BackgroundAlthough utilization of dynamic suture-button fixation for adult syndesmotic injuries has shown improved outcomes over static screw fixation, data in pediatric populations is limited. This study evaluated trends in management and identified factors influencing surgeon choice of implant for pediatric syndesmotic injuries. MethodsPediatric Orthopaedic Society of North America (POSNA) members were surveyed regarding syndesmotic injury implant preferences between October 2021 and May 2022. Respondents that opted out, treated <1 syndesmotic ankle injury in the past year, or had conflicting financial obligations were excluded. Results were summarized and analyzed using logistic regression to assess for significance between years post-training and technique preference. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for significance (P-values<0.05). ResultsAmong 103 respondents to the survey (with 102 complete responses), 25% were <5 years post-training, 24% between 5-10 years, 21% between 11-15 years, and 28% >15 years post-training. Twenty-four percent (24/102) preferred screw versus 76% (78/102) preferring suture-button implants for syndesmotic injuries. Members >15 years post-training were 4.7 times more likely to prefer screw implants compared to members <5 years post-training (OR=4.7; 95% CI, 1.14-19.34; p=0.03). Since starting their clinical practice, 62 respondents (60%) reported an implant preference change, with avoidance of secondary surgery (46/62; 74%) and extrapolation from adult outcomes (39/62; 63%) cited as primary motivating factors. Of the 40 members with no preference change, comfort with the procedure was the primary cited reason (33/40; 83%). Among those choosing operative intervention, radiograph-based cases showed preference for suture-button in 70-79% of respondents for skeletally mature patients versus 71-81% for skeletally immature patients. ConclusionOur data shows that the shift over time from screw to suture-button implant fixation for pediatric and adolescent syndesmotic ankle injuries is largely due to interest in avoiding implant removal and extrapolation from superior outcomes seen with suture-button use in adults. Larger comparative studies of pediatric and adolescent patients treated with suture-button versus screw fixation are needed to establish standards of care for these challenging injuries. Levels of EvidenceLevel V: Expert opinion