SLR - June 2019 - Vincent J. Inglima

The Management of Syndesmotic Screw in Ankle Fractures

Reference: Pogliacomi F, Artoni C, Riccoboni S, Calderazzi F, Vaienti E, Ceccarelli F. The Management of Syndesmotic Screw in Ankle Fractures. ABM [Internet]. 20Dec.2018 [cited 2May2019];90(1-S):146-9. Available from: http://www.mattioli1885journals.com/index.php/actabiomedica/article/view/8015

Scientific Literature Review

Reviewed By: Vincent J. Inglima, DPM
Residency Program: John Peter Smith Hospital, Fort Worth, TX

Podiatric Relevance: Treatment of ankle fractures is becoming an increasingly important procedure performed by foot and ankle surgeons. As multiple studies are now trying to question the ability of podiatrists to manage these injuries that clearly fall within our scope, it is essential that the foot and ankle surgeon is aware and up to date on the most correct treatment modalities and postoperative management. Syndesmotic fixation methods and postoperative courses have been changing. In a low-cost healthcare mindset, it is important to understand how to best treat our patients clinically while eliminating the financial burdens on the system. This is a great review of postoperative management of syndesmotic fixation and the need vs. need not to remove syndesmotic screws.

Methods:
Ninety patients underwent ORIF of Weber B or C closed ankle fractures with associated fixation of the syndesmosis with either a single or two parallel tricortical 3.5 mm syndesmotic screws. Patients were divided into two groups by clinician preference; Group 1 being planned syndesmotic removal and group 2 being syndesmotic fixation left intact. Immediate postoperative films analyzed tib-fib clear space, defined as “the horizontal distance between the lateral margin of the posterior tibial malleolus and the medial border of the fibula.” At 12-month follow-up, a functional evaluation was performed using OMAS and AOFAS scores as well as repeat radiographs to evaluate the tib-fib clear space.

Results:
Of the 90 patients, 65 had their syndesmotic screws removed at a mean of seven weeks (group 1), and 25 were left in place (Group 2). Outcomes for the two groups were not statistically significant in other clinical exams through OMAS or AOFAS nor radiographic analysis at 12-month follow-up.

Conclusion: This study suggests that it is not necessary to remove syndesmotic fixation in the immediate postoperative period. There is a high rate of breakage if the screws are left intact, but this study, as well as multiple others, shows little clinical significance to a broken syndesmotic screw. Furthermore, this study shows that premature removal is not indicated and that patients may do well with the hardware intact for an extended period, up to 12 months, so as to allow for full healing of the syndesmosis, without concern for clinically worse outcomes.

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