Syndesmotic Screw Removal Research Articles

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.

Impact of Syndesmotic Screw Removal on Quality of Life, Mobility, and Daily Living Activities in Patients Post Distal Tibiofibular Diastasis Repair.

Background and Objectives: While numerous studies have been conducted on syndesmotic screw management following distal tibiofibular diastasis repair, a clear consensus remains unclear. This research aims to evaluate whether the postoperative removal of syndesmotic screws leads to improved patient outcomes, specifically in quality of life, mobility, and daily living activities, and whether it offers a cost-effective solution. Materials and Methods: Patients with a history of unimalleolar or bimalleolar ankle fractures, classified according to the Danis-Weber and Lauge-Hansen systems, were included. Comprehensive evaluations were made via standardized questionnaires like the SF-36 Health Survey, HADS, and WHOQOL-BREF, distributed approximately 2 months post surgery. A total of 93 patients underwent syndesmotic screw removal while 51 retained the screws (conservative approach). Results: Patients who underwent screw removal reported superior satisfaction in mobility, with a score of 7.8, compared to 6.7 in the conservative approach (p = 0.018). Similarly, their ability to perform daily activities scored 8.1, higher than the 6.5 from the conservative cohort (p < 0.001). Pain levels were also more favorable in the screw removal group, with a score of 5.3 against 6.8 in the conservative group (p = 0.003). On the SF-36 physical domain, the screw removal group achieved a mean score of 55.9 versus 53.3 for the conservative group (p = 0.027). Notably, the HADS anxiety subscale highlighted reduced anxiety levels in the screw removal cohort with a mean score of 5.8 against 7.3 in the conservative group (p = 0.006). However, overall quality of life and recommendations to others showed no significant difference between the groups. Conclusions: Syndesmotic screw removal postoperatively leads to marked improvements in patients' mobility, daily activity abilities, and reduced postoperative pain and anxiety levels. However, overall quality of life was similar between the two approaches. The findings offer valuable insights for orthopedic decision making and patient-centered care concerning the management of syndesmotic screws after distal tibiofibular diastasis repair.

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

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

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

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. 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). 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. 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. 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.

A retrospective study of deltoid ligament repair versus syndesmotic fixation in lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption.

To compare clinical outcomes of deltoid ligament repair versus syndesmotic fixation in lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption. Patients diagnosed with lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption who received open reduction and internal fixation (ORIF) were retrospectively reviewed. Seventy-eight patients were enrolled into the study, including 40 patients treated with lateral malleolus fracture ORIF and trans-syndesmotic fixation, and 38 patients treated with lateral malleolus fracture ORIF and deltoid ligament repair. Basic information and pre- and postoperative radiological materials were reviewed. Visual analog pain scale (VAS) score, Olerud-Molander score, and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale were used for evaluating pain control and functional recovery postoperatively at different time points. No complication was reported in both groups. In the trans-syndesmotic fixation group, all patients received syndesmotic screw removal 6-8 weeks postoperatively. The Olerud-Molander score and AOFAS Ankle-Hindfoot Scale in the deltoid ligament repair group were higher than the trans-syndesmotic fixation group 3 months after operation. No statistical difference was found between the two groups in VAS score from 1 to 12 months postoperatively. Lateral malleolus fracture ORIF and deltoid ligament repair is an effective method for lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption. Compared with trans-syndesmotic fixation, deltoid ligament repair holds the advantage of not needing surgical removal of inferior tibiofibular screws postoperatively.

Functional and Radiological Outcome after Syndesmotic Screw Fixation and Removal

Functional and Radiological Outcome after Syndesmotic Screw Fixation and Removal

Outcomes of the Routine Removal of the Syndesmotic Screw.

BackgroundAnkle 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.MethodologyThis was a retrospective study analyzing the records of 52 patients who had been treated with the syndesmotic screw over a two-year span.ResultsOf 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.ConclusionsRoutine 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.

Syndesmosis Changes before and after Syndesmotic Screw Removal: A Retrospective Radiographic Study.

