Removal of Syndesmotic Screw After Fixation in Ankle Fractures: A Systematic Review

Abstract

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.

Functional outcome of routine versus on-demand removal of the syndesmotic screw

“…Furthermore, these results are comparable with outcomes from recent review studies indicating that there is no evidence to support the routine removal of syndesmotic screws. 24,25 In addition, there was no difference in AOFAS, FAOS, and EQ-5D between ODR and RR which is also in line with our initial study.…”

“…Furthermore, these results are comparable with outcomes from recent review studies indicating that there is no evidence to support the routine removal of syndesmotic screws. 24 , 25 …”

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

“…22 A systematic review published in 2021 found no evidence to support routine screw removal and that screw removal should only occur with clear indications, which were not clearly specified. 5,14 Yet, other studies seem to suggest that patients who undergo syndesmotic removal fare better than patients who have not elected to undergo hardware removal. 15 An important consideration to take into account is the associated risk of hardware removal as this is another invasive procedure for the patient.…”

“…The decision to remove rigid syndesmotic screws remains controversial. Although studies suggest there is no evidence to support routine removal of syndesmotic screws, 5 , 14 , 21 some surgeons routinely remove all hardware in all patients. In surgeons who opt for removal of syndesmotic hardware, indications can include pain, stiffness, or patient desire to avoid loose or broken hardware.…”

Syndesmotic screw removed verusus retained: A comparative functional analysis

“…Overall, there is no absolute guidelines or indications available regarding removal of syndesmotic screw [7,9] . Removal of syndesmotic screw before weight bearing has got no clinical significance.…”