Is primary total elbow arthroplasty appropriately compensated compared to other major total joint arthroplasty?

Background: Primary total elbow arthroplasty (TEA) is an uncommon operation and performed less frequently than total shoulder (TSA), knee (TKA), and hip (THA) arthroplasty. Despite lower implant survival rates and higher complications rates compared to TSA, TKA, and THA, the Centers for Medicare and Medicaid (CMS) have assigned similar work relative value unit (wRVU) allotments and estimated operative times across all 4 forms of major joint arthroplasty. In this study, we determine temporal trends in CMS wRVU allotments, and operative time estimates for these 4 surgeries and compare actual operative times and postoperative complication rates. Methods: CMS wRVU allotments and estimated operative times were collected from all publicly available CMS publications for primary TEA, TSA, TKA, and TSA. We used the National Quality Improvement Program database from 2010 to 2017 to determine actual operative times for these surgeries. Multiple linear regression analysis was used to compare wRVU/h amongst the 4 surgeries, controlling for patient demographics, comorbidity, and hospital setting. Thirty-day complication rates were also compared. Results: From 2012 to 2017, Medicare observed a 13% decline in total TEA procedures performed in comparison to a 70% increase for TSA and 29% increase in THA. The number of unique providers performing TEA declined (−6%) in comparison to a growth in surgeons performing TSA, TKA, and THA. TEA was associated with the longest operative time (152 ± 57 minutes, P < .0001) and lowest wRVU/h (10.2, P < .0001). TKA and THA had the shortest operative time (90 ± 29 and 90 ± 32, respectively) with the greatest wRVU/h (15.78 and 15.71). TEA remained the lowest wRVU/h procedure even after controlling for patient age, sex, body mass index, hospital setting, and comorbidity (P < .0001). Thirty-day complication rates for all surgeries were low, but TEA had higher rates of wound dehiscence, deep infection, pneumonia, reintubation, pulmonary embolism, and myocardial infarction (all P < .01). Conclusion: Despite similar wRVU assignments and operative time estimates for primary TEA, TSA, TKA, and THA; TEA is on average a longer surgery and carries a greater 30-day postoperative risk profile. Although CMS has assessed primary TEA to have similar work and time requirements compared to its counterparts, this procedure may be under-valued in comparison to other forms of major joint arthroplasty. Level of Evidence: Level III; Economics.