Clinical Orthopaedics and Related Research®

, Volume 471, Issue 1, pp 206–214 | Cite as

Determinants of Direct Medical Costs in Primary and Revision Total Knee Arthroplasty

  • Hilal Maradit Kremers
  • Sue L. Visscher
  • James P. Moriarty
  • Megan S. Reinalda
  • Walter K. Kremers
  • James M. Naessens
  • David G. Lewallen
Symposium: Papers Presented at the Annual Meetings of the Knee Society



TKA procedures are increasing rapidly, with substantial cost implications. Determining cost drivers in TKA is essential for care improvement and informing future payment models.


We determined the components of hospitalization and 90-day costs in primary and revision TKA and the role of demographics, operative indications, comorbidities, and complications as potential determinants of costs.


We studied 6475 primary and 1654 revision TKA procedures performed between January 1, 2000, and September 31, 2008, at a single center. Direct medical costs were measured by using standardized, inflation-adjusted costs for services and procedures billed during the 90-day period. We used linear regression models to determine the cost impact associated with individual patient characteristics.


The largest proportion of costs in both primary and revision TKA, respectively, were for room and board (28% and 23%), operating room (22% and 17%), and prostheses (13% and 24%). Prosthesis costs were almost threefold higher in revision TKA than in primary TKA. Revision TKA procedures for infections and bone and/or prosthesis fractures were approximately 25% more costly than revisions for instability and loosening. Several common comorbidities were associated with higher costs. Patients with vascular and infectious complications had longer hospital stays and at least 80% higher 90-day costs as compared to patients without complications.


High prosthesis costs in revision TKA represent a factor potentially amenable to cost containment efforts. Increased costs associated with demographic factors and comorbidities may put providers at financial risk and may jeopardize healthcare access for those patients in greatest need.

Level of Evidence

Level IV, economic and decision analyses. See Instructions for Authors for a complete description of levels of evidence


