title: Functional outcomes following syndesmotic fixation: A comparison of screws retained in situ versus routine removal - Is it really necessary?
abstract: BACKGROUND
  Syndesmotic disruption can occur in up to 20% of ankle fractures and is more common in Weber Type C injuries. Syndesmotic repair aims to restore ankle stability. Routine removal of syndesmosis screws is advocated to avoid implant breakage and adverse functional outcome such as pain and stiffness, but conflicting evidence exists to support this. The aim of the current study is to determine whether functional outcome differs in patients who had syndesmosis screws routinely removed, compared to those who did not, and whether a cost benefit exists if removal of screws is not routinely necessary.
  
  
  METHODS
  A retrospective review of consecutive syndesmosis repairs was performed from 1 January 2008 to 31 December 2010 in a single regional trauma centre. We identified 91 patients who had undergone open reduction internal fixation of an ankle fracture with placement of a syndesmosis screw at index procedure. As many as 69 patients were eligible for the study as defined by the inclusion criteria and they completed a validated functional outcome questionnaire. The functional outcomes of patients with 'retained screws' and 'removed screws' were analysed and compared using the Olerud Molander Ankle Score (OMAS).
  
  
  RESULTS
  A total of 63 patients responded with a mean follow-up period of 31 months (range 10-43 months). Of those patients, 43 underwent routine screw removal whilst 20 had screws left in situ. The groups were comparable considering age, gender and follow-up time. The 'retained' group scored higher mean OMAS scores, 81.5±19.3 compared to 75±12.9 in the 'removed' group (p=0.107). The retained group achieved higher functional scores in each of the OMAS domains as well as experiencing less pain. When adjusted for gender, the findings were found to be statistically significant (p=0.046).
  
  
  CONCLUSIONS
  Our study has shown that retained-screw fixation does not significantly impair functional capacity, with additional cost-effectiveness. We therefore advocate that syndesmosis screws be left in situ and should only be removed in case of symptomatic implants beyond 6 months postoperatively.
authors.affiliation: Orthopaedic Department, C/O Fracture Clinic, Level 2, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK. Electronic address: atuc@hotmail.com.
authors.forename: Adam
authors.initials: A
authors.lastname: Tucker
authors.forename: Julia
authors.initials: J
authors.lastname: Street
authors.forename: David
authors.initials: D
authors.lastname: Kealey
authors.forename: Sinead
authors.initials: S
authors.lastname: McDonald
authors.forename: Mike
authors.initials: M
authors.lastname: Stevenson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016512:Ankle Injuries / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery; D001863:Bone Screws; D003362:Cost-Benefit Analysis; D020878:Device Removal; D005260:Female; D005593:Fracture Fixation, Internal / Q000295:instrumentation*; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D017410:Practice Guidelines as Topic; D011859:Radiography; D020127:Recovery of Function; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D019564:Unnecessary Procedures
keywords: Ankle trauma; Diastasis; Internal fixation; Metalwork removal; Syndesmosis injury