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Syndesmotic screw removal after broken ankle?
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By Paul Fleming
Feb 18, 2013
Broke my ankle about a 8 weeks ago (being lowered off a climb by a guide, fell about six feet) and had it repaired. Now the question is, do I undergo surgery to remove syndesmotic screws? My doctor says he usually doesn't remove the screws unless they are causing pain or impede range of motion. I'm thinking this may be fine for people who aren't going to really stress their ankle, but not for someone who wants to continue climbing/skiing/kiteboarding etc. Medical articles I've read says that the screws frequently loosen or break. (olc.metrohealth.org/SubSpecial... )The most recent metastudy (ncbi.nlm.nih.gov/pmc/articles/... looks at outcomes from 7 other recent studies) says that removal of screws results in outcomes that are similar to results if the screws become loose or break. Results for the intact screws were the worst.

While it would be great to avoid surgery and the additional time I would have to spend on crutches after screw removal, I'd rather not have to deal with it later.

Anyone have to make this decision that has an opinion, or a bad experience with leaving the hardware in place?


ankle
ankle

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By DannyUncanny
From Vancouver
Feb 18, 2013
My non-medical opinion is get it removed if you can. It's the trade off between the immediate risk of surgery, or the life long risk of your body having complications with the hardware. In my case, the screws were too long (sticking out the far side) and gouging cartilage in my ankle joint.


Try and ask the surgeon if you can keep the screws. Mine wouldn't let me have them because they are supposedly a bio hazard.

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By AWinters
Administrator
From NH
Feb 18, 2013
Red-tail Hawk, Buttermilks
Looks a lot like my x-ray.

I broke mine summer of '09 and still have all the hardware with no complications. I'd say unless it's bothering you or preventing you from performing certain activities then leave it be. That stuff is meant to stay for life. I have one screw head on my outside ankle bone that I can feel thru my skin and it chafes a little with my mountaineering boots and ski boots but I've learned to deal with it. Most people I know with hardware have accepted to live with it forever. If you don't notice it then there's really no point in going thru another surgery in my opinion.


hardware
hardware

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By Guy Keesee
From Moorpark, CA
Feb 18, 2013
Big Boulder, just a bit downhill from Temple of Ka...
I like to feel mine through the skin.... lets me know just whats holding me together. :>)

I noticed that your injury was when a GUIDE lowered - dropped - you.

Were they using some sort of "funky guide style belay devise?" Just looking for info.

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By AWinters
Administrator
From NH
Feb 18, 2013
Red-tail Hawk, Buttermilks
DannyUncanny wrote:
Try and ask the surgeon if you can keep the screws. Mine wouldn't let me have them because they are supposedly a bio hazard.


That's weird. I had one screw removed that stabilized my tibia and fibula while the ligament in between them healed and my doc gladly gave it to me to keep. They cleaned it up and handed it over. My doc is one of the top orthopedists in the country (Mammoth, CA) and treats the US ski team when injured in the area. Don't understand the whole bio-hazard reasoning. Seems if it's properly cleansed then there's no risk.

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By Paul Fleming
Feb 19, 2013
Guy Keesee wrote:
I noticed that your injury was when a GUIDE lowered - dropped - you. Were they using some sort of "funky guide style belay devise?" Just looking for info.

He was using an ATC guide in lower mode (with brake strands redirected through a carabiner above the device.) Accident happened when I was getting lowered (from the top) off a 70 M ice climb. Lowered over the first two steps and when I was backing over a 6 foot ledge at the bottom I dropped to the ground. I think the problem was that I was out of sight and hearing distance (it was windy) and he continued paying out enough rope to relieve all of the stretch in the double ropes, as he did not realize I was backing across a ledge. My analysis is that it is inherently unsafe to be lowered off a climb where you are out of sight and can't hear one another. It would have been much safer to rappel, which I will do in the future.

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By Paul Fleming
Feb 19, 2013
Adam Winters wrote:
That's weird. I had one screw removed that stabilized my tibia and fibula while the ligament in between them healed and my doc gladly gave it to me to keep. They cleaned it up and handed it over. My doc is one of the top orthopedists in the country (Mammoth, CA) and treats the US ski team when injured in the area. Don't understand the whole bio-hazard reasoning. Seems if it's properly cleansed then there's no risk.

The screws bridging the tib-fib are the ones I am concerned about. I plan to ask to have those removed (or I anticipate they will break) and leave the rest in place.