Background and Objectives: In patients with ankle fractures complicated by syndesmotic injuries, no consensus has been reached on the best method of syndesmosis fixation using syndesmotic screws. One previous study revealed no difference in the tibiofibular overlap between two groups with or without syndesmotic screw removal. Other studies have indicated that distal tibiofibular diastasis exists after the removal of syndesmotic screws. In this study, we aimed to confirm the effect of syndesmotic screw removal on diastasis occurrence. We further analyzed the risk factors that may contribute to the widening of the tibiofibular syndesmosis. Materials and Methods: This retrospective study involved a review of the records of 63 patients with ankle fractures accompanied by syndesmosis injuries that required syndesmotic screw fixation. Anteroposterior radiographs were analyzed for each patient at various time points, from syndesmotic screw fixation to outpatient department follow-ups after screw removal. The changes in tibia–fibula overlap (OL), tibia–fibula clear space (CS), and medial clear space (MCS) were analyzed. Further analysis was performed to reveal potential factors that may have contributed to radiographic differences. Results: Compared with the postoperation radiographs following syndesmotic screw fixation, OL decreased (2.0 mm) and CS increased (0.8 mm) in the anteroposterior radiographs from outpatient department follow-ups. No significant changes were noted in OL or CS after syndesmotic screw removal. However, OL decreased (1.8 mm) and CS increased (0.5 mm) before syndesmotic screw removal. No significant change in MCS occurred during the whole observation period. Linear regression analysis did not reveal any significant correlations between potentially related factors and radiographic changes. Conclusions: Marked diastasis had occurred at final follow-up. Notably, the diastasis occurred before rather than after screw removal. This implies that screw removal does not significantly influence the radiographic outcomes of rotational ankle fractures.

True antiglide fixation of Danis-Weber B fibula fractures has lower rates of removal of hardware

IntroductionPlating of unstable OTA/AO 44-B2 equivalent lateral malleolus (Danis-Weber B) fractures has been associated with pain, peroneal irritation, and the need for subsequent hardware removal (ROH). The purpose of this study is to retrospectively compare the rates of ROH in unstable Weber B fractures fixed with a posterior, true antiglide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment. Thus, evaluating the role of the distal screws in rates of ROH. MethodsSkeletally mature patients that were treated for an unstable, isolated Weber B fracture at a single level-1 trauma center over a ten-year period were reviewed. Fractures treated with a single posterior plate with at least six months of follow-up were included and those fixed with a direct lateral plate were excluded. The primary outcome of this study was hardware removal defined as entire plate removal; isolated syndesmotic screw removal was not included. ResultsNinety-six patients were included in the study with average age of 46 years (range 17-83) and mean length of follow-up of 24.5 months (range 6.1-140.3). There were 33 patients in the antiglide group (mean follow-up 25.5 months) and 63 in the neutralization plate group (mean follow-up 24 months, p=0.81). Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. However, there was a statistically significant decrease in ROH rates in the antiglide group (antiglide ROH rate 15.2%; neutralization ROH rate 38.1%; p=0.02). Relative risk of ROH with antiglide plate was 0.4 (95% CI 0.17 – 0.95; p=0.04). ConclusionsAntiglide plating shows a significant risk reduction in the rate of ROH when compared to posterior based neutralization plating. A true antiglide plating construct should be considered as a safe and effective way of managing Weber B fractures with a lower relative risk of a second operation for hardware removal. Level of evidenceTherapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Syndesmotic screw removed verusus retained: A comparative functional analysis

Aim: Aim of the study is to analyse and compare the functional outcome among patients who had retained their syndesmotic screw with the group who had undergone syndesmotic screw removal. Materials and Methods: Study was conducted on 48 patients whose outcome has been evaluated ragiologically and functionally by AOFAS and OMAS score over a period of 12 months postoperatively.Results: On comparing functional as well as radiological outcome between the two groups of our study we found that the results are similar on both groups. Conclusion: The functional and radiological outcome was similar. The chances of complications due to screw breakage and infection was very minimal.

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.

