O2067: Outcomes of Suture-button versus Screw Fixation of Pediatric and Adolescent Syndesmosis Injuries

Background: Injury to the syndesmotic ligament, with or without fibula fracture, can lead to ankle instability and poor long-term outcomes if not appropriately reduced and stabilized. Multiple high-level studies in the adult literature suggest that suture-button implants may be superior to screw fixation for syndesmosis injuries, however, no such data exists in the pediatric population to guide treatment. The aim of this study was to review our institutional experience in the operative treatment of syndesmotic ankle injuries in children and adolescents, and to compare outcomes between patients treated with suture-button versus screw fixation.

Methods: A single-center tertiary care departmental database was queried for patients aged 2-18 treated surgically for syndesmotic ankle injury between 2003 and 2019. Demographic information, injury characteristics, radiographic data, and clinical and functional outcomes were collected and compared between groups.

Results: One hundred seventy-two patients were analyzed (65% male, mean age 16.2 years), of which 128 (74%) were treated with screw fixation and 44 (26%) were treated with suture-button. Notably, the suture-button implant did not become commercially available until 2009, and use at our institution was limited until approximately 2015. Since that time, however, there has been a shift from majority screw to majority suture-button use (Figure 1). There were no differences detected in demographic, injury, or treatment characteristics between groups. Radiographic outcomes showed significant improvement in ankle alignment across all patients from pre- to post-operative films, however, there was no difference between fixation types. Other outcomes, including return to weight-bearing, return to sport/activity, and pain level, were comparable between groups. Complication rates (excluding hardware removal) were similar between groups (18% in both screw and suture-button patients, p=1.00). Rates of hardware removal were significantly different, however, with 107/128 (84%) of screws and 17/44 (39%) of suture-button implants undergoing removal (p < 0.001).

Conclusion: Although there were no significant differences in clinical outcomes or complication rate between suture-button and screw fixation groups, patients with screw fixation underwent secondary surgery for hardware removal significantly more often than did patients with suture-button fixation. However, the decreased rate of secondary surgery may be a factor explaining the trend toward increased suture-button use. Future study is needed to better understand the role of surgeon preference in choice of treatment and to further elucidate whether suture-button or screw fixation is indeed superior.