appendix - lippincott williams & wilkins · decision tree 1. this is the decision tree for...

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SRIVASTAVA ET AL.

RECONSIDERING STRATEGIES FOR MANAGING CHRONIC PERIPROSTHETIC JOINT INFECTION IN TOTAL KNEE ARTHROPLASTY. USING

DECISION ANALYTICS TO FIND THE OPTIMAL STRATEGY BETWEEN ONE-STAGE AND TWO-STAGE TOTAL KNEE REVISION

http://dx.doi.org/10.2106/JBJS.17.00874

Appendix

Fig. E-1 Decision Tree 1. This is the decision tree for chronic periprosthetic infection in TKA. The top branch maps out the events for a 2-stage revision strategy. The probabilities for the events of the 2-stage revision strategy are based on compiled data from 66 published studies and of >5,000 patients.


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Fig. E-2 Continuation of Decision Tree 1. The bottom branch maps out the events for a 1-stage revision strategy. The probabilities of the events for the 1-stage revision strategy are based on compiled data from 7 studies and of 283 patients.


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Fig. E-3 Decision Tree 2. This is the decision tree for difficult-to-treat periprosthetic joint infection pathogens in TKA. The top branch maps out the events for a 2-stage revision strategy.


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Fig. E-4 Continuation of Decision Tree 2, for difficult-to-treat periprosthetic joint infection pathogens in TKA. In this decision tree, the reinfection rate in 1-stage revision is increased to 30%.


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Fig. E-5 Markov model showing different possible health states for the terminal branches of the decision trees for periprosthetic joint infection in TKA. This Markov model was used to calculate the 15-year quality-adjusted life-years (QALYs). This 15-year discounted QALY value was placed in the decision model.


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Fig. E-6 Cost-effectiveness plane for Decision Tree 1. The x axis indicates the incremental quality-adjusted life-years (QALYs) with 1-stage revision, while the y axis indicates the incremental cost of the 1-stage strategy. The solid blue and green lines are the willingness-to-pay thresholds of $50,000 per QALY and $100,000 per QALY, respectively. Data points to the right of these lines indicate that the particular trial is cost-effective according to the respective willingness-to-pay threshold. The greatest density of individual trials from the Monte Carlo Simulation is in the southeast quadrant, indicating dominance; the 1-stage strategy not only cost less but also produced greater health utility than the 2-stage strategy.


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Fig. E-7 Cost-effectiveness plane for Decision Tree 2. The x axis indicates the incremental quality-adjusted life-years (QALYs) with 1-stage revision, while the y axis indicates the incremental cost of the 1-stage strategy. The solid blue and green lines are the willingness-to-pay thresholds of $50,000 per QALY and $100,000 per QALY, respectively. Data points to the right of these lines indicate that the particular trial is cost-effective according to the respective willingness-to-pay threshold. Although the number of individual trials from the Monte Carlo Simulation is not as great in the southeast quadrant as with Decision Tree 1, the majority of trials are still in the southeast quadrant. This indicates that the 1-stage strategy not only cost less but also produced greater health utility than the 2-stage strategy despite the increased recurrence of infection in Decision Tree 2.


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Fig. E-8 Tornado charts displaying the most sensitive parameters influencing the optimal strategy for Decision Tree 1 and Decision Tree 2. Each parameter was varied 15%. The bar graph shows how the quality-adjusted life-years (QALYs) change with these varying parameters. The blue and red indicate whether the parameter is increasing or decreasing, respectively. For example, if the reinfection rate with the 2-stage strategy decreases (red), the QALYs gained with the 1-stage strategy compared with 2-stage strategy also decrease.


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TABLE E-1 Glossary of Common Terminology in Decision Analytics Terminology Explanation

Decision analytics

This is a popular discipline used in the financial, engineering, and project management fields to formally analyze important decisions. Decision analysis is especially useful in analyzing decisions with unknown variables and uncertainty in events. Predictive and prescriptive analytics have emerged from this discipline using forecasting, optimization, and simulation techniques. Utilization of decision analytics in medicine is a growing field, with techniques being utilized in cost-effectiveness studies

Discount rate This is a financial term used to capture the present value of future cash flows. The financial definition refers to the interest rate expected for a loan from a financial institution. The discount rate considers the time value of money such that 1 dollar now is more valuable than 1 dollar in the future. In cost-effective studies, the discount rate is not only used for monetary costs but also in determining health utility. The discount rate used in determining a health utility relies on the principle that a perfect health year now is more valuable than a perfect health year in the future

Markov model Also known as the Markov method. This is a stochastic method used to model transition states. The principle of Markov modeling depends only on the current state and not the prior states. The probability of transitioning from one state to another state can vary according to a predetermined distribution. Markov modeling is often used in studies analyzing cost-effectiveness to capture the value of different health states over time

Monte Carlo simulation

Also known as the Monte Carlo method or Monte Carlo experiment. This is a computational algorithm that relies on repeated random sampling to obtain numerical results. This decision-analytic tool is especially powerful when there are uncertain variables that can be modeled according to a distribution. This tool is often used in managing risk, as this method calculates not only the average value of each decision but also in what percentage of iterations a certain strategy is more valuable than another strategy

