Immediate Improvement in Physical Function After Symptomatic Syndesmotic Screw Removal

Abstract

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.

Patient-Reported Outcome Measurement Information System (PROMIS) in Orthopaedic Trauma Research

“…PROMIS can reliably identify clinical, social, and psychological risk factors for poor outcomes. [25][26][27][28][29][32][33][34][35]. Its weaknesses are lack of specificity for certain body parts, its lack of validation for mental health outcomes, and its ceiling effect in certain active patient populations [23,32,35].…”

“…PROMIS has also provided valuable insight into outcomes after specific injury patterns [25][26][27][28][29]. Kohring For patients who sustain supination-adduction type ankle fractures, older age was significantly associated with worse PROMIS Physical Function scores; additionally, the direct medial approach to the ankle, compared to the anteromedial and posteromedial approaches, was associated with better PROMIS Pain Interference scores [27].…”

“… Ochen et al [ 29 ] 2020 Retrospective cohort study, III 214 Physical function (SF) Tibial plateau fracture EQ-5D-3L Female gender and diabetes were associated with worse PROMIS Physical Function scores. Kohring et al [ 25 ] 2020 Prospective cohort study, III 129 Physical function (CAT), pain interference (CAT), depression (CAT) Ankle fracture Patients who have symptomatic ankle syndesmosis screws removed experienced pain improvement that exceeds the minimal clinically important difference in PROMIS scoring. Van der Vliet et al [ 28 ] 2019 Retrospective cohort study, III 225 Physical function (SF) Tibial plafond fracture FAAM, EQ-5D-3L For patients with tibial plafond fractures, higher BMI and worse overall health were associated with worse PROMIS Physical Function scores.…”

“…PROMIS has also provided valuable insight into outcomes after specific injury patterns [ 25 – 29 ]. Kohring et al used PROMIS Pain Interference to show that patients who have symptomatic ankle syndesmosis screws removed experienced pain improvement that exceeds the minimal clinically important difference in PROMIS scoring [ 25 ].…”

“…PROMIS has also provided valuable insight into outcomes after specific injury patterns [ 25 – 29 ]. Kohring et al used PROMIS Pain Interference to show that patients who have symptomatic ankle syndesmosis screws removed experienced pain improvement that exceeds the minimal clinically important difference in PROMIS scoring [ 25 ]. Gilley et al used PROMIS Pain Interference and Physical Function to argue that operative fixation of ankle fractures reliably helps patients regain a level of function similar to the United States population mean [ 26 ] .…”