If you have undergone surgery after a fracture of the upper or lower limb, you may be wondering when and why hardware(plates, screws and nails) is removed.
And how does it go once it is done, walking pain and rehabilitation?
I rely on my radiography knowledge to answer your questions and on medical scientific studies on the subject matter.
Happy reading!😀
Any questions? remarks? Let’s meet in the comments section at the end of this article.🙏
Last updated: Feb, 2025. Written by Juliet Semakula a diagnostic radiographer
Summary: Rehabilitation is always not necessary after surgical removal, since you have healed and returned to your normal activities like before, unless you still have issues with range of movement, pain and discomfort.
▶️Is it good to remove plates after surgery? What are the main reasons why hardware removal is needed?
When you have had surgery on a fractured bone normally different accessors such as plates, screws, nails, rod and wires are internally inserted to hold the fracture to allow healing.
Once healed, bone is strong enough to support itself, most of the time metal work is left in place to avoid needing to have more surgery.
Unfortunately, for some people, internal fixation can become loose, and it can start to irritate when you walk and wear shoes if it is the lower limb.
Over the years I have witnessed many implants in asymptomatic adults and children being removed.
And for this reason, I was keen to understand the reason why some plates are left in permanently and others are always removed after some time.
▶️Is the hardware in the upper and lower limb always removed?
The answer to this is ‘NO’, the hardware is not always removed.
There is a general rule that hardware is removed only if it causes you discomfort or if there is a complication necessitating its removal.
▶️What do scientific studies say about hardware removal after surgery:
Some scientific studies suggest that adults with these implants should not be removed unless you have symptoms especially for femoral and tibial diaphyseal plates (Richards 1992)
An analysis done by orthopaedic surgeons in the United Kingdom regarding implant removal in a symptomatic patients had this to say:
🟠92% of orthopaedic surgeons stated that they do not routinely remove metal work in asymptomatic adult patients.
🟠60% of trauma surgeons stated that they do routinely remove metal work in patients aged 16 years and under.
🟠87% of the practicing surgeons indicated that they believe it is reasonable to leave metal work for 10 years or more.
Acklin, 2018
Conclusion: Such views should be backed with policies or guidelines specific to age groups and level of surgeon who should be performing the removal procedure.
More research is needed for further validated studies that would eventually serve to steer surgeons in achieving best practice.
However, its noted that hardware removal is becoming less common over the years.
▶️When is hardware removal performed in both upper and lower limb
Here are some of the reasons of removing plates, k-wires, screws and nails after weeks, months or years of surgery (Kaiser,2019)
🔴Pain and discomfort leading to soft tissue covering with little subcutaneous tissue in the lower extremity.
🔴Discomfort while walking and running for lower limb.
🔴Prominent fixation can potentially protrude through the skin increasing the risk of infection.
🔴Some people react to the metal inserted (this is exceedingly rare).
🔴Indications such as deep infection
🔴 Restricted motion because of hardware shifting, it is no longer in place and there is a non-union of bone.
🔴The plate and screws break or become damaged causing pain. This is rare, it can happen if something is wrong with the way the bones healed)
🔴Having a new fracture at the level of hardware.
🔴Irritated tendons can happen from a screw or the plate edge rubbing on a tendon.
Having these symptoms often may require your plate to be removed, you can only discuss this with your doctor.
▶️Types of fracture surgery where normally surgical plates are removed
The most common type of fracture plates removed in children and adults are in the forearm, humerus, clavicle, fibula ankle and calcaneus.
When removal is performed in adults it’s usually due to discomfort otherwise hardware is often left in.
Some surgeons recommend at least 6 months to 1 year before considering removal.
Studies done by Acklin et al 2018:
The upper limb, routine removal of metalwork was most performed for internal fixation such as clavicle which was estimated to be 27 %
And the lower limb, routine removal of metal work was most performed for midshaft tibial fractures which was estimated at 11%
Eight months after surgery, x-ray show fracture union and Screws are visible on x-ray: image from Takuya, 2023
For these who have had the plates removed showed bone strength and recovery took 3 to 6 months and full recovery took 6 months.
Remember the degree of recovery of bone atrophy varies from site to site.
When your plates are removed you should be careful about refracture after removal because it is possible.
