Does Syndesmotic Fixation Technique Impact Complication Rates and Functional Outcomes Measured by PROMIS Scores Following Operative Repair of Ankle Fractures?

Does Syndesmotic Fixation Technique Impact Complication Rates and Functional Outcomes Measured by PROMIS Scores Following Operative Repair of Ankle Fractures? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Does Syndesmotic Fixation Technique Impact Complication Rates and Functional Outcomes Measured by PROMIS Scores Following Operative Repair of Ankle Fractures? Steven M. Hadley, Jr., Rachel Bergman, John J. Peabody, Sarah J. Westvold, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6857999/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Aug, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 9 You are reading this latest preprint version Abstract Background: It remains unclear whether syndesmotic fixation technique impacts outcomes following ankle fracture surgery. This study investigates which repair technique (transsyndesmotic screws, TightRope, and Internal Brace) results in fewest complications and best functional outcomes measured by Patient Reported Outcome Measurement Information System (PROMIS) computerized adaptive tests (CATs) of physical function (PF) and pain interference (PI). Methods: 782 patients who underwent ankle fracture surgery at a single institution between 2016–2021 were retrospectively reviewed. Two fellowship-trained orthopaedic surgeons independently reviewed all radiographs, determined fixation technique, and assessed complications. Open fractures, pilons, and neuropathies were excluded. 252 had syndesmotic injury identified via intraoperative fluoroscopy. 159/252 who had minimum one-year radiographic follow-up were included for complications analysis. These 159 were sent post-operative PROMIS CATs. 68/159 consented and were included for final analysis of PROMIS. Kruskal-Wallis test compared PROMIS across repair types. Multinomial logistic regression adjusted for propensity scores included as covariates modeled PROMIS by technique. Results: 62/159 had screw, 59/159 TightRope, and 38/159 Internal Brace. Screw complication rate was 12.9% (8/62): 8.1% (5/62) degenerative joint disease (DJD), 6.5% (4/62) syndesmotic malreduction. TightRope complication rate was 1.7% (1/59): 1.7% (1/59) DJD. Internal Brace had no radiographic complications. Mean PF was 50.5 ± 7.9 screw, 53.9 ± 9.7 TightRope, and 52.2 ± 13.1 IB (p = 0.72). Mean PI was 49.6 ± 8.2 screw, 47.9 ± 8.8 TightRope, and 49.2 ± 10.5 IB (p = 0.75). Mean PF was 5.1-points (95%CI: -0.9-11.1) higher for TightRope and 5.2-points (95%CI: -1.3-11.7) greater for Internal Brace vs. screw. Mean PI was 3.2-points less for TightRope (-3.2, 95%CI:-8.5-2.1) and 4.4-points less for Internal Brace (-4.4, 95%CI: -10.1-1.3) vs. screws. Conclusions: Syndesmotic fixation with either TightRope or Internal Brace reduces complications compared to screw. While this study was underpowered to detect differences in PROMIS, improved PROMIS for TightRope and Internal Brace vs. screws suggest that these techniques may result in better functional outcomes compared to screws. syndesmotic rupture ankle fracture PROMIS syndesmotic fixation TightRope InternalBrace syndesmotic screw patient-reported outcomes Figures Figure 1 Figure 2 BACKGROUND Various techniques are used to repair the distal tibiofibular syndesmosis. While traditionally performed with syndesmotic screws, which rigidly fixate the syndesmosis and create a static spatial relationship between the tibia and fibula, newer flexible forms of fixation including the Syndesmosis TightRope® XP (TR, Arthrex, Naples, FL) and Internal Brace™ (IB, Arthrex, Naples, FL) have been developed to preserve the natural movement of the syndesmosis. The TR is a tensioned suture construct that compresses the fibula into the incisura of the tibia, primarily providing coronal plane stability to resist syndesmotic diastasis. The IB is a synthetic augment to ligament reconstruction, in the setting of syndesmotic fixation, and in this study, it was used to reconstruct/augment the AITFL ligament, providing stability against translation in the coronal and sagittal planes and against excessive external rotation. It is unclear whether syndesmotic fixation technique impacts patient outcomes. Most studies have compared TR and screws while limited studies have evaluated IB, none of which compare complications directly between IB and screw. The majority of these studies found lower rates of syndesmotic malreduction, reoperation, posttraumatic osteoarthritis, and hardware-related complications in TR compared to screw [ 1 – 9 ]. Others found no significant differences in complication rates and rotational stability between TR and screw [ 10 – 14 ]. Similarly, the literature regarding the impact of fixation technique on functional outcomes remains controversial. Many studies suggest that TR improves American Orthopaedic Foot and Ankle Society (AOFAS) scores, Olerud-Molander ankle scores, time to weight bearing, and ability to return to sports compared to screws [ 2 – 4 , 7 , 14 – 17 ] while others found no significant differences in AOFAS, Foot and Ankle Disability Index (FADI) scores, and Foot and Ankle Ability Measure (FAAM) scores [ 1 , 6 , 8 , 9 , 18 ]. Limited data also exist regarding functional outcomes following syndesmotic fixation with IB compared to screws, with few studies suggesting that IB results in satisfactory FAAM scores and good stability, but these studies do not compare screw fixation to IB [ 19 – 21 ]. To our knowledge, no study has compared functional outcomes as measured by validated Patient Reported Outcomes Measurement Information System (PROMIS) scores between these three syndesmotic techniques. Designed as an intended gold-standard outcome measure to deliver psychometrically standardized, validated patient-reported outcomes (PROs), PROMIS exhibits improved generalizability, consistency, and reliability compared to several other legacy instruments commonly used in foot and ankle including FAAM, Foot Function Index (FFI), AOFAS scores, and Visual Analogue Scale (VAS) [ 22 – 24 ]. PROMIS also demonstrates an ability to effectively detect clinically meaningful differences for ankle fractures specifically and exhibits decreased floor and ceiling effects compared to other legacy scales [ 22 – 24 ]. Because of PROMIS’s validity, understanding of how syndesmotic fixation technique impacts PROMIS would provide important insight into the relative efficacy of the three syndesmotic fixation techniques. This study therefore aims to determine which repair technique results in the greatest functional outcomes as measured by PROMIS and in the fewest complications. We hypothesized that TR and IB would reduce complications and improve PROMIS compared to transsyndesmotic screws. METHODS Population: This investigation was an Institutional Review Board (IRB) approved retrospective review of 782 patients at a single institution who underwent ankle fracture surgery between January 2016-December 2021. Two fellowship-trained foot and ankle orthopaedic surgeons independently reviewed all radiographs and assessed reduction quality and complications at final follow-up. Multiple extremity injuries, open fractures, and pilon variants were excluded. Of 587 patients remaining, 262 patients with syndesmotic injuries determined by intraoperative fluoroscopic and direct visual examination were identified. 10 neuropathic patients were subsequently excluded. 159 of the remaining 252 patients who had minimum one-year radiographic follow-up were included for analysis. These 159 patients were sent post-operative questionnaires with PROMIS physical function (PF) and pain interference (PI) computerized adaptive tests (CATs) via REDCap. Surveys also asked whether patients experienced any activity limitations due to fear of reinjury with a binary yes/no response option. If patients did not respond to an initial email and did not decline consent, another email was sent, followed by a phone call one week later, and then two more emails prior to ceasing contact. 68/159 consented and were included for final analysis of PROMIS (Fig. 1). This response rate of 43% exceeds the acceptable orthopaedic trauma survey response rate of 30% reported in the literature [ 25 ]. Syndesmotic Repair Technique: Intraoperative fluoroscopy was used to assess for syndesmotic injury via manual external rotation stress testing. Syndesmotic injury was determined by visualization of diastasis at the anterior syndesmosis as well as the tibiofibular clear space. Surgeon preference determined stabilization method. Fellowship-trained orthopaedic surgeons in either foot and ankle (n = 4) or trauma (n = 3) performed all surgeries. In this study, by department convention at our institution, surgeons with trauma fellowship training utilized screw fixation while surgeons with foot and ankle fellowship training utilized flexible fixation to stabilize the syndesmosis. Internal Brace™ Fixation : For syndesmotic fixation via IB, 2.0mm FiberTape® suture (Arthrex, Naples, FL) is woven through the fibula plate eyelet. Next, a 3.5mm drill bit is used to create an insertional point onto the distal tibia for AITFL augmentation. The other end of fibertape is woven through the SwiveLock® insertion into the distal tibia. A bone tap is used followed by insertion of 4.75mm SwiveLock® anchor (Arthrex, Naples, FL). Appropriate tension is applied across the IB to create a stable AITFL augmentation – removing all slack with thumb reduction of the joint. TightRope® Fixation: For syndesmotic fixation via the TR, the syndesmosis is reduced (via thumb pressure) and pinned provisionally with a 2 − 0 Kirschner wire (K-wire). Fluoroscopy is used to confirm the starting point on the distal fibula for the trajectory of the TightRope® (Arthrex, Naples, FL). The TR is inserted approximately 2cm proximal to the tibiotalar joint line, making sure to start in the middle of the fibula and exit in the middle of the tibia medially while staying parallel to the ankle joint. Fluoroscopy is obtained to confirm the correct position. Afterwards, a 3.5mm cannulated drill is used to drill through all cortices over the K-wire. Next, the TR is inserted through the drilled pathway, ensuring the button sits on bone on the medial cortex of the distal tibia. Before tightening, the anterior syndesmosis is exposed again and manually reduced to anatomic position, after which the TR is tightened across the syndesmosis. Screw Fixation: For syndesmotic fixation via cortical screw placement, the syndesmosis is reduced (via thumb pressure) and pinned provisionally with a 2 − 0 K-wire. Reduction is assessed fluoroscopically and with palpation of the anterior aspect of the syndesmosis. Once satisfied with the reduction, a 3.5mm tetracortical transsydesmotic screw is placed through the fibular plate to complete the construct, after which the K-wire is removed. Outcomes: The primary outcome was postoperative PROMIS PF and PI. The secondary outcome included assessment of both radiographic and surgical complications. Postoperative radiographic complications included: degenerative joint disease (DJD), end stage arthritis, and syndesmotic malreduction. Anatomic reduction of the syndesmosis was based on standard radiographic criteria [ 26 ]. Surgical complications were collected from chart review and included: deep vein thrombosis (DVT), pulmonary embolism (PE), superficial wound complications, deep wound complications, and reoperation within 365 days. The PF and PI were developed to correspond to age-matched norms for a US general population mean score of 50 [ 27 , 28 ]. Higher PF indicates better physical function while, higher PI