Full Return to Sport in All Athletes After Suture-Button Fixation for Syndesmotic Injuries; However, Faster Recovery Was Seen in National Collegiate Athletic Association Football Players Compared with National Football League Players

Purpose

To determine the return-to-sport (RTS) rate and time to RTS for National Collegiate Athletic Association (NCAA) football players and National Football League (NFL) players after suture-button fixation for the treatment of unstable tibiofibular syndesmotic injuries and to identify possible risk factors associated with a delay in RTS.

Methods

NCAA and NFL players who underwent suture-button fixation for an isolated syndesmotic ankle injury between 2017 and 2023 were evaluated. All player information and data were retrieved from publicly available internet sources. The following information was gathered on each player’s career; NFL participation, number of seasons played before and after surgery, number of games played before and after surgery, and time between surgery and RTS. RTS was defined as the time until the first game after syndesmotic suture-button fixation.

Results

Seven NCAA and fourteen NFL players (21 ankles) were included. The mean age at surgery was 24.90 ± 4.66 years (range, 18-34 years). One hundred percent of patients were able to RTS at their level of sport. The mean time between surgery and the first game played was 139.4 ± 123.6 days (range, 12-427 days). Players played in 23.48 ± 21.9 games (range, 3-72 games) after surgery. NCAA players were able to RTS significantly earlier than NFL players (39.0 ± 20.4 days vs 189.6 ± 123.2 days, P =.005, with P <.05 denoting significance). There was no significant difference in workload after surgery for both NCAA and NFL players.

Conclusions

In this study, we found that athletes, regardless of whether they were NCAA or NFL players, were able to successfully return to their level of sport after ankle surgery. Whereas NCAA players returned to play significantly faster, both groups were able to achieve similar performance levels postoperatively in terms of the number of games played.

Level of Evidence

Level III, retrospective cohort study.

Unstable tibiofibular syndesmotic injuries, commonly referred to as “high ankle sprains,” present a significant challenge in both diagnosis and treatment, particularly among athletes. These injuries involve disruption of the ligamentous structures between the tibia and fibula, which are critical for maintaining ankle stability. ^, The distal tibiofibular syndesmosis is stabilized by 4 key ligamentous structures: the anterior-inferior tibiofibular ligament, which resists external rotation and anterior displacement of the fibula; the posterior-inferior tibiofibular ligament, which resists posterior displacement; the interosseous ligament, a thickened portion of the interosseous membrane providing central stability; and the inferior transverse ligament, which reinforces posterior ankle stability. Collectively, these ligaments maintain syndesmotic integrity and ankle mortise stability during weight-bearing and rotational stress. Syndesmotic stability is conferred by both osseous and ligamentous relationships between the distal tibia and fibula. ^, The fibula rests within a concave triangular groove (i.e., incisura) in the tibia, with its apex 6 to 8 cm proximal to the talocrural joint. ^, The anterior-inferior tibiofibular ligament, interosseous ligament, interosseous membrane, posterior-inferior tibiofibular ligament, and inferior transverse ligament compose the syndesmosis. Unstable tibiofibular syndesmotic injuries occur most commonly in sports that involve sudden twisting, cutting, or pivoting movements, especially those that put excessive rotational stress on the ankle. The sports with the highest rates of high ankle sprain injury include men’s football (2.42/10,000 athlete-exposures [AEs]), wrestling (2.11/10,000 AEs), and ice hockey (1.19/10,000 AEs). Left untreated or inadequately addressed, such injuries can lead to chronic pain, instability, and a prolonged absence from athletic activities.

Historically, the management of syndesmotic injuries has involved various surgical techniques, including screw fixation. However, screw fixation often necessitates a secondary procedure for removal and may limit physiological movement between the tibia and fibula, potentially impacting functional recovery. ^,^, In recent years, suture-button fixation has gained traction as an alternative to traditional screw fixation, with some studies showing improved outcomes compared with syndesmotic screws, such as greater fibular freedom and significantly lower rates of hardware failure that could result in a secondary procedure to remove failed hardware. ^,^, This technique uses flexible sutures anchored by small buttons, allowing for dynamic stabilization of the syndesmosis while permitting natural motion between the tibia and fibula. ^,^, Anatomic fixation directed from the posterior cortex of the fibula to the anterolateral edge of the tibia allows for dynamic stabilization.

The advantages of suture-button fixation include the elimination of the need for hardware removal, reduced risk of over-tightening, and potentially faster rehabilitation timelines. ^, As a result, this technique has become increasingly popular, particularly among high-performance athletes who require a reliable and efficient return to sport (RTS). ^, Despite its growing acceptance, the body of literature evaluating the outcomes of suture-button fixation remains limited regarding RTS among National Collegiate Athletic Association (NCAA) football players and National Football League (NFL) players. Understanding how this method performs under the extreme physical demands and performance expectations of NCAA and NFL players is both clinically and practically important.