Rollback analysis

Also known as foldback analysis. This is an iterative algorithm used to determine the value of each node. The terminal node is calculated first while working backward to the initial decision node. The value of each decision is calculated by using the weighted average of the probability of events and the value of each decision tree branch. This analysis is commonly used in decision analytics and game theory

Cost-effectiveness plane

This is an important tool used to illustrate the difference in costs and effects between different strategies. With this visual representation, the viewer is able to clearly understand the spread of costs and health effects. The plane consists of a 4-quadrant diagram in which the x axis represents the incremental level of effectiveness of a treatment or strategy while the y axis represents the additional costs of this strategy. In the northeast quadrant, the strategy produces additional health benefits but costs more than the comparative strategy. In the northwest quadrant, the strategy not only costs more but produces fewer health benefits than the comparative strategy. In the southeast quadrant, the strategy produces additional health benefits while being less costly. In the southwest quadrant, the strategy costs less but produces fewer health benefits. This analysis is widely used in the health-care industry

Strategy tables Used for 2-way sensitivity analysis, this technique shows how the optimal strategy changes in response to 2 simultaneously changing parameters. This is a particularly useful tool in decision analytics when there is uncertainty in the probability of events, value of an outcome, or cost of a decision

Tornado charts Also known as tornado plots or tornado diagrams, tornado charts are useful in a sensitivity analysis, showing the importance of each variable in the decision model. The sensitive variable is modeled as an uncertain value, while other variables are held at baseline value. This shows how important this variable is in the decision model


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TABLE E-2 Parameter Derivation for Retained Spacer in 2-Stage Revision*

No. of Patients for

Analysis No. with Retained

Spacer Retained-

Spacer Rate

Study Choi et al.17 (2011) 32 1 Gomez et al.20 (2015) 326 38 Kotwal et al.21 (2012) 58 21 Westrich et al.22 (2010) 92 9 Haddad et al.23 (2000) 57 5 Berend et al.24 (2015) 182 4 Janssen et al.32 (2016) 25 2 Shaikh et al.41 (2014) 15 2 Silvestre et al.47 (2013) 49 0 Chiang et al.57 (2011) 45 1 Cabo et al.58 (2011) 25 1 Van Thiel et al.60 (2011) 60 1 Su et al.68 (2009) 15 2 Jämsen et al.73 (2006) 34 3 Husted and Toftgaard Jensen77 (2002)

25 1

Pitto et al.84 (2005) 21 1 Total no. 1,061 92 Gross cumulative retained-spacer rate

8.7%

Adjusted cumulative retained-spacer rate (incorporates mortality rate)

8.5%

*The published studies listed above were used to calculate the retained spacer rate for 2-stage revision. First, we pooled the total

number of patients for the analysis and then we totaled the number of patients with a retained spacer. This gave us an 8.7%

retained-spacer rate. Considering that the yearly mortality rate is 1.8%, the adjusted cumulative retained-spacer rate used in the

decision model is 8.5%.


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TABLE E-3 Parameter Derivation for Arthrodesis After Placement of Antibiotic Spacer in 2-Stage Revision*

No. of Patients for Analysis No. Who Underwent

Arthrodesis Arthrodesis

Rate

Study Choi et al.17 (2011) 32 0 Gomez et al.20 (2015) 326 4 Kotwal et al.21 (2012) 58 0 Westrich et al.22 (2010) 92 6 Haddad et al.23 (2000) 57 2 Berend et al.24 (2015) 182 1 Janssen et al.32 (2016) 25 5 Shaikh et al.41 (2014) 15 0 Chiang et al.57 (2011) 45 1 Cabo et al.58 (2011) 25 5 Van Thiel et al.60 (2011) 60 0 Qiu et al.64 (2010) 10 1 Kösters et al.66 (2009) 7 1 Jämsen et al.73 (2006) 34 0 Hart and Jones74 (2006) 48 2 Husted and Toftgaard Jensen77 (2002)

25 2

Total no. 1,041 30 Gross cumulative arthrodesis rate

2.9%

Adjusted cumulative arthrodesis rate (incorporates mortality rate)

2.8%

*The published studies listed above were used to calculate the arthrodesis rate for 2-stage revision. First, we pooled the total

number of patients for the analysis and then we totaled the number of patients who underwent arthrodesis. This gave us a 2.9%

arthrodesis rate. Considering that the yearly mortality rate with explantation and placement of an antibiotic spacer is 1.8% and the

perioperative mortality rate for this additional surgery is 0.9%, the adjusted arthrodesis rate used in the decision model is 2.8%.


