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Treatment Decision Regret in Patients Who Develop Periprosthetic Joint Infection and Require Two-Stage Revision Surgery

Published:February 21, 2022DOI:https://doi.org/10.1016/j.arth.2022.01.033

      Abstract

      Background

      The decision to proceed with total joint arthroplasty (TJA) can be complex and requires an assessment of potential risks of surgery. Patients who experience the potentially devastating complication of periprosthetic joint infection (PJI) may have a poor outcome and wish they had never elected to have surgery. No study has examined decision regret related to the choice to pursue TJA in patients who develop PJI.

      Methods

      All patients who were treated for PJI with a two-stage revision at a tertiary academic medical center between 2010 and 2020 were surveyed. Ninety-six patients agreed to answer 12 questions concerning their understanding of their preoperative risk of infection and their level of regret with the decision to pursue index TJA. Patient regret was calculated using the Decision Regret Scale.

      Results

      Seventy-two percent of patients reported that their joint replacement and concomitant infection had a severe ongoing impact on their quality of life, although only 28% of respondents regretted their choice to undergo index TJA, and 65% would undergo TJA again. A higher Musculoskeletal Infection Society outcome stage (typically due to failed treatment) and lower understanding of joint infection were associated with a higher level of regret on the Decision Regret Scale (P < .001).

      Conclusion

      Self-reported decisional regret was present in only 1 in 4 patients who underwent arthroplasty despite experiencing a devastating complication, and almost two-thirds of patients with PJI reported they would undergo primary TJA again. Patients who were more informed about infection before TJA experienced less regret when they subsequently developed PJI.

      Level of Evidence

      III.

      Keywords

      Total knee and hip arthroplasty procedures are some of the most commonly performed surgical procedures in the United States [
      • Singh J.A.
      • Yu S.
      • Chen L.
      • Cleveland J.D.
      Rates of total joint replacement in the United States: future projections to 2020–2040 using the national inpatient sample.
      ]. Although these procedures are associated with high rates of improvement in pain and function, they are elective in nature and carry potentially serious risk and uncertainty in terms of outcomes. Despite advances in patient selection, surgical technique, and implant design, studies have found that between 5% and 20% of patients after total joint arthroplasty (TJA) remain dissatisfied with their outcomes [
      • Kahlenberg C.A.
      • Nwachukwu B.U.
      • Schairer W.W.
      • Steinhaus M.E.
      • Cross M.B.
      Patient satisfaction reporting after total hip arthroplasty: a systematic review.
      ,
      • Chesworth B.M.
      • Mahomed N.N.
      • Bourne R.B.
      • Davis A.M.
      OJRR Study Group
      Willingness to go through surgery again validated the WOMAC clinically important difference from THR/TKR surgery.
      ,
      • Dunbar M.J.
      • Robertsson O.
      • Ryd L.
      • Lidgren L.
      Appropriate questionnaires for knee arthroplasty. Results of a survey of 3600 patients from the Swedish Knee Arthroplasty Registry.
      ,
      • Yeo M.G.H.
      • Goh G.S.
      • Chen J.Y.
      • Lo N.N.
      • Yeo S.J.
      • Liow M.H.L.
      Are Oxford hip score and Western Ontario and McMaster Universities osteoarthritis index useful predictors of clinical meaningful improvement and satisfaction after total hip arthroplasty?.
      ,
      • Gunaratne R.
      • Pratt D.N.
      • Banda J.
      • Fick D.P.
      • Khan R.J.K.
      • Robertson B.W.
      Patient dissatisfaction following total knee arthroplasty: a systematic review of the literature.
      ,
      • Noble P.C.
      • Conditt M.A.
      • Cook K.F.
      • Mathis K.B.
      The John Insall Award: patient expectations affect satisfaction with total knee arthroplasty.
      ,
      • Robertsson O.
      • Dunbar M.
      • Pehrsson T.
      • Knutson K.
      • Lidgren L.
      Patient satisfaction after knee arthroplasty: a report on 27,372 knees operated on between 1981 and 1995 in Sweden.
      ,
      • Wylde V.
      • Learmonth I.
      • Potter A.
      • Bettinson K.
      • Lingard E.
      Patient-reported outcomes after fixed- versus mobile-bearing total knee replacement: a multi-centre randomised controlled trial using the Kinemax total knee replacement.
      ]. Potentially devastating complications like periprosthetic joint infection (PJI) can also occur and result in significant psychological and physical consequences for patients [
      • Kurtz S.M.
      • Lau E.
      • Schmier J.
      • Ong K.L.
      • Zhao K.
      • Parvizi J.
      Infection burden for hip and knee arthroplasty in the United States.
      ,
      • Aggarwal V.K.
      • Rasouli M.R.
      • Parvizi J.
      Periprosthetic joint infection: current concept.
      ]. One study showed that patients with PJI still suffer from significantly lower quality of life even years after surgically successful treatment [
      • Walter N.
      • Rupp M.
      • Hierl K.
      • Koch M.
      • Kerschbaum M.
      • Worlicek M.
      • et al.
      Long-term patient-related quality of life after knee periprosthetic joint infection.
      ].
      Regret with the decision to pursue with an elective hip or knee arthroplasty procedure is an area that has not been studied. Presumably, there is little to no regret in patients who have an uncomplicated surgical procedure and a good outcome. We therefore aimed to study decisional regret regarding the choice to pursue elective joint replacement surgery in a select group of patients potentially prone to disappointment: patients who developed a PJI and required removal of their implants. The objectives of the study were to (1) quantify decisional regret in patients who underwent two-stage revision for PJI and (2) identify risk factors for patient regret.

