All About Rehabilitation After Ankle Hardware Removal!

Is the hardware in the ankle always removed?

I will first discuss hardware removal in adults.

The general rule is that the hardware is removed only if it causes discomfort or if there is a complication necessitating its removal (such as an infection that did not respond to joint lavage or an allergy).

It also heavily depends on the practice habits of the surgeons you encounter. Some may have a more conservative approach, preferring to keep the hardware as much as possible.

Others, on the contrary, prioritize removal.

In Ireland 🇮🇪, a research team (Fenelon 2019) looked at the outcomes of 1482 people who underwent ankle fracture surgery and were followed for a period of 10 years: 1 in 10 adults had their surgical hardware removed.

In Finland 🇫🇮, 68,865 individuals who underwent surgery for a malleolar fracture between 1997 and 2016 were followed (Partio 2020). A higher number of individuals had their osteosynthesis material removed: 27% (more than 1 in 4 adults).

However, the research team notes that hardware removal is becoming less common over the years, as illustrated in the graph below:

When is hardware removal performed in the ankle?

Here are the most common reasons for removing screws and plates from the ankle (Jung 2016):

• Pain due to irritation of soft tissues during resumption of normal activities (work, sports) after consolidation.
• Late deep infections.
• Allergies or metal toxicities.
• Hardware migration (the hardware has shifted, it is no longer in place).
• Metal failure: the hardware has broken or become damaged.
• A new ankle fracture at the level of the hardware.
• Tumorigenicity (rare and highly theoretical: development of a tumor at the implant site).

When is removal performed? If it’s due to discomfort, surgeons usually recommend waiting at least 6 months to 1 year before considering removal.

This is because the inflammation resulting from the ankle fracture and surgery may take some time to subside.

Can you walk immediately after hardware removal?

Yes, in the majority of cases, it is possible to walk immediately after hardware removal at the ankle.

Especially if the hardware was removed due to discomfort and pain: this means that the bone was sufficiently well consolidated and can bear the stresses of walking.

You can walk even without crutches, walking boot, or cast if possible for you. Gradually increase distances and walking intensity according to your comfort level.

If the hardware was removed due to an infection or other issues, it is sometimes recommended to remain non-weight-bearing and walk with crutches for support. This is to facilitate bone consolidation.

This information is provided orally and in writing in your operation report. If you find it inappropriate, you can discuss it with your primary care physician or physiotherapist!

How do pain levels evolve after removing hardware from the ankle?

Generally, the aftermath of hardware removal is easier and less painful than the aftermath of hardware insertion.

However, it is normal to experience some pain, at least in the first few days following the operation. Standard methods to relieve pain can be used:

• Apply cold packs (without direct contact with the skin; place a clean cloth between the cold pack and the skin).
• Elevate the foot higher than the heart.
• Wear compression socks (if there are no contraindications).
• Take prescribed or over-the-counter pain medications.
• And any other acute pain management approach that you find effective!

Pain is usually not a sign of complication but rather related to inflammation triggered by the removal of hardware.

Typically, inflammation and pain decrease over the following days and weeks. By one month after hardware removal, they have usually significantly reduced.

What rehabilitation after ankle hardware removal?

If you have difficulty walking or experience significant pain after ankle hardware removal, physiotherapy sessions will likely be prescribed for you.

However, rehabilitation is not always necessary after surgical hardware removal. If you had fully healed and resumed all your previous activities, the removal of the hardware generally does not set you back.

After removal, monitor how you move your ankle: can you actively flex and extend it (with your own strength)? Can you do so with your hands?

Do you feel stable when walking? Do you feel confident to gradually resume all your activities?

If you answer yes to all these questions, you probably do not need specific rehabilitation.

If you have doubts or answer no to some of these questions, then an assessment with a physical therapist seems appropriate. Your primary care physician can prescribe physiotherapy sessions if your surgeon has not already done so, while waiting to see any physiotherapist without a prescription!

If needed, rehabilitation aims to regain:

• Good mobility in ankle movements.
• Muscle strength in the muscles controlling the ankle.
• Stability for everyday activities or sports activities (such as jumps).
• A minimally painful ankle.

And ankle hardware removal in children?

Considerations regarding hardware removal in children are different due to bone growth. The removal of hardware is controversial and not systematic even in children, who are among the most frequent ankle fracture patients.

A team in the United States 🇺🇸 followed 1008 children and adolescents who underwent ankle fracture surgery. 1 in 4 children (24%) had their hardware removed.

On average, the hardware was removed 276 days after the operation (approximately 9 months), with a wide range: some had their hardware removed after 3 weeks, while others after 4 years.

The research team also looked at how children progressed afterward. They found no difference in terms of new medical or surgical procedures performed on the ankle in the following years between children who had hardware removed and those in whom it was left in place.

Source: Pearce 2023