SLR - April 2018 - Shyam A. Sheth

Randomized Trial Comparing Suture Button with Single Syndesmotic Screw for Syndesmotic Injury

Anderson MR, Frihagen F, Hellund JC., Madsen JE., Figved W. Randomized Trial Comparing Suture Button with Single Syndesmotic Screw for Syndesmotic Injury. The Journal of Bone and Joint Surgery. 2018 Jan 3; 100: 2–12.

Scientific Literature Review

Reviewed By: Shyam A. Sheth, DPM
Residency Program: Temple University Hospital, Philadelphia, PA

Podiatric Relevance:
Ankle fractures with syndesmotic instability are commonly encountered and treated by foot and ankle surgeons. Open reduction internal fixation is typically warranted for treatment of an unstable ankle fracture. Traditionally, solid syndesmotic screws have been employed to stabilize syndesmotic injury and instability. More recently, the dynamic suture button has been introduced and has been suggested as a method of fixation for syndesmotic injury. This dynamic fixation enables maintenance of the tibiofibular rotation while preventing diastasis. This study reviews clinical and radiographic results of 97 randomized patients who sustained an ankle fracture with syndesmotic instability treated with syndesmotic screw or suture button. This article is of use to foot and ankle surgeons in that it compares clinical outcomes as well as radiographic outcomes of fixation in an often-seen injury to the lower extremity.

Methods: This is a therapeutic Level 1 randomized study performed on all patients who sustained a traumatic injury to the syndesmosis with or without concomitant OTA/AO type 44-C ankle fracture. A total of 97 subjects were randomized to have the syndesmosis stabilized by either a Synthes 4.5 mm cortical syndesmotic screw or an Arthrex TightRope. Outcomes were evaluated at six weeks, six months, one year and two years. The main outcome measure was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot scale. Furthermore, radiographic measurements from a CT scan were taken immediately after the surgery, at six weeks and six months.

Results: Patients with the suture button utilized in this study demonstrated better AOFAS scores throughout the evaluations, with a statistically significant difference between the groups from six months onward. The difference in the tibiofibular distance between the injured and not injured sides increased in both treatment groups during the first year. The increase in distance was greater in the syndesmotic screw group, which may suggest that the suture button provides better conditions for syndesmotic healing.

Conclusion: There was a statistically significant difference in the AOFAS score as well as a number of secondary measurements in those treated with the suture button as compared to the syndesmotic screw. Those treated with the suture button had higher AOFAS and OMA scores and had better radiographic outcomes than those who received one quadcortical syndesmotic screw. The authors’ hypothesis was supported in that the suture button would provide better patient outcomes as well as radiographic outcomes. This form of fixation also has the potential to decrease the reoperation rate, as removal of the syndesmotic screw three to six months postoperatively is often performed.

Educational Opportunities