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Ankle Pin Removal (Page 1)

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I am one year post-op from a compound tib/fib fracture. I have 8 screws and 1 plate. I have an appt with OS next week where we will discuss pin removal. I want them out! Ankle is still swollen and I feel the pins all the time when putting weight on the ankle. What does it feel like? Feels like my leg is resting on 2 very large cylindrical pieces of metal on each side of the ankle.
Question is: what is the % of pin removal cases and what are the risks?
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First Helper Lunatiq
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replied February 16th, 2012
Especially eHealthy
Ectomorph7,

The removal of hardware is usually done in cases where it is causing problems. Around the distal tibia, since there is not much of a soft tissue envelope, some patients complain of their shoes/boots rubbing on the palpable hardware under the skin. So, in these cases, usually a removal can be scheduled.


Before the hardware can be removed, the bones have to be completely healed. It is usually also recommended that the soft tissues have completely healed and the scar tissue matured and softened. During the injury and subsequent surgery, the vascularity around the area is disrupted. New blood vessels have to grow back in and the soft tissue must be able to withstand another insult.

With an open fracture (compound fracture), the soft tissues are especially of importance. Usually, the surgeons will want the soft tissue envelope over the fracture well matured, with minimal swelling or edema, no redness, no warmth before violating the area again. If the soft tissue cannot take the insult, there is a risk of skin slough, which would require graft or flap reconstruction.



So, as long as the bone is healed and the soft tissues can withstand another violation, the hardware can be removed.

The success rate of taking hardware out for pain, in cases where there is clear, definite problems caused by the hardware, is very good. However, when there is no clear problem and the hardware is taken out, just to see if it helps, then the success rate is not very good.


Removal of the hardware is any other surgical procedure and carries all of the usual risks of a major orthopedic surgery: in general these are given as - pain; infection; bleeding; wound healing problems; damage to surrounding structures including tendons, ligaments, nerves, blood vessels; failure to achieve desired results; need for further surgery; need for rehab. Special risks of this procedure in particular: failure to be able to remove part or all of the hardware; fracture of the bone when taking the hardware off, requiring replacement of new hardware.


The screw holes that are left after the removal of the hardware usually take about 6 weeks to fill in. Most surgeons will allow their patients to weight bear as tolerated, with no impact or twisting activities for 6 weeks. So, most patients are able to ambulate right off the bat, but may have to use a cane or crutches till the soreness from the surgery has subsided. A few surgeons will place a short leg cast for a few weeks for protection, depending upon what is found at surgery.



This is something that you will need to discuss with your surgeon. But, usually, with closed fractures of the distal tibia the hardware can be removed after a year to 18 months. In open tibia fractures, it may be a while longer, due to the significant soft tissue issues. Again, something to discuss with your surgeon.

Good luck.
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replied February 17th, 2012
Thank you very much for your detailed reply. I will add all of this information to my 'question list'; and report back next week.
Very much appreciate the response.
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replied February 27th, 2012
Ankle Pin Removal
A follow-up. As it turns out, I have a bone spur growing on the ankle bone at a right angle with the bone (inside bone, I guess the tibia). This is most likely what is causing the swelling and discomfort as well as the burning sensation on the 'knob'.

Other than the bone spur, ankle has healed and there is no indication of any arthritis. Surgeon has recommended all the pin/screw removal, bone spur shaving/filing, and general 'clean-up' of the area. He indicated that perhaps 75% of patients with my type of injury have the pin/screws removed.

Recovery is: 1 week ambulating w/o boot or aircast, but with crutches for balance. Then 2 weeks ambulating with cane, then should be ok.
No driving for a week; stitches out after a week.
Seems scary to have 8 pin/screw holes in my leg bones and not have to have at least an air cast. Wondering how quickly the bone fills in the holes -- forgot to ask that question.
Also, forgot to ask how likely the bone spur would grow again. These questions on the list for next visit.
Surgery is scheduled in about 3.5 weeks.

thanks again for your help.
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replied February 27th, 2012
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Ectomorph7,

In general, it takes about 6 weeks for the body to fill the screw holes in with bone.

