Syndesmosis Injury With an Ankle Fracture: Screws vs. Suture Button Fixation
- sarangndesai
- 6 hours ago
- 11 min read
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Syndesmosis Injury With an Ankle Fracture: Screws vs. Suture Button Fixation
By Sarang Desai, DO — Fellowship-Trained Orthopedic Foot and Ankle Surgeon
Sports Medicine | McKinney and Flower Mound, Texas
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Here's the short version I give patients in clinic: if your ankle fracture came with a syndesmosis ("high ankle") injury, that ligament connection between your two leg bones has to be stabilized during surgery — and today there are two good ways to do it: a syndesmotic screw or a suture button (a flexible cord-and-button device). Both work. The best available evidence — including multiple randomized trials and a 5-year follow-up study — leans toward the suture button for slightly better function, fewer implant problems, and possibly less arthritis over time. But a recent 2026 umbrella review points out that many of those differences, while real, are often small and may not be noticeable to the average patient.[1][2][3] The most important factor isn't which device — it's that the syndesmosis is put back into an anatomic (perfectly aligned) position.[4]
Let me walk you through what this injury actually is, why fixation matters so much, and how I think about the screw-versus-button decision.
For related reading: The Complete Guide to Ankle Fractures · High Ankle Sprain / Ankle Sprains & Chronic Instability
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WHAT IS THE SYNDESMOSIS — AND WHY DOES IT MATTER?
Your lower leg has two bones: the tibia (shinbone) and the fibula (the smaller outer bone). At the ankle, they're bound tightly together by a group of ligaments called the distal tibiofibular syndesmosis. Together, the two bones form a snug socket — the "mortise" — that cradles the talus and lets your ankle move smoothly.[5]
When that ligament complex tears, the two bones can spread apart (diastasis). If they heal even a couple of millimeters too far apart or slightly rotated, the talus no longer sits perfectly in its socket — and that mismatch is a well-known setup for pain, stiffness, and post-traumatic arthritis down the road.[4] That's why we take a syndesmosis injury so seriously.
Roughly 20% of all ankle fractures that need surgery also have a syndesmosis injury requiring fixation, so this is a common and important part of ankle fracture care.[1]
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HOW WE KNOW THE SYNDESMOSIS IS UNSTABLE
Not every syndesmosis injury needs a screw or button. The key question is whether it's stable or unstable. Stable injuries can often be treated without fixation; unstable ones need to be stabilized surgically.[6]
We figure this out with:
- Physical exam clues and the mechanism (usually a rotational, external-rotation injury).[5]
- X-rays, looking at the tibiofibular clear space and overlap, ideally compared to your other ankle.[5]
- CT scan — very good at detecting subtle side-to-side differences; weight-bearing CT is an emerging, excellent tool.[4]
- MRI — the reference standard for actually seeing the torn ligaments.[5]
- Intraoperative stress testing — during surgery, once the fracture is fixed, the surgeon stresses the joint (the "hook test," external rotation stress, and increasingly intraoperative ultrasound) to confirm whether it's truly unstable before deciding to add fixation.[7][8]
The takeaway: the decision to stabilize the syndesmosis is made carefully, not automatically — because both over-treating and under-treating cause problems.[4]
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THE #1 RULE: ANATOMIC REDUCTION MATTERS MORE THAN THE IMPLANT
Before comparing screws and buttons, understand this: no implant fixes a poorly aligned syndesmosis. The single most important goal is restoring the exact anatomic position of the fibula in its notch on the tibia. If the reduction is off, the outcome will be worse regardless of what hardware is used — and malreduction is one of the strongest predictors of a bad result.[4] The screw-versus-button debate is really a debate about which device best holds a good reduction and causes the fewest problems afterward.
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OPTION 1: THE SYNDESMOTIC SCREW
This is the traditional, time-tested method. One or two screws are passed through the fibula into the tibia, clamping the two bones together while the ligaments heal.[9]
Advantages:
- Rigid, strong, reliable fixation — the classic "gold standard."[10]
- Inexpensive and technically straightforward.[11]
- Very familiar to every orthopedic surgeon.
