SLR - October 2019 - Nicholas Staub
Reference: Davis M, Blum L, Talusan P, Hake M. Irrigation and Debridement of an Open Ankle Fracture with Open Reduction and Internal Fixation and Syndesmotic Fixation Using a Suture Button Device. J Orthop Trauma. 2019 Aug; 33 Suppl 1:S40-S41.Scientific Literature Review
Reviewed By: Nicholas Staub, DPM
Residency Program: SSM Health DePaul Hospital – St. Louis, MO
Podiatric Relevance: One of the most common surgically treated fractures are ankle fractures. Open fractures occur in 1.5 percent of all ankle fractures and injuries to the syndesmotic ligaments represent 13-20 percent of these fractures. Surgical repair of a syndesmotic injury is indicated due to resultant instability of the ankle mortise. If left untreated ensuing pathology can include chronic ankle instability and early degeneration of the ankle joint. Classically, rigid screw fixation of the syndesmosis has been the gold standard for treatment. There is debate regarding the need for implant removal when utilizing screws and the significance of soft tissue irritation and screw discomfort and breakage. Recently, there has been development of the suture button device to stabilize the syndesmosis. The following case presents treatment of an ankle fracture with syndesmotic instability utilizing a suture button device.
Methods: This case involves a 61-year-old female with a pronation external rotation IV ankle open ankle fracture. Initial treatment began with irrigation and debridement of all nonviable tissue. Fibula fracture was then treated with open reduction and internal fixation utilizing a plate on the lateral surface. Syndesmosis was stressed under fluoroscopy utilizing the external rotation test. Instability was appreciated as marked by a decrease in tib-fib overlap, and increase in tib-fib clear space, and medial clear space widening. Syndesmosis was stabilized with deployment of a suture button device and external rotation test was repeated.
Conclusions: A recent randomized control trial by Andersen et al. comparing suture buttons with a single syndesmotic screw in syndesmotic injuries displayed improved outcomes in walking pain, pain during rest, as well as less widening seen radiographically at two years when using suture buttons. There is also evidence to support suture buttons in a systematic review by Zhang et al. demonstrating a lower rate of post-operative complications and earlier time to weight bearing. With suture button fixation being a newer treatment option in the fixation of syndesmotic instability, more long-term studies exist on use of syndesmotic screws however newer evidence exists that support suture button devices providing better reduction and decreased need to remove hardware post-operatively.