Fate of the syndesmotic screw--Search for a prudent solution

Post-treatment Functional Outcomes of Distal Tibiofibular Syndesmosis Injuries With Varying Duration and Method of Stabilization

The purpose of this study was to assess whether the type and duration of screw fixation affects ankle joint functional scores and patient activity levels. We evaluated 55 patients who had undergone surgical treatment for ankle fracture with concomitant distal tibiofibular syndesmosis injury. The follow-up period ranged from 2 years to 4 years and 2 months (mean 36 months). Depending on the time of screw removal, patients were divided into 2 groups (the 8-15-week group-19 patients, and the 16-22-week group-36 patients). There were 17 patients with tricortical and 38 patients with quadricortical syndesmosis fixation. The following parameters were assessed: range of motion, rates of complications, level of pain in visual analogue scale (VAS), and function. In the quadricortical fixation group the range of plantar flexion p = .04 and adduction p = .043 were significantly lower in the operated than in the nonoperated limb. In the patients who had their syndesmotic screws removed after 16-22 weeks, the range of plantar flexion in the operated limb was significantly lower than that in the nonoperated limb. We observed no differences between the evaluated groups in terms of ankle joint mobility, VAS pain levels, functional outcomes, or complication rates. All the analyzed subgroups showed poorer ranges of some types of motion in the ankle and worse functional scale and VAS pain scores after treatment in comparison with those before the injury. We suggest removing the syndesmotic screws after 8-15 weeks, due to the possibility of earlier rehabilitation, faster return to work and physical activity and less burden on the health care system. Tricortical or quadricortical syndesmosis fixation is at the surgeon's discretion.

Is There Any Purpose in Routine Syndesmotic Screw Removal? Systematic Literature Review

Introduction: The aim of this systematic review is to examine the recent evidence comparing the removal and non-removal of syndesmotic screws in tibiofibular syndesmosis injuries in terms of functional, clinical, and radiographic outcomes. Methods: A comprehensive literature review was conducted to identify clinical studies on syndesmotic screw removal and its outcomes, searching the Cochrane Library and PubMed Medline for publications from 1 January 2004 to 12 February 2024. Studies were included if they involved tibiofibular syndesmotic screw fixation, assessed screw removal or retention, described clinical outcomes, and were original research with at least fifteen patients per group. Results: Most reviewed articles (18 out of 27; 67%) found no significant differences between the routine removal and retention of syndesmotic screws post-fixation. Four retrospective studies (15%) suggested that retaining screws might result in worse outcomes compared to removal. Two studies (7%) indicated that removing screws could introduce additional risks. One study (4%) observed that post-removal, there is some fibula-tibia separation without affecting the medial clear space. Another study (4%) noted that intraosseous screw breakage might increase the need for implant removal due to pain. Additionally, no significant differences in ankle function were found among groups with varying intervals of screw removal. Conclusions: The current literature does not definitively support routine removal of syndesmotic screws. Given the potential complications and financial costs, routine removal should not be performed unless specifically indicated.

Syndesmotic screws, unscrew them, or leave them? A systematic review and meta-analysis of randomized controlled trials

Background

Syndesmotic injuries are frequently stabilized using syndesmotic screws. Traditionally, these screws were routinely removed during the postoperative period, however recent literature has brought into question the necessity of routine removal, citing no change in functional outcomes and the inherent risks of a second surgery. Our study aimed to compare outcomes of patients undergoing routine syndesmotic screw removal versus those undergoing an on-demand approach to removal.

Methods

A systematic search of studies comparing routine syndesmotic screw removal to on-demand screw removal following an acute ankle fracture, or an isolated syndesmotic injury was conducted across seven databases. Only Prospective randomized controlled trials were eligible for inclusion. Data reported on by at least 2 studies was pooled for analysis.

Results

Three studies were identified that met inclusion and exclusion criteria. No significant difference in Olerud-Molander Ankle Score (MD -2.36, 95% CI -6.50 to 1.78, p = 0.26), American Orthopedic Foot and Ankle Hindfoot Score (MD -0.45, 95% CI -1.59 to .69, p = 0.44), or dorsiflexion (MD 2.20, 95% CI -0.50 to 4.89, p = 0.11) was found between the routine removal group and on-demand removal group at 1-year postoperatively. Routine removal was associated with a significantly higher rate of complications than on-demand removal (RR 3.02, 95% CI 1.64 to 5.54, p = 0.0004). None of the included studies found significant differences in pain scores or range of motion by 1-year postoperatively.

Conclusion

Given the increased risk of complications with routine syndesmotic screw removal and the comparable outcomes when screws are retained, an as-needed approach to syndesmotic screw removal should be considered.

