All-suture fixation of syndesmotic injuries: a case series

To retrospectively evaluate the clinical outcomes of patients treated for syndesmotic injuries with an all-suture construct technique and compare their patient reported outcome scores with historically published outcomes of syndesmotic injuries fixed with suspensory suture buttons.

This was a retrospective case series of patients treated at a Level 1 Trauma Center from May 1, 2018, to June 30, 2022. Ten patients aged 18 and older with unstable syndesmotic injuries treated with all-suture repair. Patients were excluded if they were treated with trans-osseous screws, had previous failed syndesmotic fixation, or suspensory suture button fixation. Patient-reported outcomes including Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and complications were recorded.

In the patients with 6 weeks or more of radiographic follow-up (N = 9), there was no evidence of nonunion, loss of fixation, hardware complication, or whitling of the fibula by the suture. At final follow-up average VAS pain scores were 1.5 out of 10 (range 0-4; SD 1.2), AOFAS ankle and hindfoot scores averaged 89.6 out of 100 (range 86-100; SD 6.1). The pain subscale of the AOFAS score averaged 37.5 out of 40 (range 35-40; SD 2.5). The functional subscale of the AOFAS score averaged 46 out of 50 (range 44-50; SD 3.0). Stiffness was reported in one patient at their follow-up visits, which resolved with continued physical therapy. There were no superficial or deep infections.

In conclusion, this case series presents the first clinical outcomes of an all-suture fixation technique for treatment of unstable syndesmotic ankle injuries. Our results suggest that the all-suture fixation technique results in similar patient reported outcomes when compared with historically reported patient reported outcomes of suspensory suture button fixation, and low rates of complication or hardware failure.