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TABLE E-4 Parameter Derivation for Amputation After Placement of Antibiotic Spacer in 2-Stage Revision*

No. of Patients for

Analysis No. Who Underwent

Amputation Amputation

Rate

Study Choi et al.17 (2011) 32 0 Gomez et al.20 (2015) 326 6 Kotwal et al.21 (2012) 58 0 Westrich et al.22 (2010) 92 1 Haddad et al.23 (2000) 57 2 Berend et al.24 (2015) 182 0 Janssen et al.32 (2016) 25 1 Shaikh et al.41 (2014) 15 0 Chiang et al.57 (2011) 45 0 Cabo et al.58 (2011) 25 0 Van Thiel et al.60 (2011) 60 0 Qiu et al.64 (2010) 10 0 Hart and Jones74 (2006) 48 0 Husted and Toftgaard Jensen77 (2002)

25 2

Total no. 1,000 12 Gross cumulative amputation percentage

1.2%

Adjusted cumulative amputation percentage (incorporates mortality rate)

1.1%

*The published studies listed above were used to calculate the amputation rate for 2-stage revision. First, we pooled the total

number of patients for the analysis and then we totaled the number of patients who underwent amputation. This gave us a 1.2%

amputation rate. Considering that the yearly mortality rate with explantation and placement of an antibiotic spacer is 1.8% and

the perioperative mortality for this additional surgery is 0.9%, the adjusted amputation rate used in the decision model is 1.1%.


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TABLE E-5 Parameter Derivation for Death at 4 Months After Placement of Antibiotic Spacer in 2-Stage Revision* Key Data Input Key Parameter

Study Cram et al.108 (2012) 30-day mortality following

revision surgery 0.9%

Social Security Admin. actuarial table109 (2018)

4-mo mortality rate for 65-year-old

0.35%

Overall 4-mo mortality rate 1.25% *The published study listed above and the expected life expectancy tabulated from the Social Security Administration actuarial

table were used to calculate the overall 4-month mortality rate after explantation and placement of an antibiotic spacer.


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TABLE E-6 Parameter Derivation for Reimplantation After Placement of Antibiotic Spacer in 2-Stage Revision*

No. of Patients Who Underwent 1st Stage

No. of Patients Who Underwent 2nd Stage

(Reimplantation) Reimplantation

Rate

Study Choi et al.17 (2011) 32 31 Gomez et al.20 (2015) 326 280 Kotwal et al.21 (2012) 58 37 Westrich et al.22 (2010) 92 76 Haddad et al.23 (2000) 57 45 Berend et al.24 (2015) 182 177 Janssen et al.32 (2016) 25 18 Shaikh et al.41 (2014) 15 13 Sabry et al.45 (2014) 314 291 Silvestre et al.47 (2013) 43 43 Kalore et al.52 (2012) 69 53 Mortazavi et al.55 (2011) 156 117 Macheras et al.56 (2011) 34 34 Chiang et al.57 (2011) 45 43 Cabo et al.58 (2011) 25 18 Van Thiel et al.60 (2011) 60 58 Gooding et al.61 (2011) 119 110 Qiu et al.64 (2010) 10 9 Kösters et al.66 (2009) 7 6 Su et al.68 (2009) 15 13 Villanueva-Martinez et al.69 (2008)

30 29

Jämsen et al.73 (2006) 34 30 Hart and Jones74 (2006) 48 46 Husted and Toftgaard Jensen77 (2002)

25 17

Pitto et al.84 (2005) 21 20 Total no. 1,842 1,614 Gross cumulative reimplantation rate

87.6%

Adjusted cumulative reimplantation rate (incorporates mortality rate)

86.3%

*The published studies listed above were used to calculate the reimplantation rate for 2-stage revision. First, we pooled the total

number of patients for the analysis and then we totaled the number of patients who underwent reimplantation. This gave us an

87.6% reimplantation rate. Considering that the yearly mortality rate for 2-stage revision is 1.8%, the adjusted reimplantation rate

used in the decision model is 86.3%.


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TABLE E-7 Parameter Derivation for Success After 2-Stage Revision*

Rate

Reinfection 15.4% Aseptic revision 5.8% Death at 8 mo 1.8% Success 77.1% *The success rate of 2-stage revision was calculated using the following equation: success = 1 − (reinfection + aseptic revision +

death at 8 mo). The reinfection rate, aseptic revision rate, and rate of death at 8 months were calculated from previously

published studies, which are listed in Tables E-10, E-8, and E-9, respectively. These values were used in the decision model.


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TABLE E-8 Parameter Derivation for 5-Year Aseptic Revision After Reimplantation in 2-Stage Revision*

No. of Patients Who

Underwent Reimplantation No. with Aseptic

Revision Aseptic

Revision Rate

Study Haddad et al.8 (2015) 74 0 Kotwal et al.21 (2012) 37 0 Westrich et al.22 (2010) 76 2 Waddell et al.33 (2016) 47 3 Watts et al.40 (2014) 111 11 Macheras et al.56 (2011) 34 1 Gooding et al.61 (2011) 110 13 Qiu et al.64 (2010) 9 0 Jämsen et al.73 (2006) 30 0 Haleem et al.75 (2004) 96 6 Meek et al.76 (2003) 47 2 Mahmud et al.79 (2012) 253 17 Ocguder et al.83 (2010) 17 1 Hofmann et al.86 (2005) 50 1

Total no. 991 57 % aseptic revision after reimplantation

5.8%

*The published studies listed above were used to calculate the aseptic revision rate following 2-stage revision. First, we pooled

the total number of patients for the analysis and then we totaled the number of patients who underwent aseptic revision. This gave

us a 5.8% aseptic revision rate.