Risk factors associated with breakage of tibio-fibular syndesmotic screws

PURPOSE

This retrospective study aimed to investigate the factors associated with the breakage of tibio-fibular syndesmotic screws (SS).

METHODS

69 patients with unstable AO-Weber Type 44-B ankle fractures who underwent three cortex SS (3.5 mm ø) fixation were included. Patients were followed for at least one year (mean, 18.3 ± 7.6 months). At the final follow-up, patients with broken (Group I) and intact (Group II) SS were compared regarding age, gender, height, weight, body mass index, fracture type, SS length, location, and orientation. Multivariate logistic regression was used to identify the independent risk factors associated with SS breakage. The sensitivity, specificity, cut-off value, and area under the ROC curve were analyzed.

RESULTS

A stepwise backward logistic regression analysis revealed that age was the only independent predictor for SS breakage (OR = 0.938, 95% CI = 0.904-0.973, R2 = 0.270). ROC curve analysis demonstrated that patients younger than 36 years were associated with seven times increased risk of SS breakage [Odds ratio (95% CI), 7.042 (2.251-22.031)].

CONCLUSION

Age under 36 years was the only significant risk factor for SS breakage. The higher incidence of breakage of the syndesmotic screw can be informed to patients younger than 36.

Predictors of Hardware Removal in Orthopaedic Trauma Patients Undergoing Syndesmotic Ankle Fixation With Screws

Background

Indications for removal of syndesmotic screws are not fully elucidated. This study aimed to determine factors related to elective syndesmotic screw removal.

Methods

Patients who underwent fixation of ankle syndesmotic injuries were included. Screw removal was offered after a minimum of 12 weeks after surgery for pain, stiffness or patient desire to remove painful or broken hardware. Patient demographics, surgical data, distance of the syndesmotic screw from the joint, location of the screw at the physeal scar, and number of syndesmotic screws placed were collected for all patients. Bivariate and multivariate analyses were performed to determine the relationship between patient characteristics and screw removal and independent predictors of hardware removal.

Results

Of 160 patients, 60 patients (38%) with an average age of 36.1 (range: 18-84) years underwent elective syndesmotic screw removal at a mean of 7 (range, 3-47) months after initial fixation. The most common reason for screw removal (50/60 patients) was ankle stiffness and pain (83%). Patients who underwent screw removal were more likely to be younger (36.1 years ± 13.0 vs 46.6 years ± 18.2, P < .001) and have a lower ASA score (2 ± 0.8 vs 2.1 ± 0.7, P = .003) by bivariate analysis. Of patients who underwent screw removal, 21.7% (13/60) had a broken screw at the time of removal. Whether the screw was placed at the physeal scar was not significantly associated with patient decision for hardware removal (P = .80).

Conclusion

Younger and healthier patients were more likely to undergo elective removal of syndesmotic hardware. Screw distance from joint and screw placement at the physeal scar were not significantly associated with hardware removal.

Level of Evidence

Level III, retrospective cohort study.

Radiographic Assessment of Tibiofibular Syndesmosis Injury with Different Durations and Types of Fixation

Introduction: There is no consensus among orthopedic surgeons on the number of cortical layers (tricortical or quadricortical fixation) involved or the duration of syndesmotic fixation after a tibiofibular syndesmosis (TFSD)-injury treatment. The purpose of this study was to assess radiographic parameters following the treatment of TFSD injuries, with various time-windows of syndesmotic screw removal and numbers of cortical layers involved. Materials and Methods: Fifty-five patients, aged from 25 to 75 years, were included in the study. The follow-up period ranged from 2 years to 4 years and 2 months. The patients were subdivided into groups based on the duration of the syndesmotic fixation (8–15 weeks—19 patients or 16–22 weeks—36 patients) and the number of cortices involved (tricortical—17 patients or quadricortical fixation—38 patients). Results: The quadricortical fixation group showed a significant development of ankle joint arthritis and subtalar joint arthritis at the final follow-up. The mean medial clear space was 2.84 mm in the tricortical fixation group and 3.5 mm in the quadricortical fixation group (p = 0.005). Both groups, with different screw removal times showed significant development of posttraumatic arthritis. A comparison of the two groups (with different time-windows of the screw removal) revealed a significant difference only in terms of the postoperative tibiofibular (TF) overlap and the observed rates of talonavicular arthritis at the final follow-up. Discussion: We found that the duration of the screw fixation had no effect on most of the evaluated radiographic parameters. Only the postoperative TF overlap was lower in the 8–15-week fixation group, and the proportion of patients with talonavicular joint arthritis at the final follow-up was higher in the 16–22-week fixation group. In addition, the number of cortices involved in the screw fixation had no effect on the radiographic outcomes in our patients, apart from the differences in one parameter—the medial clear space—at the final follow-up. Conclusion: We achieved similar radiographic results irrespective of the duration of the screw fixation and the number of cortices involved. All study subgroups showed the development of adjacent-joint arthritis following treatment. Considering the results of our study, the economic and medical aspects of treatment, and the possibility of a faster recovery, the most optimal solution seems to be the use of a tricortical fixation, with the screws being removed after 8–15 weeks.

