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.