Images showing plate removal in the humerus:
A) Six months after the surgery, the osseous union was achieved. (C) Note the firm union after the removal of the plate. Image from (Lee et al 2011)
Images showing plate removal in the lower leg:
X-ray images showing before the plates were removed and after plate removal.
▶️What are the benefits of hardware removal after surgery?
Surgical plate removal in children
The most plate, rods or wires removal in children are ankle, fibula and forearm fractures due to the high remodelling potential.
As you know children’s bones are still remodelling, most removals I have witnessed are mainly removed 3 weeks to 9 months.
A research team from America looked at over 1008 paediatrics who had undergone surgical management of a physeal ankle fracture.
And had this conclusion:
🟠A quarter of all children treated with surgery for ankle fractures undergo hardware removal within 2 years of index surgery.
🟠Younger patients with fractures that involve the epiphysis are more likely to have hardware removed.
🟠Rates of later procedures on the operative extremity were not significantly different between patients with hardware removed.
🟠And some had hardware retained at a minimum of 4 years after surgery.
Source: Pearce 2023
Surgical plate removal in adults
Most of the surgical plates I have seen inserted in wrists, arm, leg and ankle are normally left in permanently unless they become symptomatic.
Benefits:
Studies analysing the benefits of implant removal from the foot and ankle demonstrate that approximately 50% to 75% of patients reported decreased pain scores following removal (Kaiser, 2019)
Although reduced pain and patient satisfaction were the primary interest of hardware removal there were no independent studies that were done to follow up patients who had their plates removed.
For this reason, it is possible that this systematic review is not sufficient enough to offer evidence-based recommendations on whether or not metal implants should be removed after any surgery.
▶️Is it painful to have plates and screws removed?
You’ve had surgery to remove orthopaedic hardware such as metal screws, pins, or plates.
You can expect some pain and swelling around the cut (incision) during removal but usually the hardware removal is easier than when they were inserting the metal in.
I have seen patients being given local anaesthetic before the procedure, this will help with pain.
However, it is very normal to experience pain in the first few days or weeks after removal, but you should feel better within a few days.
Remember pain is not usually a sign of a complication but it is related to inflammation triggered by the removal of hardware.
Between 1-2 weeks following surgery, you will have your dressing changed and stitches removed if need be.
▶️What are possible complications of plate removal?
All these complications do apply to both upper and lower extremities
🔴Can damage neurovascular structures
🔴Delayed wound healing, causing infection.
🔴Nerve or vessel injury.
🔴Hematoma
🔴Possible refracture.
🔴Persistent pain in up to 40% of cases
Langkamer, 1990
▶️What rehabilitation is needed after hardware removal
This will depend on which part of the hardware was removed on the body.
if it is your upper limb (wrist, humerus, forearm), after removal monitor on how you move your arm, if you can activity use your upper limb without pain or any discomfort.
Then you are free to go back to your normal activities.
▶️ Can I walk after plate removal in the lower leg (foot, ankle, fibula)?
It is a good idea to keep moving even after your surgery, it helps your blood circulation and stops your body getting too weak.
Avoid any strenuous activity for the first 2 weeks, but gentle walking and exercise is helpful.
If you have difficulty walking or having pain after any kind of hardware removal in your lower leg, physiotherapy sessions will likely be prescribed for you.
If needed, rehabilitation aims to help you regain:
♦️Good mobility in movements.
♦️Muscle strength in the muscles controlling any area of the body where the hardware was removed.
♦️ Stability for everyday activities or sports activities done using your upper and lower limb such as sports.
♦️ No pain at all that prevents you from doing your activities.
Rehabilitation is always not necessary after surgical removal, since you have healed and returned to your normal activities like before, the removal of hardware will not set you back.
▶️ Do you have to wear a boot after hardware removal for lower limbs?
If only a small crew or wire was taken out, you may require little or no limitations to your normal activities.
It will be up to you to judge how you feel after removal, if you think walking with a boot at the beginning is more comfortable then wear a boot until it’s ok to move without one.
In the first few days avoid marathon training and jumping that could cause you discomfort.
I have seen some people use a walking cast boot brace after removal of ankle fixation hardware for four weeks or less.
It is important to keep the incision site dressing clean and dry, you must have been given discharge instructions from your health care provider on what to do.
▶️How soon can you drive after hardware removal?
This will depend on how confident you feel to drive again, pain and range of movement should guide your decision.
You may drive again when you feel comfortable, well healed and no longer taking any pain medication.