The screws hole can act as stress risers, which make the bone easier to break. Just like perforations in a paper make it easier to tear. This is why most surgeons will recommend no twisting or impact loading for about 6 weeks. Usually, the crutches and cane at the beginning are for the patient's comfort, as the ankle will be a little sore after the surgery. But, as long as you don't go out and try to run or play sports, you should be fine without any external support.

Many years ago, we used to put patients in casts for the six weeks. But, this was found to be unnecessary, as long as the patient takes it easy and doesn't do anything really silly.

You should be able to stationary bike, walk, swim, etc during those six weeks. Them after that, depending upon how your ankle is doing from the "housecleaning", you will be able to then start to gradually increase your impact activities.


But, again, this is something to discuss with your surgeon, after he has taken a look at the inside of your ankle.

Good luck. Hope this takes care of your discomfort.
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replied February 28th, 2012
Thanks once again for your informative response. Very much appreciated.
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replied May 21st, 2012
Thank you all for your very helpful comments. I found this website while looking for broken ankle pin removal. My wife broke her ankle on January 2, 2012 and she too went through surgery (six pins and a plate), a splint and several days of bed rest, six weeks in a rehabilitation clinic with daily physical and occupational therapy, wheelchair mobility, a walking boot in week 5 and home visits from a nurse, a physical therapist, and an occupational therapist. In week 7, she started using a foot brace that she could wear inside her shoe. Now she is walking, but complains about the pins. After reading your comments, she decided that she would be better off keeping the pins in place.
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replied May 22nd, 2012
My surgeon said the typical waiting period for pin-removal is 1 year. He wouldn't let me even ask questions until my 1-year anniversary in February 2012. I had my 8 pins and 1 plate removed on March 29, along with the shaving of the bone spur and general clean-up. I am now almost 8 weeks post pin-removal, walking well (no limpling), and back to the gym. The ankle is still quite swollen and tender, which will subside over time. However, I no longer feel as if my ankle is 'resting' on two long steel rods. My next appt with surgeon is early June.
I think you really have to give it a good year before discussing pin removal. Smile Best of everything to your wife for a smooth rest of her recovery. BTW, you must have great insurance!
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replied July 17th, 2012
July 17, 2012 -- I am now 16 weeks post screw/plate removal and the ankle is still quite swollen. It no longer feels like my ankle is resting on two cylinders on either side of my leg, so that is good. However, the surgeon does not like the swelling. We took a prescription anti-inflammatory, but that did not seem to help.
Had an MRI last week and will go to the surgeon this Thursday for follow-up. The written MRI report has 2 items of note: 1. a 3mm abnormality in the medial talar dome representing an osteochondritis dissecans. 2. an 8mm intraosseous cyst in the lateral tibial plafond.

Good news is that all the other ligaments and tendons are 'intact'. The anterior talofibular ligament is 'thickened' due to injury.

I am looking up all this stuff on-line to prepare myself for questions. Smile

Looking back, I guess it was quite an injury.
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replied September 19th, 2012
Ankle hardware removal
My son broke his ankle in 2004. He has three screws in it, he showed me recently a knot on the side of his ankle where one of the screws is working it's was out. Very disturbing to look at. He has an appointment with the surgeon on Friday to see what he recommends but I feel sure it needs to come out. It has been eight years, he is a big guy and his work requires that he be on his feet all day, lots of walking. Do you guys feel like he will have a hard time with that?
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replied September 19th, 2012
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Esma,

If the screw is so proud that it is easily felt, then there should be no problem with having it removed (I assume the fractures are completely healed by now).

Most of the time, removal of hardware requires a trip to the OR. On rare occasion, there are some patients who can tolerate having an isolated, very proud, screw removed in the clinic under local anesthesia.


