Case Study: Chronic Ankle Pain Following Surgery

Figure 1. Anteroposterior radiograph of the left ankle.
Figure 2. Lateral radiograph of the left ankle.

Case Study:
Explanation:

A 66-year-old woman presents with chronic left ankle pain. She underwent open reduction and internal fixation (ORIF) for an ankle fracture approximately 1 year ago. Anteroposterior and lateral radiographs of the left ankle are obtained (Figures 1 and 2). Since the surgery, the patient has noticed pain and occasional swelling over the lateral ankle that is made worse with physical activities. On physical examination, she has pain to palpation over the lateral ankle hardware. No erythema, warmth, or sign of infection is noted. The patient asks if removal of hardware would alleviate her symptoms.

Which statement is true regarding removal of hardware after ORIF of the ankle?

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Painful hardware of the foot and ankle is common following ORIF. The bones of the foot and ankle have little subcutaneous tissue and skin coverage that often causes sensitivity over the underlying hardware. Patients often complain of tenderness as well as heightened pain during activities. Screw displacement with tenting of the skin that is visible on radiograph is an obvious indication for removal of hardware.

Nondisplaced painful hardware is a challenging problem to address. While removal of hardware is a common procedure that is performed following foot and ankle surgery, no widely accepted indications exist for doing so. According to a study published in the Journal of Orthopaedic Trauma, 31% of patients with a history of ORIF for an unstable ankle fracture went on to have symptomatic hardware.1 The average time for removal of hardware postoperatively was 37 weeks, and only 50% of patients who had hardware removed reported an improvement in pain. Other studies have reported relief of pain in up to 65% of patients after removal of hardware from the ankle.2 Removal of hardware is usually considered well after bony union or around 8 to 12 months postoperatively if chronic pain is present.

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).

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