      Methods

      After institutional review board approval, we identified a consecutive cohort of 217 patients who were surgically treated for PJI at a tertiary academic medical center from January 2010 to December 2019. All patients who underwent hip or knee arthroplasty implant removal with subsequent placement of an antibiotic spacer with a diagnosis of infection were included. All patients were treated by 1 of the 3 board-certified arthroplasty surgeons at our institution. Patients whose index arthroplasty was performed for a fracture were excluded from the study to avoid including patients who did not have an elective index procedure.
      Patients were contacted on their primary phone listed in the electronic medical record to ascertain if they would be interested in participating in the survey. Six total attempts to contact each patient were made before assuming that patients were declining participation in the study. After contacting the subjects and explaining the purpose of the survey, patients had the opportunity to accept or decline to participate in the study. Survey responses were entered electronically with Research Electronic Data Capture (REDCap). Any patient expressing immediate medical or psychosocial concerns was immediately directed to the emergency department and documented in the electronic medical record. Any patient expressing concern regarding their mental health in response to survey questions was immediately referred to the principal investigator for further evaluation. Patient demographic data (age, sex, race, zip code, education level) and the presence of mental illness comorbidity (depression, anxiety, or bipolar disease) were documented for each patient. In addition, each patient’s outcome was categorized based on the Musculoskeletal Infection Society (MSIS) outcome scale [
      • Fillingham Y.A.
      • Della Valle C.J.
      • Suleiman L.I.
      • Springer B.D.
      • Gehrke T.
      • Bini S.A.
      • et al.
      Definition of successful infection management and guidelines for reporting of outcomes after surgical treatment of periprosthetic joint infection: from the workgroup of the Musculoskeletal Infection Society (MSIS).
      ].
      The 12-question survey administered in this study (Table 1) was developed at our institution with the assistance of a clinical psychologist. The survey was developed after reviewing previously published studies in the area of regret research and incorporated the Decision Regret Scale (DRS), a scale which measures the distress or remorse after a health care decision [
      • Brehaut J.C.
      • O’Connor A.M.
      • Wood T.J.
      • Hack T.F.
      • Siminoff L.
      • Gordon E.
      • et al.
      Validation of a decision regret scale.
      ,
      • Becerra Pérez M.M.
      • Menear M.
      • Brehaut J.C.
      • Légaré F.
      Extent and predictors of decision regret about health care decisions: a systematic review.
      ,
      • Tanno K.
      • Bito S.
      • Isobe Y.
      • Takagi Y.
      Validation of a Japanese version of the decision regret scale.
      ]. The survey assessed each patient’s level of understanding of PJI as a potential risk of elective surgery. In addition, the survey included questions to determine how joint replacement surgery and infection have impacted their overall quality of life, perception of their original decision to undergo surgery, and their willingness to consider any joint replacement surgery in the future. A 5-point Likert scale was used to measure respondents’ agreement with each question. Using the DRS questions, the patient’s decision regret score was converted to a 0-100 scale by subtracting 1 from each item and then multiplying by 25 [
      • O’Connor A.M.
      User Manual – Decision Regret Scale. Copyright 1996 [updated 2003].
      ].
      Table 1Survey Questions.
      Question NumberQuestions
      1I clearly understood my risk of infection before I underwent my first joint replacement
      2I clearly understood the impact that joint replacement infection might have on my life before I underwent my first joint replacement.
      3Prior to surgery, I had a clear understanding of potential actions or lifestyle modifications that I could take to reduce my risk of infection.
      4Following surgery, I had a clear understanding of potential actions or lifestyle modifications that I could take to reduce the risk of infection.
      5I now have a clear understanding of my risk of infection associated with this surgery.
      6I am currently concerned that I may still have residual infection.
      7It was the right decision.
      8I regret the choice that I made.
      9I would go for the same choice if I had to do it over again.
      10The choice did me a lot of harm.
      11The decision was a wise one.
      12My joint replacement and its resulting infection have had severe long-term consequences on my overall quality of life.
      Questions 7-11 were used to calculate the Decision Regret Scale score. Patients were instructed to think about the decision they had made about deciding to undergo elective total joint replacement surgery (their first joint replacement procedure).
      Descriptive statistics were performed for the frequency by which patients responded to each survey question, regret score, and MSIS outcome. Pearson correlation coefficients were run to evaluate the association of each survey question with the remaining survey questions. Pearson correlation coefficients were also run to evaluate the association of survey questions, regret score, demographic variables, MSIS outcome, and presence of mental illness with one another. Weak, moderate, and strong correlations corresponded with 0 to 0.3, 0.3 to 0.7, and 0.7 to 1.0, respectively. Cross-tabulation and chi-square analysis were then performed to evaluate the significance of the relationship between survey questions, regret score, and MSIS outcome, as well as each survey question's relationship with the other remaining 11 questions. Risk factor analysis was performed using Student t-test and one- and multiple-variable analysis of variance where appropriate. All statistical analyses were performed using Minitab v19 (Minitab LLC) with the significance level at P < .05.

