective total hip arthroplasty (THA). The patient-reported outcome-based performance measure is calculated to represent the proportion of patients meeting or exceeding the substantial clinical benefit (SCB) threshold between preoperative and postoperative patient-reported outcome measures (PROMs). The purpose of this study was to evaluate demographics, operative variables, hospital outcomes, and PROMs among two groups of patients following primary THA: those achieving SCB and those who did not reach this threshold.

Methods

A retrospective review was performed of patients undergoing primary THA at a single large academic center between January 2015 and November 2024. Demographic, operative, and outcome variables were compared between patients meeting and not meeting SCB. Multivariable analysis was performed to identify risk factors for failure to achieve SCB.

Results

A total of 1,257 patients were included; 54% were women, and 88% met SCB. Few differences between groups in demographics and complications were observed. Patients not meeting SCB more often had a contralateral hip arthroplasty (P < 0.001), government insurance (P = 0.011), and a higher preoperative Hip Disability and Osteoarthritis Outcome Score, Joint Replacement interval score (q < 0.001); these associations remained significant on multivariable analysis. At postoperative time points, functional PROMs were lower and pain scores were higher among patients not achieving SCB.

Conclusions

The institution of this new Centers for Medicare and Medicaid Services mandate puts renewed attention on the SCB metric. Our results indicate the difficulty in collecting PROMs in accordance with this mandate. Patients not meeting SCB following THA demonstrated few differences in demographics or hospital course, yet exhibited a significant difference in PROMs profile. Future studies are needed to elucidate the underlying causes of observed differences and are essential for equitable arthroplasty care.

Daniel E. Pereira MD, Charles P. Hannon MD, MBA, P. Maxwell Courtney MD, Adam J. Rana MD, Nicholas B. Frisch MD, MBA

The Journal of Arthroplasty, July 2025

Abstract

Background

Healthcare finance in the United States is continually changing with increased consolidation of healthcare organizations, fluctuating reimbursement cycles, and shifting institutional and federal policies. The economics of practicing medicine are dynamic and challenging relative to other professions. The purpose of this study was to analyze compensation trends in orthopaedic surgery over the past 20 years compared to other professions.

Methods

Income data for orthopaedic surgeons and other professions every five years from 2000 to 2020 was collected from the United States Bureau of Labor Statistics and peer-reviewed literature. Income data were adjusted for inflation and analyzed to identify trends in compensation.

Results

The rate of absolute income trajectory over two decades for orthopaedic surgeons when adjusted for inflation was −38%. Outside of healthcare professions, economists, lawyers, and engineers saw some of the highest increases with inflation-adjusted increases at +31, 26, and 24%, respectively. Orthopaedic surgeon salary rates declined the most of all professions analyzed, including all healthcare workers.

Conclusions

Adjusted orthopaedic surgeon compensation has declined significantly in the two decades between 2000 and 2020. Compared to other high-skilled professions, orthopaedic compensation showed the greatest decline in adjusted rates over time. This trend carries major implications for the future of the field, potentially affecting recruitment, satisfaction, burnout, and patient access to care. It underscores the need for a re-evaluation of compensation models in orthopaedic surgery to ensure sustainability.

Hania Shahzad MD, David Dallas-Orr MD, MBA, MTM, Shannon Tse MD, J.B. Smith MD, Christopher Deans MD, Adam J. Rana MD, John P. Meehan MD, Zachary C. Lum DO

The Journal of Arthroplasty, June 2025

Abstract

Background

The Centers for Medicare and Medicaid Services assumes two postoperative follow-up visits (PFUs) occur within the 90-day global period after total joint arthroplasty, forming the basis for reimbursement. However, recent concerns suggest this may underestimate actual postoperative care, raising questions about potential overvaluation of these procedures. This study evaluated the frequency of PFUs during the 90-day global period for total knee arthroplasty (TKA) and total hip arthroplasty (THA) and to identify at-risk patients for three or more PFUs during the global period.

Methods

We queried a national claims database to identify 102,564 and 61,423 patients who underwent TKA and THA between 2017 and 2022, respectively. PFUs (CPT 99024) within 90 days were tracked. Patients were stratified into low-risk (one to two visits) and high-risk (3+ visits) groups. Sociodemographic and clinical variables were collected. Chi-square analysis and multivariate regression models were used to assess the association between comorbidities and follow-up visit frequency.

Results

The average number of PFUs for both TKA and THA was 2.20 (SEM 0.004; 95% CI [2.19 to 2.20]; P ≤ 0.001) and 2.06 (SEM 0.005; 95% CI [2.05 to 2.07]; P ≤ 0.001), respectively. A total of 28% of the patients required three or more visits, particularly those with a higher Elixhauser Comorbidity Index and other specific comorbidities such as chronic kidney disease, pulmonary disease, heart disease, blood loss anemia, and obesity.

