Retrospective Analysis of Timing of Syndesmotic Screw Removal

Retrospective Analysis of Timing of Syndesmotic Screw Removal and Their Outcomes
Joshua
1
Hunt ,
DPM and Zeeshan S.
2
Husain ,
DPM FACFAS FASPS
1
PGY-3 Resident, Podiatric Medicine and Surgery Residency, Detroit Medical Center, Detroit, MI
2 Attending Physician, Department of Orthopedics, Podiatry Section, Detroit Medical Center, Detroit, MI
Abstract
Methodology
Results
This is a retrospective analysis performed at a single hospital (SinaiGrace Hospital, Detroit, MI) on all ankle fractures surgically repaired
by a single surgeon (ZSH) to evaluate timing of syndesmotic screw
removal and patient outcomes. Ankle fractures comprise
approximately 9% of all fractures experienced in the general public
(1). Of these ankle fractures, one in seven incur a syndesmotic injury
(2). The current treatment practice and guidelines of these injuries
have a lack of consensus in many areas including the type of construct,
how much fixation to utilize, and timing of hardware removal (3). The
successful management of ankle joint syndesmotic injuries require
anatomic reduction to ensure proper repair of the syndesmotic
ligament and reduction of the tibial-fibular incisura to optimize
functional outcomes (4-5). It is unknown how much time is needed
for the syndesmotic ligament to heal. As such, there is no agreement
on when to remove syndesmotic fixation (4).
From 2003 to 2013, 335 ankle fracture cases were identified to have
undergone open reduction with internal fixation by the senior author
(ZSH). Of these cases, 47 cases (14.0%) involved syndesmotic injuries
that were surgically repaired with metallic screws. These charts were
reviewed to record date of injury, date of surgery, if they were diabetic,
date of birth, syndesmotic screw used (type, size, quantity, and number of
cortices captured), time to weight bearing, final date of follow-up, and
date of screw removal. All radiographs were reviewed (JH) to determine
Danis-Weber and Lauge-Hansen classification fracture patterns. Patients
completed the SF-12 questionnaire at their final post-operative visit.
From 2003 to 2013, 335 ankle fractures were treated by the senior author
(ZSH). 47 cases (14.0%) met inclusion criteria with post-operative followup. Overall, 31 (66.0%) were female and 16 (34%) were male. Patient age
ranged from 14 to 70 years of age (38.7±14.2yrs). Average time to surgery
was 12.0±12.3 days. On average, 1.6±0.7 screws were used in each case.
On average, 6.0±2.3 cortices were captured per case. Patients began
partial WB at 39.9±17.4 days post-operatively.
Patients had their
syndesmotic screws removed at 166.3±178.6 days post-operatively.
Patients, in the study, had a follow-up time of 349.1±406.9 days. The
SF-12 patient questionnaire was performed on 13 (27.7%) patients via
phone interview. The answers were converted into numerical score with a
maximum score of 48. The SF-12 score was 35.4±8.5 in the syndesmotic
screw removal group and 42.5±4.9 in the syndesmotic screw retained
group.
Data
Fracture patterns and constructs in study The percentages are based on
total number of the group.
Removed
Introduction
Current literature lacks consensus in type of construct (number of
screws, type of screws, and number of cortices purchased) and timing
of hardware removal (3, 6-7). Historically, syndesmotic screws were
removed prior to weightbearing (WB) between 6-8 weeks (8-10).
Hermans, et al., showed no statistical significance between functional
outcomes and range of motion between groups with removed versus
retained hardware (11). Chissell and Jones could not conclude if
syndesmotic screws needed to be removed in Danis-Weber C type
fractures (4). A questionnaire of 310 orthopedic surgeons in the
United Kingdom (63.5% responded) demonstrated a range of
treatment preferences (6).
The majority (83.6%) removed the
syndesmotic screws before patients began full WB, 10.1% removed
them when they became symptomatic, and only 3.7% did not remove
them at all.
Similarly, Bava, et al., surveyed 153 orthopedic
surgeons, in the United States (50.3% responded showing that an
overwhelming majority, 95%, routinely removed the syndesmotic
screws (49% at 90 days, 37% at 120 days, and 14% between 120-180
days post-operatively.
DW B
DW C
SER III
SER IV
PER III
PER IV
3.5mm
4.0mm
4.5mm
4.0mm C
4.5mm C
***
20
16
7
13
9
7
1
4
27
1
2
1
55.6%
44.4%
19.4%
36.1%
25.0%
19.4%
0.8%
11.1%
75.0%
2.8%
5.6%
2.8%
Retained
7
4
2
5
0
4
1
3
7
0
0
0
63.6%
36.4%
18.2%
45.5%
36.4%
9.1%
27.3%
63.6%
-
Date Range Screw Removed
60-90 days
91-120 days
121-150 days
151-180 days
181-210 days
211-240 days
241-270 days
271-300 days
>300 days
DW- Danis-Weber
SER- supination
external rotation
PER- pronation
external rotation
SS- syndesmotic screw
C- cannulated
*- combination 4.0/4.5
Frequency
19
3
3
4
3
2
1
0
4
Syndesmotic Screw Placement
Once the malleoli have been reduced, the drill is oriented parallel to ankle
joint and approximately 30-45° posterior to coronal plane. Finally, screw
is placed without overtightening with the ankle positioned at 90°.
Ankle Joint after Screw Removal
Two cases of syndesmotic repair after screw removal.
Discussion
This study includes 47 syndesmotic injuries associated with ankle
fractures over 10 years. The incidence of syndesmotic injury from our
study is 17.0% compared to 14% stated in the literature (2). Patients only
underwent hardware removal if the syndesmotic screws became
symptomatic due to stiffness or pain with range of motion and/or
hardware failure. The number of screws and number of cortices were
comparable in the removal and retained groups (1.5 screws per 5.9
cortices and 2.0 screws per 6.2 cortices respectively). The time to WB
was comparable in both the removal and retained groups (40 days and 38
days respectively). Our preliminary data demonstrate comparable
parameters and SF-12 scores in the syndesmotic screw removal and
retained groups. However, the authors would stress the low number of
cases in each group as well as a poor questionnaire follow-up (13/47,
27.7%). 36 (77%) patients underwent syndesmotic screw removal at an
average of 166 days which is similar to the literature at 90-180 days.
However, given the large range, 64-1021 days post-operatively, and the
large standard deviation, we are unable to conclude there is a specific
post-operative timeframe at which to remove syndesmotic hardware. The
authors are working on a prospective study to better determine if the
timing of syndesmotic screw removal has any correlation to outcomes
following syndesmotic ligament injury.
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