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Syndesmotic injury

Screw or suture button — cost, removal rate, and malreduction.

Starting point, not a verdict

Drafted from the published literature and machine-assisted, then checked so that every citation resolves to a real indexed paper. It has not yet been reviewed by a clinician. Treat it as a starting point for the discussion, not as guidance.

Indication

Syndesmotic fixation is indicated for unstable distal tibiofibular syndesmosis injuries, most often encountered in the setting of operatively treated ankle fractures (Weber B and C) or as isolated high-grade ligamentous disruption. The decision point that divides surgeons is whether to use a rigid trans-syndesmotic screw, a flexible suture-button construct, or a combination of both, and whether routine implant removal is justified.

The techniques

  • Syndesmotic screw (static fixation): One or two cortical screws placed across the tibiofibular joint, typically 3.5 or 4.5 mm, engaging three or four cortices to hold the syndesmosis reduced while ligaments heal.
  • Suture button (flexible/dynamic fixation): A high-strength suture loop passed through a tibial and fibular button, tensioned to maintain reduction while permitting physiologic micromotion.
  • Combination fixation: Simultaneous use of a screw and a suture button, or staged conversion, intended to provide initial rigidity with later dynamic stability.

What the evidence says

Multiple systematic reviews and meta-analyses comparing rigid screw fixation with flexible suture-button fixation report no consistent difference in radiographic reduction parameters (medial clear space, tibiofibular clear space, tibiofibular overlap) [1]. Functional scores (AOFAS) tend to favor suture-button fixation at 3, 6, 12, and 24 months [PMID 30439535; PMID 30475639; PMID 33846031; PMID 38303073], though one large meta-analysis of RCTs found the difference did not reach statistical significance (MD 1.90, 95% CI -0.23 to 4.03) [2]. Suture-button constructs show lower rates of implant breakage (0% vs 25.4%) [3], lower implant removal rates (6% vs 22.4%) [3], and fewer malreductions (0.8% vs 11.5%) [3]. A 4DCT RCT demonstrated that flexible fixation restores syndesmotic motion closer to the uninjured side, while rigid fixation restricts motion even after screw breakage or removal [4]. Routine screw removal does not improve functional outcomes (AOFAS MD -1.84, 95% CI -4.33 to 0.66) [5] and carries a weighted mean surgical-site infection rate of 4% [1]. On-demand removal is cost-effective compared with routine removal (mean saving €3,160 per patient) [6]. Evidence for combination fixation is limited to small case series and is not addressed in the supplied comparative reviews.

What members see

Members who have switched to suture-button fixation: what is your observed malreduction rate compared with the 0.8% reported in the RCT meta-analysis [3]? For those retaining screws routinely: do you see a higher symptomatic hardware rate than the 22% removal figure in the same meta-analysis [3]? How many of you use combination constructs, and what specific indications drive that choice?

Cost and access

The only formal cost-effectiveness analysis in the supplied sources compares on-demand versus routine screw removal, finding on-demand removal saves approximately €3,160 per patient (direct and indirect costs) without QALY loss [6]. Suture-button implants are more expensive per unit than cortical screws, but the higher implant cost may be offset by lower removal rates [7]. No source provides comparative data on theatre time, imaging follow-up, or regional availability for the three techniques.

Open questions

  • Does combination fixation (screw + suture button) reduce malreduction rates below suture button alone in unstable Weber C fractures?
  • What is the long-term (>5 year) post-traumatic osteoarthritis rate after flexible versus rigid fixation?
  • Is there a role for bioabsorbable screws in this algorithm, and how do they compare on cost and complication profile?
  • How does weight-bearing protocol (immediate vs delayed) interact with fixation construct choice in functional outcomes?
  • What is the learning curve for suture-button placement, and does it affect malreduction rates in early adopters?

References

7 of 15 papers retrieved for this room are cited above. The search was limited to systematic reviews, meta-analyses and randomised trials in humans, English, 2016 onwards. Query and full result set: research/raw/syndesmosis.json.

  1. 1Comparison of suture button fixation and syndesmotic screw fixation in the treatment of distal tibiofibular syndesmosis injury: A systematic review and meta-analysis. Int J Surg 2018 · PMID 30439535 Meta-Analysis, Systematic Review
  2. 2Dynamic Fixation Versus Static Fixation for Distal Tibiofibular Syndesmosis Injuries: A Meta-Analysis. Med Sci Monit 2019 · PMID 30776287 Meta-Analysis
  3. 3Suture Button Versus Syndesmotic Screw for Syndesmosis Injuries: A Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2019 · PMID 30475639 Meta-Analysis
  4. 4In Vivo Syndesmotic Motion After Rigid and Flexible Fixation Using 4-Dimensional Computerized Tomography. J Orthop Trauma 2022 · PMID 35594514 Randomized Controlled Trial
  5. 5Is routine removal of syndesmotic screw justified? A meta-analysis. Foot (Edinb) 2021 · PMID 33992455 Meta-Analysis, Review
  6. 6Cost-effectiveness of on-demand removal of syndesmotic screws. Eur J Trauma Emerg Surg 2023 · PMID 36372813 Randomized Controlled Trial
  7. 7Syndesmotic Stabilization: Syndesmotic Screw Versus Flexible Fixation: A Systematic Review. J Foot Ankle Surg 2021 · PMID 33846031 Systematic Review

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