SLR - August 2019 - Amanda M. Kohut

Dynamic Stabilization of Syndesmosis Injuries Reduces Complications and Re-operations as Compared with Screw Fixation: A Meta-analysis of Randomized Controlled Trials

Reference: Grassi, Alberto, et al. "Dynamic Stabilization of Syndesmosis Injuries Reduces Complications and Reoperations as Compared with Screw Fixation: A Meta-analysis of Randomized Controlled Trials." The American Journal of Sports Medicine (2019).

Scientific Literature Review

Reviewed By: Amanda M. Kohut, DPM
Residency Program: University of Florida Health – Jacksonville, FL

Podiatric Relevance: The ideal construct for distal tibiofibular syndesmotic repair is quite the hot topic amongst foot and ankle surgeons as of late. Regarding the mechanical properties of the repair, both dynamic and static fixation inherently impact functional outcomes, complications, and re-operation rate. This meta-analysis from Italy evaluated the most recent level 1 studies regarding this contested issue and hypothesized that the outcomes would be equivocal between the two methods.

Methods: A systematic literature search was performed from the usual databases (PubMed, Cochran Central Register of Controlled Trials, Embase) and also included unpublished studies via Keywords used included variations of “syndesmosis”, “high ankle”, “dynamic fixation” and several trade names of popular marketed products. Eligible studies included randomized controlled studies (RCTs) comparing active versus static surgical constructs of acute syndesmosis repair with or without associated ankle fracture. There was no criteria utilized for technique, sample size, or length of follow-up. Initially, 373 articles were resulted with 7 passing inclusion and exclusion criteria.          

Results: Dynamic fixation had a significantly lower relative risk of complications – most importantly was the reduced incidence of inadequate reduction at final follow-up and/or residual instability. The re-operation rate was similar between active and static fixation; however, the overall risk was reduced as compared with screws. The AOFAS score was statistically higher among patients treated with the dynamic construct – 6 points higher at 3 months, 5.2 points at 12 months, and 8.6 points higher at 24 months. The VAS for pain was reduced at 6 months (-0.73) and at 12 months (-0.52); ankle range of motion increased by 4.36 degrees with dynamic fixation. The overall quality of evidence ranged from “moderate” to “very low”, owing to a high risk of bias, study variables, indirectness of outcome reporting, and a limited number of patients.

Conclusions: The overall risk of complications, recurrent diastasis/instability, implant breakage, inadequate reduction at follow-up, and implant-related issues was significantly reduced via flexible fixation. Most importantly, this study found that utilizing dynamic fixation of acute syndesmotic injuries was able to reduce the complications and improve functional outcomes as compared to static screw fixation. This finding rejected the initial hypothesis that both methods would have similar results. As with most systematic reviews, the heterogeneity in the included studies, small sample size, and short follow-up all limit the overall quality of this evidence. 

Educational Opportunities