designates more pain interference with activity [ 27 , 28 ]. Statistical Analysis: Hypothesis-driven testing analyzed with R Version 4.3.0 (R Foundation for Statistical Computing, Vienna, Austria) was used. Due to rarity of complications, we were unable to use statistical tests to compare complication incidence across techniques. The Kruskal-Wallis test compared PROMIS across repair types. To address imbalance of confounders across syndesmosis repair technique groups, we calculated propensity scores using a multinomial logistic regression model that included fracture subtype, Weber classification, and sex. Propensity scores for IB and TR were included as covariates in the linear regression model with BMI, age, fear of reinjury, and months of clinical follow up. We expected that diabetes would influence both treatment selection and functional outcomes; however, with only three diabetic patients in our sample, we elected not to include this variable in the propensity score model to avoid unstable estimates and extreme propensity scores. Therefore, we conducted a sensitivity analysis excluding these three patients. With a sample size of 68, we had 80% power to detect a medium to large effect size (f = 0.39, η²=0.13) at a significance level of 0.05, corresponding to a difference in mean of 7.1 for pain interference and 8.1 for physical function. We were underpowered to detect the lower end value of the minimal clinically important difference (MCID) for PROMIS of 3 [ 28 ]. Results were adjusted for fear of reinjury because prior literature demonstrated fear may play a significant role in outcomes following ankle fracture surgery [ 29 ]. Radiographic follow-up was defined as time of surgery to most recent ankle radiographs. Clinical follow-up was defined as time of surgery to last contact with the orthopaedic provider. RESULTS Patient characteristics are displayed in Table 1 . For the complications analysis, 62/159 (39.0%) underwent fixation with screw, 59/159 (37.1%) with TR, and 38/159 (23.9%) with IB. For PROMIS analysis, 18/68 had screw, 28/68 TR, and 22/68 IB. Average radiographic and clinical follow-up were 14.1 months and 35.0 months, respectively, with no significant difference in follow-up between groups (p = 0.76 and p = 0.85, respectively). For screw, 8.1% (5/62) developed DJD and 6.5% (4/62) had syndesmotic malreduction. One TR patient developed DJD (1.7%). IB had no radiographic complications (Table 2 ). Surgical complications were similar between groups (p > 0.05, Table 2 ). Screws had a 40.3% (25/62) reoperation rate, TR 3.4% (2/59) reoperation rate, and IB 13.2% (5/38) reoperation rate. Table 2 displays reoperation reason, with symptomatic hardware being the most common reason. Patients may have had more than one complication. Mean PROMIS PF was 50.5 ± 7.9 for screw fixation (n = 18), 53.9 ± 9.7 for TR (n = 28), and 52.2 ± 13.1 for IB (n = 22, p = 0.72, Table 3 ). Mean PROMIS PI was 49.6 ± 8.2 for screw, 47.9 ± 8.8 for TR, and 49.2 ± 10.5 for IB (p = 0.75). Figure 2 displays the distribution of individual PROMIS scores. Adjusted models comparing TR and IB to screws demonstrated mean PF 5.1-points (95%CI: -0.9-11.1) higher for TR (p = 0.10, Table 4 ) and 5.2-points greater for IB (95%CI: -1.3-11.7, p = 0.12, Table 4 ). Adjusted models for PI revealed mean scores of 3.2-points less for TR (-3.2, 95%CI:-8.5-2.1, p = 0.42) and 4.4-points less for IB (-4.4, 95%CI: -10.1-1.3, p = 0.65, Table 4 ) compared to screws. When excluding the three patients with diabetes (Table 4 ), TR had PF 4.4-points higher than screw (95%CI: -1.9-10.7, p = 0.16) and PI 2.5-points lower than screw (-2.5, 95%CI: -7.9-2.9, p = 0.36). IB had PF 4.4 higher PF than screw (95%CI: -2.6-11.4, p = 0.21) and PI 3.1 less than screw (-3.1, 95%CI: -9.1-2.9, p = 0.31). Table 1 Patient Characteristics: Overall and by Repair Technique Repair technique Overall (N = 68) Screw (N = 15) Tightrope (N = 28) Internal Brace (N = 22) p-value Age 0.79 18–25 6 (8.8) 3 (16.7) 2 (7.1) 1 (4.5) 26–50 39 (57.4) 10 (55.6) 16 (57.1) 13 (59.1) 51–75 23 (33.8) 5 (27.8) 10 (35.7) 8 (36.4) Sex 0.55 Female 40 (58.8) 12 (66.7) 17 (60.7) 11 (50) Male 28 (41.2) 6 (33.3) 11 (39.3) 11 (50) BMI 0.75 18.5–24.9 37 (19) 17 (21) 11 (15.9) 9 (20) 25–29.9 58 (29.7) 20 (24.7) 21 (30.4) 17 (37.8) 30 or greater 100 (51.3) 44 (54.3) 37 (53.6) 19 (42.2) Diabetes 0.26 No 65 (95.6) 17 (94.4) 28 (100) 20 (90.9) Yes 3 (4.4) 1 (5.6) 0 (0) 2 (9.1) Weber Classification 0.10 Weber B 47 (69.1) 11 (61.1) 17 (60.7) 19 (86.4) Weber C 21 (30.9) 7 (38.9) 11 (39.3) 3 (13.6) Posterior malleolus 0.25 No 54 (79.4) 14 (77.8) 20 (71.4) 20 (90.9) Yes 14 (20.6) 4 (22.2) 8 (28.6) 2 (9.1) Fracture subtype 0.08 Bimalleolar 13 (19.1) 0 (0) 7 (25) 6 (27.3) Fibula only 41 (60.3) 14 (77.8) 13 (46.4) 14 (63.6) Lateral and posterior malleolar 10 (14.7) 3 (16.7) 5 (17.9) 2 (9.1) Trimalleolar 4 (5.9) 1 (5.6) 3 (10.7) 0 (0) Table 2 Complications by Repair Type Total Screw Tightrope Internal brace Total 159 62 59 38 Radiographic complications Degenerative joint disease No 153 (96.2) 57 (91.9) 58 (98.3) 38 (100.0) Yes 6 (3.8) 5 (8.1) 1 (1.7) 0 (0) End stage arthritis No 159 (100.0) 62 (100.0) 59 (100.0) 38 (100.0) Yes 0 (0) 0 (0) 0 (0) 0 (0) Syndesmotic malreduction No 155 (97.5) 58 (93.5) 59 (100.0) 38 (100.0) Yes 4 (2.5) 4 (6.5) 0 (0) 0 (0) Surgical complications DVT post-op No 154 (96.9) 61 (98.4) 56 (94.9) 37 (97.4) Yes 5 (3.1) 1 (1.6) 3 (5.1) 1 (2.6) PE post-op No 158 (99.4) 62 (100.0) 58 (98.3) 38 (100.0) Yes 1 (0.6) 0 (0) 1 (1.7) 0 (0) Superficial wound complications No 155 (97.5) 59 (95.2) 59 (100.0) 37 (97.4) Yes 4 (2.5) 3 (4.8) 0 (0) 1 (2.6) Deep wound complications No 156 (98.1) 60 (96.8) 59 (100.0) 37 (97.4) Yes 3 (1.9) 2 (3.2) 0 (0) 1 (2.6) Reoperation within 365 days* No 127 (79.9) 37 (59.7) 57 (96.6) 33 (86.8) Yes 32 (20.1) 25 (40.3) 2 (3.4) 5 (13.2) Reason for reoperation* Pain/stiffness 19 (37.2) 15 (34.1) 1 (50) 3 (60.0) Syndesmotic screw removal 25 (49.0) 25 (56.8) - - Hardware failure 1 (2.0) - 1 (50) I&D 3 (5.8) 2 (4.5) - 1 (20.0) Revision for malreduction 1 (2.0) 1 (2.3) - - Equinus contracture 1 (2.0) - - 1 (20.0) Conversion to TTC fusion (Charcot neuroarthropathy) 1 (2.0) 1 (2.3) - - *Patients may have had more than one reason for reoperation Table 3 Mean (Standard Deviation) PROMIS Scores by Repair Technique Physical Function Pain Interference N (%) Mean (SD) p-value Mean (SD) p-value Repair technique 0.72 0.75 Screw 18 (26.5) 50.5 (7.9) 49.6 (8.2) Tightrope 28 (41.2) 53.9 (9.7) 47.9 (8.8) Internal Brace 22 (32.4) 52.2 (13.1) 49.2 (10.5) Table 4 Adjusted Association of Repair Technique with Functional Outcomes Overall cohort (N = 68) Physical Function Pain Interference Estimate (95% CI) Standardized Estimate (95% CI) P-value Estimate (95% CI) Standardized Estimate (95% CI) P-value Repair technique † Screw Reference Tightrope 5.1 (-0.9, 11.1) 0.5 (-0.1, 1.1) 0.1 -3.2 (-8.5, 2.1) -0.4 (-0.9, 0.2) 0.23 Internal Brace 5.2 (-1.3, 11.7) 0.5 (-0.1, 1.1) 0.12 -4.4 (-10.1, 1.3) -0.5 (-1.1, 0.1) 0.13 Covariates No fear of reinjury 7.6 (2.1, 13.1) 0.7 (0.2, 1.3) 0.01 -6.6 (-11.4, -1.8) -0.7 (-1.3, -0.2) 0.01 Age (years) -0.3 (-0.4, -0.1) -0.4 (-0.6, -0.2) < 0.01 0.2 (0.0, 0.3) 0.3 (0.0, 0.5) 0.02 BMI -0.2 (-0.6, 0.1) -0.2 (-0.4, 0.1) 0.16 0.3 (-0.0, 0.6) 0.2 (-0.0, 0.4) 0.08 Clinical follow up (months) 0.1 (-0.0, 0.2) 0.1 (-0.1, 0.4) 0.24 -0.0 (-0.1, 0.1) -0.1 (-0.3, 0.1) 0.49 Excluding patients with diabetes (N = 65) Physical Function Pain Interference Estimate (95% CI) Standardized Estimate (95% CI) P-value Estimate (95% CI) Standardized Estimate (95% CI) p-value Repair technique † Screw Reference Tightrope 4.4 (-1.9, 10.7) 0.4 (-0.2, 1.0) 0.16 -2.5 (-7.9, 2.9) -0.3 (-0.9, 0.3) 0.36 Internal Brace 4.4 (-2.6, 11.4) 0.4 (-0.2, 1.1) 0.21 -3.1 (-9.1, 2.9) -0.3 (-1.0, 0.3) 0.31 Covariates No fear of reinjury 7.8 (1.8, 13.8) 0.7 (0.2, 1.3) 0.01 -7.8 (-13.0, -2.6) -0.9 (-1.4, -0.3) 0 Age (years) -0.3 (-0.4, -0.1) -0.3 (-0.6, -0.1) < 0.001 0.2 (0.0, 0.3) 0.2 (0.0, 0.5) 0.04 BMI -0.3 (-0.6, 0.1) -0.2 (-0.4, 0.1) 0.16 0.2 (-0.1, 0.5) 0.2 (-0.1, 0.4) 0.16 Clinical follow up (months) 0.1 (-0.0, 0.2) 0.1 (-0.1, 0.4) 0.2 -0.0 (-0.1, 0.1) -0.1 (-0.3, 0.1) 0.45 † Adjusted for propensity scores to balance Weber classification, fracture subtype, and sex across treatment groups. DISCUSSION Anatomic reduction and fixation of the syndesmosis is critical for helping patients achieve satisfactory outcomes [ 30 , 31 ]. Some studies suggest syndesmotic instability is an independent risk factor for poor outcomes following ankle fracture surgery [ 32 , 33 ]. Because TR and IB resulted in 98% and 100%, respectively, of patients having an anatomic reduction of the ankle at minimum one year follow-up compared to 84% of patients with screw, our results suggest that TR and IB may be more effective options to ensure appropriate reduction of the syndesmosis in the long term. These rates correlate with the overall radiographic complication rates discovered in each of the three groups. There were no complications in the IB group, and the TR group had a 1.7% complication rate compared to the screw group’s 12.9%, which is consistent with values reported in the literature revealing TR has lower complication rates compared to screw [ 1 – 9 ]. The lower complication rates and higher rates of anatomic reduction of the ankle at final follow-up may be due to the ability of the TR and IB to restore more physiologic function of the syndesmosis compared to screw [ 5 , 34 ]. There were no cases of syndesmotic malreduction in patients who had fixation with either TR or IB, while screw fixation resulted in 6.5% of cases with syndesmotic malreduction. These results corroborate prior investigations that demonstrate lower rates of syndesmotic malreduction and syndesmotic widening, a radiographic indicator of syndesmotic malreduction, with TR and IB compared to screw [ 1 , 4 , 6 , 8 , 9 , 16 ]. Because the syndesmosis is crucial for the stability and integrity of the ankle joint, malreduction of the syndesmosis is a risk factor for the development of posttraumatic osteoarthritis [ 35 ]. Consequently, lower syndesmotic malreduction rates in our study may indicate why the rates of DJD are lower in TR and IB groups compared to the screw group. Our results are consistent with the literature regarding lower rates of DJD with TR compared to screw [ 7 ]. It is also important to note that DJD may take longer than one year to develop. Because our study included patients with minimum one year follow-up, the longer-term DJD rate may be higher than what we found. The incidence of surgical complications was similar between groups, while the incidence of deep wound infection was lower in the TR and IB groups, underscoring the safety of these techniques. The higher reoperation rate among screws is consistent with prior literature that demonstrates higher reoperation rates with screws compared to TR [ 4 , 8 ]. These much lower reoperation rates for TR and IB over screw indicate that they may be preferred options from a cost-effectiveness perspective [ 36 ]. We found better PROMIS scores in both TR and IB compared to screw. Our study therefore corroborates prior literature favoring the use of TR and IB for syndesmotic fixation as demonstrated by improved PROs compared to screw [ 2 – 4 , 7 , 14 – 17 ]. In adjusted models, TR was estimated to have PF 5.1-points higher and PI 3.2-points lower than screw, and IB was estimated to have PF 5.2-points higher and PI 4.4-points lower than screws. These estimated PF and PI for both TR and IB prove clinically relevant, as the values reached the MCID reported in the literature for both PROMIS PF and PI [ 28 ]. Therefore, our findings suggest that TR and IB may improve patient