Comparison of screw and suture-button techniques in the treatment of ankle syndesmotic injuries

Syndesmotic disruption frequently accompanies ankle fractures and requires stable fixation to restore distal tibiofibular congruence and function. Cortical screw and suture-button constructs are widely used; however, their relative superiority, particularly with respect to early recovery versus long-term outcomes, remains uncertain.

We conducted a single-center, retrospective, nonrandomized cohort study of adults with ankle fractures and radiographically confirmed syndesmotic injuries treated between 2017 and 2021. Patients underwent fixation according to surgeon preference using either screws (n=81) or suture-button constructs (n=25). The primary outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at 12 months. Secondary outcomes included AOFAS score at 3 months, Olerud-Molander Ankle Score (OMAS) at final follow-up, tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and complication rates. Standardized anteroposterior (AP), mortise, and lateral radiographs were obtained preoperatively and postoperatively. Median follow-up was 14 months (range: 12-19). Treatment selection was at the operating surgeon's discretion, taking into account patient age and activity level, fracture pattern and instability (including initial subluxation or dislocation), soft-tissue condition, and implant availability.

Both groups demonstrated significant radiographic improvement in TFCS, TFO, and MCS from preoperative to post-operative assessment (all p<0.001). At three months, the suture-button group achieved higher AOFAS scores than the screw group (median, 75 vs. 70; p=0.009). However, the primary outcome of AOFAS score at 12 months and the final OMAS did not differ significantly between groups (p=0.161 and p=0.090, respectively). Interpretation of the findings is limited by baseline imbalances, including a younger patient population in the suture-button group (p=0.008) and unequal group sizes (81 vs. 25). Complication rates were low and comparable between groups.

Both cortical screw and suture-button fixation provided satisfactory long-term functional and radiographic outcomes in patients with ankle fractures and syndesmotic injuries. Although suture-button fixation was associated with superior early functional recovery, this apparent advantage should be interpreted cautiously given baseline differences and potential confounding. These hypothesis-generating findings support the need for prospective randomized trials with standardized rehabilitation protocols.