Assessment of the lower limb biomechanics in patients after tibiofibular syndesmosis injury treatment

Purpose: There is no consensus as to the number of bone cortices engaged in tibiofibular syndesmosis treatment. The purpose of our study was to assess the weight distribution on the lower limbs after tricortical or quadricortical syndesmosis fixation and different timing of screw removal. Methods: A total of 55 patients who underwent treatment for acute tibiofibular syndesmosis injury were analyzed in this study. The Zebris pedobarographic platform was used to measure the distribution of body weight on the lower limbs. The study population was stratified by the time to syndesmotic screw removal (8–15 weeks versus 16–22 weeks) and the number of bone cortices involved in fixation (three [tricortical fixation] versus four [quadricortical fixation]). Results: The weight distribution on the operated and healthy limbs in patients with tricortical syndesmosis fixation was asymmetrical, with the mean load on the operated and healthy limbs of 48.38% and 51.62%, respectively. The patients who underwent quadricortical syndesmosis fixation exhibited a symmetrical distribution of weight on the operated and healthy limb. There was a symmetrical distribution of the load of body weight on the operated and healthy limbs both in the group with different times to syndesmotic screw removal. Conclusion: Tricortical syndesmosis fixation is associated with an asymmetrical weight distribution on the operated and healthy limbs. In treating tibiofibular syndesmosis injuries, based on our pedobarographic research, quadricortical syndesmosis fixation and leaving the syndesmotic screw in place for up to 15 weeks, seems more beneficial to the patient.

Untreated small posterior fragment of ankle fracture with early removal of syndesmotic screw is associated with recurrent syndesmotic instability

IntroductionThis retrospective study aimed to report outcomes of fixation of bi-malleolar or tri-malleolar fractures combined with syndesmotic injury with or without posterior malleolar fracture (PMF), and to ascertain whether syndesmotic screw removal at 6 to 8 weeks or 3 months postoperatively is more beneficial. MethodsWe retrospectively reviewed patients who received open reduction and internal fixation for bi-malleolar (without PMF) or tri-malleolar ankle fracture (with PMF) with syndesmotic injury between January 2013 and December 2017 with at least 24 months of postoperative follow-up. All patients suffered syndesmotic instabilities and were treated using a syndesmotic screw without PMF fixation. Patients with bi-malleolar fracture with syndesmotic screw removal at 6 to 8 weeks postoperatively were included in Group I, tri-malleolar fracture with syndesmotic screw removal at 6 to 8 weeks in Group II, and tri-malleolar fracture with syndesmotic screw removal at 3 months in Group III. Demographic data, clinical and radiographic outcomes were analyzed. ResultsA total of 113 patients were included (Group I, n=47; Group II, n=43; Group III, n=23). Average size of PMF was 14% in patients with tri-malleolar fractures (Groups II and III). No significant difference in ankle functional outcome among groups was observed. The recurrence rate of syndesmotic instability was 10.6% in Group I, 20.9% in Group II, and 8.7% in Group III. Although the difference in recurrence rates of syndesmotic instability among three groups was not statistically significant (P=0.264), Group II showed more interval change in tibiofibular clear space between initial postoperative radiographs and last follow-up radiographs (P=0.028) compared to the other two groups. Fracture union was achieved in all patients without screw breakage. ConclusionWe suggest that the better timing for syndesmotic screw removal is 3 months, instead of 6 to 8 weeks postoperatively, to reduce the risk of recurrence of syndesmotic instability for tri-malleolar fracture without posterior fragment fixation. Level of EvidenceLevel III- Case-control study.

Elective removal vs. retaining of hardware after osteosynthesis in asymptomatic patients\u2014a scoping review

