Technical Note Technical tip: Removal of a broken tri-cortical syndesmotic screw using a “perfect circle” technique Matthew D. Riedel a, *, Jorge Briceno b , Christopher P. Miller b , John Y. Kwon b a Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA b Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA A R T I C L E I N F O Article history: Accepted 21 February 2018 Keywords: Hardware removal Syndesmosis Technique tip Surgical technique Screw removal Ankle fracture A B S T R A C T While broken or loose syndesmotic screws are typically of no clinical consequence, occasionally breakage can result in pain, metal fretting, or bony erosion. Despite quad-cortical syndesmotic screws being relatively easy to remove due to the prominent screw tip penetrating the medial tibial cortex, removal of a broken tri-cortical screw can be technically challenging. The purpose of this manuscript is to describe a safe technique for removing the buried, broken tri-cortical screw fragment via a minimally invasive medial tibial approach by verifying the screw location using intra-operative fluoroscopy. © 2018 Elsevier Ltd. All rights reserved. Introduction Implant (i.e. hardware) removal is a very common procedure performed by orthopedists with common indications for syndes- motic screw removal being pain, reduced range of motion, or noted malreduction post-operatively [1–4]. Although retrieval of implants is often thought to be a relatively straight-forward procedure, it can be technically challenging especially when hardware is broken. Particularly problematic is a broken screw that is buried inside cancellous bone or is otherwise inaccessible by traditional techniques. Retained syndesmotic screws commonly break or loosen once the patient begins weight bearing. Several studies have demon- strated a 10–36% incidence of screw breakage, depending on timing to full weight bearing and length of followup [5–7]. Moreover, syndesmotic screws were found to be broken at the time of surgery without previous knowledge in approximately 6% of routine implant removals cases [8]. While a broken syndesmotic screw is often asymptomatic, occasionally pain can result particularly if the broken screw spans the incisura. As normal physiologic fibular translation and rotation occurs with ankle dorsiflexion, the broken screw can create a bony erosion in either the tibia or fibula. While quad-cortical syndesmotic screws are easily removed due to the prominent screw tip penetrating the medial tibial cortex, removal of a broken tri-cortical screw can be challenging. Retrieval through the fibula is often prohibitive as it involves creating a large stress riser in the fibula while medial retrieval is technically challenging due to difficulties locating the buried screw tip. The purpose of this manuscript is to describe a technique for removing the buried broken tri-cortical screw fragment via a minimally invasive medial tibial approach by verifying the screw location using intra-operative fluoroscopy and “perfect circle” technique. Technique The representative patient is a 32 year-old female who underwent successful ankle fracture open reduction internal fixation with syndesmotic stabilization (Fig. 1). She presented approximately 9 months after her index surgery complaining of significant anterolateral ankle pain. Pain was worse with weight- bearing and ankle range of motion. Radiographs demonstrated a broken tri-cortical syndesmotic screw causing erosion of the fibula secondary to the screw breaking within the fibular cortex. After successful induction of anesthesia, the patient is placed in the supine position on the operating table. A small bump is placed underneath the ipsilateral hip to slightly internally rotate the extremity. The previous lateral scar is incised and any fibular plate and screw construct (including the broken syndesmotic screw head) is removed in standard fashion (Fig. 2). While the fibular plate was removed in this representative case, this technique does * Corresponding author at: 55 Fruit Street, Suite 535, Massachusetts General Hospital, Boston, MA, USA. E-mail address: mdriedel@partners.org (M.D. Riedel). https://doi.org/10.1016/j.injury.2018.02.022 0020-1383/© 2018 Elsevier Ltd. All rights reserved. Injury, Int. J. Care Injured xxx (2018) xxx–xxx G Model JINJ 7599 No. of Pages 4 Please cite this article in press as: M.D. Riedel, et al., Technical tip: Removal of a broken tri-cortical syndesmotic screw using a “perfect circle” technique, Injury (2018), https://doi.org/10.1016/j.injury.2018.02.022 Contents lists available at ScienceDirect Injury journal homepa ge: www.elsev ier.com/locate /injury