Background: Acute syndesmosis injury (ASI) is an indication for surgical stabilization if instability is confirmed. In recent years, fixation using the knotless suture-button (SB) device has become increasingly established as an alternative to set screw fixation (SF). This study directly compared the clinical long-term results after prospective randomized inclusion. Materials and Methods: Between 2011 and 2012, 62 patients with ASI were enrolled in a prospective, randomized, and monocentric study. Forty-one patients were available for a 10-year follow-up ((31 males and 10 females), including 21 treated with SB (mean age 44.4 years), and 20 with SF (mean age 47.2 years)). In addition to comparing the demographic data and syndesmosis injury etiology, follow-up assessed the Olerud–Molander Ankle Score (OMAS) and FADI-Score (Foot and Ankle Disability Index Score) with subscales for activities of daily living (ADL) and sports activity. Results: The mean OMAS was 95.98 points (SB: 98.81, SF: 93.00), the mean FADI ADL was 97.58 points (SB: 99.22, SF: 95.86), and the mean FADI Sport was 94.14 points (SB: 97.03, SF: 91.10). None of the measurements differed significantly between the groups (p > 0.05). No clinical suspicion of chronic instability remained in any of the patients, regardless of treatment. Conclusions: The short-term results showed that athletes in particular benefit from SB fixation due to their significantly faster return to sports activities. However, the available long-term results confirm a very good outcome in the clinical scores for both approaches. Chronic syndesmotic insufficiency was not suspected in any of the patients. Level of evidence: I, randomized controlled trial.

Zusammenfassung: Die orthoplastische Chirurgie spielt eine zentrale Rolle in der Versorgung von Arbeits- und Wegeunfällen unter dem Dach der gesetzlichen Unfallversicherung. Dieser Beitrag analysiert aktuelle Standards in Akutversorgung, septischen Verläufen und Rehabilitation. Ausgewertet wurden Leitlinien der Deutschen Gesetzlichen Unfallversicherung (DGUV), Zertifizierungsanforderungen für Traumazentren sowie retrospektive Fallserien aus zugelassenen Kliniken (2015–2024). Moderne Behandlungspfade integrieren plastisch-rekonstruktive Techniken in 78% der Schwerstverletztenfälle (SAV). Septische Komplikationen nach Polytrauma zeigen eine Inzidenz von 9–12%, wobei einstufige Wechseloperationen bei 82% der Protheseninfektionen erfolgreich sind. Die interdisziplinäre Rehabilitation verkürzt die Arbeitsunfähigkeitsdauer um durchschnittlich 23%. Die Vernetzung von Akutkliniken, septischer Chirurgie und Rehabilitationszentren optimiert Outcomes. Standardisierte Qualitätsindikatoren und telemedizinische Nachsorgekonzepte bedürften weiterer Forschung und Entwicklung.