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TABLE E-9 Parameter Derivation for Death at 8 Months After 2nd Stage of 2-Stage Revision* Key Data Input Key Parameter




8-mo mortality rate for 65-year-old

0.9%

Overall 8-mo mortality rate 1.8% *The published study listed above and the expected life expectancy tabulated from the Social Security Administration actuarial

table were used to calculate the overall 8-month mortality rate after completion of 2-stage revision.


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TABLE E-10 Parameter Derivation for Reinfection After Reimplantation in 2-Stage Revision*

No. of Patients Who

Underwent Reimplantation

No. with Reinfection

After Reimplantation

Reinfection Rate

Study Haddad et al.8 (2015) 74 5 Lizaur-Utrilla et al.15 (2015) 25 3 Choi et al.17 (2011) 31 13 Gomez et al.20 (2015) 280 40 Kotwal et al.21 (2012) 37 6 Westrich et al.22 (2010) 76 20 Haddad et al.23 (2000) 45 4 Berend et al.24 (2015) 177 28 Tan et al.31 (2016) 185 50 Waddell et al.33 (2016) 47 8 Marczak et al.34 (2016) 56 5 Brimmo et al.35 (2016) 750 126 Lichstein et al.36 (2016) 109 7 Lee et al.37 (2015) 20 1 Wang et al.38 (2015) 13 3 Sakellariou et al.39 (2015) 110 15 Watts et al.40 (2014) 111 11 Shaikh et al.41 (2014) 13 0 Castelli et al.42 (2014) 50 4 Edwards et al.44 (2014) 114 25 Sabry et al.45 (2014) 291 82 Joo et al.46 (2013) 49 3 Silvestre et al.47 (2013) 43 2 Bruni et al.49 (2013) 81 5 Tigani et al.50 (2013) 38 9 Johnson et al.51 (2012) 115 20 Kalore et al.52 (2012) 53 15 Kubista et al.53 (2012) 368 58 Kohl et al.54 (2011) 16 0 Mortazavi et al.55 (2011) 117 33 Macheras et al.56 (2011) 34 3 Chiang et al.57 (2011) 43 3 Cabo et al.58 (2011) 18 3 Schindler et al.59 (2011) 23 5 Van Thiel et al.60 (2011) 58 7 Gooding et al.61 (2011) 110 14 Kim et al.62 (2011) 48 10 Park et al.63 (2010) 36 4 Qiu et al.64 (2010) 9 0 Kurd et al.65 (2010) 96 26 Kösters et al.66 (2009) 6 0 Anderson et al.67 (2009) 25 1 Su et al.68 (2009) 13 0 Villanueva-Martinez et al.69 (2008) 29 2 Hsu et al.70 (2007) 27 3 Mittal et al.71 (2007) 37 9 Huang et al.72 (2006) 21 1 Jämsen et al.73 (2006) 30 4 Hart and Jones74 (2006) 46 4 Haleem et al.75 (2004) 96 9 Meek et al.76 (2003) 47 2 Husted and Toftgaard Jensen77 17 2


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(2002) Freeman et al.78 (2007) 76 7 Mahmud et al.79 (2012) 253 16 Cuckler80 (2005) 44 0 Durbhakula et al.81 (2004) 24 2 MacAvoy and Ries82 (2005) 13 4 Ocguder et al.83 (2010) 17 2 Pitto et al.84 (2005) 20 1 Siebel et al.85 (2002) 10 0 Hofmann et al.86 (2005) 50 6 Emerson et al.87 (2002) 48 4

Total no. 4,918 755 % with reinfection after reimplantation

15.4%

*The published studies listed above were used to calculate the rate of reinfection after reimplantation. First, we pooled the total

number of patients for the analysis and then we totaled the number of patients who developed an infection. This gave us a 15.4%

reinfection rate.


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TABLE E-11 Parameter Derivation for Rate of Treatment Only with Chronic Suppressive Antibiotics After Reinfection

Following Completion of 2-Stage Revision

No. of Patients Treated with Antibiotics

No. (%) by Treatment Strategy for Reinfection

Study Haddad et al.8 (2015) 0 Lizaur-Utrilla et al.15 (2015) 0 Choi et al.17 (2011) 0 Kotwal et al.21 (2012) 1 Westrich et al.22 (2010) 1 Haddad et al.23 (2000) 3 Berend et al.24 (2015) 0 Marczak et al.34 (2016) 0 Lee et al.37 (2015) 0 Wang et al.38 (2015) 0 Sakellariou et al.39 (2015) 0 Castelli et al.42 (2014) 3 Scarponi et al.43 (2014) 0 Silvestre et al.47 (2013) 0 Bruni et al.49 (2013) 0 Tigani et al.50 (2013) 3 Kalore et al.52 (2012) 10 Kubista et al.53 (2012) 0 Kohl et al.54 (2011) 0 Mortazavi et al.55 (2011) 0 Macheras et al.56 (2011) 0 Van Thiel et al.60 (2011) 0 Gooding et al.61 (2011) 0 Kim et al.62 (2011) 0 Kösters et al.66 (2009) 0 Anderson et al.67 (2009) 0 Su et al.68 (2009) 0 Villanueva-Martinez et al.69 (2008) 0 Hsu et al.70 (2007) 0 Mittal et al.71 (2007) 2 Huang et al.72 (2006) 1 Jämsen et al.73 (2006) 1 Hart and Jones74 (2006) 2 Haleem et al.75 (2004) 0 Meek et al.76 (2003) 0 Mahmud et al.79 (2012) 0 Cuckler80 (2005) 0 Durbhakula et al.81 (2004) 0 MacAvoy and Ries82 (2005) 0 Ocguder et al.83 (2010) 0 Hofmann et al.86 (2005) 0

