Headless Compression Screws May Reduce Symptomatic Hardware After Medial Malleolus Fixation: A Comparative Cohort Study
Journal of Orthopaedic Trauma · 9 Oct 2026
† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.
Why it matters
Symptomatic hardware is one of the commonest complications after ankle fracture fixation, and implant choice over the subcutaneous medial malleolus is a modifiable decision that trainees will see daily.
The evidence
This single-centre retrospective study compared two kinds of screws for fixing medial malleolus (ankle) fractures in 306 adults: headless compression screws, which sit below the bone surface, and standard headed screws. Medial-sided hardware irritation was documented in 23 of 111 patients (20.7%) with headless screws versus 68 of 195 (34.9%) with headed screws, an adjusted odds ratio of 0.55 (95% CI 0.32 to 0.96). Rates of hardware removal (23.4% vs 30.8%), nonunion and infection did not differ significantly. Every headless screw came from a single surgeon, so the screw effect cannot be separated from that surgeon's technique.
Symptomatic hardware (medial-sided hardware irritation): Odds ratio 0.55 (95% CI 0.32 to 0.96; ratio). The interval favours the first group; the size of the benefit needs clinical interpretation.
Why this rigour score?
Retrospective cohortDesign starting point: 29.6
Raised the score
- Compared against current standard of care+3.4
Lowered the score
- A single centre's own patients−3.4
Methods at a glance
Recorded assessment- Confounding adjustmentMultivariable regression
- Covariate balance confirmedNot applicable
- Outcome assessors blindedNot reported
- Comparable start of follow-upNot reported
- Adequate statistical powerNot reported
- Prospective registrationNot met
Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.
See the full score breakdown
- Study design starting point
- 29.6
- Compared against current standard of care
- +3.4
- A single centre's own patients
- −3.4
- Journal prior (not an observed method)
- +1.4
- Final rigour score rounded
- 31 / 100
Study design sets the starting point and a ceiling of 72. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.
Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.
For journal club
1.Given that headless screws lowered documented irritation but did not significantly reduce hardware removal surgery, how would you counsel a thin patient with a medial malleolus fracture about implant choice and the likelihood of a second operation?
2.In an older patient with osteoporotic bone, would you still choose a headless compression screw over a headed screw that can buttress the fragment, and how would that choice affect your follow-up plan?
Original publication title
Headless Compression Screws May Reduce Symptomatic Hardware After Medial Malleolus Fixation: A Comparative Cohort Study