Headless Compression Screws May Reduce Symptomatic Hardware After Medial Malleolus Fixation: A Comparative Cohort Study.

OBJECTIVES

To compare rates of medial-sided symptomatic hardware, hardware removal, and fracture union following medial malleolus fixation using partially threaded, headless compression screws versus traditional partially threaded, headed screws.

METHODS

Design

Retrospective cohort.

SETTING

Single, academic, Level I trauma center.

PATIENT SELECTION CRITERIA: Skeletally mature patients who underwent operative fixation of a medial malleolus fracture [OTA/AO 44A-C] between 2021 and 2025 and had a minimum of 3 months follow-up were included.

OUTCOME MEASURES AND COMPARISONS: Demographics, injury characteristics, and surgical management was collected for the headless and headed screw cohort. The primary outcome was medial-sided symptomatic hardware. Secondary outcomes included removal of hardware from the medial malleolus, medial malleolus fracture union, and infection of the medial aspect of the ankle. A comparison between the medial malleolus screw type used was undertaken.

RESULTS

Of 306 patients, 195 (63.7%) received headed screws (mean age 56.0 years, range 18-92; 72.3% female; mean follow-up 15.1 months) and 111 (36.3%) received headless compression screws (mean age 51.0 years, range 18-95; 58.6% female; mean follow-up 13.2 months). Symptomatic hardware occurred in 34.8% of patients in the headed screw group compared with 20.7% in the headless screw group (p = 0.01), corresponding to an absolute risk reduction of 14.1%. Hardware removal rates did not differ between groups (30.8% vs 23.4%, p = 0.17). There were no differences in nonunion (3.6% vs 3.6%, p = 0.99) or infection rates (4.6% vs 5.4%, p = 0.97). On multivariable analysis, headless screw fixation was independently associated with a decreased likelihood of symptomatic hardware (odds ratio 0.55, 95% CI 0.32-0.96, p = 0.04). No independent association was observed between screw type and hardware removal.

CONCLUSIONS

Headless compression screws may be associated with a lower rate of symptomatic hardware at a mean of one year following medial malleolus fixation without compromising fracture healing or increasing infection risk. The lower observed incidence of symptomatic implants may suggest a clinically meaningful benefit of implant selection in this subcutaneous anatomic region.

LEVEL OF EVIDENCE: Level III, retrospective cohort study.