Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, Michigan.
Department of Orthopaedic Surgery, University of Texas at Austin Dell Medical School, Austin, Texas.
J Bone Joint Surg Am. 2019 Jan 2;101(1):14-24. doi: 10.2106/JBJS.17.00874.
Periprosthetic joint infection (PJI) following total knee arthroplasty is a growing concern, as the demand for total knee arthroplasty (TKA) expands annually. Although 2-stage revision is considered the gold standard in management, there is substantial morbidity and mortality associated with this strategy. One-stage revision is associated with lower mortality rates and better quality of life, and there has been increased interest in utilizing the 1-stage strategy. However, surgeons are faced with a difficult decision regarding which strategy to use to treat these infections, considering uncertainty with respect to eradication of infection, quality of life, and societal costs with each strategy. The purpose of the current study was to use decision analysis to determine the optimal decision for the management of PJI following TKA.
An expected-value decision tree was constructed to estimate the quality-adjusted life-years (QALYs) and costs associated with 1-stage and 2-stage revision. Two decision trees were created: Decision Tree 1 was constructed for all pathogens, and Decision Tree 2 was constructed solely for difficult-to-treat infections, including methicillin-resistant infections. Values for parameters in the decision model, such as mortality rate, reinfection rate, and need for additional surgeries, were derived from the literature. Medical costs were derived from Medicare data. Sensitivity analysis determined which parameters in the decision model had the most influence on the optimal strategy.
In both decision trees, the 1-stage strategy produced greater health utility while also being more cost-effective. In the Monte Carlo simulation for Decision Trees 1 and 2, 1-stage was the dominant strategy in about 85% and 69% of the trials, respectively. Sensitivity analysis showed that the reinfection and 1-year mortality rates were the most sensitive parameters influencing the optimal decision.
Despite 2-stage revision being considered the current gold standard for infection eradication in patients with PJI following TKA, the optimal decision that produced the highest quality of life was 1-stage revision. These results should be considered in shared decision-making with patients who experience PJI following TKA.
Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.
全膝关节置换术后发生假体周围关节感染（PJI）是一个日益严重的问题，因为全膝关节置换术（TKA）的需求每年都在增加。虽然 2 期翻修被认为是管理的金标准，但这种策略与大量的发病率和死亡率相关。一期翻修与较低的死亡率和更好的生活质量相关，并且人们对使用一期策略的兴趣有所增加。然而，对于这些感染的治疗，外科医生面临着一个艰难的决策，考虑到每种策略在感染根除、生活质量和社会成本方面的不确定性。本研究的目的是使用决策分析来确定 TKA 后 PJI 管理的最佳决策。
构建了一个期望价值决策树来估计 1 期和 2 期翻修相关的质量调整生命年（QALYs）和成本。构建了两个决策树：决策树 1 是为所有病原体构建的，决策树 2 是仅为难以治疗的感染（包括耐甲氧西林感染）构建的。决策模型中参数的值，如死亡率、再感染率和需要进行额外手术，均来自文献。医疗费用来自医疗保险数据。敏感性分析确定了决策模型中哪些参数对最佳策略影响最大。
在两个决策树中，1 期策略在产生更大的健康效益的同时也更具成本效益。在决策树 1 和 2 的蒙特卡罗模拟中，1 期策略在大约 85%和 69%的试验中分别是占主导地位的策略。敏感性分析表明，再感染率和 1 年死亡率是影响最佳决策的最敏感参数。
尽管 2 期翻修被认为是 TKA 后 PJI 患者感染根除的当前金标准，但产生最高生活质量的最佳决策是 1 期翻修。在与经历 TKA 后 PJI 的患者进行共同决策时，应考虑这些结果。
经济和决策分析 IV 级。请参阅作者说明，以获取完整的证据水平描述。