      Results

      Surveys were successfully completed by 96 patients out of the total cohort of 207 patients deemed eligible for this study (46.4%). Of those patients who were not included, 77 (69%) were not reachable by phone despite 6 attempts, and 34 (31%) declined participation after hearing about the study. The demographics of the patients included in the study are included in Table 2. The mean age of the patients included in the study was 69.6 years old. The majority of patients were female (57%). PJI after total knee arthroplasty (59%) was more common than total hip arthroplasty (41%). The average body mass index (kg/m2) was 30.6. Most patients had obtained a high school diploma or general educational diploma (30.2%) followed by 1-3 years of college (18.75%).
      Table 2Patient Demographics.
      VariableAverageStandard Deviation
      Age69.6 y9.6
      Gender42.7% male; 57.3% female
      Type of surgery40.6% THA; 59.4% TKA
      BMI30.610.6
      Level of educationLess than high school (16.7%); high school graduate/GED (30.2%); post–high school, trade or tech school (1.0%); 1-3 y of college or Jr college (18.75%); college grad (14.6%); post-college graduate work, higher degree (18.75%)
      BMI, body mass index; GED, general educational diploma; THA, total hip arthroplasty; TKA, total knee arthroplasty.

      Basic Survey Analysis

      Responses for the 12 novel survey questions were obtained (Table 3). A total of 53.1% of patients understood their risk of PJI in the preoperative period, although 40.6% of patients agreed and 43.8% of patients disagreed that they had a clear understanding of the interventions they could take to reduce their risk of infection before their primary surgical procedure. Patients were split on whether or not they understood the impact a PJI might have on their life before primary joint replacement, with a bimodal distribution of responses (Fig. 1). The majority of patients (97%) agreed that they now have a clear understanding of their risk of PJI. One-third of patients were concerned that they still had residual infection. Despite their eventual PJI, 75% of patients agreed or strongly agreed that their decision to undergo index arthroplasty was the correct decision, although 53% thought that the choice did them a lot of harm. A total of 71% of patients believed that their decision had severe long-term consequences on their overall quality of life (Fig. 2). When asked if they regretted the choice they made to have their primary joint replacement, 28% agreed or strongly agreed (Fig. 3). A majority of patients (65%) agreed or strongly agreed that they would go for the same choice to pursue primary joint replacement if they had to do it over again (Fig. 4).
      Table 3Survey Results.
      Survey QuestionStrongly Agree (%)Agree (%)Neither (%)Disagree (%)Strongly Disagree (%)
      I clearly understood my risk of infection before I underwent my first joint replacement15.653.14.222.94.2
      I clearly understood the impact that joint replacement infection might have on my life before I underwent my first joint replacement.6.237.57.338.510.4
      Prior to surgery, I had a clear understanding of potential actions or lifestyle modifications that I could take to reduce my risk of infection.7.340.64.243.84.2
      Following surgery, I had a clear understanding of potential actions or lifestyle modifications that I could take to reduce the risk of infection.6.243.85.241.73.1
      I now have a clear understanding of my risk of infection associated with this surgery.40.656.203.10
      I am currently concerned that I may still have residual infection.5.233.310.444.86.2
      It was the right decision.24.051.08.314.62.1
      I regret the choice that I made.12.516.75.247.917.7
      I would go for the same choice if I had to do it over again.18.846.94.221.98.3
      The choice did me a lot of harm.29.224.06.229.211.5
      The decision was a wise one.14.657.38.314.65.2
      My joint replacement and its resulting infection have had severe long-term consequences on my overall quality of life.44.828.13.119.84.2
      Outcomes of treatment for PJI were classified as per the tiered system in accordance with MSIS recommendations [
      • Lueck E.
      • Schlaepfer T.E.
      • Schildberg F.A.
      • Randau T.M.
      • Hischebeth G.T.
      • Jaenisch M.
      • et al.
      The psychological burden of a two-stage exchange of infected total hip and knee arthroplasties.
      ]. A total of 79.2% of patients were classified as MSIS tier I (infection control with no continued antibiotic), 4.2% as MSIS tier II (infection control with suppressive antibiotic therapy), and 16.7% as MSIS tier III (need for reoperation and/or revision and/or spacer retention).
      Scores on the DRS ranged from 0 (no regret) to 100 (maximal regret). The mean decision regret score was 40.1 (±26.2). Five patients (5%) reported no regret (DRS score 0) with their decision to undergo primary joint replacement. Thirty-two patients (33%) reported mild regret (DRS score 5-25), 31 patients (32%) reported moderate regret (DRS score 30-50), and 28 patients (29%) reported strong regret (DRS score greater than 50). For patients with MSIS tier I outcomes, the mean DRS score was 36.4 (±25.6), whereas the mean DRS score was 59.3 (±23.2) for patients with MSIS tier III outcomes.

