Effectiveness of suture button fixation vs screw fixation for the management of acute distal tibiofibular syndesmotic injuries: a systematic review and meta-analysis.

OBJECTIVE

The aim of this systematic review was to determine whether suture button fixation is superior to traditional screw fixation for injuries to the distal tibiofibular syndesmosis.

INTRODUCTION

Injuries to the distal tibiofibular syndesmosis that require surgical intervention are common. Effectiveness of surgical management of these injuries has been firmly established; however, there remains ongoing debate surrounding which implant should be used. Suture button fixation offers theoretical benefits allowing dynamic fixation of a mobile structure compared to the static alternative offered with screw fixation.

ELIGIBILITY CRITERIA: This review evaluated studies that met the following criteria: (i) randomized controlled trials; (ii) comparison of outcomes of suture button vs screw fixation for the management of acute syndesmotic injury (<6 weeks since injury); and (iii) skeletally mature patient (age >18 years). The primary outcome of interest was composite functional ankle scores, with secondary outcomes including range of motion, pain, joint malreduction, complication rates, re-operation rates, and return to work/sport.

METHODS

A systematic search of PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and Web of Science was conducted from inception to May 2024. Gray literature was searched via MedNar, ProQuest Dissertations and Theses, OpenGrey, and Libraries Australia. Two reviewers independently screened titles, abstracts, and full texts against prespecified eligibility criteria, critically appraised included studies using the JBI Critical Appraisal Checklist for Randomized Controlled Trials, and extracted data using the JBI data extraction tool. Outcomes were pooled using random-effects meta-analysis. Certainty of the evidence was assessed using GRADE and presented in a Summary of Findings.

RESULTS

The literature search identified 16 reports of randomized controlled trials, involving 783 unique participants comparing outcomes for suture button compared to screw fixation of acute syndesmotic injuries. Patients treated with suture button fixation had a significantly better complication profile with fewer overall complications (odds ratio [OR] 0.22, 95% CI 0.10 to 0.50, P ≤ 0.01), overall reoperations (OR 0.34, 95% CI 0.19 to 0.62, P ≤ 0.01), implant breakage (OR 0.09, 95% CI 0.03 to 0.21, P ≤ 0.01), and unplanned implant removal (OR 0.37, 95% CI 0.18 to 0.76, P =0.01) without significant differences in rates of infection (OR 1.58, 95% CI 0.61 to 4.14, P =0.35), syndesmotic malreduction (OR 0.48, 95% CI 0.22 to 1.03, P =0.06), or range of ankle plantarflexion (standardized mean difference [SMD] 0.22, 95% CI -0.07 to 0.51, P =0.13) or dorsiflexion (SMD 0.07, 95% CI -0.22 to 0.36, P =0.62). Across a range of clinical outcome measures, suture button fixation had comparable outcomes to screw fixation, with the only statistically significant difference being an improvement in the composite functional ankle score at 1 year measured using the American Orthopaedic Foot and Ankle Society (AOFAS) score (SMD 0.32, 95% CI 0.07 to 0.57).

CONCLUSIONS

Suture button fixation has a significantly improved complication profile when compared to screw fixation for the management of acute syndesmotic injuries. Suture button fixation also had slightly improved early functional outcomes, with similar short-, medium-, and long-term clinical outcomes. Suture button fixation should be recommended for the surgical management of syndesmotic injuries.

REVIEW REGISTRATION: PROSPERO CRD42022331211.