Screw fixation of the injured syndesmosis restores stability, but may reduce ankle motion. We wished to determine whether functional and radiographic results are improved by removal of syndesmosis screws. In addition, we studied whether large fragment screws have an advantage compared to small fragment screws. We hypothesised that retained intact syndesmosis screws are detrimental to ankle function. One hundred and seven adults with ankle fractures requiring syndesmosis screw fixation between 2001 and 2005 were retrospectively studied. Indications for syndesmosis fixation were a positive intraoperative external rotation stress test or inadequate lateral column buttress. Weight bearing was encouraged six weeks postoperatively. Syndesmosis screws were only removed for tenderness, prominence or ankle dorsiflexion < 0.05. The LEM score for patients with intact screws was 70 ± 26 compared with 85 ± 20 for broken, loosened or removed screws (p=0.05). The OM score for patients with intact screws was 48 ± 36 compared with 63 ± 27 for broken, loosened or removed screws (p=0.12). There was no difference in outcome comparing broken, loosened, and removed screws. The tibiofibular clear space for intact screws was 3.3 ± 1.3 compared with 4.1 ± 1.7 for removed, broken or loosened screws (p=0.02). There was no difference in outcome comparing large and small fragment screws. Patients with broken, loosened or removed syndesmosis screws have better functional outcome compared to intact screws. The syndesmosis allows fibular rotation, shortening and translation during gait; the presence of an intact syndesmosis screw may restrict this motion. There was no disadvantage to leaving broken or loosened screws in-situ

Ankle sprains in the athlete are one of the most common injuries, and syndesmosis type sprains seem to becoming diagnosed at an increasing rate. There still exists a paucity of information on optimal conservative and operative management. Treatment. Because of the spectrum of injury, there is a spectrum of treatment. if there is mortise widening, operative stabilization is required. if the mortise is normal, even with external rotation stress test positive, conservative treatment has been employed. staged conservative regimen directed at reducing pain and swelling acutely, at regaining range of motion and strength subacutely, and then progressed to functional training and finally return to sport. The timeframe for these was in the range of 2 to 6 weeks without very specific progression criteria. In the athlete, pain with rotational stress, greater severity of sprain, may treat operatively to stabilize the syndesmosis and aggressive rehab with earlier return to sport. Tightrope vs screw fixation vs both. Use of arthroscopy. Chronic sprains with recalcitrant pain and functional instability usually require operative treatment. very poor evidence exists as to the timing or type of procedure. Arthroscopy is required to confirm the diagnosis, treat intraarticular problems, and provide fixation of the distal tibiofibular syndesmosis. The postoperative regimen used is generally the same as the one used when treating an acute syndesmosis disruption. Tight rope vs Screw Fixation. clinical studies tightrope fixation has been acceptable and comparable to screw fixation. laboratory studies demonstrate comparable construct stability in the laboratory/cadaveric setting. indications for tightrope fixation are becoming more clear with more experience. my indications:. syndesmotic sprains with complete or incomplete disruption. fractures with syndesmotic disruption augment with screws, leave in place following screw removal. Summary and Controversies. Syndesmotic or high ankle sprains continue to be a common injury that result in significant time lost from sport. The conclusion that can be drawn from the current evidence is that the current diagnostic process probably fails to clearly assess the severity of the injury, which reduces the likelihood of accurately predicting the time lost from sport. Syndesmosis sprains can be a significant injuries that result in an inability to play sports for significant periods of time(up to 137 days). We need to be able to identify the more severe ones earlier in order to improve their treatment, perhaps lead to operative stabilization. Tightrope fixation avoids screw removal, minimally invasive, permanent stabilization