      Combined TJA Analysis

      The Pearson correlation coefficients and results of the cross-tabulation analysis performed between survey questions, regret score, and MSIS outcome are included in Appendix Table 1, Appendix Table 2. Survey questions that involved understanding the risk of PJI were strongly correlated with one another (r > 0.6, P < .001). A poor level of understanding of the impact that PJI might have on a patient’s life was associated with more regret regarding their decision to undergo the index arthroplasty and a smaller chance of wanting to undergo the index arthroplasty again. A patient believing that index arthroplasty was the wrong decision was strongly associated with regretting the choice to undergo joint surgery (r = 0.72) and not wanting to undergo joint replacement again (r = 0.73). Regretting the choice to undergo surgery was strongly associated with not wanting to undergo joint arthroplasty again (r = 0.84), believing that the choice did a lot of harm (r = 0.53), and believing the decision to undergo primary joint arthroplasty was a poor one (r = 0.76). Electing to not undergo surgery again was associated with agreeing with the statement that the joint replacement and its resulting PJI had severe, long-term effects on the patient’s quality of life. A higher level of regret per the regret score was associated with a worse (higher) MSIS outcome. A worse MSIS outcome and lower understanding of joint infection were associated with a higher level of regret on the DRS.
      Age group, gender, type of surgery, zip code/income, and level of education were analyzed as potential risk factors for regret after surgical management for PJI (Appendix Table 3). Female sex was associated with lack of understanding of the impact that PJI might have on the patient’s life before their index joint replacement (P = .0151). No other variables were identified as a risk factor for regret after surgical management for PJI.

