Comparison of screw and suture-button techniques in the treatment of ankle syndesmotic injuries.

BACKGROUND

Syndesmotic disruption frequently accompanies ankle fractures and requires stable fixation to restore distal tibiofibular congruence and function. Cortical screw and suture-button constructs are widely used; however, their relative superiority, particularly with respect to early recovery versus long-term outcomes, remains uncertain.

METHODS

We conducted a single-center, retrospective, nonrandomized cohort study of adults with ankle fractures and radiographically confirmed syndesmotic injuries treated between 2017 and 2021. Patients underwent fixation according to surgeon preference using either screws (n=81) or suture-button constructs (n=25). The primary outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at 12 months. Secondary outcomes included AOFAS score at 3 months, Olerud-Molander Ankle Score (OMAS) at final follow-up, tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and complication rates. Standardized anteroposterior (AP), mortise, and lateral radiographs were obtained preoperatively and postoperatively. Median follow-up was 14 months (range: 12-19). Treatment selection was at the operating surgeon's discretion, taking into account patient age and activity level, fracture pattern and instability (including initial subluxation or dislocation), soft-tissue condition, and implant availability.

RESULTS

Both groups demonstrated significant radiographic improvement in TFCS, TFO, and MCS from preoperative to post-operative assessment (all p<0.001). At three months, the suture-button group achieved higher AOFAS scores than the screw group (median, 75 vs. 70; p=0.009). However, the primary outcome of AOFAS score at 12 months and the final OMAS did not differ significantly between groups (p=0.161 and p=0.090, respectively). Interpretation of the findings is limited by baseline imbalances, including a younger patient population in the suture-button group (p=0.008) and unequal group sizes (81 vs. 25). Complication rates were low and comparable between groups.

CONCLUSION

Both cortical screw and suture-button fixation provided satisfactory long-term functional and radiographic outcomes in patients with ankle fractures and syndesmotic injuries. Although suture-button fixation was associated with superior early functional recovery, this apparent advantage should be interpreted cautiously given baseline differences and potential confounding. These hypothesis-generating findings support the need for prospective randomized trials with standardized rehabilitation protocols.