Reinfection treatment strategy 2-stage revision 173 (45.3%) 1-stage revision 5 (1.3%) Irrigation and debridement 71 (18.6%) Arthrodesis 71 (18.6%) Amputation 35 (9.2%) Chronic suppressive antibiotics 27 (7.1%)

*The published studies listed above were used to calculate the percentage of patients with reinfection treated with chronic

suppressive antibiotics. A total of 27 patients were treated with chronic suppressive antibiotics. From all of the studies compiled,

there were a total of 382 documented patients treated. This translates to a rate of 7.1% for treatment with chronic suppressive

antibiotics.


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TABLE E-12 Parameter Derivation for Rate of Arthrodesis Treatment After Reinfection Following Completion of 2-Stage

Revision

No. of Patients Treated with Arthrodesis

Did Study Evaluate Infection

Eradication?

No. with Infection

Eradicated


Study Haddad et al.8 (2015) 0 Lizaur-Utrilla et al.15 (2015) 1 No Choi et al.17 (2011) 2 No Kotwal et al.21 (2012) 0 Westrich et al.22 (2010) 3 Yes 2 Haddad et al.23 (2000) 0 Berend et al.24 (2015) 1 No Marczak et al.34 (2016) 0 Lee et al.37 (2015) 0 Wang et al.38 (2015) 0 Sakellariou et al.39 (2015) 5 No Castelli et al.42 (2014) 0 Scarponi et al.43 (2014) 38 Yes 34 Silvestre et al.47 (2013) 0 Bruni et al.49 (2013) 1 Yes 1 Tigani et al.50 (2013) 2 Yes 2 Kalore et al.52 (2012) 1 No Kubista et al.53 (2012) 9 No Kohl et al.54 (2011) 0 Mortazavi et al.55 (2011) 0 Macheras et al.56 (2011) 0 Van Thiel et al.60 (2011) 0 Gooding et al.61 (2011) 0 Kim et al.62 (2011) 0 Kösters et al.66 (2009) 0 Anderson et al.67 (2009) 1 No Su et al.68 (2009) 0 Villanueva-Martinez et al.69 (2008) 2 No Hsu et al.70 (2007) 0 Mittal et al.71 (2007) 0 Huang et al.72 (2006) 0 Jämsen et al.73 (2006) 0 Hart and Jones74 (2006) 0 Haleem et al.75 (2004) 2 Yes 2 Meek et al.76 (2003) 0 Mahmud et al.79 (2012) 1 Yes 1 Cuckler80 (2005) 0 Durbhakula et al.81 (2004) 0 MacAvoy and Ries82 (2005) 1 No 1 Ocguder et al.83 (2010) 1 Yes 1 Hofmann et al.86 (2005) 0


*The published studies listed above were used to calculate the percentage of patients with reinfection treated with arthrodesis. A

total of 71 patients were treated with arthrodesis. From all of the studies compiled, there were a total of 382 documented patients

treated. This translates to a rate of 18.6% for treatment with arthrodesis.


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TABLE E-13 Parameter Derivation for Success Rate of Arthrodesis Treatment After Reinfection Following Completion of 2-

Stage Revision*

Study No. of Patients Treated with

Arthrodesis No. with Infection

Eradicated % of Patients

Treated Successfully

Pooled studies22,43,49,50,75,79,83

48 43

Putman et al.89 (2013) 31 26 Iacono et al.90 (2012) 22 19

87.1%

*The published studies listed above were used to calculate the success rate of arthrodesis treatment. This translates to a success

rate of 87.1% for treatment with arthrodesis.


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TABLE E-14 Parameter Derivation for Rate of Irrigation and Debridement Treatment After Reinfection Following Completion

of 2-Stage Revision*

No. of Patients Treated with Irrigation and Debridement


Eradication?

