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Syndesmotic Screw – Surgery & Recovery

A syndesmotic screw is a surgical implant used to stabilize the ankle mortise after ligament injuries to the syndesmosis, holding the tibia and fibula in correct anatomical alignment.

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Things worth knowing about "Syndesmotic screw"

A syndesmotic screw is a surgical implant used to stabilize the ankle mortise after ligament injuries to the syndesmosis, holding the tibia and fibula in correct anatomical alignment.

What is a Syndesmotic Screw?

A syndesmotic screw (also called a syndesmosis screw or positional screw) is an orthopaedic implant used to stabilize the distal tibiofibular syndesmosis following injury. The syndesmosis is the strong fibrous joint connecting the tibia (shinbone) and the fibula (calf bone) just above the ankle joint. It maintains the integrity of the ankle mortise, the bony socket that guides and supports the talus during movement.

When this connection is disrupted due to ligament rupture or certain ankle fracture patterns (e.g., Weber B and C fractures), the stability of the ankle joint is significantly compromised. The syndesmotic screw is inserted surgically to reduce the fibula back to its correct position relative to the tibia and hold it there during the healing process.

Indications

A syndesmotic screw is indicated in the following conditions:

Syndesmotic ligament injuries (partial or complete rupture of the distal tibiofibular ligaments)
Ankle fractures with syndesmotic instability (especially Weber B and Weber C fracture types)
Maisonneuve fracture (proximal fibular fracture with syndesmotic involvement)
Chronic syndesmotic instability following previous ankle injuries

Surgical Technique

The procedure is typically performed under general or regional anaesthesia. The surgeon first reduces the fibula and tibia to their correct anatomical alignment. The screw is then inserted through the fibula and into the tibia, usually positioned approximately 2 to 3 cm above the ankle joint line. Importantly, the screw does not pass through the joint itself but fixes the two bones above the joint space.

Types of Implants

Several implant options are available:

Cortical metal screw (4.5 mm): The traditional rigid screw, made of titanium or stainless steel
Bioabsorbable screws: Dissolve over several months and do not require a second removal surgery
Flexible fixation devices (e.g., Tight-Rope system): Modern alternatives that allow some physiological movement of the syndesmosis

Postoperative Care and Recovery

Careful postoperative management is essential for a successful outcome:

Immobilisation: The ankle is typically immobilised in a below-knee cast or orthopaedic boot for approximately 6 weeks.
Weight-bearing restrictions: Partial or non-weight-bearing is usually required during the initial healing phase.
Screw removal: When a rigid metal screw is used, it is commonly removed in a second procedure after 8 to 12 weeks, as prolonged retention can lead to screw breakage or restrict normal ankle motion.
Physiotherapy: Following immobilisation, intensive physiotherapy is required to restore range of motion, muscle strength, and proprioception (balance and joint position sense).

Potential Complications

As with any surgical procedure, complications may occur:

Screw breakage due to premature weight-bearing
Malreduction resulting in persistent joint instability
Wound infection or delayed healing
Residual stiffness or restricted ankle mobility
Post-traumatic osteoarthritis of the ankle

Prognosis

With accurate surgical reduction and consistent rehabilitation, the prognosis following syndesmotic injury is generally favourable. Most patients are able to return to sporting activity within several months. However, precise anatomical restoration of the ankle mortise is critical to minimising the risk of long-term complications such as ankle arthritis.

References

Sman AD, Hiller CE, Refshauge KM. Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: systematic review. British Journal of Sports Medicine. 2013;47(10):620-628.
Schepers T. The syndesmotic screw and its removal: a review. Strategies in Trauma and Limb Reconstruction. 2011;6(3):115-121.
van den Bekerom MPJ, Lamme B, Hogervorst M, Bolhuis HW. Which ankle fractures require syndesmotic stabilization? Journal of Foot and Ankle Surgery. 2007;46(6):456-463.

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