Dynamic Versus Stable Fixation of Distal Tibiofibular Joint Injuries: A Meta-Analysis Comparing Functional Outcomes

Syndesmotic injuries are associated with chronic instability, persistent pain, and post-traumatic osteoarthritis. Management typically involves either static fixation with screws or dynamic fixation with suture button devices. While static fixation has historically been the standard of care, dynamic fixation allows for the preservation of physiological joint micromotion at the distal tibiofibular syndesmosis and may thus improve functional outcomes. A systematic review and meta-analysis was conducted in June 2025 using only PubMed and Google Scholar and no additional databases. Only prospective randomized controlled trials (RCTs) involving adult patients with syndesmotic injuries were included. Four RCTs comprising 250 patients were ultimately selected. Data were extracted using Covidence, risk of bias was assessed with RevMan 5.4.1, and pooled outcomes were analyzed using a random-effects model. Functional outcomes were measured using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Olerud-Molander Ankle Score (OMAS); the Visual Analogue Scale (VAS) was used to measure and compare postoperative pain. Dynamic fixation demonstrated comparable AOFAS scores (mean difference = 3.14; 95% CI: -5.34 to 11.62; p = 0.47, I² = 96%) and significantly higher OMAS scores (mean difference = 5.70; 95% CI: 0.33-11.08, p = 0.04, I² = 79%) compared with static fixation, though clinically meaningful thresholds were not met. Patients treated with dynamic fixation also reported lower pain scores (VAS mean difference = -0.77; 95% CI: -1.27 to -0.27; p = 0.003, I² = 52%). Risk of bias was low to moderate, with limitations primarily related to incomplete blinding. Dynamic fixation for syndesmotic injuries is associated with superior functional outcomes and reduced postoperative pain compared to static screw fixation. However, the substantial heterogeneity observed across pooled estimates, particularly for AOFAS (I² = 96%), limits confidence in these findings and precludes definitive conclusions. Larger RCTs with standardized postoperative protocols and reduced methodological variability are needed before guideline recommendations can be made.