function and reduce pain levels compared to screw. These improvements may be due to the fact that these two techniques more effectively restore the physiologic function and dynamic flexibility of the syndesmosis compared to screws, thereby allowing patients to achieve higher function and lower pain [ 4 , 5 , 34 ]. Ultimately, larger sample sizes are needed to prove this finding definitively, as our study was underpowered. We performed a subgroup analysis excluding diabetics, as the low number of diabetics in the cohort limited us from including them in the propensity score to avoid unstable estimates and extreme propensity scores. When excluding the three patients who had diabetes—since diabetes may be considered a risk factor for poorer outcomes—TR and IB still were estimated to have higher PF in the MCID range compared to screws, while IB still had lower PI in the MCID range compared to screws, which may suggest that TR and IB might benefit patient function and pain compared to screws [ 33 , 37 ]. Patients with all three fixation techniques achieved population mean functional outcomes regardless of technique, which is consistent with prior literature evaluating PROs including PROMIS scores following ankle fractures and underscores the importance of proper surgical repair of unstable ankle fractures [ 31 , 38 – 42 ]. This study has limitations, including the retrospective design. This study was underpowered for small and medium effects in PROMIS scores (our study needed 22 patients per group). Larger sample sizes, ideally from randomized, prospective studies evaluating PROMIS are required to conclude definitively whether TR and IB improve functional outcomes compared to screws. As with all PROs studies, this investigation was subject to recall and measurement bias. The rate of survey follow-up (43%, 68/159) may also introduce some nonresponse bias, but the response rate in this study exceeds the acceptable orthopaedic trauma response rate of 30% reported in the literature [ 25 ]. Patients may also have interpreted survey questions differently, which introduces measurement bias. Patients were necessarily at different time points post-operatively when responding (patients did not all fill out surveys at one year post-operatively for example), which may introduce measurement bias. Regardless of these limitations, this study offers valuable insight into the utility of TR and IB in maximizing functional outcomes while minimizing complications following syndesmotic fixation in operative repair of ankle fractures. This investigation is importantly the first and largest to evaluate validated PROMIS scores comparing various syndesmotic fixation techniques. This study is also the first to compare complications between IB and screw for syndesmotic fixation in ankle fracture surgery directly. CONCLUSIONS Syndesmotic fixation with TR and IB reduces radiographic complications compared to screws, particularly DJD and syndesmotic malreduction. While this study was underpowered to detect statistically significant differences in PROMIS scores, TR and IB achieved higher PF and lower PI compared to screw. These findings suggest that IB and TR may improve functional outcomes compared to screw, though further research with larger samples is needed to determine this effect definitively. Abbreviations AITFL – Anterior Inferior Tibiofibular Ligament AOFAS – American Orthopaedic Foot and Ankle Society CAT – computerized adaptive test DJD – degenerative joint disease DVT – deep vein thrombosis FAAM – Foot and Ankle Ability Measure FADI – Foot and Ankle Disability Index FFI – Foot Function Index IB - Internal Brace PE – pulmonary embolism PF – physical function PI – pain interference PRO – patient reported outcome PROMIS – Patient Reported Outcomes Measurement Information System TR – TightRope VAS – visual analogue scale Declarations Ethics Approval and Consent for Participation: This study received ethical approval from the Northwestern University IRB (STU00218343) on 11/29/2022. Consent for Publication: All patients included consented to have the data presented published. Availability of Data and Materials: Please contact the corresponding or senior author. Competing Interests: Anish R. Kadakia MD: Arthrex: consultant, royalties, Speakers Bureau, DePuy Synthes: royalties, Elsevier: royalties; Steven Hadley: HydroCision, Inc.: consultant Funding: The authors received no financial support for the research, authorship, and/or publication of this article Authors’ Contributions : All authors participated in the conception, design, data acquisition, analysis, interpretation of the data, and drafting of this manuscript. Acknowledgements: none References Andersen MR, Frihagen F, Hellund JC, Madsen JE, Figved W. Randomized Trial Comparing Suture Button with Single Syndesmotic Screw for Syndesmosis Injury. J Bone Joint Surg Am . 2018;100(1):2-12. doi:10.2106/JBJS.16.01011 Colcuc C, Blank M, Stein T, et al. Lower complication rate and faster return to sports in patients with acute syndesmotic rupture treated with a new knotless suture button device. Knee Surg Sports Traumatol Arthrosc . 2018;26(10):3156-3164. doi:10.1007/s00167-017-4820-3 Gan K, Xu D, Hu K, Wu W, Shen Y. Dynamic fixation is superior in terms of clinical outcomes to static fixation in managing distal tibiofibular syndesmosis injury. Knee Surg Sports Traumatol Arthrosc . 2020;28(1):270-280. doi:10.1007/s00167-019-05659-0 Grassi A, Samuelsson K, D'Hooghe P, et al. Dynamic Stabilization of Syndesmosis Injuries Reduces Complications and Reoperations as Compared With Screw Fixation: A Meta-analysis of Randomized Controlled Trials. Am J Sports Med . 2020;48(4):1000-1013. doi:10.1177/0363546519849909 Klitzman R, Zhao H, Zhang LQ, Strohmeyer G, Vora A. Suture-button versus screw fixation of the syndesmosis: a biomechanical analysis. Foot Ankle Int . 2010;31(1):69-75. doi:10.3113/FAI.2010.0069 Naqvi GA, Cunningham P, Lynch B, Galvin R, Awan N. Fixation of ankle syndesmotic injuries: comparison of tightrope fixation and syndesmotic screw fixation for accuracy of syndesmotic reduction. Am J Sports Med . 2012;40(12):2828-2835. doi:10.1177/0363546512461480 Ræder BW, Figved W, Madsen JE, Frihagen F, Jacobsen SB, Andersen MR. Better outcome for suture button compared with single syndesmotic screw for syndesmosis injury: five-year results of a randomized controlled trial. Bone Joint J . 2020;102-B(2):212-219. doi:10.1302/0301-620X.102B2.BJJ-2019-0692.R2 Sanders D, Schneider P, Taylor M, Tieszer C, Lawendy AR; Canadian Orthopaedic Trauma Society;. Improved Reduction of the Tibiofibular Syndesmosis With TightRope Compared With Screw Fixation: Results of a Randomized Controlled Study. J Orthop Trauma . 2019;33(11):531-537. doi:10.1097/BOT.0000000000001559 Zhang P, Liang Y, He J, Fang Y, Chen P, Wang J. A systematic review of suture-button versus syndesmotic screw in the treatment of distal tibiofibular syndesmosis injury. BMC Musculoskelet Disord . 2017;18(1):286. Published 2017 Jul 4. doi:10.1186/s12891-017-1645-7 Clanton TO, Whitlow SR, Williams BT, et al. Biomechanical Comparison of 3 Current Ankle Syndesmosis Repair Techniques. Foot Ankle Int . 2017;38(2):200-207. doi:10.1177/1071100716666278 Goetz JE, Davidson NP, Rudert MJ, Szabo N, Karam MD, Phisitkul P. Biomechanical Comparison of Syndesmotic Repair Techniques During External Rotation Stress. Foot Ankle Int . 2018;39(11):1345-1354. doi:10.1177/1071100718786500 Kortekangas T, Savola O, Flinkkilä T, et al. A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography. Injury . 2015;46(6):1119-1126. doi:10.1016/j.injury.2015.02.004 Schon JM, Williams BT, Venderley MB, et al. A 3-D CT Analysis of Screw and Suture-Button Fixation of the Syndesmosis. Foot Ankle Int . 2017;38(2):208-214. doi:10.1177/1071100716673590 Xie L, Xie H, Wang J, et al. Comparison of suture button fixation and syndesmotic screw fixation in the treatment of distal tibiofibular syndesmosis injury: A systematic review and meta-analysis. Int J Surg . 2018;60:120-131. doi:10.1016/j.ijsu.2018.11.007 Laflamme M, Belzile EL, Bédard L, van den Bekerom MP, Glazebrook M, Pelet S. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma . 2015;29(5):216-223. doi:10.1097/BOT.0000000000000245 McKenzie AC, Hesselholt KE, Larsen MS, Schmal H. A Systematic Review and Meta-Analysis on Treatment of Ankle Fractures With Syndesmotic Rupture: Suture-Button Fixation Versus Cortical Screw Fixation. J Foot Ankle Surg . 2019;58(5):946-953. doi:10.1053/j.jfas.2018.12.006 Shevate I, Salunkhe R, Pervez F, Pawar P. A Prospective Study on Fixation of Syndesmotic Ankle Injury: Tight Rope Versus Screw Fixation. Cureus . 2024;16(8):e67172. Published 2024 Aug 19. doi:10.7759/cureus.67172 Kocadal O, Yucel M, Pepe M, Aksahin E, Aktekin CN. Evaluation of Reduction Accuracy of Suture-Button and Screw Fixation Techniques for Syndesmotic Injuries. Foot Ankle Int . 2016;37(12):1317-1325. doi:10.1177/1071100716661221 Regauer M, Mackay G, Lange M, Kammerlander C, Böcker W. Syndesmotic Internal Brace TM for anatomic distal tibiofibular ligament augmentation. World J Orthop . 2017;8(4):301-309. Published 2017 Apr 18. doi:10.5312/wjo.v8.i4.301 Lenz CG, Urbanschitz L, Shepherd DW. Dynamic syndesmotic stabilisation and reinforcement of the antero-inferior tibiofibular ligament with internal brace. Foot (Edinb) . 2023;56:102026. doi:10.1016/j.foot.2023.102026 Harris NJ, Nicholson G, Pountos I. Anatomical reconstruction of the anterior inferior tibiofibular ligament in elite athletes using InternalBrace suture tape. Bone Joint J. 2022;104-B(1):68-75. doi:10.1302/0301-620X.104B1.BJJ-2021-0542.R2 Czerwonka N, Desai SS, Arciero E, Greisberg J, Trofa DP, Chien BY. Contemporary Review: An Overview of the Utility of Patient-Reported Outcome Measurement Information System (PROMIS) in Foot and Ankle Surgery. Foot & Ankle International. 2023;44(6):554-564. doi:10.1177/10711007231165752 Gausden EB, Levack A, Nwachukwu BU, Sin D, Wellman DS, Lorich DG. Computerized Adaptive Testing for Patient Reported Outcomes in Ankle Fracture Surgery. Foot Ankle Int . 2018;39(10):1192-1198. doi:10.1177/1071100718782487 SooHoo NF, Shuler M, Fleming LL. Evaluation of the validity of the AOFAS clinical rating systems by correlation to the SF-36. Foot Ankle Int. 2003;24(1):50-55. Nguyen MP, Rivard RL, Blaschke B, et al. Capturing patient-reported outcomes: paper versus electronic survey administration. OTA Int. 2022;5(3):e212. Published 2022 Sep 8. doi:10.1097/OI9.0000000000000212 Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle . 1989;10(3):156-160. doi:10.1177/107110078901000308 Hung M, Baumhauer JF, Latt LD, et al. Validation of PROMIS ® Physical Function computerized adaptive tests for orthopaedic foot and ankle outcome research. Clin Orthop Relat Res . 2013;471(11):3466-3474. doi:10.1007/s11999-013-3097-1 Hung M, Baumhauer JF, Licari FW, Voss MW, Bounsanga J, Saltzman CL. PROMIS and FAAM minimal clinically important differences in foot and ankle orthopedics. Foot Ankle Int . 2019;40(1):65-73. doi:10.1177/1071100718800304 Hadley SM, Peabody JJ, Westvold S, et al. Does Pre-Injury Level of Activity Impact Post-Recovery Activity Level Regardless of Ankle Fracture Type?. Foot Ankle Orthop . 2024;9(4):2473011424S00249. Published 2024 Dec 23. doi:10.1177/2473011424S00249 Dean DM, Ho BS, Lin A, et al. Predictors of Patient-Reported Function and Pain Outcomes in Operative Ankle Fractures. Foot Ankle Int . 2017;38(5):496-501. doi:10.1177/1071100716688176 Gilley J, Bell R, Lima M, et al. Prospective Patient Reported Outcomes (PRO) Study Assessing Outcomes of Surgically Managed Ankle Fractures. Foot Ankle Int . 