{
  "abstract": "Background:: No consensus exists on the optimal syndesmotic fixation for unstable ankle fractures. We compared strategies using a network meta-analysis (NMA) of randomized controlled trials (RCTs).\n\nMethods:: Seven databases and trial registers were searched through November 1, 2025 for RCTs of adults undergoing fixation of an ankle fracture with syndesmotic injury; quasirandomized and duplicate/follow-up reports were excluded. Interventions were grouped a priori as suture-button/dynamic fixation, metallic 3-cortex screw (reference), metallic 4-cortex screw, bioabsorbable screw, and no fixation. A frequentist random-effects NMA estimated mean differences (MD) for function (Olerud-Molander Ankle Score [OMAS] at 1 year, the outcome reported by the most trials; AOFAS) and odds ratios (OR) for malreduction and reoperation (primary definition excluding planned implant removal), with treatments ranked by P-score and effects interpreted against the minimal clinically important difference (MCID). Certainty was rated with a CINeMA-equivalent assessment.\n\nResults:: Twelve RCTs (883 patients) formed a connected network. For 1-year OMAS, suture-button fixation ranked highest (P-score 0.86; MD +5.2 points versus the 3-cortex screw; 95% CI, +1.1 to +9.2)—statistically significant but below the 10-point MCID—while the 4-cortex screw ranked lowest; heterogeneity was low (I2 = 10%) without inconsistency. The AOFAS did not differ between suture-button and the 3-cortex screw (MD 0.0; 95% CI, −4.5 to +4.5). Malreduction was lower with suture-button fixation (OR 0.26; 95% CI, 0.06-1.11; 0.27 [0.11-0.64] fixed-effect). Unplanned reoperation did not differ between constructs (suture-button OR 0.45; 95% CI, 0.17-1.16), whereas all-cause reoperation favored the suture-button and bioabsorbable constructs. Certainty of evidence was low to very low.\n\nConclusions:: Suture-button/dynamic fixation provides 1-year function at least equivalent to screws, with lower malreduction and fewer all-cause reoperations from avoiding routine implant removal. Functional differences are small and below the MCID, and certainty is low.\n\nLevel of Evidence:: Therapeutic, Level I. See Instructions for Authors for a complete description of levels of evidence.\n\nRegistration:: PROSPERO CRD420251166994.",
  "abstract_shown": true,
  "affiliations": [
    "Northland Orthopaedic Research Consortium, Whangarei Hospital, Whangarei, Northland New Zealand",
    "Northland Knee & Hip, Whangarei, Northland New Zealand",
    "Faculty of Medicine Dentistry and Health Sciences, the University of Melbourne, Parkville, VIC, Australia",
    "Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri"
  ],
  "article_type": "review article",
  "arxiv": null,
  "author_total": 4,
  "authors": [
    {
      "affs": [
        0,
        1,
        2
      ],
      "name": "Wayne Hoskins",
      "orcid": "0000-0003-0608-3065"
    },
    {
      "affs": [
        3
      ],
      "name": "Charles Gusho",
      "orcid": "0000-0002-8897-3688"
    },
    {
      "affs": [
        3
      ],
      "name": "Kevin Horner",
      "orcid": "0000-0003-4394-598X"
    },
    {
      "affs": [
        3
      ],
      "name": "Douglas Haase",
      "orcid": "0000-0002-9477-9777"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/cxahfmb4bx8wr.bib",
  "cited_by": 0,
  "doi": "10.2106/jbjs.oa.26.00303",
  "fulltext_url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC13690456/",
  "id": "cxahfmb4bx8wr",
  "issns": [
    "2472-7245"
  ],
  "landing_url": "https://doi.org/10.2106/jbjs.oa.26.00303",
  "language": "en",
  "licence": "CC-BY-NC-ND-4.0",
  "licence_label": "CC BY-NC-ND 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by-nc-nd/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "heading",
      "0050"
    ],
    [
      "heading",
      "0170"
    ],
    [
      "heading",
      "Evidence-Based Systematic Reviews"
    ],
    [
      "openalex",
      "2732|Foot and Ankle Surgery"
    ]
  ],
  "openalex": "W7223574769",
  "pdf_url": "https://europepmc.org/articles/PMC13690456?pdf=render",
  "pmcid": "PMC13690456",
  "pmid": "42924391",
  "published": "2026-10-27",
  "publisher": "Wolters Kluwer Health",
  "ris": "https://research.draconitic.com/paper/cxahfmb4bx8wr.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:17:31Z",
      "native_id": "PMC13690456",
      "source": "pmc",
      "url": "https://doi.org/10.2106/jbjs.oa.26.00303"
    },
    {
      "first_seen": "2026-10-30T12:20:33Z",
      "native_id": "MED:42924391",
      "source": "europepmc",
      "url": "https://europepmc.org/article/MED/42924391"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:2732|Foot and Ankle Surgery",
      "subfield": "surgery"
    }
  ],
  "title": "Suture-Button Fixation Provides a Statistically But Not Clinically Important Improvement in Function for Syndesmotic Injuries in Unstable Ankle Fractures",
  "title_text": "Suture-Button Fixation Provides a Statistically But Not Clinically Important Improvement in Function for Syndesmotic Injuries in Unstable Ankle Fractures",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T12:33:30Z",
  "url": "https://research.draconitic.com/paper/cxahfmb4bx8wr",
  "venue": "JBJS Open Access",
  "versions": []
}