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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Syndesmosis screws: How many, what diameter, where and should

they be removed? A literature review
A.C. Peek *, C.E. Fitzgerald, C. Charalambides
Whittington Hospital, London, UK

A R T I C L E I N F O A B S T R A C T

Article history: Although screw fixation remains the most commonly used method of syndesmosis fixation, the ideal
Accepted 8 May 2014 screw size, placement, and number remain controversial. In addition, there has been debate as to
whether the screw should always be removed, and a number of studies have looked at radiological and
Keywords: functional outcomes. In addition a number of cadaveric models have been developed, but the correlation
Syndesmosis between cadaveric findings and functional outcomes remains unclear.
Screw This systematic review of the literature aims to summarise the available evidence on how many
Fixation
screws should be placed, of what diameter, through how many cortices, at what level, and whether they
Evidence
should be removed.
ß 2014 Elsevier Ltd. All rights reserved.

Introduction and were found in 17% of supination external rotation type 4

The distal tibiofibular syndesmosis is a critical structure in
maintaining the congruency of the ankle mortise, and the
ligamentous structures account for more than 90% of the resistance
to lateral fibular displacement [1].
The anterior inferior tibiofibular ligament (AITFL) and the
superficial portion of the posterior tibiofibular ligament both
hold the fibula to the tibia and the anterior tibiofibular ligaments
also resists excessive external rotation of the talus within the
mortise. The deep part of the posterior tibiofibular ligament,
also called the transverse tibiofibular ligament, extends into the
joint and forms part of the articulating surface of the ankle joint.
The transverse tibiofibular ligament provides 33% of the
resistance to lateral displacement, and the AITFL accounts for
35% [1]. The interosseous membrane is the final component of
the syndesmosis, and consists of a number of short strong
attachments between the tibia and the fibula, which, though
forming a strong attachment, allow enough laxity to permit some
physiological movement between the fibula and tibia during
normal weight bearing [2,3]. As the foot moves from plantar
flexion to dorsiflexion, the mortise widens by 1–2 mm to
accommodate the wider anterior part of the talar dome [3].
Syndesmotic injuries are most commonly associated with
pronation external rotation injuries, and are thought to occur in
80% of Weber type C injuries [4]. They also occur Weber B injuries
* Corresponding author at: 7 Compton Terrace, UK. Tel.: +44 07870568590.
E-mail address: annapeek@doctors.org.uk (A.C. Peek).
injuries [5]. Isolated syndesmotic injuries, without bony injury, are
thought to occur mainly from forced dorsiflexion and external
rotation in combination with and axial load. Because the bony
injury does not always reliably reveal the underlying ligamentous
injury, the need for syndesmotic fixation can be evaluated
intraoperatively using a number of stress tests including external
rotation of the foot and stressing the fibula with a bone hook.
There remain a number of controversies in the management of
these injuries, and this paper seeks to clarify the recent evidence
base surrounding these. As 97% of UK consultants surveyed in 2008
use syndesmosis screws, rather than a tightrope or other device,
we have focussed on technical points surrounding syndesmosis
screws specifically [6].
We review the evidence surrounding screw diameter, the
number of screws used, the number of cortices fixed, the position
of the screw relative to the joint line, and finally whether it should
be removed.
In their survey, Monga et al. found a wide variation of practice
around the UK [6]. For example, 58% of consultants placed their
screws through 3 cortices, 33% through 4 cortices. Similar
proportions used small and large fragment screws. Thirteen
percent did not necessarily remove the syndesmosis screws and
25% allow full or partial weight bearing with the screws in situ.
A more recent extensive review of current practice in the
Netherlands found similar disparities. Similarly to UK practice,
greater than 90% used screw fixation in this injury. Although
there was variability in the fixation methods, few surgeons used
more than one screw and over 88% routinely removed the
syndesmosis screw [7].

