Comparison of the outcomes of syndesmotic ankle fractures treated with dynamic fixation versus static fixation versus fibular nail: a meta-analysis and systematic review

Introduction

The ankle joint complex is an anatomical structure that allows for substantial stability and is an essential component for gait and other functions of daily living (1). The ligaments of the ankle can be divided into three groups, which consist of the lateral ligaments, the deltoid ligament, and the syndesmotic ligaments which make up the syndesmosis complex (2). The syndesmosis complex is a combination of different anatomical structures that work to construct a stable relationship between the tibia and the fibula and consists of the anterior-inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL), the posterior-inferior tibiofibular ligament (PITFL), and the inferior transverse ligament, so it is a key player in ankle stability. An injury to syndesmosis is commonly referred to as a “high ankle sprain”, and is strongly associated with high-speed collisions, rotational injuries of the ankle, and ankle fractures (3). Although there is the possibility an isolated syndesmotic ligament injury, the majority of literature concerning syndesmotic injuries have described it in combination with malleolar fractures (3). Syndesmotic ankle fractures are an injury of the syndesmosis complex, which consists of disruptions to the syndesmotic ligaments in combination with uni-, bi-, or tri-malleolar fractures.

Currently, there are several treatment approaches for syndesmotic ankle fractures (4). The two most common surgical interventions seen in the literature are static fixation with syndesmotic screws and dynamic fixation with suture buttons. In a static fixation treatment approach, syndesmosis screws are placed from the lateral aspect of the fibula into the tibia, and this can be accomplished with single or double screws, 3.5- or 4.5-mm screws, or trans syndesmotic and supra-syndesmotic screws with tricortical or quadricortical fixation. Double screws and 4.5-mm screws result in a stronger mechanical fixation, and two-hole locking plates result in better stability with those that have Maisonneuve fractures (5). Although static fixation is seen as the go-to treatment approach for syndesmotic ankle fractures, complications such as screw breakage, loss of reduction, and local irritation and discomfort are common with this method (6). In the dynamic fixation treatment approach, a hole is drilled through the fibula and tibia, where a polyester suture is passed through and is attached at both ends with buttons. This method may allow for more flexible motion of the distal tibiofibular joint in comparison to static fixation, where normal motion between the tibia and fibula is greatly limited due to the strength of fixation (5,7). Another surgical intervention for syndesmotic ankle fractures is the use of intramedullary fibular nails. In this approach, following the reduction of the fracture, a lateral incision is made where a guidewire for nail fixation is placed distally. Following this, insertion of the fibular nail is done, and distal locking screws are inserted for stability (8,9). This treatment method has been gaining attention recently due to its minimal soft tissue dissection and reduced complication rates associated with open approaches to the ankle (10).

Due to the syndesmosis complex playing a crucial part in ankle stability and the seriousness of a syndesmosis ankle fracture, it is of high importance to identify which treatment approach provides the most favorable results for patients. There is still controversy over which treatment method for syndesmotic ankle fractures results in better clinical and functional outcomes for patients. Although there is a fair share of meta-analysis studies that compare dynamic fixation with static fixation, there are very few studies that include fibular nailing as a comparison group (4,6,10). This study aimed to compare all three treatment methods of dynamic fixation, static fixation, and fibular nailing against each other to see which surgical intervention could provide the most optimal outcome. We present this article in accordance with the PRISMA reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-14/rc) (11).

Methods

Publication search

PubMed and Embase were searched up to April 2024. The following keywords were used to identify articles: “syndesmosis injury”, “syndesmotic ankle fracture”, “syndesmosis suture button”, “syndesmosis screws”, “tightrope”, and “syndesmosis fibular nail”. All retrieved articles were manually screened for inclusion.

