Walley Kempland C, Hofmann Kurt J, Velasco Brian T, Kwon John Y
Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Foot Ankle Spec. 2017 Jun;10(3):252-257. doi: 10.1177/1938640016685153. Epub 2016 Dec 27.
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.
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.
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.
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.
Level IV: Systematic review.
虽然使用金属螺钉进行经下胫腓联合固定被认为是治疗下胫腓联合损伤的金标准，但关于术后螺钉取出的必要性和时机仍存在争议。文献中尚未形成正式的建议，在这方面临床实践差异很大。本系统评价的目的是严格审查有关下胫腓联合螺钉取出的最新文献，以便为外科医生提供基于证据的这些损伤的处理方法。
在2010年10月1日至2016年6月1日期间，使用“下胫腓联合”和“螺钉取出”的检索词在Cochrane图书馆和PubMed Medline数据库中进行检索。
共发现9项研究（1项随机对照试验和8项回顾性队列研究）描述了保留或取出下胫腓联合螺钉的结果。总体而言，取出下胫腓联合螺钉的患者在功能、临床或影像学结果方面没有差异。在6至8周之间取出螺钉时，下胫腓联合再分离复发的可能性更高。在未使用术前抗生素的情况下取出下胫腓联合螺钉时，术后感染率更高。
主要在患者因其他植入的踝关节周围硬件出现不适或术后至少8周后下胫腓联合复位不良的情况下，建议取出下胫腓联合螺钉。除非引起症状，否则不应常规取出断裂或松动的螺钉。取出时建议使用抗生素预防。在取出前应常规立即进行X线检查，并且在手术前应与患者进行正式讨论，以讨论如果术中意外遇到断裂螺钉的处理方案。当下胫腓联合螺钉取出后出现已知的下胫腓联合复位不良时，应根据需要进行X线和/或计算机断层扫描成像检查。
IV级：系统评价。