http://dx.doi.org/10.1016/j.injury.2014.05.003
0020–1383/ß 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Peek AC, et al. Syndesmosis screws: How many, what diameter, where and should they be removed? A
literature review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.05.003
G Model
JINJ-5734; No. of Pages 6
2 A.C. Peek et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Methods
We performed literature searches using Embase, Pubmed/
Medline and the Cochrane library. We included English language
papers published between January 1980 and January 2014 when
the searches were carried out. We searched using the key terms
syndesmo* AND screw* in the title or abstract. This generated 286
unique references and the abstracts were then screened manually
to identify the papers of relevance. A total of 58 articles, including
review articles and meta-analyses, were reviewed in full by ACP
and CEF. Further references of relevance from these papers were
then also obtained. Both cadaveric and in vivo studies were
included. Where letters and correspondence was sent in to
comment on an article, this was also reviewed (Diagram 1).
Screw diameter
A saw bone model evaluating shear stresses following
syndesmotic fixation found a higher shear resistance using a
single 4.5 mm screw when compared to a single 3.5 mm screw [8].
In this model the load to failure was the endpoint. However, a
cadaveric study comparing syndesmotic widening, axial and
torsional loads to failure and stiffness between a single 4.5 mm
screw and two 3.5 mm screw could find no statistically significant
difference between the two groups [9]. Another cadaveric study
Embase and medline search
Syndesmo* AND screw* in tle, English language
285 references
All abstracts reviewed
57 Full papers reviewed
Including
20 reviews and meta-analyses
Addional papers idenfied from references
Diagram 1. Flow diagram of literature review.
Please cite this article in press as: Peek AC, et al. Syndesmosis screws: How many, what diameter, where and should they be removed? A
literature review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.05.003
comparing two 3.5 mm or 4.5 mm tri- or quadricortical screws
could find no differences in fibula displacement [10].
Because there is physiologically some movement at the
tibiofibular syndesmosis, it is not known whether the stiffer
construct achieved by a 4.5 mm screw is in fact clinically desirable.
In a retrospective analysis of 51 ankles treated by a variety of
configurations, neither screw diameter nor the number of screws
placed influenced the outcome [11]. However, in this study the
majority of cases (68%) had been treated with a single 3.5 mm
cortical screw, and the remainder with a variety of screw sizes and
numbers. Thus there was no direct clinical comparison between a
single 4.5 mm screw and two 3.5 mm screws.
In a large retrospective study of 137 patients Stuart et al. [12]
found a decreased likelihood of screw breakage as screw diameter
increased, from 0% with 4.5 mm screws to 9.5% with 4 mm screws
and 12.9% with 3.5 mm screws. A similar effect was found with
regards to screw loosening. There was no analysis of screw number
in relation to screw size. However neither result was statistically
significant on review of the data and there was no association
between screw breakage and loss of syndesmotic reduction. Most
screw breakages occurred between 3 and 6 months, leading them
to conclude screw breakage most probably occurred once the
syndesmosis had healed. Loss of reduction was however seen in
several patients with screw loosening, although numbers were too
small for significant analysis.
Not directly relevant
228 papers
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In a similarly sized retrospective study [13] (106 patients)
aimed primarily at determining whether the syndesmosis screw
should be removed or not, there was no functional or radiographic
differences between patients receiving small or large fragment
screws, however the relative risks of screw breakage and loosening
with small fragment screw was 2.5 and 3, respectively. It should be
