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 Систематический обзор - надо ли рутинно удалять синдесмозный винт? |
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 Отправлено Alexander Chelnokov 21 Ноябрь 2016, 18:13
Should syndesmotic screws be removed after surgical fixation of unstable ankle fractures? a systematic review.
Bone Joint J. 2016 Nov;98-B(11):1497-1504.
Dingemans SA(1), Rammelt S(2), White TO(3), Goslings JC(1), Schepers T(1).
Author information:
(1)Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9,1105 AZ, Amsterdam, The Netherlands.
(2)UniversitätsCentrum für Orthopädie undUnfallchirurgie, Universitätsklinikum "Carl Gustav Carus" TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany.
(3)Department of Trauma andOrthopaedics, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, UK.
AIMS: In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery.
MATERIALS AND METHODS: A literature search was conducted in Medline, Embase and the Cochrane Library for articles in which the syndesmotic screw was retained.Articles describing both removal and retaining of syndesmotic screws were included. Excluded were biomechanical studies, studies not providing patientrelated outcome measures, case reports, studies on skeletally immature patients and reviews. No restrictions regarding year of publication and language wereapplied.
RESULTS: A total of 329 studies were identified, of which nine were of interest, and another two articles were added after screening the references. In all, tworandomised controlled trials (RCT) and nine case-control series were found. The two RCTs found no difference in functional outcome between routine removal andretaining the syndesmotic screw. All but one of the case-control series found equal or better outcomes when the syndesmotic screw was retained. However, allincluded studies had substantial methodological flaws.
CONCLUSIONS: The currently available literature does not support routine elective removal of syndesmotic screws. However, the literature is of insufficient qualityto be able to draw definitive conclusions. Secondary procedures incur a provider and institutional cost and expose the patient to the risk of complications.Therefore, in the absence of high quality evidence there appears to be little justification for routine removal of syndesmotic screws.
Cite this article: Bone Joint J 2016;98-B:1497-1504.
©2016 The British Editorial Society of Bone & Joint Surgery.
DOI: 10.1302/0301-620X.98B11.BJJ-2016-0202.R1 PMID: 27803225 [PubMed - in process]
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Re: Систематический обзор - надо ли рутинно удалять синдесмозный винт?
Антон Бехтерев 22 Ноябрь 2016, 01:14
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Подходит для тех случаев, когда позиционный винт установлен по правилам. Недавнее обсуждение похожей темы показало, что "позиционный винт" каждый понимает по-своему.
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Re: Систематический обзор - надо ли рутинно удалять синдесмозный винт?
Бережной Сергей 22 Ноябрь 2016, 01:49
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Сейчас есть даже тренд такой - ставить короткие, 3-4 см, позиционные винты. Чтобы не удалять их. Аргументируют тем, что лизис костной ткани, появляющийся вокруг винта с началом нагрузки, предотвратит его перелом, а микроподвижность винта не будет вызывать болевых ощущений. Ведь от перелома винта никто не застрахован, даже при правильной его установке. А сломанный винт, как правило, вызывает внутреннее неприятие, как у врачей, так и у пациентов. Несмотря на то, что чаще всего не является причиной болевых ощущений.
В дополнение к вышесказанному - работа (тоже тезисы) о лучших функциональных исходах при сравнении случаев со сломанными или удаленными винтами с не удаленными, но целыми.
J Orthop Trauma. 2010 Jan;24(1):2-6.
Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal.
Manjoo A1, Sanders DW, Tieszer C, MacLeod MD.
OBJECTIVE:
Screw fixation of the injured syndesmosis restores stability but may reduce motion. The purpose of this study is to determine whether functional outcomes and radiographic results after ankle fracture are affected by the status of the syndesmosis screw.
DESIGN:
Retrospective review of a consecutive clinical series.
PATIENTS:
One hundred six adults were reviewed radiographically; mean follow up was 15 months (range, 4-30 months). Seventy-six of the 106 patients completed formal functional testing; mean follow up was 23 +/- 13 months (range, 12-32 months).
INTERVENTION:
Open reduction and internal fixation, including fixation of the tibiofibular syndesmosis.
MAIN OUTCOME MEASUREMENTS:
Patients with intact, broken or loose, or removed syndesmosis screws were compared. Functional outcomes were measured using the Lower Extremity Measure and the Olerud Molander ankle score. Radiologic review included tibiofibular clear space, tibiofibular overlap, and medial clear space.
RESULTS:
Functional outcomes were improved in patients with fractured, loosened, or removed screws compared with those with intact screws. The Lower Extremity Measure score for patients with intact screws was 70 +/- 6 compared with 85 +/- 3 for fractured, loosened, or removed screws (P = 0.01). The Olerud Molander ankle score for patients with intact screws was 47 +/- 8.0 compared with 64 +/- 4 for fractured, loosened, or removed screws (P = 0.04). There was no difference in outcome comparing fractured, loosened, and removed screws. The tibiofibular clear space was narrowed in patients with intact screws compared with removed, fractured, or loose screws. The tibiofibular clear space for intact screws was 3.1 +/- 0.2 compared with 4.1 +/- 0.2 for removed, fractured, or loosened screws (P = 0.005). There was no difference in outcome comparing large and small fragment screws.
CONCLUSIONS:
An intact syndesmosis screw was associated with a worse functional outcome compared with loose, fractured, or removed screws. However, there were no differences in functional outcomes comparing loose or fractured screws with removed screws. Screw removal is unlikely to benefit patients with loose or fractured screws but may be indicated in patients with intact syndesmosis screws.
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