title: Removal of Hardware After Syndesmotic Screw Fixation: A Systematic Literature Review.
abstract: BACKGROUND
  While trans-syndesmotic fixation with metal screws is considered the gold standard in treating syndesmotic injuries, controversy exists regarding the need and timing of postoperative screw removal. Formal recommendations have not been well established in the literature and clinical practice is highly variable in this regard. The purpose of this systematic review is to critically examine the most recent literature regarding syndesmotic screw removal in order to provide surgeons an evidence-based approach to management of these injuries.
  
  
  METHODS
  The Cochrane Library and PubMed Medline databases were explored using search terms for syndesmosis and screw removal between October 1, 2010 and June 1, 2016.
  
  
  RESULTS
  A total of 9 studies (1 randomized controlled trial and 8 retrospective cohort studies) were found that described the outcomes of either retained or removed syndesmotic screws. Overall, there was no difference in functional, clinical or radiographic outcomes in patients who had their syndesmotic screw removed. There was a higher likelihood of recurrent syndesmotic diastasis when screws were removed between 6 and 8 weeks. There was a higher rate of postoperative infections when syndesmotic screws were removed without administering preoperative antibiotics.
  
  
  CONCLUSIONS
  Removal of syndesmotic screws is advisable mainly in cases of patient complaints related to the other implanted perimalleolar hardware or malreduction of the syndesmosis after at least 8 weeks postoperatively. Broken or loose screws should not be removed routinely unless causing symptoms. Antibiotic prophylaxis is recommended on removal. Radiographs should be routinely obtained immediately prior to removal and formal discussions should be had with patients prior to surgery to discuss management options if a broken screw is unexpectedly encountered intraoperatively. Radiographs and/or computed tomography imaging should be obtained after syndesmotic screw removal when indicated for known syndesmotic malreduction.
  
  
  METHODS
  Level IV: Systematic review.
authors.affiliation: Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Kempland C
authors.initials: KC
authors.lastname: Walley
authors.affiliation: Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Kurt J
authors.initials: KJ
authors.lastname: Hofmann
authors.affiliation: Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Velasco
authors.affiliation: Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: John Y
authors.initials: JY
authors.lastname: Kwon
mesh_terms: D016512:Ankle Injuries / Q000175:diagnosis / Q000601:surgery*; D001863:Bone Screws; D020878:Device Removal / Q000379:methods*; D005593:Fracture Fixation, Internal / Q000379:methods*; D050723:Fractures, Bone / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D011859:Radiography
keywords: ankle fracture; distal tibiofibular; implant removal; syndesmosis