Effects of Hospital and Surgeon Volume on Patient Outcomes After Total Joint Arthroplasty

Reported From the American Joint Replacement Registry

Ahmed Siddiqi, DO, MBA; Vignesh K. Alamanda, MD; John W. Barrington, MD; Antonia F. Chen, MD, MBA; Ayushmita De, PhD; James I. Huddleston III, MD; Kevin J. Bozic, MD, MBA; David Lewallen, MD; Nicolas S. Piuzzi, MD; Kyle Mullen, MPH; Kimberly R. Porter, PhD, MPH; Bryan D. Springer, MD


J Am Acad Orthop Surg. 2022;30(11):e811-e821. 

In This Article

Abstract and Introduction


Background: The purpose of this study was to evaluate outcomes and complications because it relates to surgeon and hospital volume for patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) using the American Joint Replacement Registry from 2012 to 2017.

Methods: A retrospective study was conducted on Medicare-eligible cases of primary elective THAs and TKAs reported to the American Joint Replacement Registry database and was linked with the available Centers of Medicaid and Medicare Services claims and the National Death Index data from 2012 to 2017. Surgeon and hospital volume were defined separately based on the median annual number of anatomic-specific total arthroplasty procedures performed on patients of any age per surgeon and per hospital. Values were aggregated into separate surgeon and hospital volume tertile groupings and combined to create pairwise comparison surgeon/hospital volume groupings for hip and knee.

Results: Adjusted multivariable logistic regression analysis found low surgeon/low hospital volume to have the greatest association with all-cause revisions after THA (odds ratio [OR], 1.63, 95% confidence interval [CI], 1.41–1.89, P < 0.0001) and TKA (OR, 1.72, 95% CI, 1.44–2.06, P < 0.0001), early revisions because of periprosthetic joint infection after THA (OR, 2.50, 95% CI, 1.53–3.15, P < 0.0001) and TKA (OR, 2.18, 95% CI, 1.64–2.89, P < 0.0001), risk of early THA instability and dislocation (OR, 2.47, 95% CI, 1.77–3.46, P < 0.0001), and 90-day mortality after THA (OR, 1.72, 95% CI, 1.27–2.35, P = 0.0005) and TKA (OR, 1.47, 95% CI, 1.15–1.86, P = 0.002).

Conclusion: Our findings demonstrate considerably greater THA and TKA complications when performed at low-volume hospitals by low-volume surgeons. Given the data from previous literature including this study, a continued push through healthcare policies and healthcare systems is warranted to direct THA and TKA procedures to high-volume centers by high-volume surgeons because of the evident decrease in complications and considerable costs associated with all-cause revisions, periprosthetic joint infection, instability, and 90-day mortality.

Level of Evidence: III


Elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) are two of the most commonly done and effective surgical procedures in the United States providing improvements in function and overall quality of life.[1–5] As the demand for total joint arthroplasty (TJA) continues to increase,[4,6–8] recent healthcare reform has targeted arthroplasty for potential cost savings to the healthcare system. Although TJA has been successful in reducing pain severity and restoring joint function, opportunities for improvement remain in further curtailing length of hospital stay and decreasing complications, including postoperative instability, periprosthetic fracture, and infection to further lower the overall episode of care cost and revision rates.[9]

Previous studies have found hospital and surgeon TJA volume as a strong predictor of quality outcomes and lower risk of complications.[10–21] Courtney et al[8] reported hospitals that performed greater than 100 primary TJA per year had lower Medicare costs, fewer all-cause complications, and greater patient-reported outcomes compared with low-volume centers. Using the Medicare Provider Analysis and Review Research Identifiable Files, Calderwood et al[10] found that more than 90% of US lower volume hospitals performing THA had surgical site infection risks that were substantially higher than those in the largest volume centers. Recent systematic reviews and meta-analysis have similarly reported a trend toward better postoperative outcomes with higher volume surgeons and hospitals.[9,21–23]

Therefore, some policy makers have suggested that streamlining TJA procedures at specialty and higher volume regional centers will result in improved patient care at lower cost.[8] Laucis et al[12] used data from the National Inpatient Sample (NIS) from 2002 to 2012 and reported that TJA volume increased by 148% while the US population increased only 11.6%. The authors further reported that there was a national shift of TJA procedures toward higher volume hospitals and that nearly 82% of the US population resided within 50 miles of a high-volume hospital.[12] However, despite the well-established higher surgical volume and improved outcome relationship of hospitals and surgeons, most of the current literature is derived from older Medicare claims and national registry data with smaller sample sizes.[9,21–23] Because providing value-based care continues to evolve as the central goal for healthcare organizations and clinicians,[24] it is important to understand the latest procedural hospital and surgeon volume trends. Therefore, the purpose of this study was to evaluate outcomes and complications because it relates to surgeon and hospital volume for patients undergoing primary THA and TKA using the American Joint Replacement Registry (AJRR) from 2012 to 2017.