Syndesmotic screw fixation

Last revised by Joachim Feger on 12 Dec 2021

Syndesmotic screw fixation is a rigid fixation technique for stabilization of distal tibiofibular syndesmosis injury. Depending on the injury and the surgeon's preference it can involve the placement of one or two syndesmotic screws and can be combined with an antiglide plate.

Indications include syndesmotic injuries, especially transsyndesmotic and suprasyndesmotic fibular fractures including Maissoneuve fractures 1-4.

The syndesmotic screw fixation technique comprises the following 1:

  • reduction of the fibula and ensure congruence of the distal tibiofibular joint
  • preliminary K-wire fixation (approximately 1-2 cm above the joint line)
  • confirm proper reduction
  • drilling of a bone tunnel through the fibula and tibia parallel to the tibiotalar joint line
  • insertion of the syndesmotic screw with the screw thread in the fibula and tibia
  • optional insertion of a second screw 1-2 cm proximal to the first screw

Other facts regarding syndesmotic screws that depend on the surgeon's preference 1,4:

  • size is usually 3,5 mm or 4,5 mm
  • in the majority of cases, they are placed 2-4 cm proximal to the tibial plafond
  • in about half of cases, they run through three or four cortices
  • in about half of cases, they run through an osteosynthesis plate

Complications of syndesmotic screw fixation include the following 1-8:

Screw position and tibiotalar joint congruency are usually assessed with Mortise and lateral views of the ankle.

The radiological report should include the description of the following features:

There is a general controversy concerning postoperative weight-bearing. About 80% of syndesmotic screws are removed again with controversy in respect to the time of implant removal 4.

Syndesmotic screw fixation is the most widespread method for the surgical fixation syndesmotic injuries 3,4 and has been shown to have good to excellent functional outcomes in patients with high fibular fractures 5.

However recently syndesmotic screw fixation has been challenged by fixation techniques using suture buttons, the latter showing equal to better functional outcomes with lower rates of malreduction, hardware failure and implant removal 6-8.

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