Inclusion and exclusion criteria

All retrieved studies were screened by all authors according to the following criteria: included studies must be comparative studies or randomized controlled trials (RCTs) comparing either dynamic fixation versus static fixation, dynamic fixation versus fibular nail, or static fixation versus fibular nail of the syndesmosis injury with at least one of the following outcomes: Olerud-Molander Ankle Score (OMAS), infections, or reoperation rates. Studies that did not adhere to these criteria or where full texts were not available were excluded from this study. Unfortunately, no studies were found that compared dynamic fixation to fibular nailing. To make up for this, studies that included a dynamic fixation group and studies that included a fibular nail group were combined into a “Compiled studies” group for the dynamic fixation versus fibular nail statistical analyses. For OMAS 1-year post-operation, five studies with a dynamic fixation group were combined (12-16) and three studies with a fibular nail group were combined (17-19). For OMAS 2-year post-operation, one study with a dynamic fixation group was used (13) and one study with a fibular nail group was used (19). For infection rate, 11 studies with a dynamic fixation group were combined (13-16,20-26) and five studies with a fibular nail group were combined (9,17-19,27). For reoperation rate, five studies with a dynamic fixation group were combined (13,14,20,28,29) and four studies with a fibular nail group were combined (9,17,18,27).

Assessment of study quality

All authors independently assessed the retrieved studies according to the inclusion and exclusion criteria previously mentioned. If there were any disagreements or ambiguity in a certain study, all authors gathered together to determine whether a study was to be included or excluded. This was done to minimize bias and to avoid individual errors in reading and reviewing studies. Quality of included studies were assessed using the Cochrane Risk of Bias Tool for RCTs. Parameters included random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and other bias (30). Each RCT was scored on these parameters, either as a low risk of bias, unclear risk of bias, or high risk of bias, and these can be seen on the forest plot figures (Figures 1-3). For all other studies that were not randomized, the Newcastle-Ottawa scale was used for quality assessment (31).

Figure 1 Forest plots for the outcomes between dynamic fixation versus static fixation, including (A) OMAS at 1-year post-operation, (B) OMAS at 2-year post-operation, (C) infection, (D) reoperation rate. Green “+” indicates a low risk of bias; yellow “?” indicates an unclear risk of bias; red “−” indicates a high risk of bias. Std., standardized; SD, standard deviation; IV, inverse variance; CI, confidence interval; M-H, Mantel-Haenszel; OMAS, Olerud-Molander Ankle Score.

Figure 2 Forest plots for the outcomes between fibular nail versus static fixation, including (A) OMAS at 1-year post-operation, (B) OMAS at 2-year post-operation, (C) infection, (D) reoperation rate. Green “+” indicates a low risk of bias; yellow “?” indicates an unclear risk of bias. Std., standardized; SD, standard deviation; IV, inverse variance; CI, confidence interval; M-H, Mantel-Haenszel; OMAS, Olerud-Molander Ankle Score.

Figure 3 Forest plots for the outcomes between Dynamic fixation versus Fibular Nail, including (A) OMAS at 1-year post-operation, (B) OMAS at 2-year post-operation, (C) infection, (D) reoperation rate. Std., standardized; SD, standard deviation; IV, inverse variance; CI, confidence interval; M-H, Mantel-Haenszel; OMAS, Olerud-Molander Ankle Score.

Data collection

The following information was retrieved for data collection: The first author, publication date, journal, study design, level of evidence, treatment method, OMAS, infection rate, and reoperation rate.

Statistical analysis

Statistical tests were performed using Review Manager 5.4. OMAS was shown as mean ± standard deviation (SD), while complication metrics (infection, reoperation) were shown as event rates. An inverse variance method with a standardized mean difference (SMD) was used for OMAS, and a Mantel-Haenszel method with risk ratio (RR) was used for infection and reoperation. All tests used a fixed effect analysis model. A P value ≤0.05 was considered statistically significant, and all results were presented as a forest plot with a 95% confidence interval (CI). Heterogeneity was assessed using the I² statistic. The interpretation of the I² value is as follows: 0% to 40% (might not be important), 30% to 60% (may represent moderate heterogeneity), 50% to 90% (may represent substantial heterogeneity), 75% to 100% (considerable heterogeneity) (32).

Results

Study characteristics

Nineteen studies were included in this meta-analysis with a total of 1,182 patients (Figure 4). There were 190 patients in the fibular nail group, 593 in the static fixation group, and 399 in the dynamic fixation group. Thirteen of the studies were RCTs, while the remaining six studies were non-randomized comparison studies (Table 1).