No. with Infection

Eradicated

No. (%) by Treatment Strategy

for Reinfection

Study Haddad et al.8 (2015) 0 Lizaur-Utrilla et al.15 (2015) 0 Choi et al.17 (2011) 5 No Kotwal et al.21 (2012) 6 No Westrich et al.22 (2010) 3 Yes 1 Haddad et al.23 (2000) 0 Berend et al.24 (2015) 3 Yes 3 Marczak et al.34 (2016) 0 Lee et al.37 (2015) 0 Wang et al.38 (2015) 0 Sakellariou et al.39 (2015) 15 No Castelli et al.42 (2014) 1 No Scarponi et al.43 (2014) 0 Silvestre et al.47 (2013) 0 Bruni et al.49 (2013) 0 Tigani et al.50 (2013) 2 No Kalore et al.52 (2012) 0 Kubista et al.53 (2012) 0 Kohl et al.54 (2011) 0 Mortazavi et al.55 (2011) 20 Yes 10 Macheras et al.56 (2011) 0 Van Thiel et al.60 (2011) 3 No Gooding et al.61 (2011) 0 Kim et al.62 (2011) 0 Kösters et al.66 (2009) 0 Anderson et al.67 (2009) 0 Su et al.68 (2009) 0 Villanueva-Martinez et al.69 (2008) 0 Hsu et al.70 (2007) 2 Yes 2 Mittal et al.71 (2007) 3 Yes 3 Huang et al.72 (2006) 0 Jämsen et al.73 (2006) 0 Hart and Jones74 (2006) 0 Haleem et al.75 (2004) 0 Meek et al.76 (2003) 0 Mahmud et al.79 (2012) 8 Yes 4 Cuckler80 (2005) 0 Durbhakula et al.81 (2004) 0 MacAvoy and Ries82 (2005) 0 Ocguder et al.83 (2010) 0 Hofmann et al.86 (2005) 0


*The published studies listed above were used to calculate the percentage of patients with reinfection treated with irrigation and

debridement. A total number of 71 patients were treated with irrigation and debridement. From all of the studies compiled, there

were a total of 382 documented patients treated. This translates to a rate of 18.6% for treatment with irrigation and debridement.


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TABLE E-15 Parameter Derivation for Success Rate of Irrigation and Debridement Treatment After Reinfection*

Study No. of Patients Treated with Irrigation and Debridement

No. with Infection Eradicated

% of Patients Treated Successfully

Pooled studies22,24,55,70,71,79 39 23 59.0% *The published studies listed above were used to calculate the success rate of irrigation and debridement. This translates to a

59.0% success rate for treatment with irrigation and debridement.


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TABLE E-16 Parameter Derivation for Rate of Amputation Treatment After Reinfection Following Completion of 2-Stage

Revision*

No. of Patients Treated with Amputation


Study Haddad et al.8 (2015) 0 Lizaur-Utrilla et al.15 (2015) 0 Choi et al.17 (2011) 3 Kotwal et al.21 (2012) 1 Westrich et al.22 (2010) 1 Haddad et al.23 (2000) 1 Berend et al.24 (2015) 2 Marczak et al.34 (2016) 0 Lee et al.37 (2015) 0 Wang et al.38 (2015) 0 Sakellariou et al.39 (2015) 1 Castelli et al.42 (2014) 0 Scarponi et al.43 (2014) 0 Silvestre et al.47 (2013) 0 Bruni et al.49 (2013) 0 Tigani et al.50 (2013) 0 Kalore et al.52 (2012) 2 Kubista et al.53 (2012) 11 Kohl et al.54 (2011) 0 Mortazavi et al.55 (2011) 0 Macheras et al.56 (2011) 1 Van Thiel et al.60 (2011) 0 Gooding et al.61 (2011) 0 Kim et al.62 (2011) 0 Kösters et al.66 (2009) 0 Anderson et al.67 (2009) 0 Su et al.68 (2009) 0 Villanueva-Martinez et al.69 (2008) 0 Hsu et al.70 (2007) 0 Mittal et al.71 (2007) 0 Huang et al.72 (2006) 0 Jämsen et al.73 (2006) 1 Hart and Jones74 (2006) 0 Haleem et al.75 (2004) 2 Meek et al.76 (2003) 1 Mahmud et al.79 (2012) 3 Cuckler80 (2005) 0 Durbhakula et al.81 (2004) 2 MacAvoy and Ries82 (2005) 1 Ocguder et al.83 (2010) 0 Hofmann et al.86 (2005) 0 Evans88 (2004) 2


*The published studies listed above were used to calculate the percentage of patients with reinfection treated with amputation. A

total of 35 patients were treated with amputation. From all of the studies compiled, there were a total of 382 documented patients

treated. This translates to a rate of 9.2% for treatment with amputation.


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TABLE E-17 Parameter Derivation for Rate of Treatment with 1-Stage Revision After Reinfection Following Completion of 2-

Stage Revision*

No. of Patients Treated with 1-Stage Revision


Eradication?

