Hello, my name is Chris Krulin, and today I will be presenting the Prospective Randomized Investigation of Syndesmosis Injury Fixation. Here are my disclosures. The remaining authors can be seen on the AAOS website. We know that 10-13% of ankle fractures have a syndesmotic injury. Typically operative fixation has either been rigid or flexible. This means either a screw or a suture button. Previous studies looking at a comparison between these two types have looked at removal, whether it have been implant failures or malreductions. Previous studies looking at just screws in the past have shown that when treating syndesmotic injuries, there's been no difference with size, meaning a 3.5 or a 4.5 screw, looking at the number of cortices, whether it's three or four cortices, and then also evaluating whether you use one or two screws. Again, no differences between any of that. So the purpose of our study was to compare the functional outcome scores and adverse event rates following randomized treatment of acute syndesmotic injuries with either a suture button or screw fixation. And the study's hypothesis was that suture button fixation would provide equal clinical results with fewer adverse events. This was a one-year multicenter randomized study from 2011 to 2014. Patients were identified after acute ankle trauma. Multiple syndesmotic injury was confirmed intra-op with fluoroscopy, performed external rotation tests and the hook test. And the fixation surgery was performed by foot and ankle and trauma surgeons. All reductions were also performed using a clamp to standardize the reduction technique. The randomization was kept in sealed envelopes. And once the syndesmotic injury was confirmed, then the envelope was opened. It's also important to note that the suture buttons used were secured using hand-tied knots as opposed to the newer knotless systems. Patients were then followed for one year post-operatively. And VAS scores and FFI scores were utilized at six weeks, three, six, and 12 months. Post-operative adverse events included but were not limited to symptomatic hardware, infection, loss of production, or a secondary surgery. For results, the 65 patients were enrolled, 33 were in the screw group and 32 in the suture button group. Patients were noted to have an improvement from pre-operative to post-operative. And the outcome scores between screw and suture button groups were not different at six weeks and also at 12 months post-operatively. When adverse events were evaluated, nine of the 13 patients in the screw group, or 27%, were noted to have an adverse event. This included broken screws, symptomatic screws, loose screws, and then one had an implant failure with loss of production. In the suture button group, one patient had a superficial infection from the knots of the suture button. And when looking at who returned to the OR, five of those nine with an adverse event in the screw group returned to the OR, four had removal of hardware, and one had a revision. The suture button fixation group patient had the implant removed as well. So in conclusion, the suture button had significantly less adverse events compared to the surgical screw group, short-term functional outcomes were not different with either technique, and both groups significantly improved from pre-operative to post-operative. The limitations in this study were that it was difficult to get all patients to fill out their one-year survey, and that the smaller study groups showed some evidence that the study was underpowered. If this study was compared to other previous randomized prospective studies, there was one in Norway where they looked at 97 patients, 48 in the suture button group and 49 in the surgical screw group. Their outcome scores were the AOFAS, the Ollerud and Molander ankle score, and the BAS. What was seen at two years was that the suture button had better outcome scores, and seven of the surgical screw group had recurrent diastasis versus none in the suture button group. This group then looked at that same selection of patients and evaluated them at five years and found that the suture button group continued to have significantly better outcome scores and also a lower incidence of ankle osteoarthritis. Therefore, they recommended that the suture button group or the suture button might be a better fixation device for treating acute ankle syndesmotic injuries. One other study out of Canada looked at 34 patients in the surgical suture button group and 36 patients in the surgical screw group. Two suture button patients had removal of the device for superficial infections, and 11 patients in the screw group had removal for discomfort. Three of those ended up having loss of reduction. Outcome scores were seen to be better in the suture button group as well. And even though the study was underpowered, there was a trend towards better clinical results with this flexible fixation. The authors recommended that anatomic and physiologic implants would promote faster and better healing of the syndesmosis. Thank you.

Chris Krulin

Prospective Randomized Investigation of Syndesmosis Injury Fixation

suture button

screw fixation

acute syndesmotic injuries