The syndesmosis ligament joins the two leg bones together just above the ankle. When it is injured the ligaments between the tibia and fibula tear, the two bones spread apart, abnormal forces are transmitted to the ankle joint, and arthritis inevitably follows.
Instead of allowing this to happen, surgeons place screws across this syndesmosis (a barely movable joint above the ankle) to hold the two bones of the leg together temporarily while the ligament heals. As there will always be motion around the joint that is not fused purposefully, the screws will loosen and become painful and may even break over time. Broken screws may become painful or even impossible to extract without significant injury.
To get around these complications, some companies have developed a suture wire with washers on either side that brings the two bones together. While these wire sutures are very strong in tension (holding the bones from gapping) they have absolutely no sheer force resistance and therefore the ankle bones can shift between each other. This leaves the joint inadequately stabilized and sometimes results in incompletely healed ankle ligaments. I have a problem changing from a technique that has such a high rate of success (using screws) to something that has worse results (using these suture wires).
The midfoot is sprained in many sports and most commonly involves the lis franc joint (the joint between the medial cuneiform and the base of the second metatarsal). The classical treatment has been rigid fixation across this joint with screws or plates while the ligaments heal. Once the tissue has healed, weight bearing will loosen or cause screw fracture. Again, this can be a painful problem if the screw is not removed.
I routinely recommend removal of hardware from syndesmosis and midfoot ligament reconstructions after at least 3 months. It is my belief that the ligamentous tissue is adequately healed by then to hold the foot bones together. While there is no rush to removal, if symptoms of stiffness, swelling, or pain begin to trouble the patient, I don't wait for the screws to break - I take them out.
Planned Hardware Removal Procedure
Here is a quick description of a simple hardware removal procedure:
The patient is placed under local anesthesia and sedation. A small incision is then placed over the head of the screw and the screws are removed. 1-2 stitches are used to close the wound. The surgery takes a few minutes and the wound heals enough for stitch removal after about 2 weeks. After wound healing, I restrict only cutting sport activity (those with high twisting forces) for another 4 weeks because of the theoretical risk of fracture from the screw hole.
This is a guest blog from Lance Silverman, MD. Dr. Silverman is an orthopedic specialist and founder of Silverman Ankle & Foot. Dr. Silverman is an accomplished orthopedic surgeon. He received his medical degree from Baylor College of Medicine in 1996 and is a board-certified member of the American Academy of Orthopaedic Surgeons and the American Orthopaedic Foot and Ankle Society.