Internal fixation of distal tibiofibular syndesmotic injuries: a systematic review with meta-analysis

Abstract

No consensus had been reached about the optimal method for syndesmotic fixation. The present study analysed syndesmotic fixation based on the highest level of clinical evidence in order to obtain more reliable results. Medline, Embase and Cochrane database were searched through the OVID retrieval engine. Manual searching was undertaken afterward to identify additional studies. Only randomized controlled trials (RCT) and prospective comparative studies were selected for final inclusion. Study screening and data extraction were completed independently by two reviewers. All study characteristics were summarized into a table. The extracted data were used for data analysis. Twelve studies were finally included: six of them were RCTs, two were quasi-randomized studies and four were prospective comparative studies. Four comparisons with traditional metallic screw were identified in terms of bioabsorbable screws, tricortical fixation method, suture-button device as well as non-fixation choice in low syndesmotic injuries. Both absorbable screws and the tricortical fixation method showed almost no better results than traditional quadricortical metallic screw (p>0.05). Additionally, existing studies could not illustrate their efficiency of reducing hardware removal rate. The suture button technique had significantly better functional score (p=0.003), ankle motion (p=0.02), time to full weightbearing (p<0.0001) and much less complications (p=0.0008) based on short and intermediate term follow-up data. Transfixation in low syndesmotic injuries showed poorer results than the non fixed group in all outcome measurements, but didn't reach a significant level (p>0.05). The present evidence still couldn't find superior performance of the bioabsorbable screw and tricortical fixation method. Their true effects in decreasing second operation rate need further specific studies. Better results of the suturebutton made it a promising technique, but it still needs long-term testing and cost-efficiency studies. The patients with low syndemotic injuries should be well assessed before fixation determination and the indication of screw placement in such conditions needs to be further defined.

Biomechanical comparison of bionic, screw and Endobutton fixation in the treatment of tibiofibular syndesmosis injuries

“…The widely used screw fixation has been reported to have several drawbacks: the prolonged immobilization and related complications, late syndesmotic widening after screw removal, screw loosening, screw breakage, and the need for a second operation to remove the screw [21,22]. The more recent development is the Endobutton fixation and its use is rapidly increasing; potentially, this technique has the following advantages: allows physiologic micromotion at the syndesmosis and thus an earlier return to weightbearing was possible, lessens the risk of hardware pain and the implant removal will not be necessary, without the risk of screw breakage and subsequent recurrent syndesmotic diastasis [15,[23][24][25]. However, this method still has some defects such as the suture loop may relax under weightbearing conditions, local irritation, osteolysis of the bone and subsidence of the device into the bone (as was occasionally observed), and its relatively high cost and complexity [17,26].…”

Bioabsorbable Versus Metallic Screw Fixation for Tibiofibular Syndesmotic Ruptures: A Meta-Analysis

“…The complications in the other 3 included studies was 0% to 10%. Two noncomparative studies and one review described the satisfying results of bioabsorbable screws in terms of functional scores, complications, stability, and complications (4,9,16). Wang et al (9) found a 5.2% complication rate in 77 patients with bioabsorbable screws compared with 4.3% in 70 patients with metallic screws.…”

“…Moreover, these bioabsorbable screws do not interfere with radiographic imaging (8). The disadvantages include the higher purchase costs and, according to some investigators, a possible tendency toward a greater complication rate (9).…”

Letter regarding article by Wang et al., “Internal fixation of distal tibiofibular syndesmotic injuries: a systematic review with meta-analysis”

“…

To the Editor, We read with great interest the article by Wang et al [1] titled "Internal fixation of distal tibiofibular syndesmotic injuries: a systematic review with meta-analysis" published on-line in July 2013 in International Orthopaedics. In this meta-analysis, Wang et al analysed the optimal method for syndesmotic fixation.

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