Discussion
cortical erosion, syndesmotic injury
COMPLICATIONS, COMPLICATION
The mean difference in total costs was €3,160 per patient in favour of the ODR group. Even though the upper limit of the 95% confidence interval of the ICER was marginally higher than zero, it was well below the level of willingness to pay, which is 50.000 euro, which makes ODR a cost-effective intervention [This is the first cost analysis study to focus solely on screw fixation for syndesmotic injury, comparing cost-effectiveness of syndesmotic screws removed routinely or on demand. Previously performed cost analyses have focussed on the cost-effectiveness of screw versus dynamic implants, such as the suture button [In this study, the direct costs were higher following RR, mainly because of the costs of higher frequency of surgery and more readmissions at the surgical ward. In addition, we expected the costs to be higher due to the higher rate of SSIs in the RR group, resulting in higher health care costs. Therefore, we also calculated the difference in costs excluding patients with SSI, which had no relevant effect on the results. Thus, the difference in costs cannot be explained solely by the amount of SSIs in the RR group.For indirect costs, the iPCQ and the friction costs method with age-adjusted mean daily wages were used to estimate loss of productivity. Indirect costs, defined as lost hours of productivity, were higher in the RR group. Because this cohort was part of a RCT, we can assume that the hourly wage and therefore lost productivity costs were equally divided between both groups and that this does not account for the difference.The functional outcome after 12 months, measured with OMAS, did show a difference of 1.79 with higher scores following ODR [In the subgroup analysis comparing patients aged < 60 years and patients ≥ 60 years, we found that the costs gained when choosing for ODR are higher in the younger group, which can be attributed to the fact that the younger group has less indirect costs following ODR because these costs include costs made by work deprivation. The results of this subgroup analysis could be taken into account in daily practice.This study compared ODR and RR following syndesmotic injury, and the removal was performed at the operation room. Sugi et al. recently state that it is safe to remove the syndesmotic screw in a clinical setting out of the operating room based on a complication rate of 2 SSIs in 170 patients [A limitation of our study was that unit costs might vary between hospitals due to overhead costs, which was not accounted for in the current study, leading to an estimation of the costs per patient and in total. However, due to the randomized set-up of the study, uncertainties are expected to be equally divided. Additionally, in this study, only costs made within 12 months after syndesmotic fixation were incorporated. The results thereby do not include removal of screws after this period of time, or potential late complications of retaining the syndesmotic screw. We know that if the retained syndesmotic screw breaks, the location of breakage affects the chance of cortical erosion due to the broken syndesmotic screw [