Effect of Syndesmotic Implant Removal on Dorsiflexion

Abstract

Background: There is limited evidence that syndesmotic implant removal (SIR) is beneficial. However, many surgeons advocate removal based on studies suggesting improved motion. Methodologic difficulties make the validity and applicability of previous works questionable. The purpose of this study was to examine the effect of ankle dorsiflexion after SIR using radiographically measured motion before and after screw removal utilizing a standardized load. Methods: All patients undergoing isolated SIR were candidates for inclusion. Dorsiflexion was measured radiographically: (1) immediately before implant removal intraoperatively, (2) immediately after removal intraoperatively, and (3) 3 months after removal. A standardized torque force was applied to the ankle and a perfect lateral radiograph of the ankle was obtained. Four reviewers independently measured dorsiflexion on randomized, deidentified images. A total of 29 patients met inclusion criteria. All syndesmotic injuries were associated with rotational ankle fractures. There were 11 men (38%) and 18 women (62%). The mean, and standard deviation, age was 50.3 ± 16.9 years (range 19-80). Results: The mean ankle dorsiflexion pre-operatively, post-operatively, and at a 3-month follow-up was 13.7 ± 6.6 degrees, 13.3 ± 7.3 degrees and 11.8 ± 11.3 degrees, respectively ( P = .466). For subsequent analysis, 5 patients were excluded because of the potential confounding effect of retained suture button devices. Analysis of the remaining 24 patients (and final analysis of 21 patients who had complete 3-month follow-up) demonstrated similar results with no statistically significant difference in ankle dorsiflexion at all 3 time points. Conclusion: Removal of syndesmotic screws may not improve ankle dorsiflexion motion and should not be used as the sole indication for screw removal. Level of Evidence: Level II, prospective cohort study.

Elective removal vs. retaining of hardware after osteosynthesis in asymptomatic patients – A scoping review.

“…Clinical outcomes, like range of motion, were reported in six studies. (23,24,30,(33)(34)(35) For the cohort studies and one before-after study, there was no difference in the outcomes, (23,24,35) while the other three before-after studies showed advanced range of motion. (30,33,34) Garner et al measured two components of the Short Form 36 scale for quality of life, with better outcomes for physical components in the removal group.…”

“…The literature search identi ed 13 eligible studies.) (22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) The studies were conducted in Germany, (26)(27)(28) the USA, (29,30,32,33) Switzerland, (22,34) Singapore, (23) New Zealand,(24) the UK, (31) and Japan. (35) Moreover we identi ed a protocol on an ongoing RCT regarding syndesmotic screw removal conducted in the Netherlands (36) and an entry on clinicaltrials.gov about an RCT regarding removal/retaining material in Lisfranc fractures conducted in Canada.…”

“…(26,29,31) Furthermore we identi ed eight before-after studies, comparing the same patients before implant removal and after implant removal. (22,27,28,30,(32)(33)(34)(35)…”

“…(23,32) Pain was measured similar in the retention and the removal groups of the cohort studies as in the before removal/after removal study from Chu et al. (32) Except for Briceno et al (33) all studies measured general functioning, some in various ways, Functioning was assessed with a (speci c) score, for example the OMAS for studies analysing syndesmotic screws, except in both studies from Gosling et al. (27,28) The cohort studies reported similar results in both groups for each score.…”

“…FIve studies assessed exion as a clinical outcome. (23,24,30,33) There were small positive effects in the removal group for various outcomes. However the effects differ and are not statistical signi cant.…”