Conclusions

This study reports that a large portion of total joint arthroplasty patients required more than two PFUs during the 90-day global period. High-risk patients who had complex comorbidities necessitated more frequent follow-ups, suggesting an increase in work value be added to the current global billing structure to better account for resource demands. The data presented in this study will be used by the American Association of Hip and Knee Surgeons in future discussions regarding the potential further reduction of PFUs from two to one.

Catherine M Call, Johanna Mackenzie, Zoë A Walsh, Bailey Shevenell, George Babikian, Brian J McGrory, Adam J Rana

Arthroplasty Today, June 2025

Abstract

Background

Total hip arthroplasty (THA) after prior hip or acetabular fracture fixation is considered higher risk than primary THA, as studies have shown reduced implant survival and higher infection rates. The anterior-based muscle-sparing (ABMS) approach can potentially reduce some of these risks by utilizing a new surgical interval. The goal of this study is to analyze the efficacy of the ABMS approach for conversion to hip arthroplasty surgery after previous fracture fixation with comparison to posterior approach.

Methods

This retrospective cohort study included patients with prior hip surgical intervention requiring hardware then converted to a THA using the ABMS or posterior approach at 1 institution between 2013 and 2020. Outcomes studied included postoperative complications, 30-day emergency department visits, 90-day readmission rates, any reoperation and patient-reported outcome measures.

Results

A total of 85 patients (51 male and 34 female) in the ABMS group and 17 patients (9 male and 8 female) in the posterior group were included. Within the ABMS group, the mean age was 65.6 years (±16.2) with a mean body mass index of 27.5 kg/m² (±5.4). The average operative time was 85 minutes (±35) and estimated blood loss was 178 mL (±183). There was 1 postoperative complication (dislocation) within 90 days, 1 patient made an emergency department visit within 30 days, and there were 3 readmissions within 90 days; only 1 readmission was orthopaedic in nature. One patient required reoperation (1.2%) over the study period of 5.0 years (±2.1). Patient-reported outcome measures indicate successful return of function. Operative, hospital, and outcome data were similar between patients receiving the ABMS and posterior approach.

Conclusions

This study is the first to evaluate outcomes of conversion THA using the ABMS approach, when compared to the posterior approach. Our institution’s experience demonstrates that the ABMS approach is safe and effective for conversion THA after prior fracture fixation.

Full Text: The Anterior-Based Muscle-Sparing Approach for Conversion Total Hip Arthroplasty is Safe and Effective

Catherine M. Call, MD ∙ David E. DeMik, MD ∙ Ameer M. Elbuluk, MD∙ Brian P. Chalmers, MD ∙ Carl L. Herndon, MD ∙ Nicholas B. Frisch, MD, MBA ∙ Joshua A. Kerr, MA ∙ Adam J. Rana, MD

The Journal of Arthroplasty, June 2025

Abstract

The physician fee payment for Medicare total hip arthroplasty (THA) and total knee arthroplasty (TKA) has declined markedly over the past three decades. When adjusted for inflation, today’s THA reimbursement of $1,261.25 is less than one-third of the adjusted reimbursement of 1995 at $4,172.66. Advocating for payment reform is a top priority for the American Association of Hip and Knee Surgeons (AAHKS). From 2012 to 2017, inflation-adjusted surgeon payments for Medicare primary TKA and THA have decreased by 17 and 11%, respectively [1]. This trend continued from 2017 to 2022, with a 19.6% decrease in inflation-adjusted reimbursement for primary total joint arthroplasty (TJA) [2]. Over a longer period, from 2000 to 2019, the mean physician reimbursement for all hip and knee arthroplasty procedures decreased by 38.9% after adjusting for inflation [3]. This trend is especially concerning given the rising costs and surgical complexity associated with these procedures; Ashkenazi et al. noted that increasing costs for high comorbidity burden patients undergoing THA were not matched by equivalent revenue increases, leading to reduced contribution margins [4]. These concerns are compounded by the increasing volume of patients undergoing TJA with Medicare and Medicare Advantage insurance coverage. Despite higher caseloads, payments received per case have decreased tremendously, highlighting the inadequate and unsustainable reimbursement patterns facing surgeons [5]. This landscape, fraught with economic pressures, has led to practice consolidation and poses a serious threat to patient access, with the ability to provide care for Medicare patients at risk. This article explores the history of TJA reimbursement and addresses outcomes related to this pressure that have been identified as important for preserving the future of our field and ensuring continued patient access to arthroplasty care.

