A Novel Suture Button Construct for Acute Ankle Syndesmotic Injuries; A Prospective Clinical and Radiological Analysis.

Document Type : RESEARCH PAPER


1 Department of Trauma and Orthopaedics, Faculty of Medicine, Suez Canal University, Egypt

2 Royal Orthopaedic Hospital, Birmingham, UK

3 Ashford and St Peters Hospital, Chertsey, UK


Background: The importance of the syndesmosis in ankle stability is well recognized. Numerous means of fixation have been described for syndesmotic injuries including the suture button technique. Significant cost limits the use the commercially available options. We, therefore, designed a cheap and readily available alternative construct. We aim to assess the results of using a novel suture-button construct in treatment of syndesmotic ankle injuries.
Methods: Fifty-two patients (34 males and 18 females) fulfilled our inclusion/exclusion criteria. Five patients were lost to follow-up. The remaining 47 patients were successfully followed up for a minimum of 24 months. The pre and post-surgery American Orthopedic Foot and Ankle Society scores (AOFAS) together with reported complications and post-operative radiological analysis were assessed. In this innovative construct, we utilized polyester braided surgical sutures jointly with double mini two- holed plates, a No.2 polygalactin 910 suture, a 4 mm drill bit, together with a 15 cm long suture needle with slotted end. This technique was supported with the use of the image intensifier.
Results: The AOFAS score improved significantly from a mean of 32.4 to 94.2 (P˂0.004). Radiologically, the medial clear space (MCS), tibio-fibular clear space (TFCS) (P=0.05) and tibio-fibular overlap (TFO) measurements showed a significant improvement postoperatively (P=0.02). Patients reported good satisfaction rates with a 96% success rate (95% CI: 94.0% to 99.3%).
Conclusion: We have observed that this low cost suture button construct is a simple, safe and cost effective treatment option for acute syndesmotic injuries.
Level of evidence: IV


Main Subjects

1. Lin CF, Gross ML, Weinhold P. Ankle syndesmosis
injuries: anatomy, biomechanics, mechanism of
injury, and clinical guidelines for diagnosis and
intervention. J Orthop Sports Phys Ther. 2006;
2. Salamon A, Salamon T, Nikolic V, Radic R, Nikolic T,
Jo-Osvatic A. Holistic approach to functional anatomy
of the injured ankle joint. Coll Antropol. 2003;
3. Schepers T. Acute distal tibiofibular syndesmosis
injury: a systematic review of suture-button versus
syndesmotic screw repair. Int Orthop. 2012;
4. Miller TL, Skalak T. Evaluation and treatment
recommendations for acute injuries to the ankle
syndesmosis without associated fracture. Sports Med.
2014; 44(2):179–88.
5. Hsu YT, Wu CC, Lee WC, Fan KF, Tseng IC, Lee PC.
Surgical treatment of syndesmotic diastasis: emphasis
on effect of syndesmotic screw on ankle function. Int
Orthop. 2011; 35(3):359–64.
6. Egol KA, Pahk B, Walsh M, Tejwani NC, Davidovitch RI,
Koval KJ. Outcome after unstable ankle fracture: effect
of syndesmotic stabilization. J Orthop Trauma. 2010;
7. Amendola A, Williams G, Foster D. Evidence-based
approach to treatment of acute traumatic syndesmosis
(high ankle) sprains. Sports Med Arthrosc. 2006;
8. Forsythe K, Freedman KB, Stover MD, Patwardhan AG.
Comparison of a novel FiberWire-button construct
versus metallic screw fixation in a syndesmotic injury model. Foot Ankle Int. 2008; 29(1):49–54.
9. Soin SP, Knight TA, Dinah AF, Mears SC, Swierstra
BA, Belkoff SM. Suture-button versus screw fixation
in a syndesmosis rupture model: a biomechanical
comparison. Foot Ankle Int. 2009; 30(4):346–52.
10. Klitzman R. Views and experiences of IRBs
concerning research integrity. J Law Med Ethics.
2011; 39(3):513–28.
11. Teramoto A, Suzuki D, Kamiya T, Chikenji T, Watanabe
K, Yamashita T. Comparison of different fixation
methods of the suture-button implant for tibiofibular
syndesmosis injuries. Am J Sports Med. 2011;
12. Harper MC, Keller TS. A radiographic evaluation
of the tibiofibular syndesmosis. Foot Ankle. 1989;
13. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet
DL, Lorich DG. Malreduction of the tibiofibular
syndesmosis in ankle fractures. Foot Ankle Int. 2006;
14. Miller RS, Weinhold PS, Dahners LE. Comparison of
tricortical screw fixation versus a modified suture
construct for fixation of ankle syndesmosis injury:
a biomechanical study. J Orthop Trauma. 1999;
15. Seitz WH Jr, Bachner EJ, Abram LJ, Postak P, Polando
G, Brooks DB, et al. Repair of the tibiofibular
syndesmosis with a flexible implant. J Orthop Trauma.
1991; 5(1):78–82.
16. Bava E, Charlton T, Thordarson D. Ankle fracture
syndesmosis fixation and management: the current
practice of orthopedic surgeons. Am J Orthop (Belle
Mead NJ). 2010; 39(5):242–6.
17. Thornes B, Shannon F, Guiney AM, Hession P,
Masterson E. Suture-button syndesmosis fixation:
accelerated rehabilitation and improved outcomes.
Clin Orthop Relat Res. 2005; 431(1):207–12.
18. Naqvi GA, Shafqat A, Awan N. Tightrope fixation
of ankle syndesmosis injuries: clinical outcome,
complications and technique modification. Injury.
2012; 43(6):838–42.
19. Schepers T. To retain or remove the syndesmotic
screw: a review of literature. Arch Orthop Trauma
Surg. 2011; 131(7):879–83.
20. Schepers T, Van Lieshout EM, de Vries MR, Van der
Elst M. Complications of syndesmotic screw removal.
Foot Ankle Int. 2011; 32(11):1040–4.
21. Degroot H, Al-Omari AA, El Ghazaly SA. Outcomes
of suture button repair of the distal tibiofibular
syndesmosis. Foot Ankle Int. 2011; 32(3):250–6.
22. Storey P, Gadd RJ, Blundell C, Davies MB. Complications
of suture button ankle syndesmosis stabilization with
modifications of surgical technique. Foot Ankle Int.
2012; 33(9):717–21.