      Discussion

      PJI is a devastating complication after TJA and can have substantial consequences for a patient’s quality of life. To our knowledge, the regret that a patient may feel with their decision to pursue joint replacement when they experience a poor outcome has never been studied. In this study, we found that 72% of patients reported that their joint replacement and concomitant infection had a severe impact on their quality of life, although only 28% of respondents regretted their choice to undergo index joint arthroplasty, and 65% would undergo TJA again. A worse outcome after treatment for PJI and a lower preoperative understanding of PJI were associated with a higher level of regret on the DRS.
      Several other studies have reported on the patient dissatisfaction and psychosocial stressors that patients undergo during and after surgical management for PJI [
      • Aggarwal V.K.
      • Rasouli M.R.
      • Parvizi J.
      Periprosthetic joint infection: current concept.
      ,
      • Walter N.
      • Rupp M.
      • Hierl K.
      • Koch M.
      • Kerschbaum M.
      • Worlicek M.
      • et al.
      Long-term patient-related quality of life after knee periprosthetic joint infection.
      ,
      • Lueck E.
      • Schlaepfer T.E.
      • Schildberg F.A.
      • Randau T.M.
      • Hischebeth G.T.
      • Jaenisch M.
      • et al.
      The psychological burden of a two-stage exchange of infected total hip and knee arthroplasties.
      ,
      • Helwig P.
      • Morlock J.
      • Oberst M.
      • Hauschild O.
      • Hübner J.
      • Borde J.
      • et al.
      Periprosthetic joint infection–effect on quality of life.
      ,
      • O’Toole P.
      • Maltenfort M.G.
      • Chen A.F.
      • Parvizi J.
      Projected increase in periprosthetic joint infections secondary to rise in diabetes and obesity.
      ]. Helwig et al found that the quality of life was substantially reduced after hip and knee PJI with lower SF-12 physical and mental scores [
      • Helwig P.
      • Morlock J.
      • Oberst M.
      • Hauschild O.
      • Hübner J.
      • Borde J.
      • et al.
      Periprosthetic joint infection–effect on quality of life.
      ]. Knebel et al performed a longitudinal prospective study evaluating 31 patients who underwent total knee arthroplasty that sustained a PJI and found that over half of patients met the criteria on PHQ-4 scoring for depression with quality of life and fear of disease progression comparable with oncology patients [
      • Knebel C.
      • Menzemer J.
      • Pohlig F.
      • Herschbach P.
      • Burgkart R.
      • Obermeier A.
      • et al.
      Peri-prosthetic joint infection of the knee causes high levels of psychosocial distress: a prospective cohort study.
      ]. These studies agree with our findings that a majority of patients (72%) report that a PJI had a severe negative impact on their quality of life.
      However, it is interesting that 72% of patients in our study stated that they do not regret their decision to undergo their index joint replacement, and 65% would undergo a primary joint replacement again. Only 29% reported strong regret based on the DRS (score >50). Although many studies comment on the adverse effect that PJI and subsequent surgery have on a patient’s quality of life, no previous study has evaluated a patient’s perception of their initial surgery or decision to undergo their elective joint replacement. This seemingly contradictory result of severe impact on quality of life, but willingness to undergo surgery again and lack of widespread strong regret over the initial decision to have surgery, is an interesting finding with implications for clinical care and the decision-making process around primary TJA. In decision-making theory, regret is recognized as a counterfactual emotion which requires a patient to contemplate what would have happened had they made a different choice [
      • Coricelli G.
      • Rustichini A.
      Counterfactual thinking and emotions: regret and envy learning.
      ]. It is possible that patients who underwent TJA, including even those with devastating complications from surgery, cannot contemplate not having had their index TJA owing to their preoperative pain and functional disability. Errors of inaction may also be more likely than errors of action to produce greater long-term regret [
      • Gilovich T.
      • Medvec V.H.
      The experience of regret: what, when, and why.
      ], potentially further explaining why the decision to pursue the index elective TJA does not universally lead to regret in cases with poor outcomes.
      Embedded within our survey was the DRS. The DRS was developed as a tool to measure and study regret in the context of health care–related decisions [
      • O’Connor A.M.
      User Manual – Decision Regret Scale. Copyright 1996 [updated 2003].
      ]. The DRS is a validated 5-item measure and is the most frequently used measurement tool in the surgical decision-making literature [
      • Wilson A.
      • Ronnekleiv-Kelly S.M.
      • Pawlik T.M.
      Regret in surgical decision making: a systematic review of patient and physician perspectives.
      ]. There is no established cutoff number to define the presence or absence of regret, although many studies pick an arbitrary threshold as a way to dichotomize the results [
      • Becerra Pérez M.M.
      • Menear M.
      • Brehaut J.C.
      • Légaré F.
      Extent and predictors of decision regret about health care decisions: a systematic review.
