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IS TWO-STAGE SEPTIC REVISION WORTH THE MONEY? A COST-UTILITY ANALYSIS OF A ONE-STAGE VERSUS TWO-STAGE SEPTIC REVISION OF TOTAL KNEE ARTHROPLASTY

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Abstract

Background

Two-stage exchange arthroplasty remains the gold standard for the management of prosthetic joint infection (PJI) of the knee, but several studies have demonstrated that one-stage exchange is as effective as two-stage exchange. This study aimed to support decision making via an economic evaluation of one-stage compared to two-stage exchange for total knee arthroplasty septic revision in patients who did not have compelling indication PJI (i.e., Methicillin-resistant Staphylococcus aureus, multi-organism, systemic sepsis, comorbidities, culture-negative, resistant organism, and immunocompromised) to undergo a two-stage exchange.

Methods

A cost-utility analysis was performed using a Markov cohort model from the healthcare provider perspective using Australia data. One-stage septic knee revisions were compared to two-stage exchange procedures for chronic PJI using a patient-lifetime horizon. Health outcomes were expressed as Quality-adjusted life-years (QALY), while costs were presented in 2020 Australian dollars. Sensitivity analyses, population expected values of perfect information (EVPI), and the perfect information for parameters (EVPPI) were assessed to estimate the opportunity costs surrounding the decision made at a willingness-to-pay threshold of $50,000/QALY.

Results

The incremental cost-effectiveness ratio of two-stage exchange compared to one-stage exchange was $231,000/QALY, with 98.5% of the probabilistic sensitivity simulations above the willingness-to-pay threshold. The population EVPI was $882,000, while the EVPPI for the ‘cost parameters’ was $207,000.

Conclusion

The adoption of one-stage septic knee revision is the optimal choice for patients who have a PJI and who do not have a compelling need for a two-stage exchange arthroplasty. One-stage exchange for PJI should be advocated in patients who meet the eligibility criteria.

Key Words

Introduction

It is important to always maintain a high index of suspicion for prosthetic joint infection (PJI), and their treatment is the most common reason for revision total knee arthroplasty (TKA) [

[1]

International Consensus Group. Second International Consensus Meeting on Musculoskeletal Infection 2018. (accessed June 12, 2021).