2017 ISAKOS Biennial Congress ePoster #137


Higher Incidence of Hardware Related Complications in Young Athletes Undergoing Metal Screw Fixation for Syndesmotic Injuries

Kellie K. Middleton, MD, MPH, Atlanta, Ga UNITED STATES
Joseph J. Kromka, MD, Monroeville, PA UNITED STATES
Monique C. Chambers, MD, MSL, Pittsburgh, PA UNITED STATES
Dukens LaBaze
James J. Irrgang, PT, PhD, FAPTA, Pittsburgh, PA UNITED STATES
MaCalus V. Hogan, MD, MBA, Pittsburgh, PA UNITED STATES

University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, UNITED STATES

FDA Status Cleared


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.