noted that only 11/106 patients were treated with large fragment
screws.
In a large retrospective audit over 7 years, 68 cases were
reviewed with the endpoints including failure to anatomically
reduce the syndesmosis, or early loss of fixation. A number of
variables were analysed for correlation, including size and number
of the screws and the number of cortices. 42% of fractures were
fixed either using 2 two tricortical 3.5 mm screws or one tricortical
4.5 mm screws. No correlation was found between these variables
and re-operation or loss of fixation [14].
Number of screws
Few studies directly compare one screw to two, and the
discussion with regards to the number of screws to be
recommended cannot be taken in isolation from the controversy
regarding screw diameter.
Xenos et al. published a cadaveric study [15], using radiographic
measurements, which compared a single 4.5 mm screw to two. A
single screw was found to fail under less force than 2 screws (6.2
vs. 11 Nm).
A retrospective radiographic analysis of 86 ankle fixations
comparing a single 4.5 mm screw with two 4.5 mm screws found
no difference in the radiographic parameters of the syndesmosis at
12 weeks [16]. Clinical outcomes were not reported.
In a prospective randomised study [17], with subsequent 8 year
follow up data [18], no difference was found between a single
4.5 mm quadricortical screw with planned removal at 2 months
and two 3.5 mm tricortical screws which were not routinely
removed. Radiological and functional outcomes were studied. The
study benefits from a long follow up period and the comparison of
two commonly practiced clinical scenarios, even if each variable is
not assessed independently. Obesity, a posterior malleolar
fragment, and a difference in syndesmotic width of greater than
1.5 mm between the injured and uninjured legs (as measured on
CT) were all predictors of a poorer functional outcome.
Thus although there is biomechanical evidence that a single
screw fails under a lesser load, there is no difference found in
radiographic parameters between one screw and two, and in
addition, there is no functional difference between two small
fragment screws and one large fragment screw.
Finaly Gardner et al. [19] compared 2 quadricortical screws
with a locked plate and 2 screws in a cadaveric model of
Maisoneuve type fractures and found a greater torque to failure in
external rotation with the plate. There was no difference in
syndesmotic widening found.
Number of cortices
Three cadaveric studies [10,20,21] have compared tricortical
with quadricortical fixation in simulated cadaver fixations, under
loads designed to mimic weight bearing. No difference was found.
A cadaveric study [22] compared neutral tricortical with
quadricortical lag screws (inserted after over drilling the fibula
cortices) and found that while they both achieved reduction of the
syndesmosis there was greater compression of the syndesmosis
using the quadricortical lag screws.
Four clinical studies were found, including the previously
mentioned retrospective study by Stuart et al. They found no
difference in the rate of screw loosening or screw breakage,
Please cite this article in press as: Peek AC, et al. Syndesmosis screws: How many, what diameter, where and should they be removed? A
literature review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.05.003
3
however there was trend towards an increase in loss of
syndesmotic reduction in the quadricortical group (p = 0.06).
However the groups were uneven, with only 17/137 patients
receiving quadricortical screws [12].
A retrospective study of 46 patients compared a single
quadricortical or tricortical screw (size not specified) followed
by routine removal at 3–7 months in particular in relation to the
formation of tibio-fibular synostosis [23]. There was a statistically
significant increase in the rate of MRI detected obliteration of the
syndesmosis in the quadricortical group however, there was no
difference in functional outcome.
A prospective randomised study comparing tri- or quadricor-
