Table 1.
Included trials and characteristics
| References | Study design | LOE | Comparison | Follow-up duration | Outcome measurement | Results | Main conclusions |
|---|---|---|---|---|---|---|---|
| Thordarson [23] | RCT | Level I | Absorbable screw 17 patients stainless steel screw 15 patients | Mean 11 months | Subjective complains; ankle ROM; MCS; revision rate; complications | No difference were existed between two groups. No loss of reduction and osteolysis in all patients | PLA absorbable is an attractive alternative to reduce subsequent removal without increasing complications |
| Kaukonen et al. [24] | RCT | Level I | bioabsorbable screw 20 patients; metallic screw 18 patients | Mean 35 months; range 17–51 | Subjective evaluation; ankle ROM; MCS; Return to sports; complications | Bioabsorbable screw group had better returned to sports level and less swelling (but no significant difference). No difference in joint motion (P = 0.854) and MCS | PLA absorbable screws worked slightly better than metallic ones |
| Hu et al. [25] | Quasi-randomized study | Level II | Absorbable PDLLA screw 22 patients; metallic screw 25 patients | 13.5 ± 3.0 months | Ankle ROM; AOFAS scores; TFO; TFCS; complications | No dislocation and hardware failure in both group. No difference in AOFAS (P = 0.665); Ankle ROM (P = 0.947); TFO (P = 0.360); TFCS (P = 0.531) | PDLLA absorbable screw was a reliable treatment for syndesmotic injuries. It also obviated secondary operations |
| Sinisaari et al. [26] | Prospective comparative study | Level II | Absorbable PLA screw 18 patients; metallic screws 12 patients | 12 months | Ankle ROM; OMS scores; TFCS; TFO; revision rate; complications | No significant difference was detected in any outcome | Syndesmotic rupture fixation could be done by bioabsorbable PLA screw |
| Wikerøy et al. [27] | RCT | Level I | Tricortical screw fixation 25 patients; quadricortical screw fixation 23 patients | Mean 8.4 years; range 7.7–8.9 | Ankle ROM; OMS scores; VAS scores; syndesmotic width; synostosis; articular height; complications | No differences in OMS scores (P = 0.9); VAS scores (P = 0.8) and complication. Quadricortical fixation had better dorsiflexion (P = 0.03). | Both quadricortical and two tricortical screws fixation achieved good results in syndesmotic injuries |
| Moore et al. [28] | Quasi-randomized study | Level II | Tricortical screw fixation 59 patients; quadricortical screw fixation 61 patients | 150 days | Raidolucency; complications | No difference in loss of reduction (P = 0.871); screw breakage (P = 0.689); need for hardware removal (P = 0.731) | Three or four cortical fixation had similar clinical results and can be both used in syndesmotic ruptures |
| Høiness and Strømsøe [29] | RCT | Level I | Tricortical screw fixation 34 patients; quadricortical screw fixation 30 patients | One year | Ankle ROM; OMS score; displacement; ankle joint space; revision; complication | OMS score was significantly higher in the tricortical group at three months (P = 0.025), but no difference at one year (P = 0.192); no significant difference in joint motion | Two tricortical screws improves early function but no difference in functional score, pain and dorsiflexion at one year |
| Cottom et al. [30] | Prospective comparative study | Level II | suture-button fixation in 25 patients; metallic screw fixation in 25 patients | Mean 9.4 months | Modified AOFAS score; SF-12 score; TFO; TFCS; MCS; revision; time to full weightbearing; complications | No significant differences in weight bearing time; modified AOFAS score; SF-12 score; MCS; TFO. TFCS was significantly smaller in suture-button group | Suture-button device was as effective as traditional internal screw fixation |
| Naqvi et al. [31] | Prospective comparative study | Level II | Suture-button fixation 23 patients; screw fixation 23 patients | 2.5 years; range 1.5–3.5 | AOFAS score; FADI score; syndesmotic width; MCS; TFO; TFCS; revision; complications | Syndesmotic width was significantly smaller in suture-button (P = 0.01); No difference in AOFAS and FADI score; significantly more malreduction in screw fixation (P = 0.04) | Suture-button devices was not only a feasible method of syndesmotic fixation, but also be slight better than traditional screw |
| Coetzee and Ebeling [32] | RCT | Level I | Suture-button fixation 12 patients; screw fixation 12 patients | Mean 18 months | Subjective results; ankle ROM; AOFAS score; complications | No significant difference in AOFAS score; ankle ROM and subjective stiffness was significantly better in suture-button | Suture-button device lead to better objective ankle motion as well as decreased stiffness and discomfort since it stabilize syndesmosis without eliminating normal motion |
| Pakarinen et al. [33] | RCT | Level I | None fixation 11 patients; syndesmotic screw fixation 13 patients | Mean 61 weeks; range 53–112 | Ankle range of motion; OMS score; VAS score; RAND 36-item health survey; TFCS; | No significant difference in OMS score (P = 0.5); VAS score (P = 0.38) and RAND 36 scores (P = 0.23) | Syndesmotic injuries are rare in SER ankle fractures; syndesmotic fixation did not influence the results at one-year follow-up compared with no fixation |
| Kennedy et al. [34] | Prospective comparative study | Level II | None fixation 19 patients; tricortical syndesmotic screw fixation 26 patients | 2.9 years; range 2.8–4.2 | Subjective outcomes; ankle ROM; functional score; complications | No significant difference in subjective outcomes (P = 0.86); ankle motion (P = 0.94); fracture dislocation was a predictor for poor results | Fixed or non-fixed syndesmosis had similar results in low Weber C ankle fracture |
TFCS tibiofibular clear space, TFO tibiofibular overlap, MCS medial clear space, OMS Olerud–Molander score, AOFAS American Orthopedic Foot & Ankle Society scoring system, VAS visual analogue scale