Stability at a Cost: Evaluating Postoperative Complications in Bioabsorbable vs. Metallic Syndesmotic Fixation: A Systematic Review

The use of bioabsorbable screws for syndesmotic fixation in complex ankle fractures has become increasingly popular, as they may eliminate the need for secondary surgeries for implant removal. However, their efficacy when compared against metallic screws is unclear, with some persisting concerns of higher complication rates compared to the traditional metallic option. A systematic search was conducted using PubMed and Google Scholar, yielding 332 studies. After title and abstract screening followed by full-text review, eligible randomized controlled trials comparing bioabsorbable versus metallic screw fixation in ankle syndesmotic injuries were included. The total rate of postoperative complications was primarily assessed. Risk ratios (RR) and 95% confidence intervals (CIs) were calculated. Four studies met the inclusion criteria for the meta-analysis, encompassing 257 patients. The pooled data demonstrated a significantly higher risk of complications with bioabsorbable screw fixation, including revision surgery, infection, and symptomatic hardware removal, compared to metallic screws (RR 3.35, 95% CI 1.75-6.42, p = 0.0003). Range-of-motion outcomes varied across studies but showed no clear superiority of either fixation method. The increased complication rate with bioabsorbable screws raises concerns about routine use in syndesmotic fixation. Although previous studies have suggested comparable functional outcomes and fewer reoperations due to implant removal, the current data underscore the importance of prioritizing safety and reliability. Given the risk of inflammatory reactions and hardware failure seen in bioabsorbable groups, metallic screws remain the more dependable option. Future research should focus on improving the biomechanical and biocompatibility profiles of absorbable materials before they are widely adopted in clinical use.