Outcomes of the Routine Removal of the Syndesmotic Screw

Background Ankle joint stabilization with fixation following an injury has been the practice for ankle injuries requiring stabilization. When syndesmotic screws are used to stabilize the ankle joint, the current practice encourages the removal of these screws. However, this study was performed to evaluate the outcomes of patients treated with these screws, with the view to challenging routine screw removal. Methodology This was a retrospective study analyzing the records of 52 patients who had been treated with the syndesmotic screw over a two-year span. Results Of the 26 patients who did not retain the screw, 84.6% (n = 22) had it removed based on the advice of the surgeon as per the current practice. In total, 19 (73.1%) of these patients had suffered at least one complication over the two procedures. Conversely, of the 23 patients who had retained the screw through one procedure, 14 (60.7%) had at least one complication. Conclusions Routine syndesmotic screw removal is associated with increased risks of complications compared to retaining the screws, in addition to not producing a superior outcome for the patients.

Syndesmotic Screw Breakage May Be More Problematic Than Previously Reported: Increased Rates of Hardware Removal Secondary to Pain With Intraosseous Screw Breakage

BACKGROUND

The majority of retained syndesmotic screws will either loosen or break once the patient resumes weight-bearing. While evidence is limited, anecdotal experience suggests that intraosseous screw breakage may be problematic for some patients due to painful bony erosion. This study seeks to identify the incidence of intraosseous screw breakage, variables that may predict intraosseous screw breakage, and whether intraosseous screw breakage is associated with higher rates of implant removal secondary to pain.

METHODS

Five hundred thirty-one patients undergoing syndesmotic stabilization were screened, of which 43 patients (with 58 screws) experiencing postoperative screw breakage met inclusion criteria. Patient charts were retrospectively reviewed for demographic data, comorbidities, time to screw breakage, location of screw breakage, and implant removal. Several radiographic parameters were evaluated for their potential to influence the site of screw breakage.

RESULTS

Intraosseous screw breakage occurred in 32 patients (74.4%). Screw breakage occurred exclusively in the tibiofibular clear space in the remaining 11 instances (25.6%). Intraosseous screw breakage was significantly associated with eventual implant removal after breakage (P = .034). Screws placed further from the tibiotalar joint were at less risk for intraosseous breakage (odds ratio 0.818, P = .002). Screws placed at a threshold height of 20 mm or greater were more likely to break in the clear space (odds ratio 12.1, P = .002).

CONCLUSION

Syndesmotic screw breakage may be more problematic than previously described. Intraosseous breakage was associated with higher rates of implant removal secondary to pain in this study. Placement of screws 20 mm or higher from the tibiotalar joint may decrease risk of intraosseous breakage.Levels of Evidence: Level III: Retrospective study.

Is routine removal of syndesmotic screw justified? A meta-analysis

BACKGROUND

Syndesmosis injuries are common with rotational ankle injuries, and placement of a positional syndesmotic screw to maintain its reduction is used as the ligaments heal. There is no clear consensus on routine removal or retention of syndesmotic screw. This study aimed to appraise the current evidence both on removal and retention of syndesmotic screw and to conduct a meta-analysis comparing outcomes and rate of complications of syndesmotic screw removal and retention.

METHODS

Following PROSPERO registration, a systematic search using was performed using keywords ('Syndesmosis' OR 'Syndesmotic' OR 'Transsyndesmotic' OR 'distal tibiofibular') AND ('Screw') AND ('Removal' OR 'Retention') AND 'Outcome' in various databases. No language restrictions were applied and the meta-analysis incorporated the PRISMA statement. VAS (Visual analogue scale for pain), AOFAS (American Orthopaedic Foot And Ankle Society) scores expressed as mean ± SD, and both groups' complication rates were compared. Comparisons with a random-effects model were performed, and heterogeneity between the studies was calculated using the I2 statistic. T-test for two independent sample means was used to compare pooled mean and Z-test for two proportions to assess the difference in the proportion of complications.

RESULTS

A total of 7 studies with 522 patients were included in this review for analysis. Pooled analysis showed non-significant difference in AOFAS score (MD = -1.84; 95% CI: -4.33 to 0.66; p = 0.150) as well as for VAS score (MD = -0.48; 95% CI: -1.56 to 0.60; p = 0.390) between the two groups. The value of z and p-value for complication rates was 0.6021 and 0.5485, respectively, which was not significant.

