SLR - December 2021 - Husang Lee
Reference: Kurtoglu A, Kochai A, Inanmaz ME, Sukur E, Keskin D, Türker M, Uysal M, Sen Z, Daldal I. A Comparison of Double Single Suture-Button Fixation, Suture-Button Fixation, and Screw Fixation for Ankle Syndesmosis Injury: A Retrospective Cohort Study. Medicine. 2021;100(13):e25328. doi:10.1097/MD.0000000000025328Level of Evidence: Level III
Scientific Literature Review
Reviewed By: Husang Lee, DPM
Residency Program: Saint Vincent Hospital – Worcester, MA
Podiatric Relevance: Syndesmotic injuries occur in approximately 10 percent of ankle fractures with an annual incidence of 15 per 100,000. There is no consensus on the treatment. The purpose of this study was to provide a direct comparison of single interosseous suture, double interosseous sutures, and traditional AO screw fixation in order to help guide the foot and ankle surgeon in planning reduction of syndesmotic injuries.
Methods: Functional and radiological results from patient records at the author’s affiliated institutions between 2015 and 2018 were retrospectively evaluated. Exclusion criteria was other associated injuries, open fractures, delayed presentation or diagnosis beyond six weeks, follow-up less than 12 months, incomplete radiographs or clinic notes, and neuropathic and diabetic patients. Parameters included age, gender, length of follow-up, complications, interval to weightbearing, fracture pattern, AOFAS hindfoot-ankle score, FADI scores, number of ZipTightTM devices and screws used per patient, and hardware removal. After exclusion criteria, sixty-nine patients were treated. Twenty with double interosseous suture endo button, twenty-three with single interosseous suture endobutton, and twenty-six with traditional AO screw fixation.
Results: Double interosseous suture endobutton had a mean medial clear space of 2.8 millimeters postoperatively and 3.0 at last follow-up (range 2.00-4.00mm) at last follow-up. Single interosseous suture endobutton had a mean medial clear space of 2.6 millimeters postoperatively and a 3.1 millimeters at last follow-up. Single screw had a 2.8 millimeters mean medial clear space postoperatively with a 3.4 millimeters at last follow-up with a range of (2-5 millimeters). (P<0.05) Reduction failures were seen in three patients with screw fixation and was revised during follow-up. Full weightbearing was 9.1 weeks (range 6-12 weeks) in the double suture endobutton group, 8.5 weeks (range 6-12 weeks) in the single suture endobutton group, and 9.5 weeks (range of 6-13 weeks) for single syndesmotic screw. (P=0.152). There were no statistical differences in AOFAS highfoot-ankle score and FADI score. Complications included lateral button suture irritation in two patients in the double suture group and one patient in the single suture group, which resolved without hardware removal. Superficial infection was reported in one patient in the double suture group, two in the single suture group, and three in the screw group. All were resolved with oral antibiotics.
Conclusions: Findings support that the interosseous suture endobutton system is as safe as the screw method for treatment of syndesmotic injury. The interosseous suture endobutton system had no removal of hardware, which minimizes the probability of re-diastasis. Single and double suture endobutton systems showed no statistical difference and thus more cost effective to utilize a single endobutton system.