Beyond the Screw: Mapping the Evidence Landscape of Modern Syndesmotic Fixation.

» Syndesmotic fixation has evolved from predominantly rigid screw-based techniques toward dynamic stabilization methods, including suture-button devices and anatomic augmentation of the anterior inferior tibiofibular ligament (AITFL), which aim to restore more physiologic ankle motion while maintaining stability. » Suture-button fixation demonstrates clinical advantages over traditional screw fixation, including lower rates of hardware removal and reoperation, earlier return to weight bearing, and reduced implant-related complications. However, infection and neurovascular injury during medial placement remain important device-specific risks. » AITFL augmentation using suture tape or anchors shows promise in restoring native ligament biomechanics and may be particularly beneficial for young, high-demand patients with isolated ligamentous injuries, although long-term randomized trials are needed to validate early favorable outcomes. » Despite growing evidence for dynamic and hybrid fixation strategies, high-quality comparative data remain limited, with most studies consisting of cadaveric biomechanical analyses, retrospective case series, and technique descriptions rather than prospective randomized controlled trials with long-term functional outcomes. » Future research should prioritize standardized outcome measures, patient-reported functional data, and multicenter comparative trials to determine which fixation strategies provide optimal long-term stability, functional recovery, and cost-effectiveness across different patient populations and injury patterns.