Infection is one of the worst complications to arise from a joint replacement. Despite our best efforts, no operation is truly sterile. Some bacteria enter the wound during every surgery. Usually, the human immune system can eradicate these and prevent infection. If an artificial implant is present, it is harder for the immune system to do its job. Then, after the surgery, it is a race for the skin to totally seal and prevent bacteria on the skin from entering and creating an infection. Infection that develops by one of these two methods is called a perioperative infection, because there is no way of knowing exactly how the bugs got in. Hospitals and surgery centers are required to report to the government any joint replacement infections that develop by three months post op. This captures many perioperative infections, but really a year is needed to be sure.

Rarely, infection can still spread to the joint at any time in your life from an infection elsewhere in the body through the bloodstream. Infections that occur after 1 year are late infections; they are NOT perioperative. They are not caused by the operation itself and are not under the control of the surgeon. Fortunately, they are rare.

We focus on the 3-month and 1-year perioperative infection rate because the surgeon has control of this. The 3-month perioperative infection rate at our center is well below 1%. You can find online data for any hospital but not by surgeon. From scientific studies we estimate that the national benchmark 1-year infection rate is approximately 2.5% and growing. Hospitals and surgery centers don’t collect 1-year data. Our personal rate for the last 10 years has been 0.1%. One factor that allows me to have a 1-year infection rate 25 times lower than the national benchmark is the fact that this surgery is performed mostly at a surgery center and not a hospital where sick patients bring in lots of bacteria.

Infection in joint replacement is a major problem. The infection rate varies widely among surgeons, hospitals and types of major surgeries. The national deep infection rate for joint replacement is 1-2%. Numerous factors affect this rate. Revision surgeries carry a higher rate of infection. Transfusion increases the infection rate. Patient factors such as obesity, diabetes, smoking, and various immunosuppressive conditions or medications increase the rate of infection. Long hospital stays and rehab facility stays increase the risk.

There are too many things that affect the rate of infection for us to go into detail here. You can look at databases to get an idea of how often infections happen at different hospitals, but you can’t find out how often infections happen with a specific surgeon. Generally, smaller hospitals with fewer severely ill patients and outpatient surgery centers have fewer resistant bacteria floating around.

If common minor wound problems are not managed correctly, a deep infection can result. When a deep infection occurs, implant removal is frequently required to cure it.

An individual surgeon’s infection rate is much more important to know than the rate in a given hospital. But most surgeons don’t even keep such data, much less publish it. Over many years, we have developed a detailed protocol to prevent infection. Because of this, our infection rate for primary hip resurfacing, which has been published in peer-reviewed journals, is 0.2%. Furthermore, we have managed to cure these infections without a single loss of implant over the last 7 years.

The cost of doing joint replacement at a surgeon-owned outpatient center is lower in our center and across the country. Hospitals all across the country have spent the last two decades consolidating into huge hospital groups that own most doctors’ practices. This process has been accelerated by the Obamacare rules.

Hospitals have mostly been able to create near-monopoly positions in most markets, which they have used to raise prices by a lot. At the same time, government rules (the “certificate of need,” or “CON”) make it nearly impossible for anyone to build a new independent hospital to challenge the hospital monopoly. But the advancements that have allowed us to transition major operations to an outpatient center have allowed independent (not hospital-owned) surgeon groups like ours to challenge this hospital stranglehold.

As this trend accelerates, we hope that more surgeons are lured out of hospital employment and start their own outpatient programs. Also, because of CON rules, it is difficult but not impossible to build new outpatient centers. But, as surgeon-owned outpatient centers proliferate, the cost of surgery will go down while the quality rises, as we have shown in our center.

Insurance contracting is complex and byzantine, but we’ll give an example using approximate numbers. The total cost for joint replacement at our center is $28,000 with one major insurer. This insurer posts on their website that the costs at the three major hospitals in the Columbia metro area are $35,000, $45,000, and $60,000, respectively. There are other hospitals in the country where the cost can be as high as $100,000. Hopefully, the federal government will enforce the recent executive order for price transparency, which will allow all patients to make cost comparisons in advance.