Background: Several factors can affect the success of surgical treatment of injuries to the distal aspect of the tibiofibular syndesmosis, including the bony articulation between the distal aspect of the fibula, tibia, and the supporting ligamentous structures; number and size of screws; number of cortices penetrated; and planned routine removal of screws.

Methods: We conducted a retrospective review of radiographs and clinic notes for all patients who underwent open reduction and internal fixation of injury to the tibiofibular syndesmosis, which was performed by a single surgeon (RAM), between January 2011 and December 2014. Only screws were used. The screws were removed postoperatively if pain was noted or if requested by the patients. Exclusion criteria included patients with fractures treated initially with external fixation and patients with diabetic neuropathy; ultimately, 44 patients were included in the study.

Results: During postoperative follow-up, eight screws broke and six screws loosened. Two broken screws and one loose screw were causing symptoms of pain and subsequently removed. One broken screw was replaced owing to loss of fixation. Four intact screws were causing pain and later removed.

Conclusions: There is not a clearly defined advantage to routine screw removal. Risks and costs associated with an additional operative treatment for routine removal are likely unnecessary, but removal when the hardware results in pain is recommended. Treatment outcomes were similar between cortices crossed, number of screws used, and placement of screws through plates.

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