Deep Infections After Syndesmotic Fixation With a Suture Button Device

Suture button devices such as the TightRope (Arthrex, Naples, Florida) have been increasingly used for syndesmotic fixation of ankle fractures. Despite proposed advantages, prior studies have shown equivalent outcomes, with a theoretical decreased need for removal of hardware. Complications of suture button fixation of syndesmotic instability may be underreported and include lateral suture knot inflammation with or without granuloma formation, infection, aseptic osteolysis with widening of the tibial drill tunnels, heterotopic ossification, and osteomyelitis. In this case series, the authors review the current literature and describe 3 patients with TightRope fixation for syndesmotic instability who developed deep infection. The authors believe that braided suture within suture button devices may provide an environment conducive to the propagation of infection across the syndesmotic fixation tract. Evidence of suture button migration or osteolysis of the TightRope tract should prompt an infectious workup and removal of hardware. If there is concern for infection associated with the TightRope, the authors recommend removing both metallic buttons and the entirety of the suture to prevent harboring a nidus for further infection. [Orthopedics. 2017; 40(3):e541-e545.].