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The Difference Is in What Is or Is Not Included
Commentary
Metallic Hardware Not a Considered Complication It is interesting that two different meta-analyses aimed to answer the same question. It should be made clear that reoperation for metallic hardware removal was not considered a complication in our report (1). Complications after surgery did not include incidence of reoperation, and the lower reoperation rate was regarded as an indication of the superiority of absorbable screws. Other than the incidence of foreign body reactions, the complications occurring after use of absorbable screws were not as serious as those that occured with metallic screws. Under these circumstances, we considered absorbable screws to be a preferable alternative for reconstruction of distal tibiofibular syndesmosis injuries. However, in the van der Eng et al (2) article, reoperation for metallic hardware removal was considered to be a routine procedure. First, the difference of the inclusion criteria between these two meta-analyses needs to be mentioned. English was a language criterion in van der Eng et al (2), but any language, including Chinese, was included in our article (1). Because of cultural differences, people in China have the convention that the body originates from one’s parents, and any foreign body is not allowed to be retained in the body. Second, although implant removal is
generally not necessary or recommended after successful surgical procedures, the foot and ankle can be more symptomatic from retained implants with weightbearing activities, shoe wear, and limited soft tissue cushioning. The reason for return to operating room included metallic hardware removal, infection, and nonhealing. But no independent analysis was conducted on every single factor leading to metallic hardware removal, which may be a limitation of our study. Xie Yuanlong, MCM Department of Orthopedics Zhongnan Hospital of Wuhan University Wuhan, People’s Republic of China References 1. Xie Y, Cai L, Deng Z, Ran B, Hu C. Absorbable screws versus metallic screws for distal tibiofibular syndesmosis injuries: a meta-analysis. J Foot Ankle Surg 54:663–670, 2015. 2. van der Eng DM, Schep NWL, Schepers T. Bioabsorbable versus metallic screw fixation for tibiofibular syndesmotic ruptures: a meta-analysis. J Foot Ankle Surg 54:657–662, 2015.
The Difference Is in What Is or Is Not Included We thank Journal Editor D. Scot Malay, DPM, MSCE, FACFAS, for his Editorial regarding both, seemingly overlapping, manuscripts. In addition to the differences correctly pointed out by Dr. Malay, we would like to add two large differences, which have led to the contradicting outcome of both meta-analyses. The difference in the total number of included manuscripts for each of the articles discussed (van der Eng et al [1] and Xie et al [2]) is due to the fact that our article (1) soley looked at the management of the syndesmotic injury, whereas the article by Xie et al (2) looked at ankle fractures in general, with or without syndesmotic injury. The manuscripts that were included by Xie et al (2) but that were not included by van der Eng et al (1) are those in which no distinct comparison in syndesmotic fixation is made but in which a comparison of total fixation of fracture malleoli with bioabsorbable or steel implants is made. In addition, in our meta-analysis (1), we only included articles written in English. The meta-analysis of Xie et al (2) included 6
articles that were either written in Chinese or not available via NCBI/ PubMed or Google Scholar. Tim Schepers, MD, PhD Dorien M. van der Eng, MD Department of Surgery Academic Medical Centre Amsterdam, The Netherlands
References 1. van der Eng DM, Schep NWL, Schepers T. Bioabsorbable versus metallic screw fixation for tibiofibular syndesmotic ruptures: a meta-analysis. J Foot Ankle Surg 54:657–662, 2015. 2. Xie Y, Cai L, Deng Z, Ran B, Hu C. Absorbable screws versus metallic screws for distal tibiofibular syndesmosis injuries: a meta-analysis. J Foot Ankle Surg 54:663–670, 2015.