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By Michael Schneiter
From Glenwood Springs, CO
Feb 19, 2013
Goofin' on the Grand after soloing the Upper Exum ...
Paul Fleming wrote:
Anyone have to make this decision that has an opinion, or a bad experience with leaving the hardware in place?

I would always defer to scientific studies or a doctor's expertise than personal experiences but here's my experience.

I had two screws placed in my medial malleolus of my right tibia in 2004. My doctor said then, and maintains now, that as long as they don't bother me they can stay in indefinitely. I saw him recently and we discussed it briefly. I don't even notice they're in and have had a great experience of climbing a ton, running marathons, backcountry skiing and ski mountaineering racing, etc. It has never hindered me. I felt like the area was slightly more sensitive for a year or two but nothing that held me back from doing anything. For example, if I was running in snowshoes and a snowshoe bumped that area it felt more sensitive than if I did it to the other ankle. I also wonder if sometimes that was just in my head because now I don't have those experiences and I think it could be because I've basically forgotten about it.

I have heard from people that have had screws loosen and basically start to back out and then they had them removed. But, I know it's an uncomfortable thing to have them taken out and to have to go through a recovery period again so I'm happy to leave mine in for as long as possible.

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By John Ryan
From Poncha Springs, CO
Feb 19, 2013
No Name Crack, 5.10, Supercrack Buttress, Indian C...
My wife had a bimalleoral (if I remember correctly) ankle fracture - tib/fib break during a roller derby practice. She has one plate and a bunch of screws. Her injury was early September 2012. Her orthopedic surgeon told her what you're hearing in this forum - no need to remove the hardware unless it becomes painful or annoying. So far it is not bothering her, and she has returned to her favorite activity of roller skating - not near full strength or range of motion yet but getting out there. One of her teammates had an exact fracture maybe six months earlier. She was annoyed by the hardware but left it in, and about 9 months after surgery it stopped being a nuisance to her anymore, so she left the hardware in and it doesn't seem to hinder her.

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By crankenstein
Feb 19, 2013
My hardware looks similar to the photos above and it has caused me no problems yet. It's been over a year since it was installed and I would never think about another surgery unless it was really causing a problem for me.

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By kovarpa
Feb 19, 2013
I had two screws put in when I broke my tib/fib in 2005. The screws were getting irritated when wearing boots and in general were causing pain so I had them removed ~9 months after the initial surgery.
While recovery from the injury and the first surgery was long (and painful), the recovery from having the screws removed was very quick.

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By George Bell
From Boulder, CO
Feb 19, 2013
Hip trouble ...
Hate to think of it, but what would happen if you break your leg again? Would it be better or worse to have the screws in place? Would they hold your tibia together or make whatever breaks worse? I imagine this is a pretty complex question ...

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By Woodchuck ATC
Feb 19, 2013
Rock Wars, RRG, 2008
Looks alot like mine from 5 years ago....but I only had 4 shorter screws put in. they stay in place. no problem with them so far, but as the swelling went down over 3 years, the screw heads did become noticable against my skin. As long as nothing rough grinds against the bone, it's OK for me.

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By Guy Keesee
From Moorpark, CA
Feb 19, 2013
Big Boulder, just a bit downhill from Temple of Ka...
Paul... thanks for the answer... ouch!

Agree with the lowering.

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By Chris treggE
Administrator
From Madison, WI
Feb 19, 2013
Other fun stuff.
George Bell wrote:
Hate to think of it, but what would happen if you break your leg again? Would it be better or worse to have the screws in place? Would they hold your tibia together or make whatever breaks worse? I imagine this is a pretty complex question ...


My understanding is that these plates and screws are not load bearing, they just hold stuff in the proper alignment for the bones to heal. The bones themselves are stronger than the metal.

I wouldn't have a surgery to remove stuff unless it was causing a specific problem. I still have plate and screws in my wrist from 8 years ago.

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By heather ann
Feb 3, 2014
Question: What does it feel like when your screws break? How do I know? I had a spiral fracture of my fibula, tibia in 7-8 chunks, and talus "crumbled" (apparently that is a technical term) in 10/12. Got 2 plates and 15 screws. Had 2 syndesmosis screws removed in 1/13 as planned from beginning. Dorsiflexion continued to be severely limited so had bone chips removed from joint in 4/13. Freakish swelling problems started, so had all hardware removed in 11/13 HOWEVER this surgery was with a different doctor (I live in rural upper MI, traveled to Minneapolis for surgery #4) and he put the syndesmosis screws back in. He said they would probably be fine long term. Well, about a month ago I started to develop severe pain with bearing weight AFTER resting. So, particularly bad in the morning. Feels like there are sharp rocks inside my joint. Oddly, the pain eventually goes away with continued weight bearing...then comes back after I've rested for any length of time. I carry crutches around with me and use them any time I get up for the first 1-30 minutes of walking, depending how long I've been resting. Has anybody ever experienced pain that appears to be CAUSED by rest??? Any words of wisdom would be appreciated...I'm getting tired of this. Thanks!