CONCLUSION

There doesn't appear to be a difference in functional outcome, pain scores, and complication rates between patients who had their syndesmotic screws removed and those where screw was retained. The fear of inferior outcomes with retained screws is thus unfounded, and routine removal adds to morbidity and financial burden. In conclusion, present data does not support the routine removal of the intact syndesmosis screw, and a change in practice is needed to abandon routine syndesmotic screw removal.

Functional outcome of routine versus on-demand removal of the syndesmotic screw: a multicentre randomized controlled trial

Aims

The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome.

Methods

Adult patients (aged above 17 years) with traumatic syndesmotic injury, surgically treated within 14 days of trauma using one or two syndesmotic screws, were eligible (n = 490) for inclusion in this randomized controlled noninferiority trial. A total of 197 patients were randomized for either ODR (retaining the syndesmotic screw unless there were complaints warranting removal) or RR (screw removed at eight to 12 weeks after syndesmotic fixation), of whom 152 completed the study. The primary outcome was functional outcome at 12 months after screw placement, measured by the Olerud-Molander Ankle Score (OMAS).

Results

There were 152 patients included in final analysis (RR = 73; ODR = 79). Of these, 59.2% were male (n = 90), and the mean age was 46.9 years (SD 14.6). Median OMAS at 12 months after syndesmotic fixation was 85 (interquartile range (IQR) 60 to 95) for RR and 80 (IQR 65 to 100) for ODR. The noninferiority test indicated that the observed effect size was significantly within the equivalent bounds of -10 and 10 scale points (p < 0.001) for both the intention-to-treat and per-protocol, meaning that ODR was not inferior to RR. There were significantly more complications in the RR group (12/73) than in the ODR group (1/79) (p = 0.007).

Conclusion

ODR of the syndesmotic screw is not inferior to routine removal when it comes to functional outcome. Combined with the high complication rate of screw removal, this offers a strong argument to adopt on demand removal as standard practice of care after syndesmotic screw fixation.

Cite this article: Bone Joint J 2021;103-B(11):1709–1716.

Removal of Syndesmotic Screw After Fixation in Ankle Fractures: A Systematic Review

Syndesmotic injuries can occur with ankle fractures and can lead to destabilization of the ankle joint. As a result, it usually requires a transyndesmotic screw insertion to stabilize it. Currently, there is no consensus on the type, amount and diameter of screws used, the number of cortices needed to be engaged, the recommended time to weight-bearing, and whether the screw should be removed in these types of injuries. The aim of this study is to evaluate the evidence comparing the removal and non-removal of syndesmotic screws in open and closed ankle fractures that are associated with unstable syndesmosis in terms of functional, clinical, and radiological evidence. The study also looked at the evidence behind broken screw effects. The literature search was conducted on March 16, 2021, using the Ovid Medline and Embase databases. The literature was eligible if it aimed to compare syndesmotic screw removal and retention in ankle fractures. One study found that those with a broken screw had a better clinical outcome than those with an intact screw. The studies were excluded if they were biomechanical studies, case reports, or were relevant but had no adequate English translation. Initially, 53 studies were included but after scanning for eligibility, 11 were identified (including those added from references). Nine were cohort studies, seven of which did not find any difference in functional outcome between routine removal and retention of the syndesmotic screw. Two studies found there were better clinical outcomes in the broken screw group. Another study found that there were slightly worse functional outcomes in patients with intact screws as compared with those with broken, loosened, or removed screws. Two studies were randomized control studies that no significant functional outcomes between removed and intact syndesmotic screws. However, the majority of these studies had a high risk of bias. Overall, the current literature provides no evidence to support routine removal of syndesmotic screws. Keeping in mind the clear complications and financial burden, syndesmotic screw removal should not be performed unless there is a clear indication. Furthermore, removal in the clinic, with the use of prophylactic antibiotics should be considered if indicated in cases with pain or loss of function. Further research in a structured randomized controlled trial (RCT) to examine if there is any difference in short- or long-term outcomes between removed, intact, loose, or broken syndesmotic screws might be beneficial. A multinational protocol for randomized control trials (RODEO-trial) is an example of such a study to determine the usefulness of on-demand and routine removal of screws.

Surgical Site Infections After Routine Syndesmotic Screw Removal: A Systematic Review

OBJECTIVES

To investigate the incidence of surgical site infections (SSIs) after routine removal of syndesmotic screws (SSs) placed to stabilize syndesmotic injuries.

