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"Your screws need to come out in 12 weeks. If they break, you will not have a good outcome."
3%
73/2087
"We can remove the screws, and if your screws break while attempting removal, we will need to take every measure available to remove them."
1%
23/2087
"If your screws break at some point in the next 12 weeks, we must remove them."
2%
41/2087
"If your screws break at some point in the next 12 weeks, we can try to remove them, but it won't make any difference in the outcome of your ankle."
90%
1874/2087
"If the screws become loose, we must remove them, or you will have a poor outcome."
49/2087
Select Answer to see Preferred Response
The patient sustained a left Maisonneuve injury, a proximal fibula fracture with disruption of the ankle syndesmosis, and underwent syndesmotic fixation with two 3.5 mm cortical screws. Broken or loose syndesmotic screws do not necessarily require removal. Some authors have reported superior outcomes in patients with loose or broken screws. Stabilization of the syndesmosis with screws allows for healing of the ligamentous structures torn during an injury. Maintenance of intact syndesmotic screws can restrict motion by preventing physiologic external rotation, as well as proximal and posterior translation of the fibula relative to the tibia. Screw removal or the screws breaking once the ligamentous structures have healed can theoretically allow for restoration of normal syndesmosis motion. Some authors suggest that leaving the screws in place and and allowing them to break or maintain syndesmotic fixation lead to better functional outcomes. Non-weightbearing or partial weightbearing is typically recommended for the first 8-12 weeks to allow for ligamentous healing. Manjoo et al conducted a retrospective review at a level 1 trauma center analyzing the outcomes of 106 patients that underwent syndesmotic fixation. They found functional outcomes to be superior in patients that had fractured, loosened, or removed syndesmotic screws compared to intact screws. Lash et al retrospectively reviewed functional outcomes in 141 patients that sustained ankle fractures and concluded that the majority of patients still have some functional disability at 2 years. Weber A fracture patterns had the best functional outcomes, while Weber C patterns had the worst. Tucker et al. performed a retrospective review of 63 patients that underwent syndesmotic screw fixation during ankle fracture ORIF. The 20/63 patients that retained their screws had statistically significant higher functional outcome scores and decreased pain compared to patients that underwent routine screw removal. The authors suggest that routine syndesmotic screw removal in asymptomatic patients may be unnecessary and even detrimental. Figures A-C demonstrate a proximal fibula fracture and a displaced posterior malleolus fracture with widening of the syndesmosis and posterior translation of the talus under the tibia. Figure D demonstrates trans-syndesmotic fixation with two 3.5 mm cortical screws and a 3-hole 1/3rd semi-tubular plate. Incorrect Answers: Answer 1: The patient should have a fine outcome if the screws break. Answer 2: If the screws break during retrieval, they do not necessarily need to be removed if they are not impinging on any vital structures. Answer 3: Broken screws do not require removal. Answer 5: Loosened screws do not need to be removed if they are painless and not impinging on any vital structures.
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