      ]. One recent systematic review of regret in health care decisions compared mean DRS scores across multiple studies, with an overall across-studies mean score of 16.5 and a median score of 14.3 [
      • Becerra Pérez M.M.
      • Menear M.
      • Brehaut J.C.
      • Légaré F.
      Extent and predictors of decision regret about health care decisions: a systematic review.
      ]. As one might anticipate, the mean scores were higher than this in our population of patients that had suffered a severe complication from their treatment decision. However, several studies have reported a higher mean DRS score than was seen in our MSIS 1 patient cohort, including those studying post-decision regret regarding dialysis treatment for end-stage renal disease [
      • Chiou C.-P.
      • Chung Y.-C.
      Effectiveness of multimedia interactive patient education on knowledge, uncertainty and decision-making in patients with end-stage renal disease.
      ] and fertility-related decisions in young patients with breast cancer [
      • Peate M.
      • Meiser B.
      • Cheah B.C.
      • Saunders C.
      • Butow P.
      Making hard choices easier: a prospective, multicentre study to assess the efficacy of a fertility-related decision aid in young women with early-stage breast cancer.
      ].
      With the numbers of patients available in this study, no demographic or comorbidity variables were clearly identified as risk factors for regret after surgical management of PJI. After primary TJA, generalized anxiety disorder and other psychiatric comorbidities have been identified as risk factors for pain catastrophizing which has been associated with regret [
      • Fillingham Y.A.
      • Hanson T.M.
      • Leinweber K.A.
      • Lucas A.P.
      • Jevsevar D.S.
      Generalized anxiety disorder: a modifiable risk factor for pain catastrophizing after total joint arthroplasty.
      ]. Our study did find that a lower understanding of PJI before index arthroplasty surgery is associated with a higher level of regret based on the DRS score (P < .001). Given that patients who feel more informed about infection before TJA experienced less regret when developing PJI, surgeons may be able to mitigate patient regret through preoperative education and the informed consent process. Female sex was associated with less understanding of the potential impact of PJI before the index procedure although we would caution against speculating as to the significance or meaning of this one finding given the lack of association of sex with any of the other survey questions.
      This study does have its limitations. Any study that uses a survey and relies on patient participation has concomitant response bias which could have skewed our findings and conclusions. Sampling bias may also have been introduced by not having surveyed the entire two-stage PJI cohort; we were able to survey only 96 patients, representing 44.2% of the total cohort of patients who were potentially eligible for the study. We attempted to contact each patient 6 times before assuming their declination to participate in the study. It is possible that the patients who did not answer the phone or actively declined participation would have answered the survey differently from those who were willing to participate although we do not have any evidence that this would be the case. It is also possible that those patients who did participate did not fully understand the question or intent of the survey questions, and therefore, their answers may not truly reflect how they feel regarding their regret or their understanding of the risks of PJI. We acknowledge that this survey does not give us insight into how much the patient really understood about the risk of infection or how to prevent infection before TJA; survey responses are purely subjective and cannot be cross-referenced to objective information. We minimized the likelihood of confusion by using a standardized script with pertinent and logical questions and clarified any questions if a patient had any confusion. We also have not routinely collected patient-reported outcome measures (such as Patient-Reported Outcomes Measurement Information System or Knee Injury and Osteoarthritis Outcome Score) at our intuition for patients who have undergone two-stage revision, so we could not correlate survey results with these outcomes. However, we did use the MSIS tiered system as our objective outcome measure, and this likely correlates with these patient-reported outcome measures. Finally, the patients included in this study were surgically managed in one geographic region of the United States by 3 fellowship-trained arthroplasty surgeons, which limits the generalizability of this study’s findings.
      Overall, the seemingly contradictory trends of negative impact on quality of life with low levels of regret and willingness to undergo joint surgery again indicate that patient regret after a major health care intervention, like PJI surgery, is a complex, multidimensional concept. More studies are necessary to fully understand a patient’s perception and experience when a poor outcome or major complication occurs. Further investigation is warranted to study decision regret in all patients with dissatisfaction after TJA. Future studies may also examine regret in patients who require revision surgery for aseptic indications or who undergo debridement, antibiotics, and implant retention instead of two-stage revision.