No. with Infection

Eradicated


Study Haddad et al.8 (2015) 0 Lizaur-Utrilla et al.15 (2015) 0 Choi et al.17 (2011) 2 No Kotwal et al.21 (2012) 0 Westrich et al.22 (2010) 0 Haddad et al.23 (2000) 0 Berend et al.24 (2015) 1 Yes 1 Marczak et al.34 (2016) 0 Lee et al.37 (2015) 0 Wang et al.38 (2015) 0 Sakellariou et al.39 (2015) 1 Yes 0 Castelli et al.42 (2014) 0 Scarponi et al.43 (2014) 0 Silvestre et al.47 (2013) 0 Bruni et al.49 (2013) 0 Tigani et al.50 (2013) 1 Yes 1 Kalore et al.52 (2012) 0 Kubista et al.53 (2012) 0 Kohl et al.54 (2011) 0 Mortazavi et al.55 (2011) 0 Macheras et al.56 (2011) 0 Van Thiel et al.60 (2011) 0 Gooding et al.61 (2011) 0 Kim et al.62 (2011) 0 Kösters et al.66 (2009) 0 Anderson et al.67 (2009) 0 Su et al.68 (2009) 0 Villanueva-Martinez et al.69 (2008) 0 Hsu et al.70 (2007) 0 Mittal et al.71 (2007) 0 Huang et al.72 (2006) 0 Jämsen et al.73 (2006) 0 Hart and Jones74 (2006) 0 Haleem et al.75 (2004) 0 Meek et al.76 (2003) 0 Mahmud et al.79 (2012) 0 Cuckler80 (2005) 0 Durbhakula et al.81 (2004) 0 MacAvoy and Ries82 (2005) 0 Ocguder et al.83 (2010) 0 Hofmann et al.86 (2005) 0


*The published studies listed above were used to calculate the percentage of patients with reinfection treated with 1-stage

revision. A total of 5 patients were treated with 1-stage revision. From all of the studies compiled, there were a total of 382

documented patients treated. This translates to a treatment rate of 1.3% with 1-stage revision.


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TABLE E-18 Parameter Derivation for Success Rate of Treatment with 1-Stage Revision After Reinfection*

Study No. of Patients Treated with 1-Stage Revision

No. with Infection Eradicated

% of Patients Treated Successfully

Pooled studies24,39,50 3 2 67% *The published studies listed above were used to calculate the success rate of 1-stage revision treatment. This translates to a

success rate of 67% for treatment with 1-stage revision.


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Stage Revision*

No. of Patients

Treated with 2-Stage

Revision


Eradication? No. with Infection

Eradicated


Study Haddad et al.8 (2015) 5 Yes 5 Lizaur-Utrilla et al.15 (2015) 2 No 0 Choi et al.17 (2011) 8 No Kotwal et al.21 (2012) 0 Westrich et al.22 (2010) 5 Yes 4 Haddad et al.23 (2000) 0 Berend et al.24 (2015) 20 No Marczak et al.34 (2016) 3 Yes 3 Lee et al.37 (2015) 1 Yes 1 Wang et al.38 (2015) 0 Sakellariou et al.39 (2015) 9 Yes 9 Castelli et al.42 (2014) 0 Scarponi et al.43 (2014) 0 Silvestre et al.47 (2013) 2 Yes 2 Bruni et al.49 (2013) 5 Yes 4 Tigani et al.50 (2013) 1 Yes 1 Kalore et al.52 (2012) 0 Kubista et al.53 (2012) 38 No Kohl et al.54 (2011) 0 Mortazavi et al.55 (2011) 10 No Macheras et al.56 (2011) 2 Yes 2 Van Thiel et al.60 (2011) 4 No Gooding et al.61 (2011) 14 Yes 12 Kim et al.62 (2011) 10 Yes 7 Kösters et al.66 (2009) 0 Anderson et al.67 (2009) 1 Yes 0 Su et al.68 (2009) 0 Villanueva-Martinez et al.69 (2008) 0 Hsu et al.70 (2007) 1 Yes 1 Mittal et al.71 (2007) 1 Yes 1 Huang et al.72 (2006) 0 Jämsen et al.73 (2006) 2 Yes 2 Hart and Jones74 (2006) 2 Yes 2 Haleem et al.75 (2004) 5 Yes 5 Meek et al.76 (2003) 1 Yes 0 Mahmud et al.79 (2012) 11 Yes 4 Cuckler80 (2005) 0 Durbhakula et al.81 (2004) 0 MacAvoy and Ries82 (2005) 2 No Ocguder et al.83 (2010) 2 Yes 1 Hofmann et al.86 (2005) 6 Yes 3



SRIVASTAVA ET AL.






documented patients treated. This translates to a rate of 45.3% for treatment with 2-stage revision.


SRIVASTAVA ET AL.




TABLE E-20 Parameter Derivation for Success Rate of Treatment with 2-Stage Revision After Reinfection*

Study No. of Patients Treated with

2-Stage Revision No. with Infection

Eradication % of Patients Treated

Successfully

Pooled studies8,15,22,34,37,39,47,49,50,56,

61,62,67,70,71,73-76,79,83,86

89 69 77.5%

*The published studies listed above were used to calculate the success rate of 2-stage revision treatment. This translates to a

success rate of 77.5% for treatment with 2-stage revision.


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TABLE E-21 Parameter Derivation for Success After 1-Stage Revision* Rate

Reinfection 7.4% Aseptic revision 12.0% Death at 1 yr 2.2% Success rate 78.4% *The success rate of 1-stage revision was calculated using the following equation: success = 1 − (reinfection + aseptic revision +

death at 1 year). The aseptic revision rate, death at 1 year, and reinfection were calculated from previously published studies,

which are listed in Tables E-22, E-23, and E-24, respectively. These values were used in the decision model.


