Tucker Adam, Street Julia, Kealey David, McDonald Sinead, Stevenson Mike
Orthopaedic Department, C/O Fracture Clinic, Level 2, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK.
Injury. 2013 Dec;44(12):1880-4. doi: 10.1016/j.injury.2013.08.011. Epub 2013 Aug 20.
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.
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).
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).
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.
下胫腓联合损伤在高达20%的踝关节骨折中会出现，在Weber C型损伤中更为常见。下胫腓联合修复旨在恢复踝关节稳定性。主张常规取出下胫腓联合螺钉以避免植入物断裂以及诸如疼痛和僵硬等不良功能结局，但支持此观点的证据存在矛盾。本研究的目的是确定常规取出下胫腓联合螺钉的患者与未取出螺钉的患者在功能结局上是否存在差异，以及在并非常规需要取出螺钉的情况下是否存在成本效益。
对2008年1月1日至2010年12月31日在一个地区创伤中心连续进行的下胫腓联合修复手术进行回顾性研究。我们确定了91例在初次手术时接受踝关节骨折切开复位内固定并置入下胫腓联合螺钉的患者。多达69例患者符合纳入标准，可纳入本研究，他们完成了一份经过验证的功能结局问卷。使用奥勒鲁德-莫兰德踝关节评分（OMAS）对“保留螺钉”和“取出螺钉”患者的功能结局进行分析和比较。
共有63例患者回复，平均随访期为31个月（范围10 - 43个月）。在这些患者中，43例接受了常规螺钉取出，而20例螺钉留在原位。在年龄、性别和随访时间方面，两组具有可比性。“保留”组的平均OMAS评分更高，为81.5±19.3，而“取出”组为75±12.9（p = 0.107）。保留组在OMAS的各个领域均取得了更高的功能评分，且疼痛较轻。在对性别进行调整后，发现结果具有统计学意义（p = 0.046）。
我们的研究表明，保留螺钉固定不会显著损害功能能力，且具有额外的成本效益。因此，我们主张将下胫腓联合螺钉留在原位，仅在术后6个月后出现植入物相关症状时才取出。
