SLR - February 2023 - Tyler D. Sten, DPM
Title: Does a Reduced Secondary Operation Rate Offset Higher Implant Charges When Utilizing SutureButton Fixation for Syndesmotic Injuries?
Reference: Flanagan, Christopher D. MD; Solomon, Eric BS; Michalski, Joseph MD; Stang, Thomas S. DO; Stenquist, Derek S. MD; Donohue, David MD; Shah, Anjan MD; Maxson, Benjamin DO; Watson, David MD; Ochenjele, George MD; Mir, Hassan R. MD, MBA. Does a Reduced Secondary Operation Rate Offset Higher Implant Charges When Utilizing Suture Button Fixation for Syndesmotic Injuries?. J Orthop Trauma. 2022 August 18
Level of Evidence: Level III Retrospective Cohort Review
Reviewed By: Tyler D. Sten, DPM
Residency Program: Ascension St. Vincent Indianapolis
Podiatric Relevance: Stabilization of the ankle syndesmosis continues to be a controversial topic when taking cost into consideration. Recent literature has shown implant removal rates are declining as studies have failed to demonstrate differences in functional outcomes. Nevertheless, some data suggests that the removal of symptomatic implants can improve outcomes. Fixation of the syndesmosis remains a complex problem with choice of implant whether screw or suture button, depending on setting of implantation. The main purpose of this study was to compare implant cost with secondary operation charges based on differential implant removal rates between screws and suture buttons.
Methods: This study was a level III retrospective cohort study at a single level I trauma center in the southeastern United States. Cases were isolated with the CPT code 27829 (Fracture and/or Dislocation Procedures on the Leg (Tibia/Fibula) and Ankle Joint) and queries of CPT code 20680 (removal of implant, deep) from 2016 to 2020. Inclusion criteria included rotational ankle injury the required syndesmotic fixation with either a suture button or screw construct. Review of initial injury radiographic images allowed for injury classification via the OTA/AO system, as well as an assessment of the fixation strategy used for syndesmotic stabilization. Surgeons utilized either a 3.5mm screw or one of three suture button implants. Data for list charges for each of the implants and facility charge were compiled. Charge estimates for secondary operations relied on data from AAOS Code-X and two prior studies on charges and collections.
Results: There was a total of 327 patients. Most patients underwent syndesmotic stabilization with screw fixation (73.1%). Patients undergoing screw fixation were older (48.8 vs 39.6 years, p<0.01), and had lower energy mechanisms of injury (59.3% vs 51.1%, p =0.026). Implant removal occurred at a higher rate in the screw fixation group (17.6% vs 5.7%, p=0.005) secondary to pain in most cases (78.6% vs 40%). Non-smoker status (B=1.03, p=0.04) and implant type (B=1.41, p=0.008) were identified as factors associated with implant removal. Charges for suture button were a mean of $1108, compared to $25 for a solid 3.5mm screw. The number needed to treat with a suture button construct to prevent one implant removal operation was 9, with mean resulting additional implant charges of $9747 ($1083/case). Backwards calculations using data from previous large studies estimated secondary operation charges at approximately $14220, suggesting a potential 31.5% reduction in cost for suture buttons when considering reduced secondary operation rates.
Conclusions: In conclusion, the optimal methods for syndesmotic imaging, reduction, and fixation methods remains controversial and situational. The two fixation strategies likely confer similar functional results as confirmed by previous studies. Though suture buttons have higher implant charges with higher upfront costs, the reduction in the risk for a secondary operation may offset these increased charges when considering institutional implant removal rates. Therefore, in the absence of any new evidence supporting one fixation strategy over the other, surgeons should utilize the fixation strategy they deem most appropriate in their practice setting.