Traditionally all syndesmotic fractures are treated operatively with screw fixation being the gold-standard. There are a lot of choices for the type of screw used in this procedure, including single or double, metal or bioabsorbable. Double screws provide the greatest amount of stabilization. You are correct to be concerned about having screws in your ankle, as screws also limit the normal biomechanics of the tibia and fibula at the ankle joint. The fibula must be able to rotate, translate and migrate to allow for normal ankle movement. This movement is altered with screw fixation and can potentially contribute to a problem known as malreduction.
Syndesmotic reduction becomes an important factor with all fixation procedures as malreduction is common and results in significantly worse functional outcomes. Malreduction typically takes place when the fibula is fixed in the wrong position. There are some operative solutions to minimize malreduction.
Malreduction rates decrease from 50 per cent to 15 per cent with direct visualization of the tibiofibular joint. If direct visualization is not possible with the surgical technique, intraoperative 3D imaging show promise in reducing malreduction rates as well.
Aside from screw fixation there is another option that shows promise. Suture button fixation is a new technique that may eliminate the concern of losing normal mobility as it is not a rigid fixation like the screws. A recent systematic review showed that suture button fixation resulted in similar healing time to screw fixation, but the patients reported an earlier return to work and less frequent need for implant removal. Restoring normal biomechanics to the ankle joint whether by use of suture button fixation or removal of screw fixation after healing can lead to improved syndesmotic reduction and improved functional outcomes.