Suture button compared with ventral augmentation in unstable syndesmotic injuries

Aims Little is known about the distal tibiofibular joint (DTFJ) malreduction rate following ventral anterior inferior tibiofibular ligament (AiTFL) augmentation in two-ligament syndesmotic injuries in ankle fracture cases. The aims of the current study were to assess the DTFJ malreduction rate following ventral AiTFL augmentation, and compare these to suture button stabilization in two-ligament (AiTFL, interosseous ligament (IOL)) injuries in fracture cases. Methods This retrospective radiological study assessed the quality of DTFJ reduction in ankle fractures with a two-ligament syndesmotic injury (AiTFL and IOL rupture). Patients with a syndesmotic stabilization by a single suture button system (January 2010 to October 2020) were compared with those with a ventral augmentation (October 2020 to November 2023). The quality of DTFJ reduction was assessed on postoperative bilateral CT images. The overall cohort was analyzed as well as a propensity score-matched cohort. Results Overall, 45 patients were eligible for the single suture button group and 78 patients for the ventral augmentation group. There were no significant group differences per the demographic and injury characteristics between the two groups. Neither the malreduction rate (7 (16%) vs 16 (21%); p = 0.497) nor the predominant direction of malreduction (p = 0.063) differed significantly between the two cohorts. These results stayed true for the propensity score-matched analysis (n = 41 per group). Conclusion Ventral augmentation in two-ligament, syndesmotic injuries results in similar good DTFJ reduction rates as suture button systems, with the ventral augmentation biomechanically more closely resembling the native syndesmosis. Future studies should assess patient-rated outcomes as well as more rapid rehabilitation protocols in patients treated with ventral augmentation for two-ligament, syndesmotic injuries. Cite this article: Bone Joint J 2026;108-B(3):346–354.