in bimalleolar ankle fracrtures with syndesmotic disruption is it preferred 1 or 2 syndesmotic screws?
Two screws provide a more stable fixation of the syndesmosis. However, the common practice involves only one screw, because the primary idea is to fix (not to compress !) the syndesmosis and to dynamize it by screw removal after 8 weeks. Furhermore, there is an option to leave the single screw in situ and the functional and radiological results at one-year follow-up are the same compared to cases with early removed screws. Please, see below:
http://www.ncbi.nlm.nih.gov/pubmed/25452376
Regards
There is debate in the literature on the method of fixation for these injuries and a considerable amount of research has been devoted to determine the best fixation technique for syndesmotic injuries. Surgeons have used both 3.5 and 4.5 mm cortical screws for syndesmotic fixation.Fixation may involve either three or four cortices of the fibula and tibia. Engaging three cortices permits physiologic motion but may also lead to hardware loosening and loss of alignment. Engaging four cortices improves syndesmosis stability. So 2 screws are better than 1 screw for significant inferior tibio fibular diastasis
Hi,
I tried to solve that problem in my paper Injuries of the distal tibio-fibular syndesmosis, and i think there is no simple solutions and depends on fracture type, patient etc., but in most of the cases single tricortical is a good option
Enjoy the paper
The debate between one or two is lengthy and still there is a lot of controversy.
Initially it was one with 4 cortex engagement. The cause of second thoughts on this practice was the fracture of the screws and the early because of this removal of them (at four to six weeks), which compromised the stability of the ankle.
Then the three cortex stabilisation came as solution but the 3.5 was found again weak and the 4.5 was introduced (having the facility to be easily palpated and be possible to be removed under local anaesthetic).
The two 3.5 screw technique was used in very unstable and/or osteoporotic fractures and the reason was to increase stiffness.
As the time of the screw removal, if at all, went up to 8 weeks the technique which is used by the most is a three cortex use, which is helping the stabilisation and in the same time allows some movement within joint.
If the surgeon will go for a 4.5 or a 3.5 is still a factor which is up to him and his technique and post-operative protocol which he/she applies following the audits which were conducted and the literature.
thank you Dr. George Zafiropoulos ,Panayot Tanchev
Raju Vaishya,Adrian Błasiak
surveys have been done in UK (Monga, et al., Acta Orthop Belg 74:3, 2008.) and US (Bava, et al., Am J Orthop 39:5, 2010.) looking at what people are doing. there is no consensus and numerous biomechanical strength studies have been studied.
if you are trying to limit motion, then at least 4 cortices will be needed in total regardless of how many screws you use. the more screws used and the more cortices crossed will lead to stiffer construct (preferred in neuropathic cases). in healthier individuals, i tend to use single quadricortical screw. overall, i try to make all screws quadricortical if possible... just personal preference. i have not done any in depth analysis to differentiate on outcomes yet.
one is enough , with one cortical at tibia, and not to tight
It is very variable per surgeon. In the acute injury I feel that 1 screw is stable enough but if it is a chronic instability/injury then I use 2 screws for additional stability.
i agree with previous comments on single screw. i try to make it quadricortical if possible and plan on removing at around 6mo post-op.
large surveys in europe and the US have showed no consensus on this issue with regards to number of screws and removal strategy (1,2).
i have switched to using endobuttons to minimize malunion of the tib-fib alignment (3). however, in high-risk patients (neuropathic, osteopenic, immunocompromised, etc) i will use multiple (>2) quadricortical screws to reduce excessive motion.
Article Management of distal tibio-fibular syndesmotic injuries: A s...
Article Ankle fracture syndesmosis fixation and management: the curr...
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It depends on the surgeon's opinion and decision and also the type of injury.
In the dorsally comminuted, extra-articular, nonosteoporotic distal radius fractures, the minimum number of screws—four in the distal row and two in the shaft—in volar locking plate fixation can provide sufficient stability. Further biomechanical studies involving osteoporotic bone will be necessary to confirm the results because volar plate fixation is most commonly used in patients with osteoporosis.
Review article
Plate-screw and screw-washer stability in a Schatzker type-I lateral tibial plateau fracture: a comparative biomechanical study
April 22, 2020
The one screw vs two screws and the three cortex vs four cortex fixation options are all great for fireside discussions but really do not matter.
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