Comparison of Tightrope versus Syndesmotic Screw Fixation for Functional and Radiological Outcomes in Patients with Ankle Syndesmosis Injuries: A Prospective Interventional Study Form Southern India

Introduction: Ankle syndesmosis injuries often occur due to high-energy trauma or distal fibular fractures, disrupting the stabilising ligament complex. Conventional screw fixation, while effective, requires implant removal and may be associated with complications. Tightrope fixation offers dynamic stabilisation, allowing early mobilisation with potentially fewer complications. Aim: To evaluate and compare clinical and radiological outcomes of Tightrope fixation and syndesmotic screw fixation in patients with ankle syndesmosis injuries. Materials and Methods: The present prospective interventional study conducted in the Department of Orthopaedics at SRM Medical College Hospital and Research Centre, Tamil Nadu, India over a period of 18 months (September 2023 - February 2025). A total of 60 patients with ankle syndesmosis injuries were enrolled and allocated into two groups based on clinical judgment: group A (Tightrope fixation, n=30) and group B (syndesmotic screw fixation, n=30). All patients underwent open reduction and internal fixation of the ankle fracture followed by either Tightrope or syndesmotic screw fixation for stabilization of the syndesmosis, depending on group allocation. Functional outcomes were assessed using the Olerud-Molander Ankle Score (OMAS) and the Foot and Ankle Outcome Score (FAOS). Pain was evaluated using the Visual Analog Scale (VAS). Radiological parameters included tibiofibular clear space, tibiofibular overlap, and medial clear space. Postoperative follow-up was conducted at three weeks, six weeks, three months, and six months, with a total follow-up duration of six months. Complications were also recorded. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 29, with a p-value <0.05 considered significant. Results: Mean age of participants in groups A and B were 43.2±18.3 years and 42.8±16.2 years, respectively. Gender distribution was also comparable across both groups (p=0.793). Regarding co-morbidities, Diabetes Mellitus (DM) was present in 8 (13.3%) of participants overall and Hypertension (HTN) was seen in 11 (18.3%), with similar distribution across groups. Smoking habits were nearly evenly distributed, with 40 (66.7%) of participants being non-smokers. OMAS and FAOS scores were significantly higher in the Tightrope group across all followup intervals (p<0.001). At six months, the mean VAS score was significantly lower in group A compared to group B (1.6±0.9 vs. 3.3±1.6; p<0.001). Radiological outcomes, including tibiofibular clear space and overlap, also significantly favoured group A (p<0.001). The rate of infection was lower in the Tightrope group (3.3% vs. 20%), and there were no cases of malreduction, compared to 6.7% in the screw fixation group. Conclusion: The present study demonstrates that Tightrope fixation offers superior functional recovery, pain relief, and radiological outcomes compared to syndesmotic screw fixation in ankle syndesmosis injuries treatment. Additionally, it results in fewer postoperative complications, allowing it a more feasible and efficient surgical choice for treating such injuries.