Analysis favored one-stage revision THA for infection over two-stage approach

Wolf CF. J Bone Joint Surg (Am). 2011;93:631-639. doi:10.2106/JBJS.I.01256.

Results of a decision analysis supported the use of one-stage revision total hip arthroplasty for infection over a two-stage approach.

“This study should be considered hypothesis-generating for future randomized controlled trials in which, ideally, health end points will be considered in addition to the eradication of infection,” according to authors Christopher F. Wolf, MD, University of Washington, and colleagues.

The researchers used a Markov cohort simulation to construct a decision tree that analyzed which procedure produced greater quality-adjusted life years (QALYs): a one-stage (or direct-exchange) or two-stage revision total hip arthroplasty (THA). The Markov model they used included patient- and surgeon-derived utility values, as well as a 1-year model and a lifetime model with a 10-year life expectancy.

The researchers reviewed the literature on the treatment of infected THAs. They found 11 articles on the two-stage approach and eight on the single-stage protocol. There were 321 patients in the two-stage group and 576 patients in the single-stage group.

The results showed that the direct-exchange protocol was the more favorable approach regardless of whether patient- or surgeon-derived utilities were used (0.945 vs. 0.896 and 0.897 vs. 0.861 QALYs for the patient and surgeon models, respectively), the authors wrote. Similar results were seen in the lifetime model with 10-year life expectancy (7.853 vs. 7.771 and 7.438 vs. 7.362 QALYs).

“The present analysis favors the two-stage approach when one looks at the probability of eradication of the infection at the site of total hip arthroplasty, but the direct-exchange approach is favored when the other possible outcomes, including the time interval required for treatment and possible death, are subjected to a utility analysis, with the assumptions inherent in the analytic tool,” they wrote.