Should syndesmotic screws be removed after surgical fixation of unstable ankle fractures? a systematic review.
OBJECTIVE
In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery.


METHODS
A literature search was conducted in Medline, Embase and the Cochrane Library for articles in which the syndesmotic screw was retained. Articles describing both removal and retaining of syndesmotic screws were included. Excluded were biomechanical studies, studies not providing patient related outcome measures, case reports, studies on skeletally immature patients and reviews. No restrictions regarding year of publication and language were applied.


RESULTS
A total of 329 studies were identified, of which nine were of interest, and another two articles were added after screening the references. In all, two randomised controlled trials (RCT) and nine case-control series were found. The two RCTs found no difference in functional outcome between routine removal and retaining the syndesmotic screw. All but one of the case-control series found equal or better outcomes when the syndesmotic screw was retained. However, all included studies had substantial methodological flaws.


CONCLUSIONS
The currently available literature does not support routine elective removal of syndesmotic screws. However, the literature is of insufficient quality to be able to draw definitive conclusions. Secondary procedures incur a provider and institutional cost and expose the patient to the risk of complications. Therefore, in the absence of high quality evidence there appears to be little justification for routine removal of syndesmotic screws. Cite this article: Bone Joint J 2016;98-B:1497-1504.
Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Dingemans
UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum "Carl Gustav Carus" TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany.
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Rammelt
Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, UK.
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White
Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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JC
Goslings
Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Schepers
D064386:Ankle Fractures / Q000601:surgery*; D001863:Bone Screws; D020878:Device Removal; D005593:Fracture Fixation, Internal / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D007593:Joint Instability / Q000601:surgery*; D020127:Recovery of Function; D016896:Treatment Outcome; D019564:Unnecessary Procedures
Ankle; Fracture; Functional outcome; Implant removal; Routine removal; Syndesmotic screw