The authors have reported the results of suture-button fixation of a deliberate malreduction of cadaveric ankle syndesmoses and compared them with the results of screw fixation of these syndesmoses. They found suture-button fixation to be associated with a “spontaneous” improvement of the anterior-posterior malreduction. They suggest that since imperfect reductions do in fact occur clinically, the suture button may advantageously allow a spontaneous reduction to occur, with improved patient outcome.

Syndesmotic injuries are fraught with potential complications. Traditional treatment includes reduction and fixation with screws between the fibula and tibia and has been effective, but it has not eliminated all of the problems. Loosening and breakage of the screws occur at least partially as a result of rigid immobilization of an articulation that normally has a small amount of movement with walking and other activities involving motion of the ankle. Suture-button and other alternative fixation techniques that do not rigidly fix the syndesmosis have been developed.

I have several concerns with the study. I am not certain by which mechanism the malreduced syndesmosis spontaneously reduces. Which forces are at work in a cadaver and living human that correct the malreduction? A spontaneous reduction is theoretically possible and seems to occur, but a full understanding of the mechanism is lacking. There is certainly the potential for physical activity to cause loss of reduction of an injured syndesmosis.

The primary purpose of fixation of the syndesmosis is to maintain the reduction achieved operatively until healing occurs. It seems counterintuitive to me to promote “loose” fixation in anticipation of a malreduction with the hope that somehow the loose fixation will allow spontaneous reduction. An alternative approach would be to promote techniques to obtain a good reduction as well as fixation methods to maintain that reduction until healing occurs.