A systematic review comparing the outcomes of utilizing a tricortical screw, quadricortical screw, or suture button for syndesmotic fixation.

Abstract

Optimal fixation for distal tibiofibular syndesmotic injuries remains debated, with numerous studies comparing syndesmotic screws (SS) to suture-button (SB) devices. However, limited attention has been given to differentiating tricortical screw (TS) from quadricortical screw (QS) fixation. To systematically review outcomes of SB, TS, and QS fixation to determine which technique provides superior clinical, radiographic, and patient-reported outcome measures (PROMs), as well as to determine which topics regarding syndesmotic fixation warrant further discussion. A systematic review was conducted according to a registered PROSPERO protocol. PubMed and Scopus databases were searched using a predefined Boolean equation. Randomized controlled trials (RCTs) and cohort studies with at least 1 year of follow-up and having the SB, SS, TS, or QS as a cohort were included. Data extracted included clinical outcomes, radiographic parameters, and PROMs. Risk of bias was assessed using the RoB-2 for randomized studies and ROBINS-I V2 for cohort studies. Forty studies (19 RCTs, 21 cohort studies) met inclusion criteria. Most compared SB to SS fixation, while 4 compared TS to QS. Among cohort studies, 11 were classified as having critical risk of bias. Across studies comparing SB and SS, most outcomes were equivalent. Some RCTs demonstrated improved time to weight-bearing, lower reoperation rates, and superior PROMs in the SB group. Comparison between TS and QS fixation showed no significant differences in any clinical, radiographic, or PROM outcomes, although the few studies that met inclusion were of low-quality evidence. SB fixation may yield marginally improved functional outcomes and reoperation rates compared with SS. The overall evidence remains heterogenous and frequently limited by bias. Studies directly comparing TS to QS is sparse and of insufficient quality, however, there is some belief that TS may be superior. Current gaps in the literature include differentiating which method of fixation is superior in patients with various comorbidities such as diabetes or osteoporosis. Evidence suggests that SB fixation provides comparable or slightly superior outcomes to SS fixation with a lack of evidence to support using a TS or QS. Future studies should focus on the gaps remaining in the literature.