2020;41(2):206-210. doi:10.1177/1071100719891157 Litrenta J, Saper D, Tornetta P 3rd, et al. Does Syndesmotic Injury Have a Negative Effect on Functional Outcome? A Multicenter Prospective Evaluation [published correction appears in J Orthop Trauma. 2016 Jan;30(1):e35. doi: 10.1097/BOT.0000000000000503]. J Orthop Trauma . 2015;29(9):410-413. doi:10.1097/BOT.0000000000000295 Egol KA, Pahk B, Walsh M, Tejwani NC, Davidovitch RI, Koval KJ. Outcome after unstable ankle fracture: effect of syndesmotic stabilization. J Orthop Trauma . 2010;24(1):7-11. doi:10.1097/BOT.0b013e3181b1542c Pang EQ, Bedigrew K, Palanca A, Behn AW, Hunt KJ, Chou L. Ankle joint contact loads and displacement in syndesmosis injuries repaired with Tightropes compared to screw fixation in a static model. Injury . 2019;50(11):1901-1907. doi:10.1016/j.injury.2019.09.012 Regauer M, Mackay G, Nelson O, Böcker W, Ehrnthaller C. Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries. J Clin Med . 2022;11(2):331. Published 2022 Jan 10. doi:10.3390/jcm11020331 Ramsey DC, Friess DM. Cost-Effectiveness Analysis of Syndesmotic Screw Versus Suture Button Fixation in Tibiofibular Syndesmotic Injuries. J Orthop Trauma . 2018;32(6):e198-e203. doi:10.1097/BOT.0000000000001150 Manchanda K, Nakonezny P, Sathy AK, Sanders DT, Starr AJ, Wukich DK. A systematic review of ankle fracture treatment modalities in diabetic patients [published correction appears in J Clin Orthop Trauma. 2021 Aug 05;21:101558. doi: 10.1016/j.jcot.2021.101558.]. J Clin Orthop Trauma. 2020;16:7-15. Published 2020 Dec 13. doi:10.1016/j.jcot.2020.12.013 Hadley SM, Peabody JJ, Westvold S, et al. Does Weber Classification Predict Patient Reported Outcomes using PROMIS Scores?. Foot Ankle Orthop . 2024;9(4):2473011424S00255. Published 2024 Dec 23. doi:10.1177/2473011424S00255 Del Buono A, Smith R, Coco M, Woolley L, Denaro V, Maffulli N. Return to sports after ankle fractures: a systematic review. Br Med Bull. 2013;106:179-191. doi:10.1093/bmb/lds039 Sinha A, Robertson G, Maffulli N. Doctor, I fractured my ankle. When can I return to play? An updated systematic review. Br Med Bull. 2022;143(1):35-45. doi:10.1093/bmb/ldac016 Maffulli N, Toms AD, McMurtie A, Oliva F. Percutaneous plating of distal tibial fractures. Int Orthop. 2004;28(3):159-162. doi:10.1007/s00264-004-0541-6 Gougoulias N, Khanna A, Sakellariou A, Maffulli N. Supination-external rotation ankle fractures: stability a key issue. Clin Orthop Relat Res. 2010;468(1):243-251. doi:10.1007/s11999-009-0988-2 Additional Declarations Competing interest reported. Anish R. Kadakia MD: Arthrex: consultant, royalties, Speakers Bureau, DePuy Synthes: royalties, Elsevier: royalties; Steven Hadley: HydroCision, Inc.: consultant Cite Share Download PDF Status: Published Journal Publication published 06 Aug, 2025 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Revision requested 28 Jun, 2025 Reviews received at journal 26 Jun, 2025 Reviews received at journal 24 Jun, 2025 Reviewers agreed at journal 16 Jun, 2025 Reviewers agreed at journal 12 Jun, 2025 Reviewers invited by journal 10 Jun, 2025 Editor assigned by journal 10 Jun, 2025 Submission checks completed at journal 10 Jun, 2025 First submitted to journal 09 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Kadakia","email":"","orcid":"","institution":"Northwestern University Feinberg School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Anish","middleName":"R.","lastName":"Kadakia","suffix":""}],"badges":[],"createdAt":"2025-06-10 01:38:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6857999/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6857999/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-025-06137-9","type":"published","date":"2025-08-06T15:56:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84664505,"identity":"34ee0fc6-1eda-4cc9-afde-d682f5f2ed50","added_by":"auto","created_at":"2025-06-16 05:30:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":364400,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Schema\u003c/p\u003e","description":"","filename":"Syndesmosisfigure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6857999/v1/2fae63ffd720cbdaeffdaccf.jpg"},{"id":84665795,"identity":"512e34a6-f012-44e9-9725-4da24395ffa8","added_by":"auto","created_at":"2025-06-16 05:38:51","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":130087,"visible":true,"origin":"","legend":"\u003cp\u003eIndividual PROMIS Scores by Fixation Technique\u003c/p\u003e","description":"","filename":"Syndesmosisfigure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6857999/v1/c9c8a8ffdb5586df462b7f77.jpeg"},{"id":88813983,"identity":"70485827-83b1-47e0-8e5e-cfad8b496145","added_by":"auto","created_at":"2025-08-11 15:59:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1746608,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6857999/v1/b1183105-8bc4-42dd-b099-13ca7c1d38a6.pdf"}],"financialInterests":"Competing interest reported. Anish R. Kadakia MD: Arthrex: consultant, royalties, Speakers Bureau, DePuy Synthes: royalties, Elsevier: royalties; Steven Hadley: HydroCision, Inc.: consultant","formattedTitle":"Does Syndesmotic Fixation Technique Impact Complication Rates and Functional Outcomes Measured by PROMIS Scores Following Operative Repair of Ankle Fractures?","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eVarious techniques are used to repair the distal tibiofibular syndesmosis. While traditionally performed with syndesmotic screws, which rigidly fixate the syndesmosis and create a static spatial relationship between the tibia and fibula, newer flexible forms of fixation including the Syndesmosis TightRope\u0026reg; XP (TR, Arthrex, Naples, FL) and \u003cem\u003eInternal\u003c/em\u003eBrace\u0026trade; (IB, Arthrex, Naples, FL) have been developed to preserve the natural movement of the syndesmosis. The TR is a tensioned suture construct that compresses the fibula into the incisura of the tibia, primarily providing coronal plane stability to resist syndesmotic diastasis. The IB is a synthetic augment to ligament reconstruction, in the setting of syndesmotic fixation, and in this study, it was used to reconstruct/augment the AITFL ligament, providing stability against translation in the coronal and sagittal planes and against excessive external rotation.\u003c/p\u003e \u003cp\u003eIt is unclear whether syndesmotic fixation technique impacts patient outcomes. Most studies have compared TR and screws while limited studies have evaluated IB, none of which compare complications directly between IB and screw. The majority of these studies found lower rates of syndesmotic malreduction, reoperation, posttraumatic osteoarthritis, and hardware-related complications in TR compared to screw [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Others found no significant differences in complication rates and rotational stability between TR and screw [\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, the literature regarding the impact of fixation technique on functional outcomes remains controversial. Many studies suggest that TR improves American Orthopaedic Foot and Ankle Society (AOFAS) scores, Olerud-Molander ankle scores, time to weight bearing, and ability to return to sports compared to screws [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] while others found no significant differences in AOFAS, Foot and Ankle Disability Index (FADI) scores, and Foot and Ankle Ability Measure (FAAM) scores [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Limited data also exist regarding functional outcomes following syndesmotic fixation with IB compared to screws, with few studies suggesting that IB results in satisfactory FAAM scores and good stability, but these studies do not compare screw fixation to IB [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo our knowledge, no study has compared functional outcomes as measured by validated Patient Reported Outcomes Measurement Information System (PROMIS) scores between these three syndesmotic techniques. Designed as an intended gold-standard outcome measure to deliver psychometrically standardized, validated patient-reported outcomes (PROs), PROMIS exhibits improved generalizability, consistency, and reliability compared to several other legacy instruments commonly used in foot and ankle including FAAM, Foot Function Index (FFI), AOFAS scores, and Visual Analogue Scale (VAS) [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. PROMIS also demonstrates an ability to effectively detect clinically meaningful differences for ankle fractures specifically and exhibits decreased floor and ceiling effects compared to other legacy scales [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause of PROMIS\u0026rsquo;s validity, understanding of how syndesmotic fixation technique impacts PROMIS would provide important insight into the relative efficacy of the three syndesmotic fixation techniques. This study therefore aims to determine which repair technique results in the greatest functional outcomes as measured by PROMIS and in the fewest complications. We hypothesized that TR and IB would reduce complications and improve PROMIS compared to transsyndesmotic screws.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePopulation:\u003c/h2\u003e \u003cp\u003eThis investigation was an Institutional Review Board (IRB) approved retrospective review of 782 patients at a single institution who underwent ankle fracture surgery between January 2016-December 2021. Two fellowship-trained foot and ankle orthopaedic surgeons independently reviewed all radiographs and assessed reduction quality and complications at final follow-up. Multiple extremity injuries, open fractures, and pilon variants were excluded. Of 587 patients remaining, 262 patients with syndesmotic injuries determined by intraoperative fluoroscopic and direct visual examination were identified. 10 neuropathic patients were subsequently excluded. 159 of the remaining 252 patients who had minimum one-year radiographic follow-up were included for analysis. These 159 patients were sent post-operative questionnaires with PROMIS physical function (PF) and pain interference (PI) computerized adaptive tests (CATs) via REDCap. Surveys also asked whether patients experienced any activity limitations due to fear of reinjury with a binary yes/no response option. If patients did not respond to an initial email and did not decline consent, another email was sent, followed by a phone call one week later, and then two more emails prior to ceasing contact. 68/159 consented and were included for final analysis of PROMIS (Fig.\u0026nbsp;1). This response rate of 43% exceeds the acceptable orthopaedic trauma survey response rate of 30% reported in the literature [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSyndesmotic Repair Technique:\u003c/h3\u003e\n\u003cp\u003eIntraoperative fluoroscopy was used to assess for syndesmotic injury via manual external rotation stress testing. Syndesmotic injury was determined by visualization of diastasis at the anterior syndesmosis as well as the tibiofibular clear space. Surgeon preference determined stabilization method. Fellowship-trained orthopaedic surgeons in either foot and ankle (n\u0026thinsp;=\u0026thinsp;4) or trauma (n\u0026thinsp;=\u0026thinsp;3) performed all surgeries. In this study, by department convention at our institution, surgeons with trauma fellowship training utilized screw fixation while surgeons with foot and ankle fellowship training utilized flexible fixation to stabilize the syndesmosis.