Figure 4 The PRISMA flowchart.

Dynamic fixation versus static fixation

There was a statistically significant difference in OMAS 1-year post-operation between dynamic fixation and static fixation, favoring dynamic fixation (SMD =0.43; 95% CI: 0.22 to 0.65; P<0.05) and in OMAS 2-year post-operation, favoring dynamic fixation (SMD =0.76; 95% CI: 0.33 to 1.20; P<0.05) (Figure 1A,1B). There was no statistically significant difference seen in infection rates between dynamic fixation and static fixation (Figure 1C). There was a statistically significant difference seen in reoperation rate between dynamic fixation and static fixation, favoring dynamic fixation (RR =0.55; 95% CI: 0.36 to 0.83; P=0.004) (Figure 1D).

Fibular nail versus static fixation

There was a statistically significant difference in OMAS 1-year post-operation between fibular nail and static fixation, favoring fibular nail (SMD =0.28; 95% CI: 0.03 to 0.53; P=0.03) (Figure 2A). There was no statistically significant difference seen in OMAS 2-year post-operation between fibular nail and static fixation (Figure 2B). There was a statistically significant difference seen in infection rates between fibular nail and static fixation, favoring fibular nail (RR =0.12; 95% CI: 0.04 to 0.37; P<0.05) (Figure 2C). There was a statistically significant difference seen in reoperation rate between fibular nail and static fixation, favoring fibular nail (RR =0.22; 95% CI: 0.06 to 0.86; P=0.03) (Figure 2D).

Dynamic fixation versus fibular nail

There was a statistically significant difference in OMAS 1-year post-operation between dynamic fixation and fibular nail, favoring dynamic fixation (SMD =1.07; 95% CI: 0.83 to 1.31; P<0.05) and in OMAS 2-year post-operation, favoring dynamic fixation (SMD =1.03; 95% CI: 0.60 to 1.47; P<0.05) (Figure 3A,3B). There was no statistically significant difference seen in infection rates between dynamic fixation and fibular nail (Figure 3C). There was a statistically significant difference seen in reoperation rate between dynamic fixation and fibular nail, favoring fibular nail (RR =20.41; 95% CI: 2.81 to 148.21; P=0.003) (Figure 3D).

Discussion

Syndesmotic ankle fractures are traumatic injuries that can be tremendously debilitating and painful. Due to the serious and complex nature of this injury, it is a high priority to research which treatment methods and interventions yield the most effective and optimal outcomes for patients. The two main treatment interventions that are used for this injury are static fixation with syndesmosis screws and dynamic fixation with a suture button. Intramedullary fibular nails are also an alternative treatment option that could have more benefits. Although there are studies in the literature that compare two of these treatment methods, this study seeks to compare all three treatment methods and provide a comprehensive overview on which method would be most beneficial. This meta-analysis study found that dynamic fixation had a significantly higher OMAS at both 1- and 2-year post-operation compared to static fixation, and dynamic fixation also had a significantly lower reoperation rate compared to static fixation. The fibular nail group had a significantly higher OMAS at 1-year post-operation compared to static fixation, and the fibular nail group also had a significantly lower infection and reoperation rate compared to static fixation. The dynamic fixation group had a significantly higher OMAS at both 1- and 2-year post-operation compared to the fibular nail group, and the dynamic fixation group had a significantly higher reoperation rate compared to the fibular nail group.

When looking at OMAS, multiple meta-analysis studies have shown no statistically significant difference between dynamic and static fixation (33-36). This contrasts with the results found in this study where there was a significant difference favoring dynamic fixation with OMAS at both 1- and 2-year post-operation compared to static fixation. This study’s results shed a new light on the potential benefits in functional outcomes when comparing dynamic fixation and static fixation. Concerning infection rate, meta-analysis studies in the past have shown no significant difference in infection rate between dynamic and static fixation, which is consistent with this study’s results (33,34,37). This study found that the static fixation group had a significantly higher reoperation rate compared to dynamic fixation, which is consistent with some studies in the literature (35,38). However, other studies in the literature have found no significant differences in reoperation rate (33,34). Although there is some discrepancy regarding the reoperation metric, this could be due to factors such as differing sample sizes and surgical teams, but more studies should be done to give further insight into reoperation rate differences between the two surgical interventions.

