Abstract
Patient preference for fixation technique of syndesmotic injury in the presence of an ankle fracture is not known. This study followed a five-step process for expected value decision analysis: decision tree, outcome probabilities, expected patient values, foldback analysis, and sensitivity analysis. Outcome variables were “well” (cases that did not require further procedures or suffer any complications related to surgery), surgical site infection (SSI), loss of reduction (LOR), hardware removal (HWR), and malreduction. The systematic review included 22 studies including 358 patients who underwent suture button fixation and 739 who underwent screw fixation. Outcome probabilities for suture button fixation were 76.4% well, 6.2% SSI, 5.4% LOR, 10.4% HWR, and 1.6% malreduction. Outcome probabilities for screw fixation were 47.1% well, 4.3% SSI, 8.1% LOR, 30.7% HWR, and 9.8% malreduction. After the survey and foldback analysis, overall utility values for suture button and screw fixation were 7.46 and 4.78, respectively. One-way sensitivity analysis revealed that the overall utility value for suture button fixation was greater than the utility value of screw fixation under all circumstances except when the rate of malreduction for suture button fixation was theoretically elevated to 85%. Level of evidence: therapeutic, level IV.
Highlights
BackgroundAnkle fractures are one of the most common injuries treated by orthopedic surgeons and 20% of ankle fractures that require operative fixation have syndesmotic disruption [1,2]
Of these 41 articles, 12 meta-analyses and systematic reviews were excluded, four articles were excluded due to no postoperative outcomes reported, and three articles were excluded due to the inclusion of nongeneralizable subpopulations. This resulted in 22 papers meeting our inclusion criteria, including five randomized controlled trials and eleven comparative studies, with six studies investigating screw fixation only and five studies investigating suture button fixation only [5,6,7,8,9,10,11,12,13,14,15,16,17,20,21,22,23,24,25,26,27,28]
A total of 1,097 subjects were included in these studies, with outcomes reported for 358 subjects who underwent suture button fixation 739 patients who underwent screw fixation
Summary
BackgroundAnkle fractures are one of the most common injuries treated by orthopedic surgeons and 20% of ankle fractures that require operative fixation have syndesmotic disruption [1,2]. Despite the commonality of the injury and the volume of literature produced on the subject, no consensus on syndesmosis fixation has emerged In such a situation where treatment is dictated by surgeon preference, expected value decision analysis is a tool that can be used to incorporate patient preference in complex medical decision-making [28,29,30]. This method integrates published probabilities of outcomes in the literature with patient values with regard to what postoperative outcomes he or she prefers.
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