Drawbacks:
- Screws can break. Because a screw rigidly holds bones that are meant to move slightly, it's under repeated stress. In one meta-analysis, hardware breakage occurred in about 25% of screw patients.[1]
- Higher rate of screw removal. Historically many surgeons removed the screw with a second, minor procedure — removal rates of 22–40% appear in the literature. (Notably, contemporary practice increasingly leaves intact screws in place rather than routinely removing them.)[1][11][3]
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OPTION 2: THE SUTURE BUTTON
The suture button (sometimes called a "TightRope"-type device) uses a strong cord tensioned between two small buttons — one on the fibula, one on the inner tibia. Instead of rigidly clamping, it holds the bones together while allowing the tiny, natural micromotion the syndesmosis is supposed to have.[9] This "dynamic" or "flexible" fixation is why many surgeons — myself included in the right cases — have gravitated toward it.
Advantages (per randomized trials and meta-analyses):
- Essentially no implant breakage (0% vs ~25% for screws in one meta-analysis).[1]
- Less recurrent widening over time — in the randomized trial, far fewer suture-button patients had ≥2 mm of tibiofibular widening at 2 years.[9]
- Lower rate of ankle arthritis at 5 years (35% vs 65% in the long-term randomized follow-up).[2]
Drawbacks:
- More expensive than a screw.[11]
- Can occasionally cause local soft-tissue irritation over the buttons or, rarely, its own reduction issues if placed imperfectly.
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SCREWS VS. SUTURE BUTTON: THE HEAD-TO-HEAD
Factor | Syndesmotic Screw | Suture Button | References |
Fixation type | Rigid (clamps bones) | Flexible/dynamic (allows micromotion) | |
Functional scores | Good | Slightly higher on average | |
Implant breakage | ~25% | ~0% | |
Implant removal | Higher (22–40%) | Lower (~4–6%) | |
Malreduction | Slightly higher | Lower | |
Ankle arthritis at 5 yrs | Higher (65%) | Lower (35%) | |
Cost | Lower | Higher | |
Are the differences always clinically meaningful? | — | Often small; may fall below "noticeable" threshold |
The honest, balanced bottom line: The weight of high-quality evidence favors the suture button, and its advantages in implant durability, reduced removal surgery, and long-term arthritis are real.[1][2] But the 2026 umbrella review is an important reality check: when researchers looked at whether the functional-score differences were large enough for a patient to actually feel, most fell below that threshold — meaning both devices produce good, similar day-to-day results for many people. And since routine screw removal is no longer standard, one of the button's historic advantages has narrowed.[3] This is genuinely a shared decision, and either device in experienced hands with an anatomic reduction gives you a good chance at an excellent result.[3][4]
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HOW I THINK ABOUT THE DECISION
There's no universal "right" answer, but here's the kind of reasoning that goes into it:
- The quality of the reduction comes first — that's non-negotiable regardless of implant.[4]
- Active, younger patients and athletes often benefit from the flexible fixation and lower reoperation profile of the suture button.
- The specific fracture pattern matters — associated posterior malleolus fractures, fibula length, and the exact injury pattern all factor in.[9]
- Sometimes both — in certain complex or higher-demand cases, a combination approach is used.
- Patient preferences and cost are part of an honest conversation.[11]
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RECOVERY: WHAT TO EXPECT
Recovery after ankle fracture surgery with syndesmosis fixation follows the general ankle-fracture arc, with a few device-specific nuances:
- Weight-bearing has shifted earlier. The old rule was 6–8 weeks non-weight-bearing after syndesmosis fixation. But strong recent evidence — including the 2024 WAX randomized trial — shows early weight-bearing (around 2 weeks) is non-inferior for operatively treated ankle fractures, and a 2025 study focused specifically on ankle fractures with syndesmotic injuries found early weight-bearing at 2 weeks was safe and led to better early scores and faster return to work and sport.[17][18][19]
- Suture buttons may allow somewhat earlier, more comfortable weight-bearing than rigid screws in some protocols, since they tolerate natural motion.[12]
- Range-of-motion and physical therapy are started based on your fracture, incisions, and fixation. Physical Therapy After Ankle Fracture Surgery
- Full recovery typically takes several months, with continued improvement over the first year. Syndesmosis injuries are known to recover a bit more slowly than simple ankle fractures.[6]
Every timeline is individualized to your specific fracture, your fixation, and how your soft tissues are healing.