BackgroundOsteosynthesis is the internal fixation of fractures or osteotomy by mechanical devices (also called hardware). After bone healing, there are two options: one is to remove the hardware, the other is to leave it in place. The removal of the hardware in patients without medical indication (elective) is controversially discussed. We performed a scoping review to identify evidence on the elective removal of hardware in asymptomatic patients compared to retaining of the hardware to check feasibility of performing a health technology assessment. In addition, we wanted to find out which type of evidence is available.MethodsA systematic literature search was performed in PubMed, Embase, EconLit, and CINAHL (November 2019). We included studies comparing asymptomatic patients with an internal fixation in the lower or upper extremities whose internal fixation was electively (without medical indication) removed or retained. We did not restrict inclusion to any effectiveness/safety outcome and considered any comparative study design as eligible. Study selection and data extraction was performed by two reviewers.ResultsWe identified 13476 titles/abstracts. Of these, we obtained 115 full-text publications which were assessed in detail against the inclusion criteria. We included 13 studies (1 RCT, 4 cohort studies, 8 before-after studies) and identified two ongoing RCTs. Nine assessed the removal of the internal fixation in the lower extremities (six of these syndesmotic screws in ankle fractures only) and two in the upper extremities. One study analysed the effectiveness of hardware removal in children in all types of extremity fractures. Outcomes reported included various scales measuring functionality, pain and clinical assessments (e.g. range of motion) and health-related quality of life.ConclusionsWe identified 13 studies that evaluated the effectiveness/safety of hardware removal in the extremities. The follow up times were short, the patient groups small and the ways of measurement differed. In general, clinical heterogeneity was high. Evidence on selected topics, e.g. syndesmotic screw removal is available nevertheless not sufficient to allow a meaningful assessment of effectiveness.

A Multicenter Retrospective Study Examining Complication Rates Following Syndesmotic Screw Removal

Category:Ankle; TraumaIntroduction/Purpose:20% of ankle fractures in the US involve a concomitant injury to the syndesmosis. What syndesmotic fixation is most appropriate is a subject of some debate. When syndesmotic screws are used, many of the variables surrounding treatment are unclear. One recent study quoted an alarmingly high rate of complications after syndesmotic screw removal (reference). The authors of the current study have routinely removed syndesmotic screws with little in the way of complications. This multicenter study was conducted in order to compare complication rates following syndesmotic screw removal in two institutions that regularly remove syndesmotic screws.Methods:Patient selection was based on the ankle fracture databases of the orthopedic department in two major academic institutions. At both institutions, databases includes all patients treated surgically for any type of ankle fracture between 01/2010 and 12/2016 in patients older than 18 years. Patients meeting the following inclusion criteria were selected: patients suffering any type of an acute, closed ankle fracture, syndesmotic disruption treated using a syndesmotic screw, removal of the syndesmotic screw in the same institution, and patient chart available for review. Exclusion criteria: pilon fractures, and tibial shaft fractures, as well as any postoperative infection following the original osteosynthesis. Data from the chart included age, sex, height, weight, BMI, days until screw removal, smoking status, alcohol use, diabetes status, and any wound complications or complication related to the screw removal. A logistic regression analysis was conducted to assess for predictors of wound complications after syndesmotic screw removal.Results:In our cohort of 152 patients, 1.3% of patients had wound complications. When looking at the cohorts separately, there was a reported wound complication in 3.2% (1 out of 31) of patients in institution 1, whereas there was a 0.83% (1 out of 121) wound complication rate in the cohort at institution 2 (p=0.296). There were no significant predictors of wound complications when looking at age (p=0.992), height (p=0.511), weight (p=0.735), BMI (p=0.755), days until screw removal (p=0.80), sex (p=0.404), smoking status (p=0.999), alcohol use (p=0.102), or diabetes status (p=0.269). Chi-square analysis revealed that there was not a significant association between wound complication and smoking (p=0.177), alcohol use (p=0.461) and diabetes status (p=0.602) in each cohort.Conclusion:A recent study reported a high rate of complications as a result of syndesmotic screw removal. Our multicenter study found minimal complications after syndesmotic screw removal. Further, out of two patients that did have reported complications, neither required secondary intervention as a form of treatment. These complications were considered minor and were treated with oral antibiotics.

Recurrence of Syndesmotic Diastasis Following Syndesmotic Screw Removal: Does the Time Point of Screw Removal Matter?

