Painful Hardware

Summary

Metal screws and plates are often used in surgery to fix fractures, fuse joints, or stabilize bones that have been cut (osteotomies) in the foot and ankle. In most instances, these screws and plates do not create symptoms and remain permanently in the foot. However, in some patients, hardware can become prominent or irritate a nearby tendon or other soft tissues. Some patients also complain of achiness in the foot or ankle related to weather changes. Initially, this may be treated with shoe modifications, padding over the area, and simple measures to reduce the local swelling and inflammation. However, if this is not satisfactory, patients may benefit from painful hardware removal once the fracture, fusion, or bone cut has fully healed.

Clinical Presentation

Patients that have previously had surgery to fix a fracture or to fuse a bone of the foot and ankle may have retained hardware that can become prominent and/or creates discomfort. While most retained hardware is asymptomatic, some patients will develop symptoms. The symptoms can be due to a screw or plate that rubs against a boot, or pain may be produced when the tendon or soft tissue structure rubs against the prominent screw or plate. When patients are recovering from the original injury or surgery, the symptoms and swelling are such that the hardware is usually not a significant issue. However, over time when the swelling settles, hardware can become prominent and in some instances, may need to be removed. However, some patients will complain of achiness in the foot or ankle related to weather changes. An infection can occasionally be the cause of pain as well, so your surgeon will evaluate patients for this potential problem.

Physical Exam

On exam, the hardware may be felt under the skin. There may be a bursa (fluid filled sac of tissue) or an area of inflammation associated with the area. The symptoms can often be reproduced with motion of the joint or movement of nearby tendons.

Imaging Studies

X-rays will reveal the hardware if it is metal (most screws are stainless steel or titanium). X-rays may also identify the area of the hardware which is likely to be causing the symptoms. X-rays can also tell if the hardware has shifted in location or broken. Occasionally prominent, non-absorbent sutures or other forms of retained surgical material may create symptoms but may not show up on x-rays. These objects are generally not seen on x-ray (radiolucent). MRI scans are rarely useful for painful metal implants since metal causes “artifact,” which prevents visualization of neighboring tissues, or even the entire foot.

Treatment

Most hardware that is placed to fix a fracture or fuse a joint does not need to be removed and, in fact, will not cause any symptoms. In most instances, it is either retained within the bone or is not particularly prominent with adequate covering of soft tissues. However, with some individuals and with some types of surgeries, symptoms may arise. In this instance, symptoms can be treated with local padding, such as wearing a thick sock or using a local gel pad. A change in shoes or modification of existing shoes may also be helpful. If this is not acceptable for symptom relief, then consideration should be given to removing the hardware after the fracture or fusion has fully healed. Hardware removal should be considered if there are any skin issues or signs of infection.

Surgical Removal

Surgery to remove metal implants is usually performed on an ambulatory or outpatient basis (i.e., go home the same day). For many implants, this can be done under regional or local anesthesia (i.e., a “nerve block”), which means that you can stay awake (if you want) for the procedure and not feel anything. The same incisions used for the original surgery are typically used for the removal procedure. Many of the same peri-operative risks apply for hardware removal, as for any surgical procedure. Certain foot and ankle operations have a higher rate of needing hardware removal than others. These include:

A previous ankle fracture fixation of the distal fibula
A calcaneous osteotomy with a prominent screw in the heel area.
A calcaneal fracture with hardware on the outside aspect of the heel bone.
A lateral column lengthening procedure as part of a flat foot reconstruction with hardware on the outside and front part of the heel bone (calcaneous).
Hardware placed in the midfoot and forefoot may be prominent and may need to be replaced.

Edited October 21, 2018

Previously Edited by Kenneth Hunt, MD

mf/ 5.29.18