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Background: Syndesmotic fixation is a standard treatment for tibiofibular syndesmosis injury, especially in ankle fractures, but the necessity of routine screw removal remains debated. This study evaluates the impact of routine removal on functional outcomes, complication rates, and recovery, aiming to clarify its clinical relevance. Methods: This retrospective observational study included 330 patients treated surgically for tibiofibular syndesmosis injuries at a single institution from 2016 to 2024. Patients were categorized into three groups: no removal, routine removal, and removal for clinical indications. Functional outcomes were assessed using the Olerud–Molander Ankle Score (OMAS), and complications, including infections and prolonged pain, were recorded. Statistical analyses evaluated differences between groups. Results: Of the 170 patients who completed follow-up, no significant differences in OMASs were found between the groups (p = 0.646). Complications were more frequent in reoperated patients (9% vs. 2% for non-reoperated), but routine removal did not improve functional outcomes. Younger patients showed better OMASs, highlighting age as a key factor in recovery. Fixation and fracture types had no significant impact on outcomes. Conclusions: Routine syndesmosis screw removal offers no significant functional benefits, as demonstrated by comparable OMASs across groups (median OMAS: 85 for non-reoperated, 80 for routinely reoperated, and 80 for indication-based reoperated patients). However, routine removal is associated with a higher complication rate. A selective approach focusing on clinical indications is recommended to minimize unnecessary surgeries and optimize patient outcomes. Future research should focus on redefining evidence-based management strategies for syndesmotic fixation.

Background/Objectives: Acute ankle sprains are common injuries that significantly affect both sports and daily activities. Syndesmotic injuries, a specific type of ligamentous damage, can occur as a part of a sprain or alongside fractures, affecting approximately 20% of ankle fractures. The aim of this study was to evaluate negative prognostic factors influencing surgical outcomes in tibiofibular syndesmotic injuries associated with ankle fractures. Methods: Data from 246 patients were analyzed to examine the impact of initial ankle dislocation, fracture type, and fixation method on postoperative complications and reoperation rates. Ankle joint fractures were treated with open reduction and internal fixation using an anatomically contoured plate designed for optimal tibia and fibula fixation. Four methods of syndesmosis fixation were recorded: one three-cortical screw, one four-cortical screw, two screws (either both four-cortex screws or one three-cortex and one four-cortex screw), or one endobutton. Data analysis was performed using SPSS version 25 (IBM Corp., Armonk, NY, USA). Results: Key findings reveal no significant association between initial dislocation and the necessity for reoperation (p = 0.613). However, smoking combined with dislocation significantly increases reoperation rates (35% vs. 15.5%, p = 0.026). Fixation type influenced outcomes, with single four-cortex screws linked to pain but fewer infections. Infection was the most common complication (33.3%), predominantly after fixation with a single three-cortex screw. Men had higher rates of fixation destabilization and infections, while women experienced pain persisting beyond six months postoperatively Conclusions: Patient-specific factors influence syndesmotic injury outcomes. Smoking, gender, and fixation type impact complications, emphasizing the need for tailored surgical approaches to enhance recovery and minimize reoperation risks. Future research should aim to corroborate these findings in larger, multicentric cohorts to refine surgical strategies for syndesmotic injury management.