Randomized Controlled Trial Comparing Suture Button Versus Fibulink Fixation for Acute Ankle Syndesmosis Injuries

Ankle fractures are a common injury with potentially significant morbidity. Syndesmosis injury occurs in 10% to 13% of ankle fractures and poses a greater risk to long-term outcomes for patients1,2. If not recognized and adequately reduced, injuries to the syndesmosis have shown to result in instability, persistent pain, and post-traumatic arthritis3. 11% of cases are accompanied by symptomatic advanced osteoarthritis after fixation of the syndesmosis4. The gold standard for syndesmosis fixation has traditionally been screw fixation5. However, issues with screw fixation include screw breakage, screw loosening, reoperation, and malreduction6-8. This has been speculated to be a result of the ankle syndesmosis, a dynamic construct, being inappropriately fixed with static fixation. Due to growing concerns with static screw fixation, implants based on the flexible suture button design, such as the TightRope system, gained traction. Advantages with these designs include superior outcome scores, as well as lower rates of osteoarthritis and reoperation7,9,10. However, despite achieving improved joint mechanics, these systems have their drawbacks as well, such as infection or damage to the superficial medial neurovascular bundle9. The Fibulink Syndesmosis Repair System, a relatively new design that became clinically available in 2017, has showed promising results. It has been promoted as an implant that potentially provides both the fixation of a screw and flexibility of a suture to respect the dynamic nature of the ankle joint. Benefits of this design include eliminating damage to the medial neurovascular bundle and soft tissues, promoting physiologic motion of the ankle joint, and allowing improved tension control. In a case series with 14 patients that received the Fibulink implant, Desai found no complications with a mean follow-up of 9.5 months9. However, more long-term data is needed in order to draw any conclusions. The potential advantage of this system over suture button designs is that it incorporates the rigidity of screw fixation on top of the dynamic fixation of suture button implants. It also addresses the limitations of suture button designs, such as avoiding medial soft tissue disruption and lack of two-way tension control. The comparison between screw fixation and suture button designs has been thoroughly investigated in the literature. To our knowledge, there is no study that directly compares outcomes with the Fibulink implant to suture button implants. It is imperative to directly compare these methods so we can definitively assess their suitability and provide patients that sustain these injuries the best method of fixation in order to improve patient outcomes. The purpose of this study is to compare radiographic and clinical outcomes in patients who sustain an acute ankle fracture with an associated syndesmosis injury by comparing two surgical treatments currently in the practice of the study investigators. The study will compare suture button fixation versus Fibulink implant in patients with this injury. Inadequate syndesmosis fixation has been found to result in significant morbidity to patients, including persistent pain, instability, and post-traumatic arthritis. This emphasizes the need to assess the available methods of fixation in order to minimize negative long-term consequences. Currently, standard single screw fixation remains a common choice among orthopaedic surgeons. However, there is some evidence of superior outcomes with dynamic fixation, using designs such as the suture button or the Fibulink system, in terms of functional results, residual pain, and other measures. With an enhanced understanding of patient outcomes with these methods of fixation, we will better be able to determine more effective ways to manage these injures and offer guidance for optimal management and patient satisfaction.