Suture-Button Fixation Provides a Statistically But Not Clinically Important Improvement in Function for Syndesmotic Injuries in Unstable Ankle Fractures
4 affiliations
- 1Northland Orthopaedic Research Consortium, Whangarei Hospital, Whangarei, Northland New Zealand
- 2Northland Knee & Hip, Whangarei, Northland New Zealand
- 3Faculty of Medicine Dentistry and Health Sciences, the University of Melbourne, Parkville, VIC, Australia
- 4Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
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).
Methods:: 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.
Results:: 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.
Conclusions:: 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.
Level of Evidence:: Therapeutic, Level I. See Instructions for Authors for a complete description of levels of evidence.
Registration:: PROSPERO CRD420251166994.
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BibTeX
@article{hoskins2026suturebutton,
title = {{Suture-Button Fixation Provides a Statistically But Not Clinically Important Improvement in Function for Syndesmotic Injuries in Unstable Ankle Fractures}},
author = {Wayne Hoskins and Charles Gusho and Kevin Horner and Douglas Haase},
journal = {JBJS Open Access},
year = {2026},
month = oct,
doi = {10.2106/jbjs.oa.26.00303},
url = {https://doi.org/10.2106/jbjs.oa.26.00303},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Suture-Button Fixation Provides a Statistically But Not Clinically Important Improvement in Function for Syndesmotic Injuries in Unstable Ankle Fractures
AU - Wayne Hoskins
AU - Charles Gusho
AU - Kevin Horner
AU - Douglas Haase
PY - 2026
DA - 2026/10/27
JO - JBJS Open Access
DO - 10.2106/jbjs.oa.26.00303
UR - https://doi.org/10.2106/jbjs.oa.26.00303
AB - 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). Methods:: 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. Results:: 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. Conclusions:: 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. Level of Evidence:: Therapeutic, Level I. See Instructions for Authors for a complete description of levels of evidence. Registration:: PROSPERO CRD420251166994.
SN - 2472-7245
ER -