O3235: Ankle Syndesmotic Injury in Pediatric Athletes: Do Syndesmotic Screws or Button Fixation Lead to Faster Weight Bearing and Return to Sports?

Background: Ankle sprains and fractures are some of the most common injuries affecting pediatric and adolescent athletes. Approximately 20% of all ankle fractures result in concomitant injury to the distal tibiofibular syndesmosis which can result in functional disability and delayed return to sport. While traditional treatment of these injuries has been with syndesmotic screws, recent research in the adult population suggests fixation with suture buttons offer similar fixation and advantages including decreased time to full weight bearing and decreased rates of hardware breaking or needing removal. Few studies have compared functional outcomes of these fixation types in the pediatric and adolescent athlete. Thus, the purpose of this study was to compare complication rates and outcomes in children and adolescents with ankle syndesmosis injuries treated with suture button versus screw fixation.

Methods: Following IRB approval, a retrospective review was conducted of all patients less than 19 years of age who presented with an ankle syndesmosis injury secondary to sports or recreational injury from 2008-2022 at a single tertiary pediatric hospital. Demographics, clinical information, outcomes, and complications data were collected. Kaplan-Meir Log Rank Tests were used to compare time immobilized, non-weightbearing, and to return to sports by treatment type. Chi-square and Fisher’s Exact Test were used to determine association between treatment type and outcome of interest. P< 0.05 was considered statistically significant.

Results: Ninety-nine patients (62% male) were included with an average age of 16 years (range: 11-18 years). Almost all (93.9%) had concomitant fractures (58.1% Weber C, 36.6% Weber B) and 43.4% were sports-related injuries with the most popular sports played being football (35.2%), basketball (22.2%), and soccer (14.8%). 46 patients were treated with suture button fixation versus 53 with screw fixation. Patients treated with suture buttons were able to bear weight sooner than patients treated with screws, 54.0 days versus 77.9 days respectively (p < 0.001). There was no significant difference in duration immobilized or time to return to sports between fixation groups (p = 0.543 and 0.290, respectively). At an average 4-month follow-up, 13.2% of patients with screw fixation had broken hardware on imaging. Patients treated with screws were significantly more likely to have a secondary procedure for hardware removal than those treated with suture buttons (83.0 versus 4.3%, p< 0.001) (Table 1).

Conclusion: Suture buttons are associated with a quicker time to full weight bearing and a decreased risk of broken hardware or hardware removal. These findings are especially important for the pediatric athlete, as they may be more susceptible to syndesmotic injury and are motivated to return to play. Although we did not find a significant difference in time to return to sports, with earlier time to return to weight bearing, patients may progress to more advanced rehabilitation and physical therapy earlier.