Recommended X-ray Views for Foot Hardware Evaluation
For evaluating foot hardware, obtain standard three-view radiographs consisting of anteroposterior (AP), medial oblique, and lateral projections, ideally performed weight-bearing when the patient can tolerate it.
Standard Radiographic Protocol
The three standard views (AP, medial oblique, and lateral) provide sufficient radiographic evaluation of the osseous anatomy and hardware positioning in the foot 1
Weight-bearing radiographs are strongly preferred over non-weight-bearing films because they detect dynamic abnormalities such as hardware loosening, joint malalignment, and implant displacement that may not be apparent when the foot is unloaded 1
If the patient cannot bear weight due to pain, limited mobility, or risk of further displacement, non-weight-bearing radiographs are an acceptable alternative, though they provide less functional information 1
Anatomic-Specific Considerations
Hindfoot/Calcaneal Hardware
- For hardware in the calcaneus, add an axial Harris-Beath view to the standard three views, as this projection optimally evaluates the posterior foot and can assess hardware position relative to the subtalar joint 1, 2
Midfoot Hardware
The standard three-view series adequately visualizes midfoot hardware without additional projections 1
Bilateral comparison views can be helpful when evaluating subtle malalignment or hardware positioning, particularly in the midfoot where anatomic relationships are complex 1
Forefoot Hardware
The standard three views are generally sufficient for metatarsal and phalangeal hardware 1
The oblique view is particularly valuable in the forefoot, as it uniquely reveals abnormalities and increases diagnostic confidence when interpreted alongside AP and lateral views 3
Clinical Pitfalls to Avoid
Do not rely solely on non-weight-bearing films when assessing hardware stability or alignment, as this can miss clinically significant displacement or loosening that only manifests under physiologic load 1
Ensure consistent positioning between serial studies—inconsistent cassette-side positioning or weight-bearing status makes comparison difficult and can obscure subtle hardware migration 4
Standard lateral foot radiographs should be obtained with the medial side down (great toe up), which is the expected orientation in clinical practice and facilitates comparison 4
When to Consider Advanced Imaging
CT is appropriate for evaluating complex hardware positioning, assessing bone quality around implants, or when plain radiographs are equivocal regarding hardware complications 1
MRI should be considered if there is clinical concern for soft tissue complications (infection, tendon injury) around hardware, though it is not routinely used for initial hardware assessment 1