A decision analysis of amputation versus reconstruction for severe open tibial fracture from the physician and patient perspectives

Abstract

Although reconstruction is often the primary choice of surgeons after an open tibial fracture, there is no evidence to support the long-term effectiveness of flap reconstruction over below-knee amputation. The aim of this study was to perform a decision analysis to evaluate treatment preferences for type IIIB and IIIC tibial fractures. Reconstructive microsurgeons, physical medicine physicians, and patients with lower extremity trauma completed a Web-based standard gamble utility survey to generate quality-adjusted life years (QALYs). Physicians assigned quite high utility values, and there was a slight preference for reconstruction over amputation, with a gain of only 0.55 QALY. Patients assigned significantly lower utility values and also favored reconstruction over amputation, but with a larger gain of 5.54 QALYs. The disparate utilities assigned by the physicians and the patients highlight the necessity of realistic discussion of outcomes, regardless of the management methods.

Figure 1

Equation for utility

Figure 2

Type IIIB and IIIC tibial fracture decision tree structure

Figure 3

Equation for QALYs

Figure 4

Type IIIB and IIIC tibial fracture decision tree

Figure 5

Sensitivity analysis on healthy remaining years of life using physician-rated utilities

Figure 6

Sensitivity analysis on healthy remaining years of life using patient-rated utilities