Your son needs to discuss all of his options with his orthopedic surgeon, once the ankle has been thoroughly evaluated. But, again, a proud screw which is rubbing or causing other obvious problems can be easily taken out (there are the usual risks of any surgical procedure).

Usually, the ankle is protected for a few weeks after hardware removal, till the screw holes fill in. But, as to the amount of protection needed differs between patients (situations). This is something else that your son should ask the surgeon.

Good luck.
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replied February 6th, 2013
Hi Achomes
Thanks for your post.

I had an ankle fusion 1 1/2 years ago and have had no real pain relief. My foot, however is more stable. I am having a hardware removal (5 screws)

I can understand your wifes feelings and the tough thing is that no one can say the pin removal will relieve pain. Mine is being done because one pin is pushing into the bone beneath it.

Jessie
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replied February 13th, 2013
I had double fracture dislocation 3 years ago, had plate and 5 screws out 1 year later leaving 2 in. Recently had ex ray and I still have the holes, these have not healed, I am due to have the final 2 pins out from inner ankle and am a bit worried in case it breaks again
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replied February 14th, 2013
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CrapCook,

It is not uncommon for the "holes" to be visible forever, even thought they are filled in with bone. When the screws are in place, the outer rim of the hole becomes sclerotic and will stay that way forever, even though the cancellous bone has filled in the inner part of the bone.

However, if you truly do not have any bone healing within the screw holes (just filled with fibrous tissue or scar), then you are at higher risk for a future fracture due to the holes acting as stress risers.

It is possible, if the surgeon is going to be back "in there" to remove some more screws, for him/her to currette out the fibrous tissue and pack in a little bone graft to get the screw hole to fill in.

If you concerned about the hole, discuss it with your surgeon.

Good luck.
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replied February 14th, 2013
Your saying about no bone growth seems to be agreeing with what my back surgeon is saying with regards a spinal fusion that failed. He said there was no active bone growth there either. I will mention it to the surgeon on Tuesday when I go in. If this is something that my body 'can't' do what options are there?
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replied February 15th, 2013
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CrapCook,

Usually, with the screw holes, what happens is that the holes fill in with fiborus tissue (a type of scar) and this prevents the body from filling the hole in with cancellous bone (spongy bone).

If this is the case, then the fibrous tissue has to be manually removed with a currette (instruments that looks like a tiny ice cream scoop) and then the hole packed with cancellous bone graft, usually harvested from the iliac crest (pelvic brim) or the proximal metaphysis of the tibia.

The cancellous bone graft not only brings in scaffolding for the new bone to grow on, it also has some of the osteoprogenitor cells in it to "jump start" the healing process.

Again, with the screw holes it is usually some scar tissue which is blocking the bone from growing back into the hole.


With the spine, it just sometimes happens that patient do not fuse when a spinal fusion is done. Of course, the patient should be evaluated for reasons why the fusion did not occur, such as an infection, bone defeciency diseases, poor surgical technique (such as not getting a solid fixation with the hardware, so that the bone can heal), and so on. Of course, smoking is very detrimental to any bone healing and can actually prevent fusions and fracture healing.


But, again, if your surgeon is going to be back in around the ankle to take more screws out, and there is truly no bone growth withing the previous holes, they should probably be curretted and bone grafted, so that they do not continue to act as stress risers. Sometimes, just curretting out the fibrous tissue will do the job, but usually it does take adding in some bone graft, since they have not healed once already.


Hope you do well with your upcoming hardware removal. Good luck.
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replied February 27th, 2013
I had the screws out but the specialist found that he could not just unscrew them but had to drill them out, have been non weight bearing again for a week and go back today as there is a chance he has broke it again. He said that he had to drill as the screws were stuck so where the bone is thin there is a high chance of breakage. Does this mean my ankle will always now be at risk, as not only drill and screw holes but general weekness now
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replied February 27th, 2013
Also have golfers elbow so using crutches has agravated that and also back where I have the exsisting problems, can you suggest any supplements that could be taken to help as joints really don't seem to be coping now and I am not 50 till may
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replied February 27th, 2013
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CrapCook,

As to the supplements, some patients swear by the joint supplements which have the natural joint proteins in them: glucosamine, chondroitin sulfate, and hyaluronic acid. You can usually pick up these in pill form or in drink form at your local pharmacy. However, it has been noted that the patients who do get a benefit from these, have to use them for an extended period of time (three months or more) before a benefit is noted. Some patients will note a benefit sooner, but the authorities say that a patient should not give up on them until they have been used for at least three months.