DATA SOURCES

A systematic literature search was performed in the PubMed, Cochrane, and EMBASE databases for studies published online before February 2020, using the key words and synonyms of "syndesmotic screw" ("ankle fractures" or "syndesmotic injury") and "implant removal."

STUDY SELECTION

Studies were eligible for inclusion when they described >10 adult patients undergoing elective/scheduled removal of the SS.

DATA EXTRACTION

The 15 included articles were assessed for quality and risk of bias using the Newcastle-Ottawa Scale. Baseline characteristics of the studies, the study population, the intervention, the potential confounders, and the primary outcome (% of SSIs) were extracted using a customized extraction sheet.

DATA SYNTHESIS

The primary outcome was presented as a proportion of included patients and as a weighted mean, using inverse variance, calculated in RStudio. Furthermore, potential confounders were identified.

CONCLUSIONS

The percentage of SSIs ranged from 0% to 9.2%, with a weighted mean of 4%. The largest proportion of these infections were superficial (3%, 95% confidence interval: 2-5), compared with 2% deep infections (95% confidence interval: 1-4). These rates were comparable to those of other foot/ankle procedures indicating that the individual indication for SS removal (SSR) should be carefully considered. Future studies should focus on valid indications for SSR, the influence of prophylactic antibiotics on an SSI after SSR, and complications of retaining the SS to enable a fair benefits/risks comparison of routine versus on-demand removal of the SS.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Research progress in diagnosis and treatment of distal tibiofibular syndesmosis injury]

Objective

To review the research progress in the diagnosis and treatment of distal tibiofibular syndesmosis injury.

Methods

The recent literature about distal tibiofibular syndesmosis injury was reviewed and analyzed.

Results

Distal tibiofibular syndesmosis injury is commonly seen in ankle joint injury, the anatomical complexities make diagnosis and treatment difficult. Preoperative physical examination, radiologic evaluation, and intraoperative stress-testing are important for the diagnosis. Aggressive treatment is also recommended for these injuries to prevent long-term chronic instability. Internal fixation is the main treatment, including metal screw, degradable screw, elastic fixation, and hybrid techniques. Metal screw fixation is still the current mainstream, but elastic fixation represented by Suture-button is more in line with the physiological characteristics of ankle joint, and the rate of secondary operation is low while the clinical outcome is satisfactory. The application prospect of elastic fixation is worthy of expectation.

Conclusion

It's crucial for patient with ankle fracture to repair the distal tibiofibular syndesmosis injury. How to diagnose the injury more accurately and simply, how to increase the success rate of reduction, and how to reduce the complications of surgery are still worthy for further exploration.

Patterns and Implications of Early Syndesmotic Screw Failure in Rotational Ankle Fractures

BACKGROUND

The purpose of this study was to identify characteristic patterns of syndesmotic screw (SS) failure, and any effects on clinical outcome.

METHODS

A retrospective study was performed using a consecutive series of patients treated with open reduction and internal fixation with trans-syndesmotic screws for unstable ankle fractures with syndesmotic injury between 2015 and 2017. Patient demographics, fracture characteristics and classification, rates and patterns of trans-syndesmotic screw breakage, and backout were analyzed. Functional outcome was assessed using passive range of motion (ROM) and Maryland Foot Score (MFS).

RESULTS

A total of 113 patients (67%) had intact screws and 56 patients (33%) demonstrated either screw breakage or backout. Patients with SS failure were younger (P = .002) and predominantly male (P = .045). Fracture classification and energy level of injury were not associated with screw failure. Nine screws (11%) demonstrated backout (2 also broke) and 56 other screws broke. There was no association between the number of screws or cortices of purchase and screw failure. There was a trend toward a higher proportion of screw removal (20%) in this failed SS group compared with the intact SS group (12%) (P = .25), but with similar ankle ROM and MFS (P > .07).

CONCLUSION

Syndesmotic screw breakage was common in younger, male patients. Despite similarities in ankle range of motion and clinical outcome scores to patients with intact screws, there was a trend towards more frequent screw removal. This information can be used to counsel patients pre- and postoperatively regarding the potential for screw failure and subsequent implant removal.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Immediate Improvement in Physical Function After Symptomatic Syndesmotic Screw Removal

OBJECTIVE

To investigate the immediate impact of removing symptomatic syndesmotic screws on PROMIS outcomes and ankle range of motion (ROM) in patients who had previously undergone ankle fracture open reduction and internal fixation (ORIF) and syndesmotic fixation and later experienced functional limitations.

DESIGN

Prospective cohort study.

SETTING

Level 1-trauma center.