Direct Medical Cost Unicompartmental Knee Arthroplasty Periprosthetic Joint Infection Nationwide Inpatient Sample High Hospitalization Cost 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Agency for Healthcare Research and Quality. Procedures with the Most Rapidly Increasing Hospital Costs, 2004–2007. HCUP Statistical Brief #82. Rockville, MD: Agency for Healthcare Research and Quality; 2009.Google Scholar
  2. 2.
    American Academy of Orthopaedic Surgeons. United States Bone and Joint Decade: The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008.Google Scholar
  3. 3.
    Centers for Medicare & Medicaid Services. Berenson-Eggers Type of Service (BETOS) codes. 2011. Available at: Accessed December 5, 2011.
  4. 4.
    Baser O, Supina D, Sengupta N, Wang L, Kwong L. Clinical and cost outcomes of venous thromboembolism in Medicare patients undergoing total hip replacement or total knee replacement surgery. Curr Med Res Opin. 2011;27:423429.PubMedCrossRefGoogle Scholar
  5. 5.
    Berry DJ, Kessler M, Morrey BF. Maintaining a hip registry for 25 years: Mayo Clinic experience. Clin Orthop Relat Res. 1997;344:61–68.PubMedCrossRefGoogle Scholar
  6. 6.
    Berry DJ, von Knoch M, Schleck CD, Harmsen WS. Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg Am. 2005;87:2456–2463.PubMedCrossRefGoogle Scholar
  7. 7.
    Bozic KJ, Morshed S, Silverstein MD, Rubash HE, Kahn JG. Use of cost-effectiveness analysis to evaluate new technologies in orthopaedics: the case of alternative bearing surfaces in total hip arthroplasty. J Bone Joint Surg Am. 2006;88:706–714.PubMedCrossRefGoogle Scholar
  8. 8.
    Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am. 2005;87:1746–1751.PubMedCrossRefGoogle Scholar
  9. 9.
    Davenport DL, Henderson WG, Khuri SF, Mentzer RM Jr. Preoperative risk factors and surgical complexity are more predictive of costs than postoperative complications: a case study using the National Surgical Quality Improvement Program (NSQIP) database. Ann Surg. 2005;242:463–468; discussion 468–471.PubMedGoogle Scholar
  10. 10.
    Dreghorn CR, Roughneen P, Graham J, Hamblen DL. The real cost of joint replacement. Br Med J (Clin Res Ed). 1986;292:1636–1637.CrossRefGoogle Scholar
  11. 11.
    Dummit LA. Medicare’s bundling pilot: including post-acute care services. Issue Brief Natl Health Policy Forum. 2011;841:1–23.PubMedGoogle Scholar
  12. 12.
    Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8–27.PubMedCrossRefGoogle Scholar
  13. 13.
    Finkler SA. The distinction between cost and charges. Ann Intern Med. 1982;96:102–109.PubMedGoogle Scholar
  14. 14.
    Gioe TJ, Sharma A, Tatman P, Mehle S. Do “premium” joint implants add value? Analysis of high cost joint implants in a community registry. Clin Orthop Relat Res. 2011;469:48–54.PubMedCrossRefGoogle Scholar
  15. 15.
    Hawker GA, Badley EM, Croxford R, Coyte PC, Glazier RH, Guan J, Harvey BJ, Williams JI, Wright JG. A population-based nested case-control study of the costs of hip and knee replacement surgery. Med Care. 2009;47:732–741.PubMedCrossRefGoogle Scholar
  16. 16.
    Healy WL, Finn D. The hospital cost and the cost of the implant for total knee arthroplasty: a comparison between 1983 and 1991 for one hospital. J Bone Joint Surg Am. 1994;76:801–806.PubMedGoogle Scholar
  17. 17.
    Hebert CK, Williams RE, Levy RS, Barrack RL. Cost of treating an infected total knee replacement. Clin Orthop Relat Res. 1996;331:140–145.PubMedCrossRefGoogle Scholar
  18. 18.
    Hellmann M, Mehta SD, Bishai DM, Mears SC, Zenilman JM. The estimated magnitude and direct hospital costs of prosthetic joint infections in the United States, 1997 to 2004. J Arthroplasty. 2010;25:766–771.e1.PubMedGoogle Scholar
  19. 19.
    Huddleston JM, Long KH, Naessens JM, Vanness D, Larson D, Trousdale R, Plevak M, Cabanela M, Ilstrup D, Wachter RM. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28–38.PubMedGoogle Scholar
  20. 20.
    Kelly MP, Bozic KJ. Cost drivers in total hip arthroplasty: effects of procedure volume and implant selling price. Am J Orthop. 2009;38:E1–E4.PubMedCrossRefGoogle Scholar
  21. 21.
    Kim S. Changes in surgical loads and economic burden of hip and knee replacements in the US: 1997–2004. Arthritis Rheum. 2008;59:481–488.PubMedCrossRefGoogle Scholar
  22. 22.
    Klouche S, Sariali E, Mamoudy P. Total hip arthroplasty revision due to infection: a cost analysis approach. Orthop Traumatol Surg Res. 2010;96:124–132.PubMedCrossRefGoogle Scholar