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInternal\u003c/b\u003e \u003cb\u003eBrace\u0026trade; Fixation\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eFor syndesmotic fixation via IB, 2.0mm FiberTape\u0026reg; suture (Arthrex, Naples, FL) is woven through the fibula plate eyelet. Next, a 3.5mm drill bit is used to create an insertional point onto the distal tibia for AITFL augmentation. The other end of fibertape is woven through the SwiveLock\u0026reg; insertion into the distal tibia. A bone tap is used followed by insertion of 4.75mm SwiveLock\u0026reg; anchor (Arthrex, Naples, FL). Appropriate tension is applied across the IB to create a stable AITFL augmentation \u0026ndash; removing all slack with thumb reduction of the joint.\u003c/p\u003e\n\u003ch3\u003eTightRope® Fixation:\u003c/h3\u003e\n\u003cp\u003eFor syndesmotic fixation via the TR, the syndesmosis is reduced (via thumb pressure) and pinned provisionally with a 2\u0026thinsp;\u0026minus;\u0026thinsp;0 Kirschner wire (K-wire). Fluoroscopy is used to confirm the starting point on the distal fibula for the trajectory of the TightRope\u0026reg; (Arthrex, Naples, FL). The TR is inserted approximately 2cm proximal to the tibiotalar joint line, making sure to start in the middle of the fibula and exit in the middle of the tibia medially while staying parallel to the ankle joint. Fluoroscopy is obtained to confirm the correct position. Afterwards, a 3.5mm cannulated drill is used to drill through all cortices over the K-wire. Next, the TR is inserted through the drilled pathway, ensuring the button sits on bone on the medial cortex of the distal tibia. Before tightening, the anterior syndesmosis is exposed again and manually reduced to anatomic position, after which the TR is tightened across the syndesmosis.\u003c/p\u003e\n\u003ch3\u003eScrew Fixation:\u003c/h3\u003e\n\u003cp\u003eFor syndesmotic fixation via cortical screw placement, the syndesmosis is reduced (via thumb pressure) and pinned provisionally with a 2\u0026thinsp;\u0026minus;\u0026thinsp;0 K-wire. Reduction is assessed fluoroscopically and with palpation of the anterior aspect of the syndesmosis. Once satisfied with the reduction, a 3.5mm tetracortical transsydesmotic screw is placed through the fibular plate to complete the construct, after which the K-wire is removed.\u003c/p\u003e\n\u003ch3\u003eOutcomes:\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was postoperative PROMIS PF and PI. The secondary outcome included assessment of both radiographic and surgical complications. Postoperative radiographic complications included: degenerative joint disease (DJD), end stage arthritis, and syndesmotic malreduction. Anatomic reduction of the syndesmosis was based on standard radiographic criteria [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Surgical complications were collected from chart review and included: deep vein thrombosis (DVT), pulmonary embolism (PE), superficial wound complications, deep wound complications, and reoperation within 365 days.\u003c/p\u003e \u003cp\u003eThe PF and PI were developed to correspond to age-matched norms for a US general population mean score of 50 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Higher PF indicates better physical function while, higher PI designates more pain interference with activity [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eHypothesis-driven testing analyzed with R Version 4.3.0 (R Foundation for Statistical Computing, Vienna, Austria) was used. Due to rarity of complications, we were unable to use statistical tests to compare complication incidence across techniques. The Kruskal-Wallis test compared PROMIS across repair types. To address imbalance of confounders across syndesmosis repair technique groups, we calculated propensity scores using a multinomial logistic regression model that included fracture subtype, Weber classification, and sex. Propensity scores for IB and TR were included as covariates in the linear regression model with BMI, age, fear of reinjury, and months of clinical follow up. We expected that diabetes would influence both treatment selection and functional outcomes; however, with only three diabetic patients in our sample, we elected not to include this variable in the propensity score model to avoid unstable estimates and extreme propensity scores. Therefore, we conducted a sensitivity analysis excluding these three patients. With a sample size of 68, we had 80% power to detect a medium to large effect size (f\u0026thinsp;=\u0026thinsp;0.39, η\u0026sup2;=0.13) at a significance level of 0.05, corresponding to a difference in mean of 7.1 for pain interference and 8.1 for physical function. We were underpowered to detect the lower end value of the minimal clinically important difference (MCID) for PROMIS of 3 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Results were adjusted for fear of reinjury because prior literature demonstrated fear may play a significant role in outcomes following ankle fracture surgery [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRadiographic follow-up was defined as time of surgery to most recent ankle radiographs. Clinical follow-up was defined as time of surgery to last contact with the orthopaedic provider.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003ePatient characteristics are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. For the complications analysis, 62/159 (39.0%) underwent fixation with screw, 59/159 (37.1%) with TR, and 38/159 (23.9%) with IB. For PROMIS analysis, 18/68 had screw, 28/68 TR, and 22/68 IB.\u003c/p\u003e \u003cp\u003eAverage radiographic and clinical follow-up were 14.1 months and 35.0 months, respectively, with no significant difference in follow-up between groups (p\u0026thinsp;=\u0026thinsp;0.76 and p\u0026thinsp;=\u0026thinsp;0.85, respectively).\u003c/p\u003e \u003cp\u003eFor screw, 8.1% (5/62) developed DJD and 6.5% (4/62) had syndesmotic malreduction. One TR patient developed DJD (1.7%). IB had no radiographic complications (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSurgical complications were similar between groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Screws had a 40.3% (25/62) reoperation rate, TR 3.4% (2/59) reoperation rate, and IB 13.2% (5/38) reoperation rate. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e displays reoperation reason, with symptomatic hardware being the most common reason. Patients may have had more than one complication.\u003c/p\u003e \u003cp\u003eMean PROMIS PF was 50.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9 for screw fixation (n\u0026thinsp;=\u0026thinsp;18), 53.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7 for TR (n\u0026thinsp;=\u0026thinsp;28), and 52.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1 for IB (n\u0026thinsp;=\u0026thinsp;22, p\u0026thinsp;=\u0026thinsp;0.72, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Mean PROMIS PI was 49.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2 for screw, 47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 for TR, and 49.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 for IB (p\u0026thinsp;=\u0026thinsp;0.75). Figure\u0026nbsp;2 displays the distribution of individual PROMIS scores.\u003c/p\u003e \u003cp\u003eAdjusted models comparing TR and IB to screws demonstrated mean PF 5.1-points (95%CI: -0.9-11.1) higher for TR (p\u0026thinsp;=\u0026thinsp;0.10, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) and 5.2-points greater for IB (95%CI: -1.3-11.7, p\u0026thinsp;=\u0026thinsp;0.12, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Adjusted models for PI revealed mean scores of 3.2-points less for TR (-3.2, 95%CI:-8.5-2.1, p\u0026thinsp;=\u0026thinsp;0.42) and 4.4-points less for IB (-4.4, 95%CI: -10.1-1.3, p\u0026thinsp;=\u0026thinsp;0.65, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) compared to screws.\u003c/p\u003e \u003cp\u003eWhen excluding the three patients with diabetes (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), TR had PF 4.4-points higher than screw (95%CI: -1.9-10.7, p\u0026thinsp;=\u0026thinsp;0.16) and PI 2.5-points lower than screw (-2.5, 95%CI: -7.9-2.9, p\u0026thinsp;=\u0026thinsp;0.36). IB had PF 4.4 higher PF than screw (95%CI: -2.6-11.4, p\u0026thinsp;=\u0026thinsp;0.21) and PI 3.1 less than screw (-3.1, 95%CI: -9.1-2.9, p\u0026thinsp;=\u0026thinsp;0.31).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Characteristics: Overall and by Repair Technique\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eRepair technique\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOverall\u003c/b\u003e (N\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eScrew\u003c/b\u003e (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eTightrope\u003c/b\u003e (N\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eInternal Brace\u003c/b\u003e (N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.79\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026nbsp;(8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026nbsp;(16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026nbsp;(7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u0026nbsp;(4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u0026nbsp;(57.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026nbsp;(55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u0026nbsp;(57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u0026nbsp;(59.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u0026nbsp;(33.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u0026nbsp;(27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026nbsp;(35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u0026nbsp;(36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.55\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026nbsp;(58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u0026nbsp;(66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u0026nbsp;(60.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u0026nbsp;(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u0026nbsp;(41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u0026nbsp;(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u0026nbsp;(39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u0026nbsp;(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18.5\u0026ndash;24.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u0026nbsp;(19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u0026nbsp;(21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u0026nbsp;(15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u0026nbsp;(20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;29.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u0026nbsp;(29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u0026nbsp;(24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u0026nbsp;(30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u0026nbsp;(37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026nbsp;or\u0026nbsp;greater\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u0026nbsp;(51.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u0026nbsp;(54.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u0026nbsp;(53.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u0026nbsp;(42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.26\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u0026nbsp;(95.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u0026nbsp;(94.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u0026nbsp;(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u0026nbsp;(90.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026nbsp;(4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026nbsp;(5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026nbsp;(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeber Classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeber\u0026nbsp;B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u0026nbsp;(69.