The authors were able to find one meta-analysis that compared fibular nailing with static fixation, where they found that the fibular nail group had a significantly higher OMAS at 1-year post-operation than the static fixation group, which is consistent with this study’s results (10). The same study also found a statistically significant difference in infection rates that favored fibular nailing but found no significant difference in reoperation rate (10). Although the results for the infection rate were consistent with this study’s results, this study found that there was a statistically significant difference in reoperation rate. A possible reason for this discrepancy is that in one of the included comparison studies, this study did not count removals of locking screws in the fibular nail group because it did not specify whether this was a planned removal of the screw fixation (18). This study defines a reoperation as a second operation performed due to a complication from the first procedure and does not include planned reoperations such as the removal of hardware. Due to this decision, there was a difference in event rates between this study and the other meta-analysis study, so further research should be done for reoperation rate (10).

The authors could not find any studies in the literature that compared dynamic fixation with fibular nailing, so the results of from this study provides a new outlook on the efficacy between the two surgical treatment approaches. This study found that dynamic fixation could provide better functional outcomes but potentially has a higher risk of reoperation compared to the fibular nail approach.

The reason for the superior clinical outcomes of dynamic fixation compared to static fixation and fibular nail are most likely due to the mechanisms behind the fixation method. With the use of the suture button in dynamic fixation, this allows for the reduction of the fractured ankle while simultaneously bringing the ruptured syndesmotic ligaments closer together to heal. The lack of need for hardware removal in dynamic fixation for most cases most likely contributes to better clinical outcomes as well.

This study has several limitations. First, there was a sizeable difference in sample sizes between the three treatment approaches, with 190 patients in the fibular nail group, 593 in the static fixation group, and 399 in the dynamic fixation group. Static fixation and dynamic fixation groups had a larger sample size due to those surgical interventions having been studied more in the literature, while the fibular nail method is not seen nearly as much in comparison studies. This difference in sample sizes could contribute to variability and more margin of error in the results. Another limitation is the mix of study designs, with both RCT and non-randomized comparison studies being included in this meta-analysis. This mix of study designs decreases this study’s level of evidence, where the ideal level of evidence for a meta-analysis study is one with all RCTs. One limitation is that some of the outcome metrics had a limited number of studies included in its statistical analyses due to these metrics not being reported in all studies. Another limitation that some might point out is how this study included articles that might have had instances of both a syndesmosis injury with an isolated syndesmosis ligament injury and a syndesmosis injury that is in combination with a malleolar fracture. Although the authors understand this concern, it has been noted that most of the literature considering syndesmosis injuries have been in combination with an ankle fracture and not an isolated syndesmotic ligament injury (3). The methodology of doing a meta-analysis can make up for this variance. Finally, there were instances of high risks of bias in blinding of outcome assessment (13,14) and selective reporting (14,20), and also instances of high heterogeneity in the comparison of reoperation rate between dynamic fixation and static fixation and OMAS 1-year post-operation between fibular nail and static fixation.

Conclusions

Dynamic fixation had a higher OMAS for 1- and 2-year post-operation compared to both static fixation and the fibular nail treatment method, exhibiting better functional outcomes. Dynamic fixation also had a lower risk for reoperation compared to static fixation, but a higher risk compared to the fibular nail group. The fibular nail group had a higher OMAS at 1-year post-operation and a lower risk of both infection and reoperation rate compared to static fixation. This study found the dynamic fixation treatment method to be the superior approach in terms of surgical interventions for a syndesmosis ankle fracture, with the fibular nail method being a reliable second option. However, more studies with larger sample sizes and high-quality methodology that focus on long-term functional outcomes and other complication metrics are required before cementing dynamic fixation as the standard of care for syndesmosis ankle fractures.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-14/rc

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-14/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-14/coif). J.L. serves as an unpaid editorial board member of Annals of Joint from April 2024 to December 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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