Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, U.S.A.
Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, U.S.A..
Arthroscopy. 2018 Mar;34(3):967-975. doi: 10.1016/j.arthro.2017.08.246. Epub 2017 Nov 6.
To provide further guidance on the optimal decision between anterior cruciate ligament (ACL) graft removal versus retention in the setting of septic arthritis following reconstruction using an expected value decision analysis.
A systematic review and expected value decision analysis and sensitivity analyses were performed to quantify the clinical decision. A decision tree was created with 5 outcomes of interest: nonoperative complications, revision surgery, early reoperation, late reoperation, and "well." Pooled probabilities of each outcome were generated through a systematic literature review. We included only peer-reviewed studies, published in English, with at least 6 months of follow-up. One hundred randomly selected volunteers were given descriptions of the clinical scenario, the 2 treatment options, and outcomes of interest. Patients younger than 18 and older than 50 years and those previously treated for either ACL injury or septic arthritis, or both, were excluded from the analysis to minimize bias. These hypothetical patients indicated preferences for each outcome on a visual analog scale and responses were averaged to generate overall "utility values." Fold-back analysis summed products of pooled outcomes probabilities with respective averaged utility values. The resulting overall expected values for graft removal and debridement were compared, with the highest expected value considered to be superior. We then performed 1-way sensitivity analyses to mitigate sample bias.
Fold-back analysis revealed graft removal to be strongly favored over retention, with overall expected values of 17.2 and 8.64, respectively. The most important contributor to the difference in overall expected values was late reoperation (8.59 vs 2.50 for removal and retention, respectively). Despite adjustments made to the rates of revision and early reoperation during the 1-way sensitivity analyses, graft removal remained the optimal strategy.
This expected value decision analysis revealed that ACL graft removal was strongly favored by patients over graft retention in the setting of postoperative septic arthritis when consideration was given to the probabilities of wellness, nonoperative complications, revision surgery, early reoperation, and late reoperation. Sensitivity analysis revealed that although variation in rates of other outcomes did not impact this preference, the rate of late reoperation had a substantial impact. Only a sizable increase in the probability of late reoperation (from 0% to 60%) after graft removal would cause potential patients to favor graft retention.
Level IV, systematic review and decision analysis.
通过期望值决策分析，在重建后发生感染性关节炎的情况下，进一步为前交叉韧带（ACL）移植物去除与保留提供最佳决策指导。
进行了系统评价和期望值决策分析以及敏感性分析，以量化临床决策。创建了一个具有 5 个感兴趣结果的决策树：非手术并发症、翻修手术、早期再手术、晚期再手术和“良好”。通过系统文献回顾生成每个结果的汇总概率。我们仅纳入了经过同行评审、发表在英语期刊上、随访时间至少 6 个月的研究。随机抽取 100 名志愿者，对临床情况、2 种治疗方案和感兴趣的结果进行描述。排除年龄小于 18 岁和大于 50 岁、ACL 损伤或感染性关节炎、或两者均接受过治疗的患者，以尽量减少偏倚。这些假设患者使用视觉模拟量表对每个结果表示偏好，然后对响应进行平均，以生成总体“效用值”。回溯分析将汇总的结果概率与各自的平均效用值相乘。比较移植物去除和清创术的总体期望值，认为最高的期望值是优越的。然后，我们进行了 1 种敏感性分析，以减轻样本偏差。
回溯分析显示，与保留相比，移植物去除具有明显优势，总体期望值分别为 17.2 和 8.64。对总体期望值差异影响最大的是晚期再手术（去除和保留分别为 8.59 和 2.50）。尽管在 1 种敏感性分析中对翻修和早期再手术的比率进行了调整，但移植物去除仍然是最佳策略。
本期望值决策分析表明，在术后感染性关节炎的情况下，与保留移植物相比，患者强烈倾向于移除 ACL 移植物，同时考虑到健康、非手术并发症、翻修手术、早期再手术和晚期再手术的可能性。敏感性分析表明，尽管其他结果的比率变化不会影响这种偏好，但晚期再手术的比率有很大的影响。只有在移除移植物后晚期再手术的概率（从 0%增加到 60%）大幅增加，潜在患者才会倾向于保留移植物。
IV 级，系统评价和决策分析。
