[Ortho] Систематический обзор - надо ли рутинно удалять синдесмозный винт?

Бережной Сергей orthoforum на weborto.net
Вт Ноя 22 02:25:33 YEKT 2016


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.
Бережной Сергей

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