Table 3.

The characteristics of the included studies (c)

Study (year)	Rehabilitation process (SBG)	Rehabilitation process (SG)	Time to full weight bearing (weeks) SBG VS SG	Key findings
Kocadal et al. 2016 [4]	Short leg splints for 3 weeks, after splint removal, partial weight bearing was allowed. At the sixth postoperative week, full weight bearing was allowed	Short leg splints for 3 weeks, after splint removal, partial weight bearing was allowed. At the sixth postoperative week, full weight bearing was allowed	NR	Although the functional outcomes were similar, the restoration of the fibular rotation in the treatment of syndesmotic injuries by screw fixation was troublesome and the volume of the distal tibiofibular space increased with the suture-button fixation technique.
Kim et al. 2016 [2]	A below-the-knee cast for 1 week, partial weightbearing at 6weeks postoperatively	A below-the-knee cast for 1 week, partial weightbearing 6 to 8 weeks postoperatively	NR	Both suture-button and metal screw fixation are effective treatment methods for an ankle fracture accompanied by syndesmotic injury.
Seyhan 2015 [17]	Plaster-splint for two Weeks and then pressure-socks for 4 weeks Partial weight bearing using double crutches and then complete weight bearing at the end of the 3rd month	Plaster-splint for two Weeks and then pressure-socks for 4 weeks Partial weight bearing using double crutches and then complete weight bearing at the end of the 3rd month (after screw removal)	NR	Elastic fixation is as functional as screw fixation in the treatment of ankle syndesmosis injuries. The unnecessary need of a second surgical intervention for removal of the fixation material is another advantageous aspect of this method of fixation.
Kortekangas 2015 [8]	A below-the-knee cast with the ankle joint at a 90° for 6 weeks with partial weight bearing. At 6 weeks, the cast was removed, the ankle was examined, and a research physiotherapist instructed the patient in rehabilitation exercises. No additional bracing was used and weight bearing was allowed as tolerated	A below-the-knee cast with the ankle joint at a 90° for 6 weeks with partial weight bearing. At 6 weeks, the cast was removed, the ankle was examined, and a research physiotherapist instructed the patient in rehabilitation exercises. No additional bracing was used and weight bearing was allowed as tolerated	NR	Syndesmotic screw and TightRope had similar postoperative malreduction rates. After at least 2 years of follow-up, malreduction rates may slightly increase when using trans-syndesmotic screw fixation, but reduction was well maintained when fixed with TightRope. Neither the incidence of ankle joint osteoarthritis nor functional outcome significantly differed between the fixation methods.
Laflamme 2015 [9]	No weight bearing in a cast for 6 weeks and then rehabilitation without protection	No weight bearing in a cast for 6 weeks and then rehabilitation without protection	NR	Dynamic fixation seems to result in better clinical and radiographic outcomes. The implant offers adequate syndesmotic stabilization without failure or loss of reduction, and the reoperation rate is significantly lower than with conventional screw fixation.
Naqvi 2012 [11, 25]	All patients were immobilized in a below-the-knee, nonweightbearing cast for 6 weeks, followed by physical therapy and weightbearing as tolerated	All patients were immobilized in a below-the knee, nonweightbearing cast for 6 weeks, followed by physical therapy and weightbearing as tolerated	8.0/9.1	TightRope provides a more accurate method of syndesmotic stabilization. Syndesmotic malreduction is the most important independent predictor of clinical outcomes.
Cottom 2009 [12]	A non–weight-bearing splint for 10 days postoperatively, and a weight-bearing cast was maintained for 3 additional weeks until transfer into a removable boot walker with full weight bearing to tolerance	A non–weight-bearing splint for 10 days postoperatively, and a weight-bearing cast was maintained for 3 additional weeks until transfer into a removable boot walker with full weight bearing to tolerance	5.52/10.52 4.93/9.5 (the Maisonneuve fracture group and the isolated soft tissue ligamentous injuries were analyzed separately)	Interosseous suture with endobuttons is a reasonable option for repair of ankle syndesmotic injuries, and may be as effective as traditional internal screw fixation
Coetzee 2009 [15]	A short leg cast splint for two weeks with nonweightbearing and then a pneumatic Cam boot was applied for partial weightbearing . At six weeks, Cam boot removal for weightbearing if the syndesmosis appears stable and any associated fractures were healed	A short leg cast splint for two weeks with nonweightbearing and then a pneumatic Cam boot was applied for partial weightbearing . At six weeks, Cam boot removal for weightbearing if the syndesmosis appears stable and any associated fractures were healed	NR	The TightRope® fiber wire fixation group had a statistically significant better range of motion compared to conventional screw fixation. The AOFAS ankle and hindfoot score did not show a significant difference between the two groups at medium term follow-up.
Thornes 2005 [18]	A below-knee cast for 6 weeks and then full weightbearing at 6 weeks postoperatively after cast removal. (2 weeks, patients with stable plate osteosynthesis of the fibula fracture were allowed partial weightbearing up to 50% of body weight with a below-knee cast)	A below-knee cast at least for 6 weeks and then full weightbearing at 6 weeks postoperatively after cast removal.	NR	Suture-button fixation is simple, safe, and effective. Patients have had improved outcomes and faster rehabilitation, without needing routine implant removal.

SBG suture-button group, SG screw group, NR no report