      Conclusion

      PJI is a devastating complication after TJA that leads some patients who develop infection to regret their decision to pursue their index elective surgery. However, our study suggests that overall levels of regret may be lower than previously thought by orthopedic surgeons. Furthermore, most patients who develop PJI and require a two-stage revision would still make the same choice to have elective TJA if they had to do it over again. Efforts should be made to educate patients about the possibility of PJI during the informed consent process before TJA as this appears to be associated with lower levels of regret should the patient develop this complication.

      Appendix

      Appendix Table 1Statistical Tests to Evaluate Relationships Between Survey Questions, MSIS Outcome, and Regret Score.
      Variable 1Variable 2P value
      Understood infectionUnderstood impact<.0001
      Understood infectionBefore surgery, I had a clear understanding<.0001
      Understood infectionAfter surgery, I had a clear understanding<.0001
      Understood infectionI now have a clear understanding.1944
      Understood infectionResidual infection.3358
      Understood infectionIt was the right decision.0197
      Understood infectionI regret the choice I made.0127
      Understood infectionI would go for the same choice.0107
      Understood infectionThe choice did me a lot of harm.1137
      Understood infectionThe decision was a wise one.0096
      Understood infectionMy joint replacement and resulting infection.7569
      Understood impactBefore surgery, I had a clear understanding<.0001
      Understood impactAfter surgery, I had a clear understanding<.0001
      Understood impactI now have a clear understanding.4704
      Understood impactResidual infection.5868
      Understood impactIt was the right decision.0092
      Understood impactI regret the choice I made.1403
      Understood impactI would go for the same choice.0041
      Understood impactThe choice did me a lot of harm.2105
      Understood impactThe decision was a wise one.7146
      Understood impactMy joint replacement and resulting infection.8769
      Before surgery, I had a clear understandingAfter surgery, I had a clear understanding<.0001
      Before surgery, I had a clear understandingI now have a clear understanding.0634
      Before surgery, I had a clear understandingResidual infection.0984
      Before surgery, I had a clear understandingIt was the right decision.0267
      Before surgery, I had a clear understandingI regret the choice I made.0021
      Before surgery, I had a clear understandingI would go for the same choice.0016
      Before surgery, I had a clear understandingThe choice did me a lot of harm.0045
      Before surgery, I had a clear understandingThe decision was a wise one.0850
      Before surgery, I had a clear understandingMy joint replacement and resulting infection.4572
      After surgery, I had a understandingI now have a clear understanding.0043
      After surgery, I had a clear understandingResidual infection.1111
      After surgery, I had a clear understandingIt was the right decision.0308
      After surgery, I had a clear understandingI regret the choice I made.0001
      After surgery, I had a clear understandingI would go for the same choice<.0001
      After surgery, I had a clear understandingThe choice did me a lot of harm.0077
      After surgery, I had a clear understandingThe decision was a wise one.0404
      After surgery, I had a clear understandingMy joint replacement and resulting infection.5689
      I now have a clear understandingResidual infection.1032
      I now have a clear understandingIt was the right decision.8704
      I now have a clear understandingI regret the choice I made.1464
      I now have a clear understandingI would go for the same choice.1874
      I now have a clear understandingThe choice did me a lot of harm.0722
      I now have a clear understandingThe decision was a wise one.7554
      I now have a clear understandingMy joint replacement and resulting infection.5837
      Residual infectionIt was the right decision.9210
      Residual infectionI regret the choice I made.5808
      Residual infectionI would go for the same choice.4302
      Residual infectionThe choice did me a lot of harm.1052
      Residual infectionThe decision was a wise one.3869
      Residual infectionMy joint replacement and resulting infection<.0001
      It was the right decisionI regret the choice I made<.0001
      It was the right decisionI would go for the same choice<.0001
      It was the right decisionThe choice did me a lot of harm.0018
      It was the right decisionThe decision was a wise one<.0001
      It was the right decisionMy joint replacement and resulting infection.2062
      I regret the choice I madeI would go for the same choice<.0001
      I regret the choice I madeThe choice did me a lot of harm<.0001
      I regret the choice I madeThe decision was a wise one<.0001
      I regret the choice I madeMy joint replacement and resulting infection.0889
      I would go for the same choiceThe choice did me a lot of harm<.0001
      I would go for the same choiceThe decision was a wise one<.0001
      I would go for the same choiceMy joint replacement and resulting infection.0394
      The choice did me a lot of harmThe decision was a wise one<.0001
      The choice did me a lot of harmMy joint replacement and resulting infection<.0001
      The decision was a wise oneMy joint replacement and resulting infection<.0001
      Understood infectionMSIS.527205
      Understood impactMSIS.734999
      Before surgery, I had a clear understandingMSIS.41102
      After surgery, I had a clear understandingMSIS.2925
      I now have a clear understandingMSIS.042338
      Residual infectionMSIS.04937
      It was the right decisionMSIS.033576
      I regret the choice I madeMSIS.249182
      I would go for the same choiceMSIS.04937
      The choice did me a lot of harmMSIS.02817
      The decision was a wise oneMSIS.01187
      My joint replacement and resulting infectionMSIS.02283
      Regret scoreMSIS.031127
      MSIS, Musculoskeletal Infection Society.
      Results with P values <.05 are bolded.
      Appendix Table 2Pearson Correlation Coefficients to Evaluate Relationships Between Survey Questions, MSIS Outcome, and Regret Score.
      Variable 1Variable 2Pearson Coefficient
      Understood infectionUnderstood impact0.63477815