Category:AnkleIntroduction/Purpose:Ankle fractures involving disruption to the syndesmotic complex are regularly treated with reduction and syndesmotic screw fixation. When syndesmotic screw fixation is used, it is a common to remove the screw after enough time has passed to allow for sufficient healing of the ligamentous tibiofibular syndesmosis complex. Delayed removal increases the risk of screw loosening or breakage, and more importantly prolongs the time to full weight bearing. Currently, there is little evidence supporting a definitive time point for screw removal. This multicenter study compared two different post-operative protocols following syndesmotic screw insertion. The goal was to determine an optimal time point for screw removal by assessing syndesmotic diastasis between these two institutions, each of which removed the screw at different time points.Methods:Patients from two institutions treated surgically for any type of ankle fracture between 01/2010 and 12/2016 that met the following inclusion criteria were selected: patients suffering any type of an acute, closed ankle fracture, syndesmotic disruption treated using a syndesmotic screw, removal of the syndesmotic screw in the same institution, at least one x-ray (mortise view) prior to screw removal and one following screw removal available for review. Exclusion criteria were open / pilon / tibial shaft fractures. The syndesmotic screw was removed approximately 12 weeks after insertion in the first institution, and 6 weeks after insertion in the second. Four radiographic measurements were performed and averaged by three researchers: medical clear space (oblique), tibio-fibular clear space, and tibio-fibular overlap. An independent samples t-test was conducted to analyze differences in radiographic parameters between the two cohorts. Measurements after syndesmotic screw insertion and at final follow-up after removal were compared.Results:The average time to removal of syndesmotic screw was 79.71 days in institution one (n=31) and 50.92 days in institution two (n=121) (p<0.001). For institution 1 the paired samples t-test revealed no significant differences when comparing measurements prior to syndesmotic screw removal with after screw removal for the tibio-fibular overlap (p=0.088) and tibio- fibular clear space (p=0.312) measurements. A significant difference was observed only regarding the medial clear space (p=0.008). For institution 2, significant differences were observed for all of these measurements (p<0.001). When comparing the measurements after syndesmotic screw removal between the two institutions, the independent samples t-test revealed significant differences in regard to the tibio-fibular overlap (p=0.001) and tibio-fibular clear space (p=0.004) measurements, but not in the medial clear space measurement (p=0.959).Conclusion:Removal of the syndesmotic screw after seven weeks led to a significant loss of reduction of the syndesmosis. In contrast, screw removal after 11 weeks did not lead to a significant loss of reduction. Our results suggest that it is not advisable to remove syndesmotic screws after 7 weeks. It is common to have the patient partial or non-weight bearing until screw removal to avoid screw breakage. To recommend non-weight bearing for 11 weeks will delay return to work and daily activity, and can lead to significant atrophy, however, it does allow for better maintenance of reduction.

True Antiglide Fixation of Weber B Ankle Fractures has Lower Rates of Removal of Hardware

Category:Trauma; AnkleIntroduction/Purpose:Plating of unstable OTA/AO 44-B1 lateral malleolus fractures has been associated with pain, peroneal irritation, and subsequent hardware removal. There has been speculation that this is due to the prominent plate and distal screw placement. Previous studies have looked at posterior vs lateral plate position but have had fairly low numbers in each group. The purpose of this study was to retrospectively compare the rates of hardware removal in unstable OTA/AO-type 44-B1 lateral malleolus fractures fixed with a posterior, true anti-glide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment thus evaluating the role of the distal screw in rates of hardware removal.Methods:Skeletally mature patients that were treated for an isolated OTA/AO 44-B1 fracture over a ten-year period (2007- 2017) were reviewed. Fractures treated with a single posterior plate were included and those fixed with a direct lateral plate were excluded. We evaluated post-op radiographs to determine application of a true anti-glide plate or a neutralization plate with screws in the distal fragment. Radiographic follow-up was used to determine bony union, malunion and need for hardware removal. Hardware removal was determined as entire plate removal; isolated syndesmotic screw removal was not included. Patients were excluded if they had less than six months of follow up. Relative risk was determined for the rate of hardware removal based on fixation technique.Results:There were 548 OTA/AO 44-B1 fractures treated over the course of ten years (2007-2017). After screening, 88 patients were included in the study. The majority of excluded patients lacked adequate follow-up. Average age of the cohort was 46 years old (range 17-84), with 47 females and 41 males included. Average length of follow up was forty months (range 6.1- 140.3). There were 28 patients in the true anti-glide plate group and sixty in the neutralization plate group. Five (18%) in the anti- glide plate group and 19 (32%) in the neutralization plate underwent a second procedure of hardware removal. Relative risk of hardware removal was 0.56 (95% CI 0.23-1.36, p=0.2). There was a 100% union rate with 0% malunion in both groups.Conclusion:Anti-glide plating has a near 50% relative risk reduction in the rate of hardware removal when compared to posterior based neutralization plating. Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. A true anti-glide plating construct should be considered as a safe and effective way of managing OTA/AO 44-B1 lateral malleolus fractures with a lower relative risk of a second operation for hardware removal.

