Avoiding the Removal of Syndesmotic Screws after Distal Tibiofibular Diastasis Repair: A Benefit or a Drawback?

Abstract

There is still no general agreement about the most effective form of syndesmosis fixation with syndesmotic screws for patients affected by ankle fractures that are accompanied by syndesmotic injuries. In the same manner, no consensus has been reached yet on whether or not the tibiofibular syndesmotic screw is more beneficial if removed or not, as well as the exact timing of removal if this proves superiority. The purpose of this research was to verify whether or not removing syndesmotic screws reduces the risk of developing a diastasis and compare outcomes in patients whose syndesmotic screw was or was not removed at all. A retrospective observational study was carried out to cover a period of five years and a computed sample size of almost 300 cases. Patients were included in the current study if their history was positive for ankle fracture with distal tibiofibular diastasis repair with syndesmotic screws. Loss of reduction was more frequent after screw removal (8.5% vs. 2.1%), although the quality of reduction was generally excellent in both groups. The mean AOFAS score was significantly better in patients who had their tibiofibular screw removed (92.6 vs. 88.4), but the tibiofibular clear space and incisura fibularis depth widened more following the second intervention (3.8 mm vs. 3.6 mm, and, respectively, 4.3 vs. 4.1). Lastly, the same patients with tibiofibular screw removal had a significantly higher cost of total interventions and more days of medical leave (21 vs. 15 days on average). It seems that a strong conclusion in favor of removing or not removing syndesmotic screws after distal tibiofibular diastasis repair cannot be given. However, several radiographic findings lean toward the benefit of those patients whose tibiofibular screws were not removed, although mobility was notably better after the screw was removed. Furthermore, treatment expenses are greatly lowered if a subsequent operation for screw removal is avoided, as well as if individuals who have a single surgery take a shorter medical leave.

Intramedullary osteosynthesis for ankle fractures and distal tibiofibular syndesmotic disruption

“…Все методы активно применяются в травматологической практике и безопасны для использования, но, как и для любого хирургического вмешательства, данные методики имеют осложнения в виде раневых инфекций, поломки имплантата, повторных хирургических вмешательств, повреждения сосудистонервных пучков, хронической нестабильности голеностопного сустава, послеоперационного артроза и мальредукции, что оказывает непосредственное влияние на качество жизни пациентов, отдаленные результаты, степень подвижности голеностопного сустава [34][35][36][37]. В результатах данных исследований выявлены различия в частоте осложнений между вариантами хирургического лечения.…”

Syndesmotic fixation in Weber B ankle fractures: A systematic review

“…Weber B fractures occur at the level of the syndesmosis and where a long oblique fracture may also extend above the syndesmosis [ 2 ]. Ankle fractures most frequently occur in young men and elderly women while fracture-dislocations usually occur in severe trauma [ 3 ]. Weber Type B fractures often arise from external rotation with the foot supinated (SER) or pronated (PER), hence they also correspond with Lauge-Hansen SER IV ankle fractures [ 4 ].…”

“…Weber B fractures are the most common injury treated in orthopaedic surgery and are managed using open reduction and internal fixation (ORIF) if displaced [ 5 , 6 ]. Altered tibiofibular joint kinematics in Weber B fractures are responsible for syndesmotic damage seen in Weber B fractures [ 3 ]. The syndesmosis is injured in up to 40% of cases resulting in an unstable injury with a syndesmotic diastasis [ 4 ].…”

“…It is agreed upon that ankle stability relies on maintaining the integrity of the lateral column of the ankle [ 7 ]. Weber B fractures are associated with post-traumatic osteoarthritis and limb-threatening complications [ 3 ].…”

“…Syndesmotic fixation (SF) using screws has been most successful in the management of syndesmotic injuries but is prone to breaking or loosening, requiring routine hardware removal that increases the risk of infection and a loss of syndesmotic reduction [ 3 ]. Although implantable suture buttons allow micromotion and potentially eliminate the need for hardware removal while matching the mechanical strength of screws, they may also result in hardware irritation, infection, osteomyelitis, and osteolysis [ 3 ]. Furthermore, a study of 238 Weber B fractures post-lateral malleolar fixation identified 93 cases of syndesmotic instability [ 8 ].…”