Suture Button versus Screw Fixation for Distal Tibiofibular Injury and Expected Value Decision Analysis

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.