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By Kevinmurray
Feb 3, 2014
I have the same problem with pain after rest or even driving for a while. Spiral fracture of big bone at ankle on rt. leg with an external fixator for three months is what is the cause of my problem. Very limited mobility is what causes most of the pain. This happened 11 years ago and I just deal with it. Pain goes away with a couple minutes of weight on it. Sorry no words of advice. High possibility of arthritis with these types of breaks, lot's to look forward to.

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By Bernadette Morris
Jun 18, 2014
I had broken my ankle, as my doctor would describe it, as having the ankle slide clean of my foot. After four years of keeping it in the hardware began to cause issue where my ankle would lock up if it got too cold. They removed my pin February of this year and did an anthroscopy to remove as much inflamed cartilage as possible. All went well until two weeks ago where it appeared my ankle was starting to cave from the outside in toward my old injury. Personally, Im concerned for the structure of my ankle and if it was a wise choice to take it out at all. I'm most likely going to see my doc about getting x rays done once again. Its always good to consider the wellbeing of ones bones because you cannot guarantee how they will mend especially since my work has always consisted of long periods of time standing and manual labor.

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By Anita K
Nov 2, 2014
my  robo ankle
my robo ankle

ok...I am new here so bare with me. Back in Feb (2014) I broke my rt ankle while on the job. (I am a waitress at a very well known chain restaurant). Ha a trimaleolar fracture...very painful. After surgery (6 screws and 2 plates), I went back to work. Still in a ton of pain and my bosses having a fit cause I am constantly in pain were on my back (in fear of losing my job).....Now its November and I just went to the workers comp doc who told me that 2 of the screws have started backing out of the bones (that one really long screw thats on my xray pic is one of the problem screws.
Well....i feel like I have 2 toothaches on either side of my leg. I am at my wits end....so I made an appt with the ortho doc to have em removed. Is this surgery painful...whats the usual recovery time...when can I expect to get back to work?

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By Lee Green
Nov 3, 2014
My opinion as a physician, professor, and the former owner of a set of screws and plates in my femur: have them out. If you are the typical patient, i.e., sedentary, they won't be a problem and it's safest to leave them, avoiding the small but nonzero risk of surgery. Be careful of the advice of most surgeons though, who are used to dealing with the typical sedentary patient. Your mileage *will* vary, not just "may". Climbers are not typical patients.

The review you cite was well done, but suffers from the inherent limitation of all systematic reviews: it can only address what the studies reviewed covered. The studies were done on typical patients, and the results can't be extrapolated to those who differ in significant ways.

The hardware makes stress risers in the bone, increasing the risk of fracture in the future. It is also more likely to cause problems (scarring, pain, contracture) in the soft tissues on which they inevitably impinge in an active person than in the usual sofa spud.

Bottom line is that the right answer is context-dependent. For 90% of patients, who are either sedentary or whose activity is low-intensity, the right answer is leave them alone. More serious recreational athletes and especially adventure sports participants are IMO best off removing them once healed.

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By Anita K
Nov 3, 2014
I am not intoclimbing, hiking, or really any sports. I am a hard worker in the restaurant industry...which means...heavy lifting...running back and forth...climbing on ladders to get stock...climbing up the shelves when ya cant find the ladder...and doing all this as fast as possible. (I am not independently wealthy and have to work hard to pay my bills). So...I guess take em out is the way to go.....but am not looking foreward to more pain and recovery time. Plus, my boss isnt happy cause the injury occurred on the job. So I am trying not to miss more time from work for fear that they may fire me. And if they do fire me, who is going to hire a 50 yr old female with a bad leg?

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By Paul Fleming
Nov 3, 2014
Sounds like worker's comp should cover your injury. I would guess that it is illegal to fire someone for missing work due to an injury suffered on the job. (I'm not a lawyer though, so you should ask someone who is.)

I have not had the screws removed and after almost two years they have not caused me any problem. I can climb/ski as well as ever and jumping from the top of a bouldering wall onto pads doesn't cause any problems. Running is not great, but I've been doing it to try to stress syndesmotic tissue/vasculature that was damaged in surgery and force it to rebuild.

Good luck!

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