SLR - January 2018 - Anne P. Stroze

Five-Year Outcomes After Treatment for Acute Instability of the Tibiofibular Syndesmosis Using a Suture Button Fixation System

Reference: Förschner PF, Beitzel K, Imhoff AB, Buchmann S, Feuerriegel G, Hofmann F, Karampinos DC, Jungmann P, Pogorzelski J. Five-Year Outcomes After Treatment for Acute Instability of the Tibiofibular Syndesmosis Using a Suture Button Fixation System Orthop J Sports Med. 2017 Apr 27;5(4).

Scientific Literature Review

Reviewed By: Anne P. Stroze, DPM
Residency Program: Wheaton Franciscan Healthcare, St. Joseph Hospital, Milwaukee, WI

Podiatric Relevance: Acute instability of the tibiofibular syndesmosis is commonly seen and treated by podiatric surgeons. There are multiple methods of treatment for failed conservative measures, including screw and suture button-type fixation. Although suture button method has become widely accepted as an appropriate method of treatment, long-term results have not been reported. This study assesses both the clinical and MRI outcomes of suture button fixation for acute instability of the tibiofibular syndesmosis, with the hypothesis that patients would not suffer pain, malfunction or develop cartilaginous lesions after fixation.

Methods: This is a level-IV, retrospective case series of 19 patients with a mean follow-up of 62 (+/- 31) months, eight demonstrating injured PITFL and 11 with torn AITFL. Patients were treated for isolated acute injuries within three weeks from index injury with syndesmotic suture button fixation. Patients were then assessed utilizing the Foot and Ankle Disability Index questionnaire (FADI), clinical examination of ROM using AOFAS ankle hindfoot scoring and 3-T MR image analysis utilizing the Ankle Osteoarthritis Scoring System (AOSS). Scores were then analyzed using spearman correlations and paired T-tests.

Results: Postoperatively, the median FADI score was 136, and AOFAS was 100. Three patients refused MRI because they no longer had any pain or malfunction. MRI demonstrated intact anterior and posterior syndesmotic ligaments, with increased thickening compared to the contralateral ankle. There was no significant difference between cartilage or the affected and contralateral ankles, with a median AOSS score of 1.5 on the ipsilateral and 0 on the contralateral ankle. Malreduction was noted in only two patients. Although results were positive, suture button removal was required in five patients, and revision was required in one patient (two years after initial surgery). MRI results did not correlate with clinical scores.

Conclusions: Both short-term and midterm results of the suture button system demonstrate better results than those reported previously in literature. The authors concluded this to be an excellent treatment for isolated injuries, resulting in stable ankles without early or advanced osteoarthritic changes at midterm follow-up. The majority of patients were able to return to previous athletic activity by 10 to 12 weeks. Although results demonstrate excellent findings, the sample size is limited to only 19 patients, three of which did not have MRI examination. Although screw removal as a follow-up procedure is avoided with use of suture button, physicians should be aware that irritation from hardware placement is still likely.

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