If you still feel uncomfortable, take time off work and rest, for any swelling try to elevate your leg, eat a well-balanced diet and keep your spirits high.
Be patient before you know it you will be back to your normal activities like before.
Different countries have their own driving legal instructions. Try to find out what regulations your own country says about driving.
This article may be of use to you as well.
♦️Driving after surgery for any fracture.
We have come to the end of this article, any questions in the comment’s questions.
Wishing you a quick recovery!🙋
Below are some of the references I have relied on for this article
📚Sources:
Acklin YP, Bircher A, Morgenstern M, Richards RG, Sommer C. Benefits of hardware removal after plating. Injury. 2018 Jun;49 Suppl 1:S91-S95. doi: 10.1016/S0020-1383(18)30311-5. PMID: 29929702.
Richards RH, Palmer JD, Clarke NM. Observations on removal of metal implants. Injury. 1992;23(1):25-8. doi: 10.1016/0020-1383(92)90120-h. PMID: 1541494.
Shah KV, Patel SD, Rajasekaran K, Cannady SB, Chalian AA, Brody RM. Risk Factors for Plate Infection, Exposure, and Removal in Mandibular Reconstruction. Otolaryngol Head Neck Surg. 2024 Dec;171(6):1705-1714. doi: 10.1002/ohn.928. Epub 2024 Aug 5. PMID: 39101319; PMCID: PMC11605025.
Kaiser PB, Watkins I, Riedel MD, Cronin P, Briceno J, Kwon JY. Implant Removal Matrix for the Foot and Ankle Orthopaedic Surgeon. Foot Ankle Spec. 2019 Feb;12(1):79-97. doi: 10.1177/1938640018791015. Epub 2018 Aug 22. PMID: 30132700.
Langkamer VG, Ackroyd CE. Removal of forearm plates. A review of the complications. J Bone Joint Surg Br. 1990 Jul;72(4):601-4. doi: 10.1302/0301-620X.72B4.2380210. PMID: 2380210.
Langkamer VG, Ackroyd CE. Removal of forearm plates. A review of the complications. J Bone Joint Surg Br. 1990 Jul;72(4):601-4. doi: 10.1302/0301-620X.72B4.2380210. PMID: 2380210.
Pearce RJ, Cazzulino A, Swarup I. Rates and Factors Associated With Hardware Removal in Physeal Ankle Fractures: Analysis of the Pediatric Health Information System. Foot Ankle Orthop. 2023 Jun 28;8(2):24730114231182396. doi: 10.1177/24730114231182396. PMID: 37425339; PMCID: PMC10328018.
Wang J, Chidambaram R, Mok D. Is removal of clavicle plate after fracture union necessary? Int J Shoulder Surg. 2011 Oct;5(4):85-9. doi: 10.4103/0973-6042.90998. PMID: 22223957; PMCID: PMC3249928.
Lee, Hyun-Joo & Oh, Chang-Wug & Kim, Do-Hyung & Park, Kyeong Hyeon. (2011). Minimally Invasive Anterior Plating of Humeral Shaft Fractures. Journal of the Korean Fracture Society. 24. 341. 10.12671/jkfs.2011.24.4.341.
Zhang J, Xiao B, Wu Z. Surgical treatment of calcaneal fractures with bioabsorbable screws. Int Orthop. 2011 Apr;35(4):529-33. doi: 10.1007/s00264-010-1183-5. Epub 2011 Jan 5. PMID: 21207026; PMCID: PMC3066330.
Takuya Usami, Naoya Takada, Kazuki Nishida, Hiroaki Sakai, Hidetoshi Iwata, Hiroki Yonezu, Isato Sekiya, Yuko Nagaya, Yoshino Ueki, Hideki Murakami, Gen Kuroyanagi,Fixation of intra-articular calcaneal fractures: A comparative study of the postoperative outcome between HA/PPLA screws and locking plates, Heliyon,Volume 9, Issue 3,2023,e14046,ISSN 2405-
Thune A, Hagelberg M, Nåsell H, Sköldenberg O. The benefits of hardware removal in patients with pain or discomfort after fracture healing of the ankle: a systematic review protocol. BMJ Open. 2017 Aug 11;7(8):e014560. doi: 10.1136/bmjopen-2016-014560. PMID: 28801390; PMCID: PMC5724201.