SLR - June 2021 - Kari Phan

Suture-Button Versus Screw Fixation in Adolescent Syndesmotic Injuries: Functional Outcomes and Maintenance of Reduction

Reference: Lurie BM, Paez CJ, Howitt SR, Pennock AT. Suture-button Versus Screw Fixation in Adolescent Syndesmotic Injuries: Functional Outcomes and Maintenance of Reduction. J Pediatr Orthop. 2021 Mar 22.

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Kari Phan, DPM
Residency Program: MetroWest Medical Center – Framingham, MA

Podiatric Relevance: The tibiofibular syndesmosis often needs to be fixed in an unstable ankle fracture. While the conventional fixation is syndesmotic screw, recently the use of suture-button has been adopted in both adults and adolescents. Many studies report a lower rate of hardware removal and improved syndesmosis reduction where the suture-button has been shown to reduce the sagittal plane malreduction. The aim of this study was to compare the outcomes of syndesmotic screw versus suture-button in adolescent syndesmotic injuries through maintenance of reduction, complication rates, and functional outcomes.

Methods: This is a retrospective review of adolescent patients ages 10-19 at a single Level 1 Pediatric Trauma Center from 2010-2019. Fixation of the syndesmosis was necessary when with force on the distal fibula and there is a >2 millimeters of lateral translation of the fibula with widening of the ankle mortise or >2 millimeters of posterior translation of the fibula relative to the tibia. Choice of fixation method was made by treating surgeon on a case by case basis. Decision to leave in or remove fixation at three months was up to the surgeon on a case by case basis. Diastasis, loss of syndesmotic reduction, was defined as either >2 millimeters increase in tibiofibular clear space or >2 millimeters decrease in tibiofibular overlap. Functional outcome measures were obtained at a minimum of one-year post surgery using the Foot and Ankle Ability Measure.  

Results: Seventy-seven adolescents were included in this study, 54 male and 23 females. 45 patients (28 male), were treated with a syndesmotic screw and 32, (26 male), were treated with a suture-button. One patient treated with the syndesmotic screw needed a revision due to continued widening of the syndesmosis with continued increase in medial clear space. Revised with an open reduction internal fixation with a suture-button. No patients in the suture-button group had postoperative malreduction or diastasis. Eight patients in the syndesmotic screw group and nine in the suture-button group weighed >100 kilograms. Implant removal was more common in syndesmotic screw fixation (80 percent) than suture-button fixation (12.5 percent). Infections occurred in both groups. One superficial infection and one deep infection in the syndesmotic screw group. One superficial infection and no deep infection in the suture-button group. There was no significant difference in the functional outcome in a mean follow-up of four years.

Conclusions: In the present study,  both the syndesmotic screw and suture-button maintained the reduction and provided similar Foot and Ankle Ability Measure outcomes. Suture-button fixation had a significantly lower rate of implant removal due to symptomatic reasons, reducing long term healthcare costs and improving quality of life. Both fixations maintained the reduction of the syndesmosis in adolescents weighing greater than 100 kilogram. There has been an increase in evidence for adult patients in which suture-button provides a lower rate of postoperative diastasis compared to the syndesmotic screw. The study recommends the use of suture-button as a fixation for syndesmotic injuries in adolescent patients.

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