title: Fate of the syndesmotic screw--Search for a prudent solution.
abstract: BACKGROUND
  Ankle fractures are common injuries. Since the recognition of the importance of syndesmotic injury in ankle fractures, much of the scientific work has been focused on concomitant syndesmotic injury. Despite the invention of novel devices for restoration and maintenance of the congruent syndesmosis following syndesmotic injury, the metallic syndesmotic screw is still considered to be the "gold standard". The aim of this study was to compare the clinical results in patients who retained the syndesmosis screw with those in whom the screw was removed following open reduction and internal fixation of the malleolar fracture associated with syndesmosis disruption.
  
  
  METHODS
  This was a retrospective study of 82 patients. Minimum follow-up was 12 months. Clinical evaluation included American Orthopaedic Foot and Ankle Society (AOFAS) score and Visual Analogue Scale (VAS) for patient general satisfaction. The condition of the screw (removed, intact or broken), presence of radiolucency around the syndesmotic screw and the tibiofibular clear space were recorded using final follow-up radiographs.
  
  
  RESULTS
  Three cortices were engaged in 66 patients (80%) and quadricortical fixation was performed in the remaining 16 patients (20%). The number of engaged cortices did not correlate with the clinical outcome and screw fracture. A single syndesmotic screw was used in 71 patients (86%. The mean AOFAS score in the group with intact screw (I) was 83; the scores in the group with broken screw (B) and removed screw (R) were 92.5 and 85.5, respectively. There was a statistically significant difference between the three groups: this was due to the difference between groups I and B; the difference between groups I and R and groups B and R were not statistically significant. There were no statistically significant differences in VAS results.
  
  
  CONCLUSIONS
  There were no statistically significant differences in clinical outcome between the group with the screw retained and the group in which the screw was removed; however, the group with broken screws had the best clinical outcome based on AOFAS score. Widening of the syndesmosis after screw removal was not evident. We do not recommend routine syndesmosis screw removal.
authors.affiliation: University Clinic of Traumatology, Medical Faculty of Skopje, Skopje, Macedonia. Electronic address: kaftan_igor@yahoo.com.
authors.forename: Igor
authors.initials: I
authors.lastname: Kaftandziev
authors.affiliation: University Clinic of Traumatology, Medical Faculty of Skopje, Skopje, Macedonia.
authors.forename: Marko
authors.initials: M
authors.lastname: Spasov
authors.affiliation: University Clinic of Traumatology, Medical Faculty of Skopje, Skopje, Macedonia.
authors.forename: Simon
authors.initials: S
authors.lastname: Trpeski
authors.affiliation: Institute of Epidemiology and Biostatistics, Medical Faculty of Skopje, Skopje, Macedonia.
authors.forename: Beti
authors.initials: B
authors.lastname: Zafirova-Ivanovska
authors.affiliation: Orthopaedics and Traumatology Department, Our Lady of Lourdes Hospital, Drogheda, Louth, Ireland.
authors.forename: Bore
authors.initials: B
authors.lastname: Bakota
mesh_terms: D000328:Adult; D000368:Aged; D016512:Ankle Injuries / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D000843:Ankle Joint / Q000503:physiopathology / Q000601:surgery*; D001863:Bone Screws; D020878:Device Removal / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000379:methods*; D017102:Fracture Healing; D050723:Fractures, Bone / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D016059:Range of Motion, Articular; D020127:Recovery of Function; D012189:Retrospective Studies; D016896:Treatment Outcome; D016474:Weight-Bearing
keywords: Ankle fracture; Functional outcome; Removal; Syndesmosis; Syndesmotic screw