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u0026nbsp;(61.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u0026nbsp;(60.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u0026nbsp;(86.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeber\u0026nbsp;C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u0026nbsp;(30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u0026nbsp;(38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u0026nbsp;(39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u0026nbsp;(13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePosterior malleolus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u0026nbsp;(79.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u0026nbsp;(77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u0026nbsp;(71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u0026nbsp;(90.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u0026nbsp;(20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u0026nbsp;(22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u0026nbsp;(28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026nbsp;(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFracture subtype\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.08\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBimalleolar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u0026nbsp;(19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u0026nbsp;(25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u0026nbsp;(27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFibula\u0026nbsp;only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u0026nbsp;(60.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u0026nbsp;(77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u0026nbsp;(46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u0026nbsp;(63.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral\u0026nbsp;and\u0026nbsp;posterior\u0026nbsp;malleolar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026nbsp;(14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026nbsp;(16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026nbsp;(17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026nbsp;(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrimalleolar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026nbsp;(5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026nbsp;(5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026nbsp;(10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications by Repair Type\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScrew\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTightrope\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInternal brace\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eRadiographic complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDegenerative joint disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153 (96.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (91.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (98.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEnd stage arthritis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSyndesmotic malreduction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155 (97.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (93.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDVT post-op\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154 (96.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (98.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (94.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37 (97.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePE post-op\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158 (99.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (98.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSuperficial wound complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155 (97.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (95.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37 (97.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDeep wound complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156 (98.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (96.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37 (97.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReoperation within 365 days*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127 (79.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (59.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57 (96.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (86.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (40.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (13.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReason for reoperation*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain/stiffness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u0026nbsp;(37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026nbsp;(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSyndesmotic screw\u0026nbsp;removal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026nbsp;(49.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026nbsp;(56.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHardware failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u0026amp;D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026nbsp;(4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevision for malreduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026nbsp;(2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEquinus contracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to TTC fusion (Charcot neuroarthropathy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e*Patients may have had more than one reason for reoperation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean (Standard Deviation) PROMIS Scores by Repair Technique\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003ePhysical Function\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003ePain Interference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRepair technique\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.72\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScrew\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026nbsp;(26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.5\u0026nbsp;(7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49.6\u0026nbsp;(8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTightrope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u0026nbsp;(41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.9\u0026nbsp;(9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.9\u0026nbsp;(8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal Brace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u0026nbsp;(32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.2\u0026nbsp;(13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49.2\u0026nbsp;(10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdjusted Association of Repair Technique with Functional Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall cohort (N\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c11\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003ePhysical Function\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c11\" namest=\"c8\"\u003e \u003cp\u003ePain Interference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eStandardized Estimate (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eStandardized Estimate (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRepair technique\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScrew\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"10\" nameend=\"c11\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eReference\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTightrope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e5.1\u0026nbsp;(-0.9,\u0026nbsp;11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.5\u0026nbsp;(-0.1,\u0026nbsp;1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-3.2\u0026nbsp;(-8.5,\u0026nbsp;2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e-0.4\u0026nbsp;(-0.9,\u0026nbsp;0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal Brace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e5.2\u0026nbsp;(-1.3,\u0026nbsp;11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.5\u0026nbsp;(-0.1,\u0026nbsp;1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-4.4\u0026nbsp;(-10.1,\u0026nbsp;1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e-0.5\u0026nbsp;(-1.1,\u0026nbsp;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCovariates\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo fear of reinjury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e7.6\u0026nbsp;(2.1,\u0026nbsp;13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.7\u0026nbsp;(0.2,\u0026nbsp;1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-6.6\u0026nbsp;(-11.4,\u0026nbsp;-1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e-0.7\u0026nbsp;(-1.3,\u0026nbsp;-0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e-0.3\u0026nbsp;(-0.4,\u0026nbsp;-0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-0.4\u0026nbsp;(-0.6,\u0026nbsp;-0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.2\u0026nbsp;(0.0,\u0026nbsp;0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.3\u0026nbsp;(0.0,\u0026nbsp;0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e-0.2\u0026nbsp;(-0.6,\u0026nbsp;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e-0.2\u0026nbsp;(-0.4,\u0026nbsp;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.3\u0026nbsp;(-0.0,\u0026nbsp;0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.2\u0026nbsp;(-0.0,\u0026nbsp;0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical follow up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.1\u0026nbsp;(-0.0,\u0026nbsp;0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.1\u0026nbsp;(-0.1,\u0026nbsp;0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.0\u0026nbsp;(-0.1,\u0026nbsp;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e-0.1\u0026nbsp;(-0.3,\u0026nbsp;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExcluding patients with diabetes (N\u0026thinsp;=\u0026thinsp;65)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePhysical Function\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c11\" namest=\"c8\"\u003e \u003cp\u003e\u003cb\u003ePain Interference\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eStandardized Estimate\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStandardized Estimate\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRepair technique\u003c/b\u003e \u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eScrew\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c11\" namest=\"c3\"\u003e \u003cp\u003e\u003cem\u003eReference\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTightrope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026nbsp;(-1.9,\u0026nbsp;10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.4\u0026nbsp;(-0.2,\u0026nbsp;1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e-2.5\u0026nbsp;(-7.9,\u0026nbsp;2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-0.3\u0026nbsp;(-0.9,\u0026nbsp;0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eInternal Brace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026nbsp;(-2.6,\u0026nbsp;11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.4\u0026nbsp;(-0.2,\u0026nbsp;1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e-3.1\u0026nbsp;(-9.1,\u0026nbsp;2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-0.3\u0026nbsp;(-1.0,\u0026nbsp;0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCovariates\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNo fear of reinjury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.8\u0026nbsp;(1.8,\u0026nbsp;13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.7\u0026nbsp;(0.2,\u0026nbsp;1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e-7.8\u0026nbsp;(-13.0,\u0026nbsp;-2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-0.9\u0026nbsp;(-1.4,\u0026nbsp;-0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.3\u0026nbsp;(-0.4,\u0026nbsp;-0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-0.3\u0026nbsp;(-0.6,\u0026nbsp;-0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.2\u0026nbsp;(0.0,\u0026nbsp;0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.2\u0026nbsp;(0.0,\u0026nbsp;0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.3\u0026nbsp;(-0.6,\u0026nbsp;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-0.2\u0026nbsp;(-0.4,\u0026nbsp;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.2\u0026nbsp;(-0.1,\u0026nbsp;0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.2\u0026nbsp;(-0.1,\u0026nbsp;0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eClinical follow up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.1\u0026nbsp;(-0.0,\u0026nbsp;0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.1\u0026nbsp;(-0.1,\u0026nbsp;0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e-0.0\u0026nbsp;(-0.1,\u0026nbsp;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-0.1\u0026nbsp;(-0.3,\u0026nbsp;0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003eAdjusted for propensity scores to balance Weber classification, fracture subtype, and sex across treatment groups.