Immediate Improvement in Physical Function After Symptomatic Syndesmotic Screw Removal.

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. Prospective cohort study. Level 1-trauma center. 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. Symptomatic SSR for patients with functional limitations and decreased ankle ROM. PROMIS physical function (PF) and pain interference T-scores and ankle ROM before and after screw removal. 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). Patients experienced an immediate and significant improvement in PF outcomes and ankle ROM after symptomatic SSR for ankle fracture ORIF with syndesmotic fixation. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is it necessary to remove syndesmotic screw before weight-bearing ambulation?

In syndesmosis injury, whether the syndesmosis screw should be removed prior to weight-bearing remains controversial. The aim of this study was to compare the functional outcome between removed screw and retained groups and between recurrence of diastasis and no diastasis groups.Fifty-six patients who had undergone open reduction and internal fixation due to syndesmosis injury were retrospectively evaluated and divided into four groups: (A) removed syndesmotic screw before weight-bearing (postoperative 3 months, n = 28), (B)retained (n = 28), (C) recurrence of diastasis (n = 9), and (D) no diastasis (n = 47). Radiological diastasis, American Orthopedic Foot Ankle Society Score (AOFAS), Short Form Health Survey-12 (SF-12), and complications (screw loosening and breakage) were evaluated between groups.AOFAS ankle-hindfoot score was 75.10 ± 10.40 in group A, 77.07 ± 10.60 in group B. SF-12 was 45.78 ± 5.68 in group A and 47.33 ± 5.83 in group B, showing no significant difference in AOFAS ankle-hindfoot score or SF-12 (P = .487, P = .319, respectively) between groups A and B. Radiological diastasis developed significantly (P = .025) more in group A (8/28) compared to that in group B (1/28). However, screw loosening or breakage developed significantly (P = .001) more in group B (4/28) compared to that in group A (0/28). AOFAS ankle-hindfoot score was 70.33 ± 6.22 in group C and 76.50 ± 10.26 in group D. SF-12 was 49.85 ± 3.83 in group C and 47.40 ± 8.01 in group D, showing no significant difference between groups C and D in AOFAS ankle-hindfoot score or SF-12 (P = .808, P = .948, respectively).Removal of syndesmotic screw before weight-bearing does not influence clinical outcomes. Although unrelated to clinical progress, recurrence of diastasis significantly increased in screw removed group. Therefore, removal of syndesmotic screw is unnecessary before weight-bearing.

Immediate Improvement in Physical Function after Symptomatic Syndesmotic Screw Removal

Category:Ankle, TraumaIntroduction/Purpose:The purpose of this study was 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 symptomatic syndesmotic screws and functional limitation.Methods:A total of 346 ankle fractures were treated from February 2015 to May of 2018. 58 patients with ankle fractures with syndesmotic instability and fixation who underwent syndesmotic screw removal (SSR) were included in the analysis. Cohort data was collected for 71 patients who underwent ORIF with syndesmotic fixation, but without screw removal during the same study period.Results:Patients who underwent SSR had a statistically significant improvement in the physical function (PF) T-score to 44.5 (p<0.01) in the early post-operative period (average 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 no significant difference in PF T-scores between the SSR group and cohort comparison group (44.5 vs 41.6; p=0.06) after screw removal. Removal of symptomatic implants resulted in an early improvement of total arc ankle ROM by 20° (p<0.01).Conclusion:There was an early clinically meaningful and statistically significant improvement in physical function outcomes and ankle ROM after symptomatic syndesmotic screw removal for patients who underwent ankle fracture ORIF with syndesmotic fixation. The final outcomes after screw removal in these patients was similar to the outcomes of asymptomatic patients who did not require syndesmotic screw removal within the same post-operative timeframe.