tical screws in 127 patients two 3.5 mm screws no significant
difference was found in screw breakage, screw loosening, loss of
reduction or need for the removal of hardware [24]. In the
tricortical group there was loss of reduction in three patients, all of
whom had been non-compliant with non-weight bearing instruc-
tions. No loss of reduction was seen in the quadricortical group.
Functional outcomes were not reported.
A meta-analysis [25] including those patients mentioned above
and the long term follow up published by Wikeroy et al. [18] and
Hoiness et al. [17] concluded that early functional outcome scores
were higher in the tricortical group however other variables
including number of screws and removal were not controlled for
specifically.
In addition a study of 52 patients evaluating whether to keep or
remove the syndesmosis screw used both tri- and quadricortical
fixation and no functional difference was found between the
groups, or any difference between the rates of screw breakage [26].
Finally there is a case report of tibialis posterior rupture due to a
prominent quadricortical screw [27].
Thus overall it can be said that there is no clear evidence to
favour either tricortical or quadricortical fixation either from
biomechanical studies, and there is no evidence of functional
difference between the two groups. As there can be complications
associated with quadricortical fixation (synostosis, tendon rup-
ture), it would seem logical to favour tricortical fixation.
Position of the screw
The screw(s) may be placed either through the syndesmosis
(within 2 cm of the tibial plafond) or above the syndesmosis (2–
5 cm from the tibial plafond).
A cadaveric study carried out on 17 pairs of legs found a
significantly less syndesmotic widening with a trans-syndesmotic
screw [28].
A retrospective study comparing supra- and trans-syndesmotic
screw placement, with other variables unchanged found no
difference in range of movement, clinical or radiological param-
eters. The authors do acknowledge however that the study was
underpowered with 19 patients in each group [29].
Stuart et al.s’ previously mentioned retrospective analysis also
found no difference between the two groups [12].
Removal of the screw
In a cadaveric study of 8 ankles, with the syndesmotic ligaments
left intact to simulate a healed ligament, range of movement under
load was studied before and after a single quadricortical 4.5 mm
screw 3 cm above the syndesmosis. No difference was found in
plantar or dorsiflexion but there was significantly less talar
rotation [30].
There are a number of clinical studies comparing removal or
retention of the syndesmosis screw.
In a retrospective study in a centre where syndesmotic screws
were removed only if dorsiflexion was less than 108 or is they were
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symptomatic, 76 patients were reviewed 1 year postoperatively
[13]. Comparing intact with removed screws, functional outcomes
were significantly better in those whose screw had been removed.
However there was no difference in functional outcomes between
those with non-functioning (broken or loose) screws and those
whose screw had been removed.
In a second study with a similar methodology 52 patients were
recruited at a minimum of 1 year postoperatively. Those with
broken screws left in situ had the best functional outcome scores
and there was no difference found between those with intact or
removed screws [26].
A smaller study by Bell et al. reviewed Weber C type fractures in
30 patients and found no differences in functional scores between
23 patients who had their screw removed between 6 and 12 weeks
and seven in whom the screw was left in situ [31]. However they
concluded screws should be removed in an attempt to prevent
screw breakage (which occurred in 2/7 patients), making the
argument that a broken screw is more difficult to remove should
this become necessary.
Miller et al. carried out a prospective study of 25 patients, in
which they stabilised the syndesmosis with a locked plate and
screw construct through 4 cortices [32]. Despite all patients being