  23. 23.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785.PubMedCrossRefGoogle Scholar
  24. 24.
    Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res. 2009;467:2606–2612.PubMedCrossRefGoogle Scholar
  25. 25.
    Lavernia C, Lee DJ, Hernandez VH. The increasing financial burden of knee revision surgery in the United States. Clin Orthop Relat Res. 2006;446:221–226.PubMedCrossRefGoogle Scholar
  26. 26.
    Lavernia CJ, D’Apuzzo MR, Hernandez VH, Lee DJ, Rossi MD. Postdischarge costs in arthroplasty surgery. J Arthroplasty. 2006;21:144–150.PubMedCrossRefGoogle Scholar
  27. 27.
    Leibson CL, Katusic SK, Barbaresi WJ, Ransom J, O’Brien PC. Use and costs of medical care for children and adolescents with and without attention-deficit/hyperactivity disorder. JAMA. 2001;285:60–66.PubMedCrossRefGoogle Scholar
  28. 28.
    Losina E, Thornhill TS, Rome BN, Wright J, Katz JN. The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic. J Bone Joint Surg Am. 2012;94:201–207.PubMedCrossRefGoogle Scholar
  29. 29.
    Losina E, Walensky RP, Kessler CL, Emrani PS, Reichmann WM, Wright EA, Holt HL, Solomon DH, Yelin E, Paltiel AD, Katz JN. Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume. Arch Intern Med. 2009;169:1113–1121; discussion 1121–1112.PubMedCrossRefGoogle Scholar
  30. 30.
    March L, Cross M, Tribe K, Lapsley H, Courtenay B, Brooks P. Cost of joint replacement surgery for osteoarthritis: the patients’ perspective. J Rheumatol. 2002;29:1006–1014.PubMedGoogle Scholar
  31. 31.
    Meyers SJ, Reuben JD, Cox DD, Watson M. Inpatient cost of primary total joint arthroplasty. J Arthroplasty. 1996;11:281–285.PubMedCrossRefGoogle Scholar
  32. 32.
    Oduwole KO, Molony DC, Walls RJ, Bashir SP, Mulhall KJ. Increasing financial burden of revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2010;18:945–948.PubMedCrossRefGoogle Scholar
  33. 33.
    Parvizi J, Pawasarat IM, Azzam KA, Joshi A, Hansen EN, Bozic KJ. Periprosthetic joint infection: the economic impact of methicillin-resistant infections. J Arthroplasty. 2010;25:103–107.PubMedCrossRefGoogle Scholar
  34. 34.
    Reuben JD, Meyers SJ, Cox DD, Elliott M, Watson M, Shim SD. Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty. J Arthroplasty. 1998;13:172–179.PubMedCrossRefGoogle Scholar
  35. 35.
    Shwartz M, Iezzoni LI, Moskowitz MA, Ash AS, Sawitz E. The importance of comorbidities in explaining differences in patient costs. Med Care. 1996;34:767–782.PubMedCrossRefGoogle Scholar
  36. 36.
    Slover J, Espehaug B, Havelin LI, Engesaeter LB, Furnes O, Tomek I, Tosteson A. Cost-effectiveness of unicompartmental and total knee arthroplasty in elderly low-demand patients: a Markov decision analysis. J Bone Joint Surg Am. 2006;88:2348–2355.PubMedCrossRefGoogle Scholar
  37. 37.
    Sood N, Huckfeldt PJ, Escarce JJ, Grabowski DC, Newhouse JP. Medicare’s bundled payment pilot for acute and postacute care: analysis and recommendations on where to begin. Health Aff (Millwood). 2011;30:1708–1717.CrossRefGoogle Scholar
  38. 38.
    Stargardt T. Health service costs in Europe: cost and reimbursement of primary hip replacement in nine countries. Health Econ. 2008;17:S9–S20.PubMedCrossRefGoogle Scholar
  39. 39.
    Vekeman F, LaMori JC, Laliberte F, Nutescu E, Duh MS, Bookhart BK, Schein J, Dea K, Olson WH, Lefebvre P. Risks and cost burden of venous thromboembolism and bleeding for patients undergoing total hip or knee replacement in a managed-care population. J Med Econ. 2011;14:324–334.PubMedCrossRefGoogle Scholar
  40. 40.
    Wei MH, Lin YL, Shi HY, Chiu HC. Effects of provider patient volume and comorbidity on clinical and economic outcomes for total knee arthroplasty: a population-based study. J Arthroplasty. 2010;25:906–912.e1.PubMedGoogle Scholar
  41. 41.
    Wilson NA, Schneller ES, Montgomery K, Bozic KJ. Hip and knee implants: current trends and policy considerations. Health Aff (Millwood). 2008;27:1587–1598.CrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Hilal Maradit Kremers
    • 1
    • 2
  • Sue L. Visscher
    • 1
  • James P. Moriarty
    • 1
  • Megan S. Reinalda
    • 1
  • Walter K. Kremers
    • 1
  • James M. Naessens
    • 1
  • David G. Lewallen
    • 2
  1. 1.Department of Health Sciences ResearchCollege of Medicine, Mayo ClinicRochesterUSA
  2. 2.Department of Orthopedic SurgeryCollege of Medicine, Mayo ClinicRochesterUSA

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