Periprosthetic joint infection (PJI) is among the most serious complications following total joint arthroplasty (Hewlett et al., 2025). As arthroplasty volumes increase in the United States (US), the burden of PJI continues to rise, intensifying demand for expertise in diagnosis and management (Shichman et al., 2023). Optimal care requires multidisciplinary collaboration across diagnosis, surgical strategy, and antimicrobial therapy. Guidelines emphasize the important role of infectious disease (ID) physicians, whose involvement has been associated with improved outcomes, including reduced hospital length of stay, lower readmission rates, improved treatment success, reduced use of inappropriate antibiotics, and reduced related healthcare costs (Hewlett et al., 2025; Lucas et al., 2025; Ntalos et al., 2019).

The US faces a significant shortage of ID physicians. Approximately 80 % of counties lack an ID physician, with rural areas disproportionately affected (Walensky and McCann, 2025). Workforce concerns have intensified as fellowship recruitment has declined; in the 2024 match, 51 % of ID fellowship positions went unfilled, largely due to compensation disparities relative to other specialties (Andrews et al., 2024). Orthopaedic infection care is particularly vulnerable because it requires sustained collaboration between orthopaedic surgeons and ID specialists, yet the scope of ID participation varies widely across institutions.

The economic impact of PJI further highlights the need for sustainable care models. PJI care can represent a substantial financial burden for health systems, creating financial pressures that often conflict with an expanded need for multidisciplinary infection care and highlighting the importance of reimbursement structures that adequately support ID physicians' involvement (Samuel et al., 2020).

Similar concerns exist internationally. European bone and joint infection networks, including the European Bone and Joint Infection Society (EBJIS), now jointly endorses a PJI definition developed with the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) study group for implant-associated infections (McNally et al., 2021), reflecting the inherent multidisciplinary nature of PJI. Dedicated bone and joint infection units, typified by the Oxford Bone Infection Unit, emphasize the need for protected time for coordination between specialties (Colston and Atkins, 2018). Analogous models in transplant ID, where US programmes provide salary support for non-billable work, and European musculoskeletal-oncology care are built around longitudinal, reimbursed multidisciplinary care (Gronchi et al., 2021; Strauss et al., 2021).

Despite the central role of ID physicians in orthopaedic infection care, little is known about how this work is financially supported in the US. We therefore conducted a national survey of ID physicians with clinical expertise in orthopaedic infections to characterize compensation models, institutional infrastructure and uncompensated responsibilities.

A total of 52 ID physicians completed the survey. Responses are summarized in Fig. 1.

In this descriptive national survey, most ID physicians specializing in orthopaedic infections reported no protected time or funding for essential non-billable work central to PJI care. This reflects a mismatch between the complexity of PJI management and compensation models that reward billable encounters, consistent with prior reports that work-relative value-unit assignments underestimate infection-care-related efforts in revision arthroplasty (Samuel et al., 2020; Cortés-Penfield et al., 2024).

Respondents described substantial uncompensated responsibilities, including care coordination, curbside consultation, protocol development, and multidisciplinary discussions, activities that influence surgical planning and patient outcomes. Despite evidence that embedded ID involvement improves clinical outcomes and offsets associated costs, institutional support was limited. Similar patterns have been reported internationally: Denes et al. (2014) prospectively recorded approximately 2700 ID curbside consultations per year at a single French teaching hospital, accounting for 20 % of one physician's clinical time and an estimated EUR 77 000 of non-reimbursed work annually (Denes et al., 2014). Using the Association of American Medical Colleges median academic ID salary as a benchmark, each 0.1 full-time equivalent of unfunded orthopaedic ID effort corresponds to roughly USD 26 000 per physician per year in opportunity cost; although illustrative and not measured in this survey, this estimate reflects the magnitude of uncompensated work reported by respondents.

These gaps may be amplified as arthroplasty volume expands while the ID workforce contracts and fellowship positions remain unfilled. Without deliberate investment in the orthopaedic ID workforce, access to experienced orthopaedic ID specialists may become even more restricted.

Transplant ID offers a potential model: over 75 % of US transplant programmes provide salary support for non-billable multidisciplinary work, recognizing its importance to outcomes and programme viability (Schaenman et al., 2017). Although regulatory and reimbursement mechanisms differ, orthopaedic infection care similarly requires sustained interdisciplinary management of high-risk patients.

Another parallel exists in oncology. Multidisciplinary tumour boards are a standard of care across cancer types and, in the US, are required for accreditation by the American College of Surgeons Commission on Cancer with demonstrated improvements in diagnostic accuracy and outcomes (Specchia et al., 2020). Sarcoma care in particular requires longitudinal multidisciplinary coordination for which European ESMO-EURACAN-GENTURIS guidelines recommend referral to established centres with formalized team structures and protected time for coordination (Gronchi et al., 2021; Strauss et al., 2021; Beird et al., 2022). Given the shared features with PJI, including complex diagnostics, staged treatment, and prolonged follow-up, a similar, reference-centre framework could be considered for complex orthopaedic infections.

Economic considerations further underscore the need for reform. While some tertiary centres achieve financial sustainability for complex PJI referrals, PJIs are widely recognized as a substantial economic burden due to repeat procedures and prolonged hospitalizations (Samuel et al., 2020). Current reimbursement systems often fail to account for the longitudinal ID expertise, emphasizing the need to reassess reimbursement mechanisms, including Centers for Medicare and Medicaid Services policies.

Practical institutional steps (Table 1) could include shared full-time-equivalent support between orthopaedic surgery and medicine divisions, formalized compensation for participation in structured multidisciplinary PJI conferences, dedicated orthopaedic ID nursing and pharmacy resources, and targeted education investments in orthopaedic care.

Key challenges include rising clinical burden, inadequate reimbursement, workforce shortages, uncompensated non-billable work, and fragmented institutional support. Proposed solutions emphasize shared funding models, enhanced reimbursement mechanisms, formalized compensation for essential non-billable activities, adoption of established multidisciplinary care frameworks, and investment in dedicated orthopaedic infectious disease resources.

This study has limitations, including a modest sample size, reliance on self-reported data without objective compensation or productivity metrics, and the absence of inferential statistical testing. MSIS and IDSA-BOJO membership is also weighted toward academic ID physicians with a sustained orthopaedic focus, so the findings cannot be generalized to private-practice, community-hospital, or non-US ID physicians, where reimbursement and workforce structures differ substantially; these settings should be prioritized for future international sampling. Nonetheless, these findings provide an early national characterization of compensation gaps and structural variability in orthopaedic ID practice and should be regarded as hypothesis generating pending confirmation in larger, internationally representative samples.

In conclusion, ID physicians provide essential expertise for PJI and other complex orthopaedic infections, yet in this descriptive US survey, the compensation frameworks reported often did not include dedicated support for the non-billable work central to multidisciplinary PJI care. As arthroplasty volumes rise and the ID workforce remains strained, service-line funding models and structured multidisciplinary support, potentially informed by the transplant-ID and European musculoskeletal-oncology reference-centre frameworks, may help align institutional investment with patient outcomes. Confirmatory international studies with larger, more diverse samples are needed before specific reimbursement policy recommendations can be made.