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TABLE E-22 Parameter Derivation for 5-Year Aseptic Revision After 1-Stage Revision*

No. of Patients Who

Underwent 1-Stage Revision No. with Aseptic Revision Aseptic

Revision Rate

Study Haddad et al.8 (2015) 28 0 Zahar et al.25 (2016) 59 7 Tibrewal et al.26 (2014) 50 9 Buechel et al.30 (2004) 21 3

Total no. 158 19 % aseptic revision after 1-stage revision

12.0%

*The published studies listed above were used to calculate the aseptic revision rate following 1-stage revision. First, we pooled

the total number of patients for the analysis and then we totaled the number of patients who underwent aseptic revision. This gave

us a 12.0% aseptic revision rate.


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TABLE E-23 Parameter Derivation for Death at 1 Year After 1-Stage Revision* Key Data Input Key Parameter




12-mo mortality rate for 65-yr-old

1.3%

Overall 1-yr mortality rate 2.2% *The published study listed above and the expected life expectancy tabulated from the Social Security Administration actuarial

table were used to calculate the overall 12-month mortality rate after 1-stage revision.


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TABLE E-24 Parameter Derivation for Reinfection After 1-Stage Revision*

No. of Patients Who Underwent 1-Stage

Revision No. with Reinfection Reinfection

Rate

Study Haddad et al.8 (2015) 28 0 Zahar et al.25 (2016) 59 5 Tibrewal et al.26 (2014) 50 4 Jenny et al.27 (2013) 47 6 Singer et al.28 (2012) 63 3 Sofer et al.29 (2005) 15 1 Buechel et al.30 (2004) 21 2

Total no. 283 21 % with reinfection after 1-stage revision

7.4%

*The published studies listed above were used to calculate the rate of reinfection after 1-stage revision. First, we pooled the total

number of patients for the analysis and then we totaled the number of patients who developed an infection. This gave us a 7.4%

infection rate.


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TABLE E-25 Parameter Derivation for Rate of Treatment Only with Chronic Suppressive Antibiotics After Reinfection

Following 1-Stage Revision*

No. of Patients Treated

with Antibiotics No. (%) by Treatment Strategy for Reinfection After 1-Stage Revision

Study Zahar et al.25 (2016) 0 Tibrewal et al.26 (2014) 1 Jenny et al.27 (2013) 1 Singer et al.28 (2012) 0 Buechel et al.30 (2004) 0


*The published studies listed above were used to calculate the percentage of patients with reinfection treated with chronic

suppressive antibiotics. A total of 2 patients were treated with chronic suppressive antibiotics. From all of the studies compiled,

there were a total of 17 documented patients treated. This translates to a rate of 11.8% for treatment with chronic suppressive

antibiotics.


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TABLE E-26 Parameter Derivation for Rate of Arthrodesis Treatment After Reinfection Following 1-Stage Revision*

No. of Patients Treated with

Arthrodesis

No. (%) by Treatment Strategy for Reinfection After 1-Stage

Revision



*The published studies listed above were used to calculate the percentage of patients with reinfection treated with arthrodesis. A

total of 3 patients were treated with arthrodesis. From all of the studies compiled, there were a total of 17 documented patients

treated. This translates to a rate of 17.6% for treatment with arthrodesis.


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TABLE E-27 Parameter Derivation for Rate of Irrigation and Debridement Treatment After Reinfection Following Completion

of 1-Stage Revision*

No. of Patients Treated with Irrigation and Debridement

No. (%) by Treatment Strategy for Reinfection After 1-Stage Revision



*The published studies listed above were used to calculate the percentage of patients with reinfection treated with irrigation and

debridement. A total number of 4 patients were treated with irrigation and debridement. From all of the studies compiled, there

were a total of 17 documented patients treated. This translates to a rate of 23.5% for treatment with irrigation and debridement.


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TABLE E-28 Parameter Derivation for Rate of Amputation Treatment After Reinfection Following Completion of 1-Stage

Revision*

No. of Patients Treated

with Amputation No. (%) by Treatment Strategy for Reinfection After 1-Stage Revision



*The published studies listed above were used to calculate the percentage of patients with reinfection treated with amputation. A

total of 1 patient was treated with amputation. From all of the studies compiled, there were a total of 17 documented patients

treated. This translates to a rate of 5.9% for treatment with amputation.


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TABLE E-29 Parameter Derivation for Rate of Treatment with Repeat 1-Stage Revision After Reinfection Following Completion

of 1-Stage Revision

No. of Patients Treated with 1-Stage

Revision No. (%) by Treatment Strategy for Reinfection After 1-Stage Revision



*The published studies listed above were used to calculate the percentage of patients with reinfection treated with another 1-stage




SRIVASTAVA ET AL.





Stage Revision*

No. of Patients Treated with 2-Stage

Revision No. (%) by Treatment Strategy for Reinfection After 1-Stage Revision




revision. A total of 1 patient was treated with 2-stage revision. From all of the studies compiled, there were a total of 17


appendix - lippincott williams & wilkins · decision tree 1. this is the decision tree for...

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