PATIENTS/PARTICIPANTS

Fifty-eight patients with ankle fractures with syndesmotic instability that required ORIF with syndesmotic fixation who underwent syndesmotic screw removal (SSR) and 71 patients who underwent ankle ORIF with syndesmotic fixation, but without screw removal during the same study period.

INTERVENTION

Symptomatic SSR for patients with functional limitations and decreased ankle ROM.

MAIN OUTCOME MEASUREMENTS

PROMIS physical function (PF) and pain interference T-scores and ankle ROM before and after screw removal.

RESULTS

Patients who underwent SSR had a statistically significant improvement in the PF T-score to 44.5 (P < 0.01) in the early postoperative period (mean 48 days) after screw removal. The screw removal occurred an average of 184 days after initial ORIF. This PF T-score change also met the minimally clinically important difference. There was a trend toward a significant improvement in PF T-scores for the SSR group as compared to the cohort group (44.5 vs. 41.6; P = 0.06) after screw removal. Removal of symptomatic implants resulted in an early mean improvement of total arc ankle ROM by 17 degrees (P < 0.01).

CONCLUSIONS

Patients experienced an immediate and significant improvement in PF outcomes and ankle ROM after symptomatic SSR for ankle fracture ORIF with syndesmotic fixation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reduction and fixation of anterior inferior tibiofibular ligament avulsion fracture without syndesmotic screw fixation in rotational ankle fracture

Objective

We aimed to present the radiographic and functional outcomes of anatomical reduction and fixation of anterior inferior tibiofibular ligament (AITFL) avulsion fracture without syndesmotic screw fixation in rotational ankle fracture.

Methods

We retrospectively reviewed 66 consecutive patients with displaced malleolar fracture combined with AITFL avulsion fracture. We performed reduction and fixation for the AITFL avulsion fracture when syndesmotic instability was present after malleolar fracture fixation. A syndesmotic screw was inserted only when residual syndesmotic instability was present even after AITFL avulsion fracture fixation. The radiographic parameters were compared with those of the contralateral uninjured ankles. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were assessed 1 year postoperatively.

Results

Fifty-four patients showed syndesmotic instability after malleolar fracture fixation and underwent reduction and fixation for AITFL avulsion fracture. Among them, 45 (83.3%) patients achieved syndesmotic stability, while 9 (16.7%) patients with residual syndesmotic instability needed additional syndesmotic screw fixation. The postoperative radiographic parameters were not significantly different from those of the uninjured ankles. The mean AOFAS score was 94.

Conclusion

Reduction and fixation of AITFL avulsion fracture obviated the need for syndesmotic screw fixation in more than 80% of patients with AITFL avulsion fracture and syndesmotic instability.

Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association Members and Evidence-Based Treatment Recommendations

OBJECTIVES

To describe current practice patterns of orthopaedic trauma experts regarding the management of ankle fractures, to review the current literature, and to provide recommendations for care based on a standardized grading system.

DESIGN

Web-based survey.

PARTICIPANTS

Orthopaedic Trauma Association (OTA) members.

METHODS

A 27-item web-based questionnaire was advertised to members of the OTA. Using a cross-sectional survey study design, we evaluated the preferences in diagnosis and treatment of ankle fractures.

RESULTS

One hundred sixty-six of 1967 OTA members (8.4%) completed the survey (16% of active members). There is considerable variability in the preferred method of diagnosis and treatment of ankle fractures among the members surveyed. Most responses are in keeping with best evidence available.

CONCLUSIONS

Current controversy remains in the management of ankle fractures. This is reflected in the treatment preferences of the OTA members who responded to this survey.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for authors for a complete description of levels of evidence.

Evaluation of Syndesmosis Reduction after Removal Syndesmosis Screw in Ankle Fracture with Syndesmosis Injury

Background:

Ankle fracture–dislocation with a syndesmotic injury has been treated with syndesmotic screw fixation. There are little evidences about the safety and efficacy of syndesmotic screw removal on the syndesmotic malreduction. This study aimed to evaluate the effects of syndesmotic screw removal of distal attachment of the fibula and tibia bones on the syndesmotic reduction and also impact of syndesmotic screw removal on the final functional score of ankle joint.

Materials and Methods:

Patients who underwent syndesmotic screw fixation for diagnosed syndesmosis injury during internal fixation surgery for ankle fractures from April 2017 to March 2018 were assessed for enrollment in our study. During open reduction and internal fixation for ankle fracture, existence of syndesmosis injury was evaluated using the Cotton test and external rotation stress test. Appropriate rehabilitation including short leg cast and nonweight bearing have been accomplished for a duration 12 weeks before removing of syndesmotic screws. At 12 weeks, screws were removed. After 1-month weight bearing, bilateral axial computed tomography (CT) scan and single-leg weight-bearing X-ray for injured ankle were obtained.

