Better outcome for suture button compared with single syndesmotic screw for syndesmosis injury: five-year results of a randomized controlled trial

Abstract

Aims In a randomized controlled trial with two-year follow-up, patients treated with suture button (SB) for acute syndesmotic injury had better outcomes than patients treated with syndesmotic screw (SS). The aim of this study was to compare clinical and radiological outcomes for these treatment groups after five years. Methods A total of 97 patients with acute syndesmotic injury were randomized to SS or SB. The five-year follow-up rate was 81 patients (84%). The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. Secondary outcome measures included Olerud-Molander Ankle (OMA) score, visual analogue scale (VAS), EuroQol five-dimension questionnaire (EQ-5D), range of movement, complications, reoperations, and radiological results. CT scans of both ankles were obtained after surgery, and after one, two, and five years. Results The SB group had higher median AOFAS score (100 (interquartile range (IQR) 92 to 100) vs 90 (IQR 85 to 100); p = 0.006) and higher median OMA score (100 (IQR 95 to 100) vs 95 (IQR 75 to 100); p = 0.006). The SS group had a higher incidence of ankle osteoarthritis (OA) (24 (65%) vs 14 (35%), odds ratio (OR) 3.4 (95% confidence interval (CI) 1.3 to 8.8); p = 0.009). On axial CT we measured a significantly smaller mean difference in the anterior tibiofibular distance between injured and non-injured ankles in the SB group (–0.1 mm vs 1.2 mm; p = 0.016). Conclusion Five years after syndesmotic injury treated with either SB or SS, we found better AOFAS and OMA scores, and lower incidence of ankle OA, in the SB group. These long-term results favour the use of SB when treating an acute syndesmotic injury. Cite this article: Bone Joint J 2020;102-B(2):212–219.

Suture button versus syndesmosis screw fixation in pronation-external rotation ankle fractures: A minimum 6-year follow-up of a randomised controlled trial

“…Raeder Raeder et al reported high rates of syndesmosis malreduction, 70% in the SS group and 72% in the SB group, at five years. Moreover, unlike our findings, Reader et al found an increase in the overall malreduction rate during follow-up, from postoperative (32%) to five years (71%); however, the malreduction rates per group were only reported at five years [24] . The high malreduction rates in that study might be due to syndesmosis screw removal; they removed the SS after a mean of 85.9 days postsurgery, which might explain the late widening of the syndesmosis described earlier by Schepers et al (2011) and Hsu et al (2010) [ 24 , 37 , 38 ].…”

“…In their study, 11 patients had the SB removed before the two-year follow-up visit, but the exact timing of removal was not reported [ 19 , 24 ]. Moreover, their method for detecting syndesmosis malreduction was different than ours, but that does not explain the increasing rate of malreduction during follow-up, which was not observed in our study [24] . Our low malreduction rates in both the SS and SB groups were probably due to the experienced orthopaedic trauma surgeons, who performed all the operations during office hours, and the assessment of syndesmosis reduction with intraoperative CT of both ankles.…”

“…Additionally, post-traumatic ankle joint osteoarthritis (OA) may take over ten years to develop [ 22 , 23 ]. Currently, only one study has compared these two syndesmosis fixation methods and provided long-term results from a fiveyear follow-up [24] . Therefore, studies with longer follow-ups are needed to definitively address whether the two fixation methods differ in the maintenance of syndesmosis reduction, OA development, or the long-term ankle functional outcome.…”

Acute, isolated and unstable syndesmotic injuries are frequently associated with intra-articular pathologies

“…Today, surgical treatment consists of closed reduction of the distal tibiofibular joint and indirect fixation, either static or dynamic. Although static fixation by means of one or two syndesmotic screws is considered to be the most common procedure, emerging evidence points at a superior patient reported outcome for the dynamic fixation by a suture button system [ 31 ].…”

Is there any change in surgeon’s attitude to the management of ankle fractures accompanying syndesmotic injury? A nationwide survey

“…However, SFD has been shown to provide adequate fixation in cadaveric and clinical studies, and there are also publications indicating better functional results than screws. [ 21 ] The major disadvantage of using SFD is its cost and low availability compared with screws and is probably the reason for its limited use in this survey. Although the cost of SFD is higher than screws, when secondary procedures for device removal are considered, the cost for dynamic fixation has been found to be lower.…”