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COMMON MISCONCEPTIONS
- "A high ankle injury is just a bad sprain." When it comes with an ankle fracture and instability, it's a surgical problem — and left unstable, it leads to arthritis.[4]
- "The suture button is always better." It has real advantages, but recent analysis shows the functional differences are often small, and both devices work well when the reduction is anatomic.[3]
- "I'll definitely need a second surgery to remove hardware." Suture buttons rarely need removal, and modern practice increasingly leaves intact screws in place too.[3][11]
- "The device is what determines my outcome." The alignment (reduction) matters more than the implant.[4]
- "I have to stay off it for two months." Early protected weight-bearing around 2 weeks is now well supported for many of these injuries.[18][19]
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FREQUENTLY ASKED QUESTIONS
1. What is a syndesmosis injury?
It's a tear of the ligaments binding your tibia and fibula together at the ankle. When it happens with an ankle fracture and creates instability, it usually needs surgical stabilization.[4][5]
2. How common is it with an ankle fracture?
About 20% of ankle fractures needing surgery also have a syndesmosis injury requiring fixation.[1]
3. How do you decide if it needs fixation?
Through imaging (X-ray, CT, MRI) and intraoperative stress testing after the fracture is fixed. Only truly unstable syndesmoses are stabilized.[4][7]
4. Which is better — screw or suture button?
Overall evidence leans toward the suture button (better function, fewer broken implants, less removal surgery, possibly less arthritis), but a 2026 review notes many differences are small and may not be noticeable. Both are good options.[1][2][3]
5. Why do screws break?
A rigid screw holds bones that naturally want to move slightly, so it's under repeated stress — breakage occurred in about 25% in one meta-analysis. A broken but symptom-free screw isn't always a problem.[1]
6. Will I need surgery to remove the hardware?
Suture buttons rarely need removal (~4–6%). Screws were historically removed more often, but current practice increasingly leaves intact, symptom-free screws in place.[3][11]
7. What is malreduction, and why does it matter?
It means the fibula healed slightly out of position. It's one of the strongest predictors of a poor outcome and arthritis — which is why anatomic reduction is the top priority.[4]
8. Does the suture button let me walk sooner?
Sometimes. Some studies show earlier weight-bearing and faster return to work with suture buttons, and early weight-bearing at ~2 weeks is now well supported for these injuries generally.[12][18][19]
9. Will I get arthritis?
There's a risk, especially if the joint isn't perfectly realigned. In the 5-year randomized data, arthritis was less common with the suture button (35% vs 65%).[2]
10. Why see a fellowship-trained foot and ankle surgeon?
Because achieving and confirming an anatomic reduction — the thing that matters most — takes experience, careful intraoperative testing, and judgment about which device fits your injury and goals.[4]
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THE BOTTOM LINE
If your ankle fracture includes an unstable syndesmosis injury, it needs to be stabilized — and both syndesmotic screws and suture buttons are proven, effective options. The best evidence, including a 5-year randomized trial, modestly favors the suture button for function, implant durability, and lower arthritis, while a 2026 umbrella review reminds us those differences are often small and both devices do well.[1][2][3] What matters most is an anatomic reduction by an experienced surgeon, confirmed with careful intraoperative testing.[4] With early protected weight-bearing now well supported, recovery is often faster than patients expect.[18][19]
If you've fractured your ankle and been told you have a "high ankle" or syndesmosis injury — or you want a clear explanation of your fixation options — bring your imaging and come in. The right plan depends on your specific injury and your goals.
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RELATED READING
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ABOUT THE AUTHOR
Dr. Sarang Desai is a fellowship-trained orthopedic foot and ankle surgeon with particular expertise in sports medicine. With over 15 years of experience, Dr. Desai serves as a professional sports team physician and treats the full spectrum of foot and ankle conditions — including ankle fractures and syndesmosis (high ankle) injuries, ankle fracture-dislocations, pilon, talus, and calcaneus fractures, cartilage injuries, chronic ankle instability, peroneal tendon disorders, Achilles tendon injuries, Jones fractures, Lisfranc injuries, bunions, foot and ankle arthritis, total ankle replacement, and complex revision surgery.
He is a published researcher, an orthopedic implant inventor, a national lecturer, and a former University of Texas All-American athlete.
