Syndesmotic screw fixation is associated with higher overall treatment costs when compared with suture button stabilisation in a single UK major trauma centre

Ankle fractures frequently involve syndesmotic disruption, requiring stable fixation to restore joint function. Syndesmotic screw fixation remains widely used but carries significant drawbacks, including implant breakage, stiffness, and frequent need for removal. Suture button stabilisation offers clinical and economic advantages by preserving physiological motion and reducing reoperation rates. This study evaluates these costs under normal, unselected clinical practice, where implant choice and removal decisions were made independently by treating surgeons without protocol influence.

This retrospective cohort study compares treatment costs of syndesmosis screw fixation and suture button stabilisation for syndesmotic injuries in a single UK Major Trauma Centre. 75 patients aged 16-60 years, with length stable or length stabilised ankle fractures with syndesmotic injuries, between October 2020 to October 2023 were included.

The two cohorts were demographically similar and operative times were comparable (p = 0.170). Complications and reoperations were significantly higher with screw fixation (p < 0.001), with 56.8% undergoing removal, adding £31,460 in costs over three years. Overall, screw fixation cost £687 more per case than suture button stabilisation. Screw fixation became more costly when the hardware removal rate exceeded 8%. This dropped further to 2% when costs of additional follow up visits were also included.

Despite a higher initial implant cost, suture button stabilisation demonstrated fewer complications and no hardware removals. In contrast, 56.8% of screw fixation cases underwent implant removal, leading to screw fixation costing £687 more per case on average, highlighting the superior clinical and economic value of suture button stabilisation in this pragmatic study.