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAnatomic reduction and fixation of the syndesmosis is critical for helping patients achieve satisfactory outcomes [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Some studies suggest syndesmotic instability is an independent risk factor for poor outcomes following ankle fracture surgery [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Because TR and IB resulted in 98% and 100%, respectively, of patients having an anatomic reduction of the ankle at minimum one year follow-up compared to 84% of patients with screw, our results suggest that TR and IB may be more effective options to ensure appropriate reduction of the syndesmosis in the long term. These rates correlate with the overall radiographic complication rates discovered in each of the three groups. There were no complications in the IB group, and the TR group had a 1.7% complication rate compared to the screw group\u0026rsquo;s 12.9%, which is consistent with values reported in the literature revealing TR has lower complication rates compared to screw [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The lower complication rates and higher rates of anatomic reduction of the ankle at final follow-up may be due to the ability of the TR and IB to restore more physiologic function of the syndesmosis compared to screw [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere were no cases of syndesmotic malreduction in patients who had fixation with either TR or IB, while screw fixation resulted in 6.5% of cases with syndesmotic malreduction. These results corroborate prior investigations that demonstrate lower rates of syndesmotic malreduction and syndesmotic widening, a radiographic indicator of syndesmotic malreduction, with TR and IB compared to screw [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause the syndesmosis is crucial for the stability and integrity of the ankle joint, malreduction of the syndesmosis is a risk factor for the development of posttraumatic osteoarthritis [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Consequently, lower syndesmotic malreduction rates in our study may indicate why the rates of DJD are lower in TR and IB groups compared to the screw group. Our results are consistent with the literature regarding lower rates of DJD with TR compared to screw [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It is also important to note that DJD may take longer than one year to develop. Because our study included patients with minimum one year follow-up, the longer-term DJD rate may be higher than what we found.\u003c/p\u003e \u003cp\u003eThe incidence of surgical complications was similar between groups, while the incidence of deep wound infection was lower in the TR and IB groups, underscoring the safety of these techniques. The higher reoperation rate among screws is consistent with prior literature that demonstrates higher reoperation rates with screws compared to TR [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These much lower reoperation rates for TR and IB over screw indicate that they may be preferred options from a cost-effectiveness perspective [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe found better PROMIS scores in both TR and IB compared to screw. Our study therefore corroborates prior literature favoring the use of TR and IB for syndesmotic fixation as demonstrated by improved PROs compared to screw [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In adjusted models, TR was estimated to have PF 5.1-points higher and PI 3.2-points lower than screw, and IB was estimated to have PF 5.2-points higher and PI 4.4-points lower than screws. These estimated PF and PI for both TR and IB prove clinically relevant, as the values reached the MCID reported in the literature for both PROMIS PF and PI [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Therefore, our findings suggest that TR and IB may improve patient function and reduce pain levels compared to screw. These improvements may be due to the fact that these two techniques more effectively restore the physiologic function and dynamic flexibility of the syndesmosis compared to screws, thereby allowing patients to achieve higher function and lower pain [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Ultimately, larger sample sizes are needed to prove this finding definitively, as our study was underpowered.\u003c/p\u003e \u003cp\u003eWe performed a subgroup analysis excluding diabetics, as the low number of diabetics in the cohort limited us from including them in the propensity score to avoid unstable estimates and extreme propensity scores. When excluding the three patients who had diabetes\u0026mdash;since diabetes may be considered a risk factor for poorer outcomes\u0026mdash;TR and IB still were estimated to have higher PF in the MCID range compared to screws, while IB still had lower PI in the MCID range compared to screws, which may suggest that TR and IB might benefit patient function and pain compared to screws [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients with all three fixation techniques achieved population mean functional outcomes regardless of technique, which is consistent with prior literature evaluating PROs including PROMIS scores following ankle fractures and underscores the importance of proper surgical repair of unstable ankle fractures [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39 CR40 CR41\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has limitations, including the retrospective design. This study was underpowered for small and medium effects in PROMIS scores (our study needed 22 patients per group). Larger sample sizes, ideally from randomized, prospective studies evaluating PROMIS are required to conclude definitively whether TR and IB improve functional outcomes compared to screws. As with all PROs studies, this investigation was subject to recall and measurement bias. The rate of survey follow-up (43%, 68/159) may also introduce some nonresponse bias, but the response rate in this study exceeds the acceptable orthopaedic trauma response rate of 30% reported in the literature [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Patients may also have interpreted survey questions differently, which introduces measurement bias. Patients were necessarily at different time points post-operatively when responding (patients did not all fill out surveys at one year post-operatively for example), which may introduce measurement bias.\u003c/p\u003e \u003cp\u003eRegardless of these limitations, this study offers valuable insight into the utility of TR and IB in maximizing functional outcomes while minimizing complications following syndesmotic fixation in operative repair of ankle fractures. This investigation is importantly the first and largest to evaluate validated PROMIS scores comparing various syndesmotic fixation techniques. This study is also the first to compare complications between IB and screw for syndesmotic fixation in ankle fracture surgery directly.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eSyndesmotic fixation with TR and IB reduces radiographic complications compared to screws, particularly DJD and syndesmotic malreduction. While this study was underpowered to detect statistically significant differences in PROMIS scores, TR and IB achieved higher PF and lower PI compared to screw. These findings suggest that IB and TR may improve functional outcomes compared to screw, though further research with larger samples is needed to determine this effect definitively.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eAITFL \u0026ndash; Anterior Inferior Tibiofibular Ligament\u003c/p\u003e\n\u003cp\u003eAOFAS \u0026ndash; American Orthopaedic Foot and Ankle Society\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCAT \u0026ndash; computerized adaptive test\u003c/p\u003e\n\u003cp\u003eDJD \u0026ndash; degenerative joint disease\u003c/p\u003e\n\u003cp\u003eDVT \u0026ndash; deep vein thrombosis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFAAM \u0026ndash; Foot and Ankle Ability Measure\u003c/p\u003e\n\u003cp\u003eFADI \u0026ndash; Foot and Ankle Disability Index\u003c/p\u003e\n\u003cp\u003eFFI \u0026ndash; Foot Function Index\u003c/p\u003e\n\u003cp\u003eIB - \u003cem\u003eInternal\u003c/em\u003eBrace\u003c/p\u003e\n\u003cp\u003ePE \u0026ndash; pulmonary embolism\u003c/p\u003e\n\u003cp\u003ePF \u0026ndash; physical function\u003c/p\u003e\n\u003cp\u003ePI \u0026ndash; pain interference\u003c/p\u003e\n\u003cp\u003ePRO \u0026ndash; patient reported outcome\u003c/p\u003e\n\u003cp\u003ePROMIS \u0026ndash; Patient Reported Outcomes Measurement Information System\u003c/p\u003e\n\u003cp\u003eTR \u0026ndash; TightRope\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVAS \u0026ndash; visual analogue scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent for Participation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the Northwestern University IRB (STU00218343) on 11/29/2022.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eAll patients included consented to have the data presented published.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003ePlease contact the corresponding or senior author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eAnish R. Kadakia MD: Arthrex: consultant, royalties, Speakers Bureau, DePuy Synthes: royalties, Elsevier: royalties; Steven Hadley: HydroCision, Inc.: consultant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors received no financial support for the research, authorship, and/or publication of this article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e: All authors participated in the conception, design, data acquisition, analysis, interpretation of the data, and drafting of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003enone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAndersen MR, Frihagen F, Hellund JC, Madsen JE, Figved W. 