Offices in McKinney and Flower Mound, Texas, serving patients throughout Plano, Frisco, Denton, Lewisville, Southlake, Dallas, Fort Worth, Arlington, and the greater Dallas–Fort Worth metroplex and beyond.
SCHEDULE AN APPOINTMENT
📞 (972) 547-0047
📍 McKinney, TX | Flower Mound, TX
If you've fractured your ankle and want an expert opinion on your syndesmosis fixation options — bring your X-rays, CT, or MRI and come in. Getting the reduction right is what matters most, and experience makes the difference.
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This article is for educational purposes only and does not constitute personal medical advice. Always consult a qualified physician about your individual situation.
References
Suture Button Versus Syndesmotic Screw for Syndesmosis Injuries: A Meta-Analysis of Randomized Controlled Trials. Shimozono Y, Hurley ET, Myerson CL, Murawski CD, Kennedy JG. The American Journal of Sports Medicine. 2019;47(11):2764-2771. doi:10.1177/0363546518804804.
Better Outcome for Suture Button Compared With Single Syndesmotic Screw for Syndesmosis Injury: Five-Year Results of a Randomized Controlled Trial. Ræder BW, Figved W, Madsen JE, et al. The Bone & Joint Journal. 2020;102-B(2):212-219. doi:10.1302/0301-620X.102B2.BJJ-2019-0692.R2.
Suture Button Versus Syndesmotic Screw Fixation in Acute Ankle Fractures With Syndesmotic Injury: An Umbrella Review of Functional Outcomes and Clinical Relevance Based on the Minimal Clinically Important Difference. Nieuwenkamp CL, Tausendfreund J, Schepers T. Injury. 2026;57(3):113054. doi:10.1016/j.injury.2026.113054.
Diagnosis and Treatment of Syndesmotic Unstable Injuries: Where We Are Now and Where We Are Headed. Bejarano-Pineda L, DiGiovanni CW, Waryasz GR, Guss D. The Journal of the American Academy of Orthopaedic Surgeons. 2021;29(23):985-997. doi:10.5435/JAAOS-D-20-01350.
Distal Tibiofibular Syndesmosis: Anatomy, Biomechanics, Imaging Approach, and Postoperative Evaluation. Silva LNMD, Morimoto LR, Watanabe GG, et al. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2026;46(2):e250065. doi:10.1148/rg.250065.
Evaluation and Treatment Recommendations for Acute Injuries to the Ankle Syndesmosis Without Associated Fracture. Miller TL, Skalak T. Sports Medicine (Auckland, N.Z.). 2014;44(2):179-88. doi:10.1007/s40279-013-0106-1.
Technical Note: Intraoperative Ultrasound Measurement for Evaluating the Stability of the Inferior Tibiofibular Joint in Patients With Ankle Fractures. Lu H, Zhu J, Deng J, et al. Injury. 2023;54(10):111014. doi:10.1016/j.injury.2023.111014.
Standardized Analysis of Syndesmosis Stability in Ankle Trauma With an Innovative Syndesmosis-Test-Tool: A Biomechanical Study. Kohler FC, Hallbauer J, Herrmann L, et al. Scientific Reports. 2024;14(1):1659. doi:10.1038/s41598-024-51872-4.
Randomized Trial Comparing Suture Button With Single Syndesmotic Screw for Syndesmosis Injury. Andersen MR, Frihagen F, Hellund JC, Madsen JE, Figved W. The Journal of Bone and Joint Surgery. American Volume. 2018;100(1):2-12. doi:10.2106/JBJS.16.01011.
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The Clinical Efficacy of Suture-Button Fixation and Trans-Syndesmotic Screw Fixation in the Treatment of Ankle Fracture Combined With Distal Tibiofibular Syndesmosis Injury: A Retrospective Study. Xu Y, Kang R, Li M, et al. The Journal of Foot and Ankle Surgery : Official Publication of the American College of Foot and Ankle Surgeons. 2022 Jan-Feb;61(1):143-148. doi:10.1053/j.jfas.2021.07.009.
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Surgical Versus Non-Surgical Interventions for Displaced Intra-Articular Calcaneal Fractures. Lewis SR, Pritchard MW, Solomon JL, Griffin XL, Bruce J. The Cochrane Database of Systematic Reviews. 2023;11:CD008628. doi:10.1002/14651858.CD008628.pub3.
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