Title : Functional outcomes following syndesmotic fixation: Comparison of tightropes, screws and break-away screws in syndesmotic repairs
Abstract:
Introduction: Malleolar ankle fractures are often associated with tibiofibular syndesmotic injury. Accurate reduction and stable fixation of the syndesmosis are critical to maximize patient outcomes, but with different techniques and tools available, there is currently no consensus on how to optimally fix the syndesmosis. We have reviewed the functional outcomes associated with different management options.
Methods: We conducted a retrospective evaluation of ankle fractures managed operatively in our centre during the year 2023. We gathered information on injury characteristics, incidence of syndesmotic injury, method of repair, mobilisation, complications and outcomes.
We evaluated patient characteristics, reported pain, activity limitation, ankle motion and stability, and compared outcomes across the three management options available in our centre, syndesmotic screws, TightRopes and Titanium Breakaway screws.
Results: A total of 152 patients were evaluated, with 63 of them undergoing syndesmotic repair. The most commonly syndesmotic repair technique was syndesmotic screws (n=36, 57.1%), least commonly used technique was the more recently popularised breakaway screws (n=6, 9.5%). Evaluation of outcomes showed that among the syndesmotic screw group, 30.5% (n=11) patients had no complains of pain, activity limitation, ankle motion or stability, compared to 40% (n=8) in the tightrope group or 66.7% (n=4) in the breakaway screw group. 52.7% (n=19) complained of mild symptoms across one or more of the parameters in the syndesmotic screw group, 55% (n=11) in the TightRope group and 33.3% (n=2) in the breakaway screw group. 22.2% (n=8) complained of moderate to severe symptoms across one or more parameters in the syndesmotic screw group, 16.6% (n=6) needing reoperation for removal of metalwork due to failure or disconfort, compared to 10% (n=2) in the syndesmotic repair group, where one patient complained of severe pain due to a raised button, needing reoperation, and one patient complained of sever restriction of ankle motion. There were no reported complains of moderate or severe symptoms in the breakaway screw patients.
Conclusion: In this retrospective cohort, syndesmotic screws were the most commonly utilised repair method. Functional outcomes varied across techniques, with a higher proportion of patients reporting no symptoms in the TightRope and breakaway screw groups compared to traditional syndesmotic screws. Notably, breakaway screws demonstrated the most favourable profile in this series, with the greatest proportion of asymptomatic patients and no reported moderate or severe symptoms; however, their use was limited by small patient numbers. Reoperation for metalwork-related complications was most frequent in the syndesmotic screw group and least frequent in the TightRope cohort. These findings suggest that dynamic fixation methods and newer implant designs may offer improved patient-reported outcomes and reduced need for secondary procedures. Overall, while breakaway screws show promising early results, the small sample size limits definitive conclusions. Larger, prospective studies are required to validate these findings and guide consensus on optimal syndesmotic fixation strategy.
