Syndesmotic screws, unscrew them, or leave them? A systematic review and meta-analysis of randomized controlled trials.

Background: Syndesmotic injuries are frequently stabilized using syndesmotic screws. Traditionally, these screws were routinely removed during the postoperative period, however recent literature has brought into question the necessity of routine removal, citing no change in functional outcomes and the inherent risks of a second surgery. Our study aimed to compare outcomes of patients undergoing routine syndesmotic screw removal versus those undergoing an on-demand approach to removal.

Methods: A systematic search of studies comparing routine syndesmotic screw removal to on-demand screw removal following an acute ankle fracture, or an isolated syndesmotic injury was conducted across seven databases. Only Prospective randomized controlled trials were eligible for inclusion. Data reported on by at least 2 studies was pooled for analysis.

Results: Three studies were identified that met inclusion and exclusion criteria. No significant difference in Olerud-Molander Ankle Score (MD -2.36, 95% CI -6.50 to 1.78, p = 0.26), American Orthopedic Foot and Ankle Hindfoot Score (MD -0.45, 95% CI -1.59 to .69, p = 0.44), or dorsiflexion (MD 2.20, 95% CI -0.50 to 4.89, p = 0.11) was found between the routine removal group and on-demand removal group at 1-year postoperatively. Routine removal was associated with a significantly higher rate of complications than on-demand removal (RR 3.02, 95% CI 1.64 to 5.54, p = 0.0004). None of the included studies found significant differences in pain scores or range of motion by 1-year postoperatively.

Conclusion: Given the increased risk of complications with routine syndesmotic screw removal and the comparable outcomes when screws are retained, an as-needed approach to syndesmotic screw removal should be considered.