How long should ankle hardware be kept in place after surgery?

Hardware Retention Duration After Ankle Surgery

Ankle hardware should typically remain in place permanently unless symptomatic, with routine removal after bony union (approximately 3-6 months) being an acceptable option that improves pain and function in most patients. 1

Evidence-Based Timeline for Hardware Management

Immediate Post-Operative Period (0-10 days)

• Short-term rigid immobilization (<10 days) can be used to control initial pain and swelling 2, 3
• Transition to functional support (ankle brace) rather than prolonged casting after this initial period 2, 3

Early Recovery Phase (2-6 weeks)

• Functional support with an ankle brace should be maintained for 4-6 weeks rather than rigid immobilization 2, 3
• This approach provides superior outcomes including earlier return to work (8.23 days faster) and better patient satisfaction compared to prolonged immobilization 2
• Prolonged immobilization beyond 4 weeks results in suboptimal outcomes including ankle stiffness and impaired mobility 2, 3

Hardware Removal Considerations

Timing for Removal:

• Hardware removal is typically performed after bony union is confirmed, generally at 3-6 months post-operatively 1
• Removal performed 9-18 months after insertion has lower complication rates than removal after 18 months (3x higher odds of incomplete removal/breakage with delayed removal) 4
• Average time for ankle arthrodesis fusion is 11.8 weeks (range 8-18 weeks), after which hardware removal can be considered if symptomatic 5

Clinical Outcomes of Hardware Removal:

• 72.5% of patients experience improved ankle stiffness after hardware removal 1
• 81.3% report less discomfort while walking on uneven ground 1
• 80.8% of patients are satisfied with hardware removal 1
• Pain scores decrease from average 3.4 to 1.3 after removal 1
• 88% of patients who undergo hardware removal for pain experience postoperative pain relief 4

Complications of Hardware Removal:

• Overall complication rate is 9.5% in pediatric populations, though this data is relevant for understanding risk 4
• Most common complications include sustained new-onset postoperative pain (2.6%), incomplete hardware removal (1.6%), and perioperative fracture (1.4%) 4
• Hardware removal performed at an average of 11 months post-operatively for symptomatic screws is common practice 5

Clinical Decision Algorithm

Indications for Hardware Removal:

• Persistent hardware-related pain despite conservative management 1
• Ankle stiffness limiting function 1
• Discomfort during ambulation on uneven surfaces 1
• Patient preference after informed discussion of risks and benefits 1

Contraindications to Removal:

• Active infection (hardware must remain until infection cleared in certain fracture patterns requiring stability) 6
• Inadequate bony union 5
• High-risk fracture patterns requiring permanent fixation for stability 6

Common Pitfalls to Avoid

• Premature removal: Removing hardware before adequate bony union (typically <3 months) risks fracture instability 5
• Delayed removal: Waiting beyond 18 months increases risk of incomplete removal and hardware breakage by 3-fold 4
• Routine removal in asymptomatic patients: While removal improves outcomes even with minimal symptoms, the 9.5% complication rate must be weighed against benefits 1, 4
• Prolonged immobilization: Keeping patients in rigid casts beyond 10 days leads to worse functional outcomes; transition to functional bracing 2, 3

National Trends

• Hardware removal rates have decreased from 31% in 2001 to 13% in 2016, reflecting evolving practice patterns toward selective rather than routine removal 7
• The proportion of removals within the first 3 months has also decreased, suggesting better patient selection and timing 7