Table 1.

Biomechanical studies of suture-button repair of distal tibiofibular syndesmotic injuries

Study	Intervention	Control	Main study conclusions
Seitz et al. (1991) [49]	10 FFCA with No5 braided polyester suture and polyethylene buttons	10 FFCA with single 3.5 mm tri-cortical screw	Pull-out strength SB lower, but more consistent. Less dependent on bone quality. Failure always through button
Thornes et al. (2003) [58]	8 ECA with No5 braided polyester suture and metallic endobuttons	8 ECA with single 4.5 mm four-cortical screw	No significant difference between SB and screw fixation. SB more consistent performance
Forsythe et al. (2008) [17]	10 FFCA with TightRope	10 FFCA with single 4.5 mm four-cortical screw	Significantly greater diastasis in the suture-button group at all external rotation loads. No hardware failures. Screw failed at lower load compared to the suture-button
Soin et al. (2009) [52]	10 FFCA with two TightRopes	10 FFCA with single 3.5 mm four-cortical screw	No significant difference in translation and rotation between SB and screw. Screw had significantly greater failure torque versus SB. Two SB behave similarly to the syndesmotic screw in the syndesmotic rupture injury model
Klitzman et al. (2010) [29]	8 FFCA with TightRope	Same 8 FFCA with single 3.5 mm screw	Syndesmotic gap after testing not significantly different between intact and the SB group, screw group had significantly smaller gap
Teramoto et al. (2011) [55]	6 FFCA sequentially tested intact, syndesmotic injury, single TightRope, double TightRope, anatomical TightRope, and 3.5-mm screw model		Screw most rigid fixation, anatomical SB adequate fixation, single and double SB insufficient stabilization in multidirectional testing

FFCA fresh frozen cadaver ankles, ECA embalmed cadaver ankles, SB suture-button device