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A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. \u003cem\u003eJ Orthop Trauma\u003c/em\u003e. 2015;29(5):216-223. doi:10.1097/BOT.0000000000000245\u003c/li\u003e\n\u003cli\u003eMcKenzie AC, Hesselholt KE, Larsen MS, Schmal H. A Systematic Review and Meta-Analysis on Treatment of Ankle Fractures With Syndesmotic Rupture: Suture-Button Fixation Versus Cortical Screw Fixation. \u003cem\u003eJ Foot Ankle Surg\u003c/em\u003e. 2019;58(5):946-953. doi:10.1053/j.jfas.2018.12.006\u003c/li\u003e\n\u003cli\u003eShevate I, Salunkhe R, Pervez F, Pawar P. A Prospective Study on Fixation of Syndesmotic Ankle Injury: Tight Rope Versus Screw Fixation. \u003cem\u003eCureus\u003c/em\u003e. 2024;16(8):e67172. Published 2024 Aug 19. doi:10.7759/cureus.67172\u003c/li\u003e\n\u003cli\u003eKocadal O, Yucel M, Pepe M, Aksahin E, Aktekin CN. 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Anatomical reconstruction of the anterior inferior tibiofibular ligament in elite athletes using InternalBrace suture tape. Bone Joint J. 2022;104-B(1):68-75. doi:10.1302/0301-620X.104B1.BJJ-2021-0542.R2\u003c/li\u003e\n\u003cli\u003eCzerwonka N, Desai SS, Arciero E, Greisberg J, Trofa DP, Chien BY. Contemporary Review: An Overview of the Utility of Patient-Reported Outcome Measurement Information System (PROMIS) in Foot and Ankle Surgery. Foot \u0026amp; Ankle International. 2023;44(6):554-564. doi:10.1177/10711007231165752\u003c/li\u003e\n\u003cli\u003eGausden EB, Levack A, Nwachukwu BU, Sin D, Wellman DS, Lorich DG. Computerized Adaptive Testing for Patient Reported Outcomes in Ankle Fracture Surgery. \u003cem\u003eFoot Ankle Int\u003c/em\u003e. 2018;39(10):1192-1198. doi:10.1177/1071100718782487\u003c/li\u003e\n\u003cli\u003eSooHoo NF, Shuler M, Fleming LL. Evaluation of the validity of the AOFAS clinical rating systems by correlation to the SF-36. Foot Ankle Int. 2003;24(1):50-55.\u003c/li\u003e\n\u003cli\u003eNguyen MP, Rivard RL, Blaschke B, et al. Capturing patient-reported outcomes: paper versus electronic survey administration. OTA Int. 2022;5(3):e212. Published 2022 Sep 8. doi:10.1097/OI9.0000000000000212\u003c/li\u003e\n\u003cli\u003eHarper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. \u003cem\u003eFoot Ankle\u003c/em\u003e. 1989;10(3):156-160. doi:10.1177/107110078901000308\u003c/li\u003e\n\u003cli\u003eHung M, Baumhauer JF, Latt LD, et al. Validation of PROMIS \u0026reg; Physical Function computerized adaptive tests for orthopaedic foot and ankle outcome research. \u003cem\u003eClin Orthop Relat Res\u003c/em\u003e. 2013;471(11):3466-3474. doi:10.1007/s11999-013-3097-1\u003c/li\u003e\n\u003cli\u003eHung M, Baumhauer JF, Licari FW, Voss MW, Bounsanga J, Saltzman CL. PROMIS and FAAM minimal clinically important differences in foot and ankle orthopedics. \u003cem\u003eFoot Ankle Int\u003c/em\u003e. 2019;40(1):65-73. doi:10.1177/1071100718800304\u003c/li\u003e\n\u003cli\u003eHadley SM, Peabody JJ, Westvold S, et al. Does Pre-Injury Level of Activity Impact Post-Recovery Activity Level Regardless of Ankle Fracture Type?. \u003cem\u003eFoot Ankle Orthop\u003c/em\u003e. 2024;9(4):2473011424S00249. Published 2024 Dec 23. doi:10.1177/2473011424S00249\u003c/li\u003e\n\u003cli\u003eDean DM, Ho BS, Lin A, et al. Predictors of Patient-Reported Function and Pain Outcomes in Operative Ankle Fractures. \u003cem\u003eFoot Ankle Int\u003c/em\u003e. 2017;38(5):496-501. doi:10.1177/1071100716688176\u003c/li\u003e\n\u003cli\u003eGilley J, Bell R, Lima M, et al. Prospective Patient Reported Outcomes (PRO) Study Assessing Outcomes of Surgically Managed Ankle Fractures. \u003cem\u003eFoot Ankle Int\u003c/em\u003e. 2020;41(2):206-210. doi:10.1177/1071100719891157\u003c/li\u003e\n\u003cli\u003eLitrenta J, Saper D, Tornetta P 3rd, et al. Does Syndesmotic Injury Have a Negative Effect on Functional Outcome? A Multicenter Prospective Evaluation [published correction appears in J Orthop Trauma. 2016 Jan;30(1):e35. doi: 10.1097/BOT.0000000000000503]. \u003cem\u003eJ Orthop Trauma\u003c/em\u003e. 2015;29(9):410-413. doi:10.1097/BOT.0000000000000295\u003c/li\u003e\n\u003cli\u003eEgol KA, Pahk B, Walsh M, Tejwani NC, Davidovitch RI, Koval KJ. Outcome after unstable ankle fracture: effect of syndesmotic stabilization. \u003cem\u003eJ Orthop Trauma\u003c/em\u003e. 2010;24(1):7-11. doi:10.1097/BOT.0b013e3181b1542c\u003c/li\u003e\n\u003cli\u003ePang EQ, Bedigrew K, Palanca A, Behn AW, Hunt KJ, Chou L. Ankle joint contact loads and displacement in syndesmosis injuries repaired with Tightropes compared to screw fixation in a static model. \u003cem\u003eInjury\u003c/em\u003e. 2019;50(11):1901-1907. doi:10.1016/j.injury.2019.09.012\u003c/li\u003e\n\u003cli\u003eRegauer M, Mackay G, Nelson O, B\u0026ouml;cker W, Ehrnthaller C. Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries. \u003cem\u003eJ Clin Med\u003c/em\u003e. 2022;11(2):331. Published 2022 Jan 10. doi:10.3390/jcm11020331\u003c/li\u003e\n\u003cli\u003eRamsey DC, Friess DM. Cost-Effectiveness Analysis of Syndesmotic Screw Versus Suture Button Fixation in Tibiofibular Syndesmotic Injuries. \u003cem\u003eJ Orthop Trauma\u003c/em\u003e. 2018;32(6):e198-e203. doi:10.1097/BOT.0000000000001150\u003c/li\u003e\n\u003cli\u003eManchanda K, Nakonezny P, Sathy AK, Sanders DT, Starr AJ, Wukich DK. A systematic review of ankle fracture treatment modalities in diabetic patients [published correction appears in J Clin Orthop Trauma. 2021 Aug 05;21:101558. doi: 10.1016/j.jcot.2021.101558.]. J Clin Orthop Trauma. 2020;16:7-15. Published 2020 Dec 13. doi:10.1016/j.jcot.2020.12.013\u003c/li\u003e\n\u003cli\u003eHadley SM, Peabody JJ, Westvold S, et al. Does Weber Classification Predict Patient Reported Outcomes using PROMIS Scores?. \u003cem\u003eFoot Ankle Orthop\u003c/em\u003e. 2024;9(4):2473011424S00255. Published 2024 Dec 23. doi:10.1177/2473011424S00255\u003c/li\u003e\n\u003cli\u003eDel Buono A, Smith R, Coco M, Woolley L, Denaro V, Maffulli N. Return to sports after ankle fractures: a systematic review. Br Med Bull. 2013;106:179-191. doi:10.1093/bmb/lds039\u003c/li\u003e\n\u003cli\u003eSinha A, Robertson G, Maffulli N. Doctor, I fractured my ankle. When can I return to play? An updated systematic review. Br Med Bull. 2022;143(1):35-45. doi:10.1093/bmb/ldac016\u003c/li\u003e\n\u003cli\u003eMaffulli N, Toms AD, McMurtie A, Oliva F. Percutaneous plating of distal tibial fractures. Int Orthop. 2004;28(3):159-162. doi:10.1007/s00264-004-0541-6\u003c/li\u003e\n\u003cli\u003eGougoulias N, Khanna A, Sakellariou A, Maffulli N. Supination-external rotation ankle fractures: stability a key issue. Clin Orthop Relat Res. 2010;468(1):243-251. doi:10.1007/s11999-009-0988-2\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"syndesmotic rupture, ankle fracture, PROMIS, syndesmotic fixation, TightRope, InternalBrace, syndesmotic screw, patient-reported outcomes","lastPublishedDoi":"10.21203/rs.3.rs-6857999/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6857999/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eIt remains unclear whether syndesmotic fixation technique impacts outcomes following ankle fracture surgery. This study investigates which repair technique (transsyndesmotic screws, TightRope, and \u003cem\u003eInternal\u003c/em\u003eBrace) results in fewest complications and best functional outcomes measured by Patient Reported Outcome Measurement Information System (PROMIS) computerized adaptive tests (CATs) of physical function (PF) and pain interference (PI).\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003e782 patients who underwent ankle fracture surgery at a single institution between 2016\u0026ndash;2021 were retrospectively reviewed. Two fellowship-trained orthopaedic surgeons independently reviewed all radiographs, determined fixation technique, and assessed complications. Open fractures, pilons, and neuropathies were excluded. 252 had syndesmotic injury identified via intraoperative fluoroscopy. 159/252 who had minimum one-year radiographic follow-up were included for complications analysis. These 159 were sent post-operative PROMIS CATs. 68/159 consented and were included for final analysis of PROMIS. Kruskal-Wallis test compared PROMIS across repair types. Multinomial logistic regression adjusted for propensity scores included as covariates modeled PROMIS by technique.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003e62/159 had screw, 59/159 TightRope, and 38/159 \u003cem\u003eInternal\u003c/em\u003eBrace. Screw complication rate was 12.9% (8/62): 8.1% (5/62) degenerative joint disease (DJD), 6.5% (4/62) syndesmotic malreduction. TightRope complication rate was 1.7% (1/59): 1.7% (1/59) DJD. \u003cem\u003eInternal\u003c/em\u003eBrace had no radiographic complications. Mean PF was 50.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9 screw, 53.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7 TightRope, and 52.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1 IB (p\u0026thinsp;=\u0026thinsp;0.72). Mean PI was 49.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2 screw, 47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 TightRope, and 49.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 IB (p\u0026thinsp;=\u0026thinsp;0.75). Mean PF was 5.1-points (95%CI: -0.9-11.1) higher for TightRope and 5.2-points (95%CI: -1.3-11.7) greater for \u003cem\u003eInternal\u003c/em\u003eBrace vs. screw. Mean PI was 3.2-points less for TightRope (-3.2, 95%CI:-8.5-2.1) and 4.4-points less for \u003cem\u003eInternal\u003c/em\u003eBrace (-4.4, 95%CI: -10.1-1.3) vs. screws.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eSyndesmotic fixation with either TightRope or \u003cem\u003eInternal\u003c/em\u003eBrace reduces complications compared to screw. While this study was underpowered to detect differences in PROMIS, improved PROMIS for TightRope and \u003cem\u003eInternal\u003c/em\u003eBrace vs. screws suggest that these techniques may result in better functional outcomes compared to screws.\u003c/p\u003e","manuscriptTitle":"Does Syndesmotic Fixation Technique Impact Complication Rates and Functional Outcomes Measured by PROMIS Scores Following Operative Repair of Ankle Fractures?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 05:30:46","doi":"10.21203/rs.3.rs-6857999/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-28T08:35:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-26T18:02:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-24T07:48:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330770646288827242934083041666387884017","date":"2025-06-16T17:58:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12654661317183013434852536127315638637","date":"2025-06-12T18:30:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-10T15:08:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-10T14:43:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-10T13:06:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2025-06-10T01:32:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"791b2783-251a-4f56-9be3-68d94104b137","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-11T15:58:20+00:00","versionOfRecord":{"articleIdentity":"rs-6857999","link":"https://doi.org/10.1186/s13018-025-06137-9","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2025-08-06 15:56:52","publishedOnDateReadable":"August 6th, 2025"},"versionCreatedAt":"2025-06-16 05:30:46","video":"","vorDoi":"10.1186/s13018-025-06137-9","vorDoiUrl":"https://doi.org/10.1186/s13018-025-06137-9","workflowStages":[]},"version":"v1","identity":"rs-6857999","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6857999","identity":"rs-6857999","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}