Occult syndesmotic injury in chronic lateral ankle instability treated with Broström repair and suture-button stabilization

doi:10.5312/wjo.125993

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World Journal of Orthopedics

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2218-5836

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Study

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Orthop. Oct 18, 2026; 17(10): 125993
Published online Oct 18, 2026. doi: 10.5312/wjo.125993

Occult syndesmotic injury in chronic lateral ankle instability treated with Broström repair and suture-button stabilization

Gui-Cheng Li, Cheng-Bo Du, Hao Lu, Jia-Bao Ju, Hai-Lin Xu

Gui-Cheng Li, Cheng-Bo Du, Hao Lu, Jia-Bao Ju, Hai-Lin Xu, Department of Orthopaedic and Traumatology, Peking University People’s Hospital, Peking University, Beijing 100044, China

Gui-Cheng Li, Cheng-Bo Du, Hao Lu, Jia-Bao Ju, Hai-Lin Xu, Diabetic Foot Treatment Center, Peking University People’s Hospital, Peking University, Beijing 100044, China

Gui-Cheng Li, Cheng-Bo Du, Hao Lu, Jia-Bao Ju, Hai-Lin Xu, Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, Beijing 100044, China

Co-first authors: Gui-Cheng Li and Cheng-Bo Du.

Author contributions: Li GC was written the first draft of the manuscript; Li GC and Du CB contributed to clinical data interpretation and manuscript preparation; they contributed equally to this article, they are the co-first authors of this manuscript; Lu H and Ju JB carried out material preparation, data collection, and data analysis; Xu HL supervised the entire study and was responsible for the overall study design, project administration, critical revision of the manuscript; Li GC, Du CB, Lu H, Ju JB, and Xu HL contributed to the study conception and design; and all authors commented on previous versions of the manuscript, contributed to manuscript revision, and approved the final manuscript.

AI contribution statement: Portions of this manuscript were edited using AI tools solely for language refinement. The authors carefully reviewed and verified all AI-assisted outputs and take full responsibility for the scientific content of the manuscript.

Supported by Peking University People’s Hospital Scientific Research Development Funds, No. RDGS2024-07; Beijing Municipal Natural Science Foundation, No. L234015; and Beijing Traditional Chinese Medicine Science and Technology Development Fund, No. BJZYZD-2025-12.

Institutional review board statement: This study was approved by the Medical Ethics Committee of Peking University People’s Hospital, approval No. 2018PHB131-01.

Informed consent statement: Written informed consent to participate in the study was obtained from all individual participants.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

Data sharing statement: The datasets generated and/or analyzed during the current study are not publicly available because of privacy concerns and the presence of potentially identifiable patient information, but are available from the corresponding author upon reasonable request.

Corresponding author: Hai-Lin Xu, MD, Professor, Department of Orthopaedic and Traumatology, Peking University People’s Hospital, Peking University, No. 11 Xizhimen South Street, Beijing 100044, China. hailin@bjmu.edu.cn

Received: July 22, 2026
Revised: August 13, 2026
Accepted: October 14, 2026
Published online: October 18, 2026
Processing time: 86 Days and 22.7 Hours

Abstract

BACKGROUND

Chronic lateral ankle instability may coexist with occult syndesmotic injury despite the absence of definite distal tibiofibular diastasis on static imaging. Because symptoms may overlap with those of isolated lateral ankle instability, this condition can remain unrecognized. This study hypothesized that selected patients with persistent anterior syndesmotic symptoms and stress-confirmed occult syndesmotic instability would demonstrate sustained improvement after combined Broström repair and suture-button stabilization.

AIM

To evaluate 5-year clinical outcomes of combined Broström repair and suture-button stabilization in this selected cohort.

METHODS

This uncontrolled retrospective case series at a tertiary hospital included 16 of 1487 patients treated from April 2018 to May 2021. Eligibility required chronic lateral ankle instability, focal syndesmotic symptoms, no static diastasis, failed conservative treatment, and qualitative confirmation by three intraoperative stress tests. No comparator or quantitative diagnostic threshold was used. All underwent combined Broström repair and suture-button stabilization. Repeated outcomes were analyzed using Friedman and Bonferroni-adjusted exact Wilcoxon tests.

RESULTS

The median injury-to-surgery interval was 21.0 months (interquartile range, 8.25-120.0 months). Preoperative visual analogue scale, American Orthopaedic Foot and Ankle Society, Foot and Ankle Ability Measure, and Karlsson scores were 3.00 ± 1.32, 69.69 ± 12.11, 69.67 ± 12.15, and 64.00 ± 11.86, respectively. At 5 years, scores were 0.44 ± 0.63, 92.06 ± 6.89, 89.21 ± 10.19, and 88.12 ± 8.69 (all adjusted P < 0.001; paired Cohen’s dz, -2.03, 2.06, 1.94, and 2.40). All patients returned to work at 2.44 ± 0.68 months. Seven patients (43.8%) underwent button removal at 1 year; none had implant-related symptoms at 5 years.

CONCLUSION

In this uncontrolled case series, combined treatment was associated with improvement, but the findings are exploratory and do not establish the independent benefit of suture-button stabilization.

Keywords: Syndesmosis; Occult syndesmotic injury; Suture-button; Chronic lateral ankle instability; Broström repair

Core Tip: This study highlights a selected subgroup of patients with chronic lateral ankle instability who had persistent anterior syndesmotic symptoms despite the absence of definite distal tibiofibular diastasis on static imaging. Occult syndesmotic instability was supported by qualitative stress testing under anesthesia. Combined Broström repair and suture-button stabilization was associated with sustained clinical improvement at 5 years. These hypothesis-generating findings support careful syndesmotic assessment and a selective approach to stabilization but do not establish an independent treatment effect.