Therefore, the purpose of this study was to determine the RTS rate and time to RTS for NCAA football players and NFL players after suture-button fixation for the treatment of unstable tibiofibular syndesmotic injuries and to identify possible risk factors associated with a delay in RTS. We hypothesized that all NFL and NCAA players treated with suture-button fixation for unstable tibiofibular syndesmotic injuries would RTS at their level of competition and that RTS would not be significantly different between NFL and NCAA football players after surgery.

Methods

This retrospective cohort study included NCAA football players and NFL players who sustained in-season syndesmotic ankle injuries between 2017 and 2023. Players were included in the study if they sustained a syndesmotic ankle injury identified by means of publicly available sources such as NFL.com , player profiles, team news reports, and injury reports using similar methods to those used in previously published investigations. ^,^, Each reported injury was cross-referenced with at least 2 of the aforementioned sources to confirm a diagnosis of syndesmotic ankle injury and subsequent suture-button fixation. The aforementioned sources were used to further confirm the dates of injury by cross-referencing with statistical pages to verify a gap in playing time during the time away from sport and to verify the documented date of injury and date of RTS for each player. Players were included only if they had participated in an NCAA football game or NFL game before their injury. Players were excluded if their injury or surgical treatment could not be verified, if they had not participated in a game prior to the injury, if they did not return to NCAA or NFL participation after treatment, or if there was insufficient publicly available information to confirm their inclusion.

Descriptive data for each player, including body mass index (BMI), age, and position at the time of injury, were collected from team statistical pages. Successful RTS was defined as any documented NCAA football or NFL game play after syndesmotic suture-button fixation. The total numbers of seasons and games played after the injury were documented. Overall career data before and after the date of injury were collected to better assess longitudinal changes in level of function.

Statistical Analysis

Descriptive statistics, including means and standard deviations, were used to summarize continuous variables such as age, BMI, time to RTS, number of preinjury games played, and number of post-injury games played. Categorical variables, such as playing position, were summarized using frequencies and percentages. Differences between groups (e.g., RTS) were analyzed using appropriate statistical tests such as the χ ² and Fisher exact tests for categorical data (e.g., comparison of player position) and t test for continuous data (e.g., age at the time of injury and BMI), with the level of significance set at P <.05.

Results

Seven NCAA football players and fourteen NFL players (21 ankles) were included ( Fig 1 ). The mean age at the time of surgery was 24.90 ± 4.66 years, with a range of 18 to 34 years. There was a significant difference ( P <.001) in mean age between NCAA football players (20.0 ± 1.2 years) and NFL players (27.3 ± 3.6 years) ( Table 1 ). There were no significant differences between the 2 cohorts when comparing BMI and position played. There was a significant difference ( P <.001) in the number of preinjury games played between the NCAA cohort (8.6 ± 1.7) and NFL cohort (13.5 ± 2.0).

Image, AltText currently not available — Fig 1

Table 1

Descriptive Data for NCAA Football Players and NFL Players

Variable	NCAA (n = 7)	NFL (n = 14)	P Value
Age at time of injury, yr, mean ± SD	20.0 ± 1.2	27.3 ± 3.6	<.001
BMI at time of injury, mean ± SD	29.0 ± 4.3	29.0 ± 4.0	.99
Position, n (%)
Quarterback	2 (28)	2 (16)	.57
Running back	0 (0)	3 (23)	.52
Wide receiver	2 (28)	5 (38)	.74
Tight end	1 (14)	0 (0)	.14
Offensive line	1 (14)	1 (7)	.59
Defensive line	0 (0)	2 (16)	.29
Cornerback	1 (14)	1 (7)	.59
Time to RTS, d, mean ± SD	39.0 ± 20.4	189.6 ± 123.2	.005
No. of preinjury games played per season, mean ± SD	8.6 ± 1.7	13.5 ± 2.0	<.001
No. of post-injury games played per season, mean ± SD	8.6 ± 4.6	11.2 ± 5.9	.32

BMI, body mass index; NCAA, National Collegiate Athletic Association; NFL, National Football League; RTS, return to sport; SD, standard deviation.

All athletes (100%) were able to RTS at their level of competition after surgery. The mean time from surgery to the first game played postoperatively was 139.4 ± 123.6 days, with a range of 12 to 427 days. The mean time to RTS for NCAA players was 39.0 ± 20.4 days, whereas NFL players took an average of 189.6 ± 123.2 days ( P =.005) ( Fig 2 ).