Meghan A. Whitmarsh-Brown MD, Catherine M. Call MD, Joshua A. Kerr MA, Carl L. Herndon MD, Christopher F. Deans MD, Ameer M. Elbuluk MD, Ramakanth R. Yakkanti MD, Adam J. Rana MD

The Journal of Arthroplasty, October 2025

Abstract

Background

Periprosthetic joint infection (PJI) centers of excellence (COEs) have been discussed as an innovative model to improve health care quality and value in treating PJI. A national network of regional PJI centers may have the ability to improve patient outcomes, standardize treatment protocols, accelerate research, and provide economies of scale while caring for this patient population with complex needs. This study surveyed perceptions toward establishing a PJI COE among members of the American Association of Hip and Knee Surgeons (AAHKS).

Methods

A 16-question survey was approved by the AAHKS Advocacy Committee and distributed to all 2,529 fellow-level members of AAHKS. Study results were analyzed using descriptive statistics. There were 626 survey responses (24.8% response rate).

Results

More than two-thirds of survey participants (69%) reported that they would consider participation in some form of PJI COE. Most surgeons believe managing PJI is a cost to their hospital system. The top concern among respondents was that PJI COE may become a “dumping ground” for inappropriate referrals. Participants reported financial concerns regarding the possibility that establishing such a program may trigger a reevaluation of reimbursement for primary total joint arthroplasty procedures.

Conclusions

Although primary total joint arthroplasty is a target of national health care cost containment efforts, PJI is yet to be addressed. This gives AAHKS the opportunity to prospectively advocate for reform. A PJI COE designed to perform a high volume of infection revision procedures may be advantageous in providing the specialized and longitudinal care required by PJI patients. The AAHKS surgeons expressed interest and reservations in the establishment of PJI COEs that can inform future policy.

Ramakanth R. Yakkanti, MD, Catherine M. Call, BA, Charles P. Hannon, MD, MBA, Chad A. Krueger, MD, P. Maxwell Courtney, MD, Adam J. Rana, MD

The Journal of Arthroplasty, February 2025

Abstract

Prior authorization (PA) is a management process used by payors to regulate whether a procedure will be approved and covered as part of a patient's care plan. The reported benefit of PA is to improve the value and quality of care delivered to patients by ensuring appropriate treatments. However, in practice, it is often viewed as a payor-driven cost-control measure, creating barriers within the field of arthroplasty care for both surgeons and patients to access medically indicated treatment. Prior authorization can create substantial hurdles for arthroplasty surgeons, especially in securing surgical authorizations, imaging requirements, and navigating viscosupplementation approvals. These obstacles not only delay procedures but can also delay and jeopardize patient outcomes. This article explores the impact of PA on joint arthroplasty surgery, the historical context of the PA system, strategies to minimize denials, and relevant upcoming legislative efforts to reduce its impact.

Catherine M. Call BA, Andrew D. Lachance MD, Thomas M. Zink MD, Henry Stoddard MPH, George M. Babikian MD, Adam J. Rana MD, Brian J. McGrory MD, MS

The Journal of Arthroplasty, June 2024

Abstract

Background

The effect of biological sex on the outcomes of total hip arthroplasty (THA) remains unclear. Accounting for biological sex in research is crucial for reproducibility and accuracy. Average combined data may mask sex-related variation and obscure clinically relevant differences in outcomes. The aim of this study is to investigate hospital and patient-reported outcome measures (PROMs) after THA by biological sex to elucidate differences and ultimately provide more equitable care.

Methods

We performed a retrospective review of patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographics, operative variables, hospital outcomes, and PROMs were compared between men and women patients. The PROMs included preoperative, 6-weeks, 6-months, and 1-year Single Assessment Numeric Evaluation, Visual Analog Scale, Hip Disability and Osteoarthritis Outcome Score Joint Replacement, University of California, Los Angeles, and Patient-Reported Outcomes Measurement Information System mental and physical scores, as well as satisfaction scores.

Results

A total of 6,418 patients were included (55% women). Women were older (P < .001), had a lower body mass index (P < .001), and were more likely to have public insurance (P < .001). Fewer women were discharged to home or self-care (P < .001). Women had higher rates of cementation (P < .001) and fracture within 90 days (P < .001), and these associations remained significant with adjusted multivariable analyses. Women had significantly higher pain and lower functional scores preoperatively; postoperatively, most PROMs were equivalent.

Conclusions

Important differences were observed in several areas. Demographic parameters differed, and a variable effect of biological sex was observed on surgical and hospital outcomes. Women had an increased incidence of cemented femoral components (indicated for osteoporotic bone) and postoperative fractures. Women’s PROMs demonstrated globally lower functional scores and higher pain preoperatively. Differences attributed to sex should continue to be investigated and accounted for in risk-stratification models. Future studies are needed to elucidate the underlying causes of observed biological sex differences and are essential for equitable arthroplasty care.