Number of Cortices

Cadaveric RCT with 2x 3.5mm screws

No difference No difference

Retrospective Xray review

Single 4.5mm vs two 4.5mm
No difference
Retrospective study
No correlation with loss of syndesmotic reduction

Sawbone model
Greater load to failure
with 4.5mm screws
Number of screws

Cadaveric Cadaveric Size of screws

Greater load to failure with 2 screws No difference

Retrospective studies
No statistically significant difference

2x 3.5 tricortical left in situ vs

1x 4.5 quadricortical removed

Prospective randomized trial

2 small fragment left in situ vs
Single large fragment removed
No difference

Routine removal or not?

Several studies comparing functional outcomes

No difference between broken/loose and removed screws
Contradictory results comparing intact and removed screws

Cadaveric
Less talar rotation with screw in situ
No difference in dorsiflexion

Position of screw

Cadaveric Retrospective studies

Less widening with trans-syndesmotic screw No difference

Diagram 2. Summary of evidence available.

Please cite this article in press as: Peek AC, et al. Syndesmosis screws: How many, what diameter, where and should they be removed? A
literature review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.05.003
G Model
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allowed to weight bear with this construct in situ, only one screw
broke and two loosened. All implants were routinely removed at
the 4 month mark. Range of movement and functional scores
improved significantly following removal of the syndesmotic
fixation device. Authors therefore concluded that the above
construct should be routinely removed in the postoperative period.
In contrast a retrospective review of 52 patients treated with a
more minimal construct (single 3.5 mm tricortical screw) found no
functional difference when comparing patients who underwent
screw removal or whose screw had broken at 6, 12 and 16+ weeks.
In addition no difference was found between those with broken
or removed screws. More patients showed recurrence of syndes-
motic widening in the groups in whom the screws were removed
earlier but this was not statistically significant nor was it
associated with worse functional scores [33].
Finally a retrospective study following up 63 patients a
minimum of 10 months post operatively found no significant
difference between those whose screw was retained compared
to those whose screw was removed as part of routine practice [34].
In this series the fixation methods varied, according to the
surgeons preference. They concluded that routine removal was
unnecessary in the absence of symptoms relating to the screw
and commented on the financial cost of removal. The integrity of
the screws was not commented upon.
In addition to the above, there have been a number of case
reports and case series relating to complications of syndesmotic
screw removal. The largest is a retrospective case series of 76
patients which found 9.2% rate of wound infection, 2.6% of which
required reoperation following routine removal between 6 and 8
weeks [35]. There was a 6.6% rate of recurrent diastasis. It should
be noted that prophylactic antibiotics were not used at the time of
removal in this study. There was a trend towards a lesser risk of
recurrent diastasis in patients who were left with the screw in situ
for greater than 8 weeks but the sample sizes were too small to
detect significance.
A large prospective study by Van den Bekerom et al. [36] found
just one case of recurrent syndesmosis in 236 consecutive
fixations, with routine removal between 6 and 12 weeks.
There have been reports of stress fractures of the tibia following
syndesmotic screw removal [37,38].
Clanton et al. evaluated the torsional strength of a cadaveric
construct in which the syndesmosis screw had been placed then
removed, and compared it with the use of a 1/3 tubular plate and
screw construct, the plate remaining in situ after removal of the
syndesmosis screw [39]. There was no statistical difference found
between the two constructs but it was interesting to note that
failure occurred through a tibial fracture.
Discussion
The principle conclusions are summarised in a spider diagram
(Diagram 2). Reviewing evidence regarding syndesmosis screws is
complex due to the large number of variables involved, each of
which may correlate with the others. For example, removal or not
of the screw cannot be considered without taking into account the
nature of the construct: screw size and number, number of
cortices.
In addition, there difficulties in interpreting the outcome
measures: for example, several studies have defined failure of the
screws as breakage or loosening of the screws, whereas one study
found this in fact was associated with the best outcomes. Therefore
while some studies have concluded that a fixation is superior on
the basis of fewer hardware failures it is difficult to extrapolate this
to clinical outcomes. This review highlights the caveats that must
be considered when translating cadaveric and biomechanical
studies into clinical practice.
Please cite this article in press as: Peek AC, et al. Syndesmosis screws: How many, what diameter, where and should they be removed? A
literature review. Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.05.003
5
There is no functional evidence that a more rigid fixation of the
syndesmosis, (with more cortices, a larger or more screws)
improves outcome or indeed prevents loss of reduction of
the syndesmosis, however a power analysis published in associa-
tion with Stuart et al.s’ paper suggests very large patient number
would be required to demonstrate this [12]. However, it can be
noted that there is no functional evidence to favour screw
removal other than in the more rigid plate and two quadricortical
screw construct described by Miller et al. [32]. In addition there is
a documented complication rate following screw removal. 87%
of Dutch surgeons removed syndesmosis screws, most between 6
and 8 weeks, and most were single screws [7]. Risk of breakage
was sited by a 41% of orthopaedic surgeons for screw removal [7].
Despite the prevalence of this regime, there is no evidence to
support it.
It is notable that despite the prevalence of the injury, most
studies are small, the largest study involved 236 ankles, but most
had around 50 patients. Thus lack of evidence of difference may
simply represent a type 2 error.
There are multiple additional variables that we have not
considered in this review, in particular the post-operative regime
and weight bearing allowed.
This literature review does not examine other types of
syndesmotic fixation, for example tightropes or bioabsorbable
screws, as these are less frequently used, but we acknowledge that
the ongoing controversy as to the optimal mode of syndesmotic
screw fixation causes difficulties in the interpretation of trials
investigating alternatives.
In conclusion we suggest that tricortical fixation with a single
4.5 mm screw left in situ unless it is causing symptoms or reduced
range of movement would be the least likely to subject the patient
to complications with no evidence to support any other regime has
a better functional outcome.
Conflict of interest statement
The authors state that there are no conflicts of interest.
Acknowledgements
We would like to thank Richard Peacock, Lead Clinical Librarian
at the (now closed) Archway Healthcare Library for his assistance
in searching for and obtaining the referenced papers.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.injury.2014.05.
003.
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