No Resident Left Behind: Statistical Illiteracy and What Lies Beyond the Abstract We have all done it before. Read an abstract, made a conclusion, then flipped to the next article. The intellectual equivalent of a fast food drive-through, abstracts are quick, convenient, but ultimately devoid of the nutrition we need. The dependence on abstracts is a habit we acquire early in school. Sheepishly it’s attributed to limited time; however, often our statistical illiteracy
and lack of understanding of research methods keeps us from traveling beyond the pre-packaged, processed delight that exists at the beginning of each article. Two meta-analyses (van der Eng et al [1] and Xie et al [2]) presented in this issue compare absorbable versus nonabsorbable syndesmotic fixation. These articles serve as an example of the risk
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.05.013
Metallic Hardware Not a Considered Complication It is interesting that two different meta-analyses aimed to answer the same question. It should be made clear that reoperation for metallic hardware removal was not considered a complication in our report (1). Complications after surgery did not include incidence of reoperation, and the lower reoperation rate was regarded as an indication of the superiority of absorbable screws. Other than the incidence of foreign body reactions, the complications occurring after use of absorbable screws were not as serious as those that occured with metallic screws. Under these circumstances, we considered absorbable screws to be a preferable alternative for reconstruction of distal tibiofibular syndesmosis injuries. However, in the van der Eng et al (2) article, reoperation for metallic hardware removal was considered to be a routine procedure. First, the difference of the inclusion criteria between these two meta-analyses needs to be mentioned. English was a language criterion in van der Eng et al (2), but any language, including Chinese, was included in our article (1). Because of cultural differences, people in China have the convention that the body originates from one’s parents, and any foreign body is not allowed to be retained in the body. Second, although implant removal is
generally not necessary or recommended after successful surgical procedures, the foot and ankle can be more symptomatic from retained implants with weightbearing activities, shoe wear, and limited soft tissue cushioning. The reason for return to operating room included metallic hardware removal, infection, and nonhealing. But no independent analysis was conducted on every single factor leading to metallic hardware removal, which may be a limitation of our study. Xie Yuanlong, MCM Department of Orthopedics Zhongnan Hospital of Wuhan University Wuhan, People’s Republic of China References 1. Xie Y, Cai L, Deng Z, Ran B, Hu C. Absorbable screws versus metallic screws for distal tibiofibular syndesmosis injuries: a meta-analysis. J Foot Ankle Surg 54:663–670, 2015. 2. van der Eng DM, Schep NWL, Schepers T. Bioabsorbable versus metallic screw fixation for tibiofibular syndesmotic ruptures: a meta-analysis. J Foot Ankle Surg 54:657–662, 2015.
The Difference Is in What Is or Is Not Included We thank Journal Editor D. Scot Malay, DPM, MSCE, FACFAS, for his Editorial regarding both, seemingly overlapping, manuscripts. In addition to the differences correctly pointed out by Dr. Malay, we would like to add two large differences, which have led to the contradicting outcome of both meta-analyses. The difference in the total number of included manuscripts for each of the articles discussed (van der Eng et al [1] and Xie et al [2]) is due to the fact that our article (1) soley looked at the management of the syndesmotic injury, whereas the article by Xie et al (2) looked at ankle fractures in general, with or without syndesmotic injury. The manuscripts that were included by Xie et al (2) but that were not included by van der Eng et al (1) are those in which no distinct comparison in syndesmotic fixation is made but in which a comparison of total fixation of fracture malleoli with bioabsorbable or steel implants is made. In addition, in our meta-analysis (1), we only included articles written in English. The meta-analysis of Xie et al (2) included 6
articles that were either written in Chinese or not available via NCBI/ PubMed or Google Scholar. Tim Schepers, MD, PhD Dorien M. van der Eng, MD Department of Surgery Academic Medical Centre Amsterdam, The Netherlands
References 1. van der Eng DM, Schep NWL, Schepers T. Bioabsorbable versus metallic screw fixation for tibiofibular syndesmotic ruptures: a meta-analysis. J Foot Ankle Surg 54:657–662, 2015. 2. Xie Y, Cai L, Deng Z, Ran B, Hu C. Absorbable screws versus metallic screws for distal tibiofibular syndesmosis injuries: a meta-analysis. J Foot Ankle Surg 54:663–670, 2015.
No Resident Left Behind: Statistical Illiteracy and What Lies Beyond the Abstract We have all done it before. Read an abstract, made a conclusion, then flipped to the next article. The intellectual equivalent of a fast food drive-through, abstracts are quick, convenient, but ultimately devoid of the nutrition we need. The dependence on abstracts is a habit we acquire early in school. Sheepishly it’s attributed to limited time; however, often our statistical illiteracy
and lack of understanding of research methods keeps us from traveling beyond the pre-packaged, processed delight that exists at the beginning of each article. Two meta-analyses (van der Eng et al [1] and Xie et al [2]) presented in this issue compare absorbable versus nonabsorbable syndesmotic fixation. These articles serve as an example of the risk
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.05.013