What are the potential causes of pain in an elderly woman with a history of Open Reduction Internal Fixation (ORIF) of the ankle?

Causes of Pain in an Elderly Woman with Previous Ankle ORIF

Pain following ankle ORIF in elderly patients most commonly stems from post-traumatic osteoarthritis, hardware irritation, soft tissue complications from the surgery itself, or inadequate rehabilitation—with post-traumatic arthritis being the predominant long-term cause. 1, 2, 3

Primary Hardware and Surgical-Related Causes

Hardware Complications

• Prominent or irritating hardware is a frequent cause of persistent pain after ankle ORIF, particularly over the medial or lateral malleolus where plates and screws may cause soft tissue irritation 1, 3
• Hardware failure or loosening can occur, though studies show this is relatively uncommon even with early weight-bearing protocols 3
• Malunion occurs in approximately 5% of elderly patients after ORIF, leading to altered ankle biomechanics and chronic pain 1

Wound and Soft Tissue Complications

• Delayed wound healing affects approximately 9% of elderly patients after ankle ORIF, which can lead to chronic soft tissue pain and scarring 1
• Deep infection occurs in only 1% of cases but must be excluded as it significantly impacts morbidity 1
• Wound edge necrosis is a significant risk in elderly patients and can result in persistent pain even after healing 1

Post-Traumatic Osteoarthritis

• Post-traumatic arthritis develops commonly after ankle fractures, particularly when anatomical congruity of the ankle mortise is not perfectly restored 2
• Poor alignment of the ankle mortise on radiographs correlates directly with worse pain outcomes and functional results 2
• The elderly population (50% of those ≥65 years have baseline osteoarthritis) is particularly susceptible to accelerated degenerative changes after trauma 4

Inadequate Rehabilitation and Deconditioning

Muscle Weakness and Stiffness

• Quadriceps and ankle muscle weakness develops rapidly during immobilization and is a major contributor to persistent pain and functional limitation 4
• Ankle stiffness from prolonged immobilization causes altered gait mechanics and compensatory pain 5
• Patients who were less mobile pre-injury (using walking frames) have significantly longer recovery periods and worse outcomes 1

Insufficient Weight-Bearing Progression

• Delayed or inadequate progression to weight-bearing can prolong recovery and contribute to chronic pain patterns 5
• Early weight-bearing (within 3 weeks) leads to better functional outcomes without increasing complication rates 5

Referred and Concurrent Pain Sources

Other Joint Pathology

• Hip or lumbar spine pathology can refer pain to the ankle region and must be considered, especially if ankle radiographs appear satisfactory 4
• Concurrent knee osteoarthritis (affecting 50% of those ≥65 years) may alter gait and increase ankle stress 4

Neurologic Causes

• Peripheral neuropathy (particularly in diabetic patients) can cause altered pain perception and chronic discomfort 4
• Nerve entrapment or irritation from surgical scarring may cause neurologic heel or ankle pain 4

Diagnostic Approach

Initial Evaluation

• Standard ankle radiographs are the first-line imaging to assess hardware position, fracture healing, and alignment 4
• Look specifically for: malunion, hardware prominence, loss of ankle mortise congruity, and signs of post-traumatic arthritis 2

Advanced Imaging When Indicated

• CT without contrast is useful for evaluating occult fractures, subtle malunion, or hardware-related bone complications 4
• MRI without contrast is most sensitive for soft tissue pathology, occult fractures with bone marrow edema, ligamentous injury, and early cartilage damage 4
• MRI should be considered if pain persists beyond 1-3 weeks with normal radiographs 4

Common Pitfalls to Avoid

• Do not dismiss pain as "normal aging"—the American Geriatrics Society explicitly rejects this approach, as treatable causes are common 4
• Avoid attributing all symptoms to the ankle without evaluating the hip and lumbar spine, particularly if ankle imaging is unremarkable 4
• Do not overlook diabetes as a risk factor for wound complications and altered pain perception—diabetes significantly predicts wound dehiscence 3
• Recognize that poor pre-injury mobility (requiring walking frame) predicts prolonged hospital stays (116 days vs 19 days) and difficult recovery 1
• Be aware that soft bone quality in elderly patients may have precluded adequate fixation of one malleolus in up to 12% of cases, leading to persistent instability 1