Background: Lower-extremity arthroplasty constitutes the largest burden on health-care spending of any Medicare diagnosis group. Demand for upper extremity arthroplasty also continues to rise. It is necessary to better understand costs as health care shifts toward a bundled-payment accounting approach. We aimed (1) to identify whether variation exists in total cost for different types of joint arthroplasty, and, if so, (2) to determine which cost parameters drive this variation. Methods: The cost of the episode of inpatient care for 22,215 total joint arthroplasties was calculated by implementing time-driven activity-based costing (TDABC) at a single orthopaedic specialty hospital from 2015 to 2018. Implant price, supply costs, personnel costs, and length of stay for total knee, total hip, anatomic total shoulder, reverse total shoulder, total elbow, and total ankle arthroplasty were analyzed. Individual cost parameters were compared with total cost and volume. Results: Higher implant cost appeared to correlate with higher total costs and represented 53.8% of the total cost for an inpatient care cycle. Total knee arthroplasty was the least-expensive and highest-volume procedure, whereas total elbow arthroplasty had the lowest volume and highest cost (1.65 times more than that of total knee arthroplasty). Length of stay was correlated with increased personnel cost but did not have a significant effect on total cost. Conclusions: Total inpatient cost at our orthopaedic specialty hospital varied by up to a factor of 1.65 between different fields of arthroplasty. The highest-volume procedures—total knee and hip arthroplasty—were the least expensive, driven predominantly by lower implant purchase prices. Clinical Relevance: We are not aware of any previous studies that have accurately compared cost structures across upper and lower-extremity arthroplasty with a uniform methodology. The present study, because of its uniform accounting process, provides reliable data that will allow clinicians to better understand cost relationships between different procedures.

Fungal periprosthetic joint infection (PJI) is a devastating complication because it can be difficult to diagnose, manage, and eradicate. Fungal PJI treatment requires a systematic approach. Increased awareness is essential when patients with painful arthroplasties present with immunosuppression, significant comorbidities, multiple surgeries, and history of drug use. Every suspected fungal PJI should be promptly diagnosed using readily available serum and synovial fluid markers. Surgical management involves débridement, antibiotics, and implant retention, onestage exchange arthroplasty, prosthetic articulating spacers, and two-stage exchange arthroplasty. Because mycotic infections develop robust biofilms, the utility of débridement, antibiotics, and implant retention and one-stage revisions seem limited. A thorough irrigation and débridement is essential to decrease infection burden. Adjunctive local and systemic antifungal therapy is critical, although the agent choice and duration should be tailored appropriately. Future high-quality studies are needed to develop standardized guidelines for the management of fungal PJI.M ore than 1 million total joint arthroplasties (TJAs) are performed in the United States annually, 1 with notable increases projected over the next few decades. 2 With the increasing number of TJAs, periprosthetic joint infections (PJIs) are projected to increase over time. Although notable improvements have reduced the rate of PJI, 3 infection still remains a common cause of revision TJA. 4 Although gram-positive organisms are responsible for most PJIs, 5 fungal infections are increasing in prevalence. 6 Fungal PJI represents 1% of all joint infections, and its diagnosis may be more difficult compared with bacterial pathogens because of diverse clinical presentations. Sur-gical and medical management of fungal PJI are more challenging than gram-positive or negative infections because patients are often immunocompromised with a higher risk of persistent infection. Although increased attention has been dedicated to the diagnosis and management of bacterial septic joints, no standardized guidelines exist for the diagnosis and management of fungal PJI because of its rarity. It is unknown if the protocol for treating bacterial PJI can also be extrapolated to fungi, as there is inconsistent data with regards to the use of systemic, local and oral antifungal agents. This review carefully outlines the diagnosis and management options for fungal PJI.