Results:

Of all 60 participants, 42 cases (70%) were male and 18 cases (30%) were female. Postoperative ankle radiographies were normal except one case with increased medial clear space. It was interesting findings that from total 60 cases, 18 patients (30%) had evidence of syndesmosis malreduction on postoperative initial CT scan, and after removing of syndesmotic screws (12 weeks) and a period of weight bearing and rehabilitation (4 weeks), there is evidence of appropriate reduction in 13 cases (of 18 patients [72.2%]) on final CT scans.

Conclusion:

Syndesmotic screw removal and weight bearing may be advantageous to achieve final anatomic reduction of the syndesmosis. Syndesmotic screw removal at appropriate time could not improve foot functional outcomes; however, more studies with the larger sample size are required to confirm the results of the study.

Distal Tibiofibular Syndesmosis Dysfunction: A Systematic Literature Review of Dynamic Versus Static Fixation Over the Last 10 Years

The goal of the present work was to perform a systematic review of the literature of the past 10 years regarding dynamic and static fixation of the distal tibiofibular syndesmosis to determine any clinical differences between the 2 procedures. A literature search of the PubMed MEDLINE database was conducted to identify relevant studies related to distal tibiofibular syndesmosis. Studies before January 1, 2007, were excluded to limit the project to the recent literature. Clinical outcomes, device removal rates, time to weightbearing after the initial procedure, and the cost effectiveness of each device were explored. In these 26 studies, 350 patients were treated using a dynamic technique and 845 were treated using a static technique. The weighted American Orthopedic Foot and Ankle Score was 91.70 (standard error [SE] 1.87) for dynamic fixation patients and the weighted average was 86.48 (SE 2.17) for static fixation patients (p = .068). A secondary procedure to remove the fixation device was performed in 7.7% of dynamic fixation patients and in 39.4% of static fixation patients when studies with 100% device removal were excluded (p < .0001). The mean time to weightbearing was 5.96 (SE 0.72) weeks for patients who underwent dynamic fixation and 10.45 (SE 0.99) weeks for those who had static fixation (p = .0002). The cost for dynamic fixation was found to be less than that for static fixation when secondary procedures for device removal were considered. Based on similar clinical functional scores, lower secondary procedure rates, faster time to full weightbearing, and lower costs to patients, dynamic fixation of the distal tibiofibular syndesmosis may be a superior option compared with static fixation.

The management of syndesmotic screw in ankle fractures

BACKGROUND AND AIM

There is a wide debate about the number, diameter and length of the syndesmotic screw and necessity and timing for its removal. The aim of this study is to determine whether functional and radiological outcomes differ in patients operated for Weber type B and C ankle fractures who had syndesmotic screws removed (group 1) compared to those who did not (group 2). Furthermore, authors want to define if it is really necessary to remove this device and its correct timing.

MATERIALS AND METHODS

90 patients were eligible for the study. The functional outcomes were analyzed 1 year after surgery using OMAS and AOFAS scores. Radiographic evaluation assessed the tibiofibular distance immediately and 12 months after surgery and fracture's healing.

RESULTS

Clinical and x-rays results were similar in both groups at follow-up.

DISCUSSION

Fractures with interruption of syndesmosis are lesions that, if not well treated, are complicated by joint stiffness, residual pain and post-traumatic osteoarthritis. Syndesmotic screw removal is not routinely performed, thus accepting the risk of rupture but avoiding a new surgery.

CONCLUSIONS

Results observed suggest that syndesmotic screw removal is not necessary. If surgeon decide to remove this device correct timing is mandatory in order to obtain satisfactory long-term results.

Technical tip: Removal of a broken tri-cortical syndesmotic screw using a "perfect circle" technique

While broken or loose syndesmotic screws are typically of no clinical consequence, occasionally breakage can result in pain, metal fretting, or bony erosion. Despite quad-cortical syndesmotic screws being relatively easy to remove due to the prominent screw tip penetrating the medial tibial cortex, removal of a broken tri-cortical screw can be technically challenging. The purpose of this manuscript is to describe a safe technique for removing the buried, broken tri-cortical screw fragment via a minimally invasive medial tibial approach by verifying the screw location using intra-operative fluoroscopy.

Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial)

BACKGROUND

Syndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome.

DESIGN

This is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12 months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up.

DISCUSSION

If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs.

TRIAL REGISTRATION

This study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov ( NCT02896998 ) on July 15th 2016.

The Role of Implant Removal in Orthopedic Trauma

Although implant removal is common after orthopedic trauma, indications for removal remain controversial. There are few data in the literature to allow evidence-based decision-making. The risk of complications from implant removal must be weighed against the possible benefits and the likelihood of improving the patient's symptoms.