      Understood infectionBefore surgery, I had a clear understanding0.65160549
      Understood infectionAfter surgery, I had a clear understanding0.60828808
      Understood infectionI now have a clear understanding0.07865372
      Understood infectionResidual infection−0.1513486
      Understood infectionIt was the right decision0.32489561
      Understood infectionI regret the choice I made−0.226396
      Understood infectionI would go for the same choice0.32278863
      Understood infectionThe choice did me a lot of harm−0.2920838
      Understood infectionThe decision was a wise one0.27494932
      Understood infectionMy joint replacement and resulting infection−0.1278678
      Understood impactBefore surgery, I had a clear understanding0.56959783
      Understood impactAfter surgery, I had a clear understanding0.53601853
      Understood impactI now have a clear understanding0.01488482
      Understood impactResidual infection0.02201325
      Understood impactIt was the right decision0.2488672
      Understood impactI regret the choice I made−0.2614513
      Understood impactI would go for the same choice0.35093879
      Understood impactThe choice did me a lot of harm−0.2695292
      Understood impactThe decision was a wise one0.24269968
      Understood impactMy joint replacement and resulting infection−0.1500639
      Before surgery, I had a clear understandingAfter surgery, I had a clear understanding0.90657083
      Before surgery, I had a clear understandingI now have a clear understanding0.07059911
      Before surgery, I had a clear understandingResidual infection−0.1701791
      Before surgery, I had a clear understandingIt was the right decision0.41434338
      Before surgery, I had a clear understandingI regret the choice I made−0.4702157
      Before surgery, I had a clear understandingI would go for the same choice0.44315479
      Before surgery, I had a clear understandingThe choice did me a lot of harm−0.4378964
      Before surgery, I had a clear understandingThe decision was a wise one0.378884
      Before surgery, I had a clear understandingMy joint replacement and resulting infection−0.219168
      After surgery, I had a clear understandingI now have a clear understanding0.06230493
      After surgery, I had a clear understandingResidual infection−0.1357076
      After surgery, I had a clear understandingIt was the right decision0.42741
      After surgery, I had a clear understandingI regret the choice I made−0.4845471
      After surgery, I had a clear understandingI would go for the same choice0.46257445
      After surgery, I had a clear understandingThe choice did me a lot of harm−0.4289261
      After surgery, I had a clear understandingThe decision was a wise one0.39027424
      After surgery, I had a clear understandingMy joint replacement and resulting infection−0.1780795
      I now have a clear understandingResidual infection0.13886721
      I now have a clear understandingIt was the right decision0.03994883
      I now have a clear understandingI regret the choice I made−0.0031255
      I now have a clear understandingI would go for the same choice−0.0664866
      I now have a clear understandingThe choice did me a lot of harm0.05674465
      I now have a clear understandingThe decision was a wise one−0.0956525
      I now have a clear understandingMy joint replacement and resulting infection0.09427119
      Residual infectionIt was the right decision−0.0327952
      Residual infectionI regret the choice I made0.01878371
      Residual infectionI would go for the same choice−0.0229493
      Residual infectionThe choice did me a lot of harm0.14382969
      Residual infectionThe decision was a wise one−0.0443755
      Residual infectionMy joint replacement and resulting infection0.27751572
      It was the right decisionI regret the choice I made−0.7192122
      It was the right decisionI would go for the same choice0.72837225
      It was the right decisionThe choice did me a lot of harm−0.4818353
      It was the right decisionThe decision was a wise one0.74032754
      It was the right decisionMy joint replacement and resulting infection−0.3409499
      I regret the choice I madeI would go for the same choice−0.8339924
      I regret the choice I madeThe choice did me a lot of harm0.53167612
      I regret the choice I madeThe decision was a wise one−0.735491
      I regret the choice I madeMy joint replacement and resulting infection0.3005913
      I would go for the same choiceThe choice did me a lot of harm−0.5703183
      I would go for the same choiceThe decision was a wise one0.83794705
      I would go for the same choiceMy joint replacement and resulting infection−0.3548424
      The choice did me a lot of harmThe decision was a wise one−0.591351
      The choice did me a lot of harmMy joint replacement and resulting infection0.49899719
      The decision was a wise oneMy joint replacement and resulting infection−0.3969151
      Understood infectionMSIS−0.1694335
      Understood impactMSIS0.07681029
      Before surgery, I had a clear understandingMSIS−0.1243288
      After surgery, I had a clear understandingMSIS−0.1495655
      I now have a clear understandingMSIS−0.1346838
      Residual infectionMSIS0.41536407
      It was the right decision.MSIS−0.3923192
      I regret the choice I madeMSIS0.5283102
      I would go for the same choiceMSIS−0.2912920
      The choice did me a lot of harmMSIS0.4029487
      The decision was a wise oneMSIS−0.618203
      My joint replacement and resulting infectionMSIS0.7419201
      Regret scoreMSIS0.5928382
      Coefficients >abs (0.5) are bolded.
      MSIS, Musculoskeletal Infection Society.
      Appendix Table 3Statistical Tests to Identify Risk Factors for Regret After Surgical Management of PJI.
      Survey QuestionAge GroupSexType of SurgeryZip Code/IncomeLevel of Education
      10.94230.18630.71580.61930.6845
      20.43220.01510.09180.61690.4934
      30.30650.94630.96650.56100.6373
      40.39730.94460.87390.69120.7234
      50.21690.80160.87120.94500.2248
      60.27390.73380.43510.82410.9218
      70.25400.65510.76950.69750.2061
      80.72190.11860.78670.47180.2696
      90.63080.18210.76780.69950.2854
      100.38040.24790.79270.60520.3728
      110.94310.88150.05630.34250.7271
      120.91410.45830.94190.37630.2508
      Regret score0.91930.44240.63680.49240.2075
      PJI, periprosthetic joint infection.
      Results with P values <.05 are bolded.

      Appendix A. Supplementary Data

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