Young athletes who undergo metal screw fixation for high ankle sprain syndesmotic injuries have a significantly higher incidence of subsequent screw breakage and screw removal.
Ankle injuries are the most common presenting injury in the athletic population with the incidence of high ankle sprains – or injuries involving the distal tibiofibular syndesmosis – having recently increased. These injuries can have a major impact on return to play, chronic pain, and long-term disability compared to low lateral ankle sprains. As such, surgical reduction and internal fixation is the recommended treatment for severe injuries in young and/or athletic patients. Rigid metal screw fixation is the most common construct used to reduce the distal tibiofibular joint; however, screw breakage, stiffness, and hardware-related pain are commonly encountered problems when screws are used in the general population. With increasing popularity of suspensory fixation, there is a need for further evaluation of metal screw syndesmotic fixation in athletes. We hypothesize that rates of screw breakage, screw removal, and hardware-associated pain after syndesmotic screw fixation will be higher in young athletes.
This study was a retrospective review of patients who underwent syndesmotic injury stabilization with a metal screw construct after sustaining a high ankle sprain. Exclusion criteria included injury to the contralateral ankle, polytrauma, neurological impairment, and age <15 years. Chi-squared and Fisher’s exact tests were used to compare The effects of athletic participation, age (younger vs. older than 25), and the use of 1 vs. 2 screws on the incidence of screw breakage, screw removal, and hardware-associated pain.
Twenty-seven patients (15 male, 12 female) met the eligibility criteria. The mean age was 35 years (SD 21). Of these patients, 13 athletes were identified, 12 patients were < 25 years old, and 15 patients had single screw fixation. Athletes had an increased risk of screw breakage (p=0.006) and screw removal (p<0.001), but there was no difference in hardware-associated pain (p=0.440). With respect to age, individuals younger than 25 years had a significantly increased rate of screw removal (p=0.001) with the difference in the incidence screw breakage approaching significance (p=0.060). There was no difference in hardware-associated pain (p=0.706) between age groups. In athletes treated with 1 vs. 2 screws, there were no differences found for screw breakage (p=0.545), screw removal (p=0.364), or hardware associated pain (p=1.000).
Rigid screw fixation provides an effective method of syndesmotic stabilization in the general population; however, younger patients and those who are athletes have a significantly higher incidence of subsequent screw breakage and screw removal. In such patients, use of suspensory fixation may negate such complications, avoiding a second surgery for hardware removal. Additional long-term prospective studies are needed to compare outcomes of rigid fixation to suspensory fixation and hybrid constructs of both.