Removal of Hardware After Syndesmotic Screw Fixation: A Systematic Literature Review

BACKGROUND

While trans-syndesmotic fixation with metal screws is considered the gold standard in treating syndesmotic injuries, controversy exists regarding the need and timing of postoperative screw removal. Formal recommendations have not been well established in the literature and clinical practice is highly variable in this regard. The purpose of this systematic review is to critically examine the most recent literature regarding syndesmotic screw removal in order to provide surgeons an evidence-based approach to management of these injuries.

METHODS

The Cochrane Library and PubMed Medline databases were explored using search terms for syndesmosis and screw removal between October 1, 2010 and June 1, 2016.

RESULTS

A total of 9 studies (1 randomized controlled trial and 8 retrospective cohort studies) were found that described the outcomes of either retained or removed syndesmotic screws. Overall, there was no difference in functional, clinical or radiographic outcomes in patients who had their syndesmotic screw removed. There was a higher likelihood of recurrent syndesmotic diastasis when screws were removed between 6 and 8 weeks. There was a higher rate of postoperative infections when syndesmotic screws were removed without administering preoperative antibiotics.

CONCLUSION

Removal of syndesmotic screws is advisable mainly in cases of patient complaints related to the other implanted perimalleolar hardware or malreduction of the syndesmosis after at least 8 weeks postoperatively. Broken or loose screws should not be removed routinely unless causing symptoms. Antibiotic prophylaxis is recommended on removal. Radiographs should be routinely obtained immediately prior to removal and formal discussions should be had with patients prior to surgery to discuss management options if a broken screw is unexpectedly encountered intraoperatively. Radiographs and/or computed tomography imaging should be obtained after syndesmotic screw removal when indicated for known syndesmotic malreduction.

LEVELS OF EVIDENCE

Level IV: Systematic review.

Syndesmosis Stabilisation: Screws Versus Flexible Fixation

Orthopedic surgery is not short of situations where there is controversy regarding optimum management. Treating ankle syndesmosis injuries is an example where practice varies widely and there are many questions that remain unsatisfactorily answered. When addressing the type of syndesmosis stabilization that is required it is essential to ascertain the extent of instability. Only then can a logical approach to restoring the ankle mortise be achieved. Fixation of fibula shaft fractures and posterior malleolus fractures can restore sufficient stability to render syndesmosis stabilization unnecessary. The indications and techniques for stabilizing the distal tibiofibular joint are reviewed with clinical examples.

Should syndesmotic screws be removed after surgical fixation of unstable ankle fractures? a systematic review

AIMS

In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery.

MATERIALS AND METHODS

A literature search was conducted in Medline, Embase and the Cochrane Library for articles in which the syndesmotic screw was retained. Articles describing both removal and retaining of syndesmotic screws were included. Excluded were biomechanical studies, studies not providing patient related outcome measures, case reports, studies on skeletally immature patients and reviews. No restrictions regarding year of publication and language were applied.

RESULTS

A total of 329 studies were identified, of which nine were of interest, and another two articles were added after screening the references. In all, two randomised controlled trials (RCT) and nine case-control series were found. The two RCTs found no difference in functional outcome between routine removal and retaining the syndesmotic screw. All but one of the case-control series found equal or better outcomes when the syndesmotic screw was retained. However, all included studies had substantial methodological flaws.

CONCLUSIONS

The currently available literature does not support routine elective removal of syndesmotic screws. However, the literature is of insufficient quality to be able to draw definitive conclusions. Secondary procedures incur a provider and institutional cost and expose the patient to the risk of complications. Therefore, in the absence of high quality evidence there appears to be little justification for routine removal of syndesmotic screws. Cite this article: Bone Joint J 2016;98-B:1497-1504.

Management of syndesmotic injuries: What is the evidence?

Ankle fractures are accompanied by a syndesmotic injury in about 10% of operatively treated ankle fractures. Usually, the total rupture of the syndesmotic ligaments with an external rotation force is associated with a Weber type B or C fracture or a Maisonneuve fracture. The clinical assessment should consist of a comprehensive history including mechanism of injury followed by a specific physical examination. Radiographs, and if in doubt magnetic resonance imaging, are needed to ascertain the syndesmotic injury. In the case of operative treatment the method of fixation, the height and number of screws and the need for hardware removal are still under discussion. Furthermore, intraoperative assessment of the accuracy of reduction of the fibula in the incisura using fluoroscopy is difficult. A possible solution might be the assessment with intraoperative three-dimensional imaging. The aim of this article is to provide a current concepts review of the clinical presentation, diagnosis and treatment of syndesmotic injuries.