SLR - December 2009 - Jennifer K. Fong
Reference:
Hamid, N., Loeffler, B.J., Braddy, W. et al. (2009). Outcome after fixation of ankle fractures with an injury to the syndesmosis: the effect of the syndesmosis screw. The Journal of Bone and Joint Surgery (British), 91-B, 1069-1073.
Scientific Literature Reviews
Reviewed by: Jennifer K. Fong, DPM
Residency Program: Botsford Hospital
Podiatric Relevance:
This study provides useful data for comparison of clinical and radiological outcomes after open reduction internal fixation (ORIF) of ankle fractures and with syndesmotic injury.
Methods:
A retrospective study was conducted between 2001 and 2005 on fifty-two patients with a Weber B or C type ankle fracture and associated syndesmosis injury. All patients underwent ORIF for repair of the ankle fracture and the syndesmosis disruption. Patients with age <18 years, placement of syndesmosis screws other than for syndesmosis disruption, chronic syndesmosis injury (>1 month old), post-operative infection, post-operative hardware failure before bone healing, post-operative complications necessitating additional surgery, and placement of bioabsorbable syndesmosis screws were all excluded from the study. All patients were non-weightbearing for a minimum of eight weeks and were allowed to weight-bear if there was radiologic evidence of fracture healing. The syndesmosis screws were removed at twelve weeks post-operatively at the surgeon's discretion, resulting in three distinct patient groups: those with intact screws (I), those with broken screws (B) and those with screws removed (R). The American Orthopedic Foot and Ankle Society (AOFAS) ankle/hindfoot score and pain visual analog scale (VAS) were used to assess post-surgical outcome. Tenderness or lack thereof at the syndesmosis screw was also recorded in addition to radiologic evaluation.
Results:
Of the fifty-two patients, 27 had intact screws, 10 had broken screws and 15 had their screws removed. Patients were seen for at least 12 months after surgery with a mean follow-up of 30 months. The mean AOFAS ankle/hindfoot score was 83.07 for Group I, 92.40 for Group B, and 85.80 for Group R. The mean AOFAS subscores for pain were 29.25 (Group I), 36.0 (Group B) and 30.0 (Group R). The mean AOFAS subscores for function were 45.67 (Group I), 46.4 (Group B) and 45.8 (Group R). The mean VAS of ankle pain was 2.31 (Group I), 0.96 (Group B) and 0.74 (Group R). Two of the 37 patients with retained screws (ie. Group I plus Group B) had local tenderness at the screw. Of the 37 patients with retained screws, 25 had radiographs with radiolucency around the screw. The mean tibiofibular clear space of all 52 patients was 4.1 mm with no patient exceeding 6 mm of clear space. No correlation between screw radiolucency and VAS or AOFAS scores was noted. No statistical difference was observed between the clinical outcomes of patients who had the intact screw and those who had the screw removed.
Conclusions:
Based on the study results, patients with the broken syndesmosis screw fared better than the other patients in terms of clinical outcome. Additionally widening of the clear space, which would be indicative of loss of correction, was not observed in patients with broken screws or removed screws. Therefore, it may not be necessary to preemptively remove intact screws or broken screws in patients who have undergone placement of syndesmotic screws for repair of syndesmotic disruptions.