Effectiveness of suture button fixation versus 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 requiring 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. METHODS: A systematic literature search was conducted in October 2022 and again in May 2024, identifying 16 randomized controlled trials, involving 783 unique participants comparing outcomes for suture button compared to screw fixation of acute syndesmotic injuries. RESULTS: Patients treated with suture button fixation had a significantly better complication profile with fewer overall complications (odds ratio [OR] 0.22, 95% CI 0.10-0.50, P =<0.01), overall reoperations (OR 0.34, 95% CI 0.19-0.62, P =<0.01), implant breakage (OR 0.09, 95% CI 0.03-0.21, P =<0.01), and unplanned implant removal (OR 0.37, 95% CI 0.18-0.76, P =0.01) without significant differences in rates of infection (OR 1.58, 95% CI 0.61-4.14, P =0.35), syndesmotic malreduction (OR 0.48, 95% CI 0.22-1.03, P =0.06), or range of ankle plantarflexion (mean difference [MD] = 0.22, 95% CI -0.07-0.51, P =0.13) or dorsiflexion (MD = 0.07, 95% CI -0.22-0.36, 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 American Orthopaedic Foot and Ankle Society (AOFAS) score at 1 year. 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.