Background
Methods
Eligibility criteria
Information sources and search
Data collection
Quality assessment
Results
Study selection
Quality of the included studies
Study (year) | Targeted population | Study type | Number: SBG VS SG | Mean age (years): SBG VS SG | Suture-button usage | Cortical screw usage | Follow-up | MINORS score |
---|---|---|---|---|---|---|---|---|
Kocadal 2016 [4] | Turkey Ankara, | Retrospective comparative study | 26/26 | 43.3/44.8 | 1 ZipTight Fixation System | One 3.5mm screw (4 cortices) | 16.7 ± 11.0 months | 18 |
Kim 2016 [2] | Korea Busan | Historical control study | 24/20 | 51.3/40.5 | 1 TightRope implant | One 3.5mm screw (3 cortices) | 13.4 / 14.6 months | 12 |
Seyhan 2015 [17] | Turkey Istanbul | Retrospective comparative study | 15/17 | 33.2 /32.0 | 1 TightRope implant | One 4.5 mm screw (4 cortices) | 14.6 (12–50) months | 17 |
Kortekangas 2015 [8] | Finland Oulu | Prospective randomized controlled clinical trial | 21/19 | 46.0 /43.5 | 1 TightRope implant | One 3.5 mm screw (3 cortices) | At least 2 years, mean 36 months in TightRope group,37 months in the syndesmotic screw group) | — |
Laflamme 2015 [9] | Netherland And Canada. | Prospective Randomized Multicenter Trial | 34/36 | 40.1/ 39.3 | 1 TightRope implant | One 3.5mm screw (4 cortices) | 12 months | — |
Ireland Drogheda, | Cohort study | 23/23 | 42/40 | 16 cases with one TightRope implant 7 cases with two TightRope implant | 20 cases with one screw 3 cases with two screws (4 cortices) | 2.5 years | 16 | |
Cottom 2009 [12] | America Columbus | Prospective cohort study | 25/25 | 34.68/36.68 | 21 cases with a single interosseous suture endobutton 4 cases with dual interosseous suture endobuttons | 12 cases with a single screw 13 cases with 2 screws | 10.78 months /8.2 months | 17 |
Coetzee 2009 [15] | America Minneapolis | Prospective, randomized clinical trial | 12/12 | 35/38 | All but one had two TightRopes | 4.0 mm, 4.5 mm and 6.5 mm screws | 2.3year | — |
Thornes 2005 [18] | Ireland | Retrospective cohort study | 16/16 | 32/31 | A suture-button (One #5 braided polyester suture and two endobuttons) | One four-cortical syndesmosis screw | 12 months | 18 |
The characteristics of the included studies
Study (year) | Main functional evaluation | Mean scores SBG VS SG | Implant removal SBG VS SG | Implant failure SBG VS SG | Malreduction SBG VS SG | Complications SBG VS SG | Routine screw removal (yes or no) |
---|---|---|---|---|---|---|---|
Kocadal et al. 2016 [4] | AOFAS | 88.4 /86.1 | 1/10 | 0/1 | NR | 2 (1 low-grade infection and implant irritation)/1 reflex sympathetic dystrophy | No |
Kim et al. 2016 [2] | AOFAS | 88.1/86.6 | NR | 0/5 | NR | NR | NR |
Seyhan 2015 [17] | AOFAS | 93.73/93.35 | 2/17 | 0/0 | 0/0 | 6 (2 Implant discomfort and 4 soft tissue irritation )/2 Implant discomfort | Yes |
Kortekangas 2015 [8] | Olerud–Molander score | 82/84 | 1/3 | 0/16(broken in three patients and loosened in 13 patients) | 1/3 | 1 post-operative infection/3 local irritation | No |
Laflamme 2015 [9] | Olerud–Molander score | 93.3/ 87.7 | 2/11 | 0/13 | 0/4 | 3(two superficial infection and one partial syndesmosis ossification)/12(1 partial syndesmosis ossification and 11 discomfort) | No |
AOFAS | 89.56/86.52 | NR | NR | 0/5 | NR | Yes | |
Cottom 2009 [12] | Modified AOFAS (a maximum of 63 possible points) | 50.64/53.45 | 0/17 | 0/12 (screw loosening in 5 patients and 7 cases of screw breakage) | NR | NR | No |
Coetzee 2009 [15] | AOFAS | 94/88 | 1/1 | 0/1 | NR | 1 superficial infection/0 | No |
Thornes 2005 [18] | AOFAS | 93/ 83 | 0/12 | NR | NR | No major complications or wound infections | No |
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. |
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. |