Usually, if there is just a crack in the bone from drilling out a screw, it will heal along with the screw holes. So, a little extra protection may be needed, but not much more than that.

Usually, screws have to be drilled out when the hex head hole that the screw driver fits into is stripped, or the threads of the screw are stripped. It is just like trying to get a stripped screw out of wood or metal, the shaft of the screw is bored out, a special instrument placed in the hole, and the rest of the screw removed. Usually, this can be done without making the screw hole too much larger than it would have normally been. Occasionally, the whole screw shank and threads have to be overdrilled, then the hole is just a bit larger.


So, hopefully, if you do have a crack in the bone, it will heal right along with the screw holes, without any increased problems.


Good luck. Hope you do well post-op.
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replied February 28th, 2013
Thank you for all your help, went yesterday and he had removed the 1 screw but the other he couldn't so just cut the head and part the shaft off, leaving the rest in place. Luckily no crack just a small hole which is already showing signs of repair. Told can weightbear now, but gradual, not surprising.
Could you tell me though how long do disolvable stitches take to disolve.
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replied March 1st, 2013
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CrapCook,

As to the dissolveable sutures, how long it takes them to dissolve, is determined by what they are made out of.

Some sutures are designed to fail in about 3 weeks, while others fail in about 6-8 weeks, and in some, they are designed to fail a long time out, even as much as a year after placement.


In orthopedics it is rare to but dissolveable sutures in the skin. They can produce a lot of inflammation. Usually, dissolveable sutures are placed in the subQ tissues, which need to be help for about 6 weeks, until they are healed, and then the suturs are no longer needed.

Most sutures placed in the skin are nylon, which do not dissolve. So, the patient has to have them removed at around 7 days (give or take). The concern of using dissolvable sutures in the skin, is that they are very inflammotory. Causing redness, swelling, tenderness in the skin, while the patient is waiting for them to fail.


So, you would have to ask your surgeon about the dissolveable sutures. There are just too many of the them used nowadays, with too many different rates of failure in them.


Hope your ankle gets better soon.

Good luck.
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replied March 2nd, 2013
I was assured that they were dissoveable stitches but they are extremely tight and are now weeping. Also the main tendon down the front of my ankle is swollen and very sore. Between the tight stitches and the tendon it is very hard to walk. Please any advice would be helpful
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replied March 2nd, 2013
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CrapCook,

Well, the good old RICE: rest, ice, compression, and ELEVATION is the best treatment. You might throw in some anti-inflammatory medication (if you can take it).

But, rest and elevation is the best management for swelling and edema.

You should still try to move the toes and ankle, so that they do not become stiff. But, do it in a controlled way, so that you do not irritate the tissues even more.

You can also use a little compression, an ace wrap or a support stocking, to help push the edema back into the lymphatic channels, so it can be taken up the leg back into the body core.


There are some skin closures which are dissolvable. Also, there is a techniques to put dissolvable sutures in the SubQ tissue, and then place steri-strips on the skin. Thus, no sutures have to be removed. Also, the medical device companies are always coming up with new and improved ways to close the skin. A few years ago, they tried the super glue closure. Which worked fine if the surgeon had basically already closed the incision with the subQ sutures, so there was not a whole lot the glue had to do. But, in other cases, it was a disaster. It mixed with blood and turned brown and ugly. The surgeons got stuck to the patient, trying to hold the skin edges together. So, after a little while, it was not really used much any more in the OR. But, again, the companies are coming up with new stuff all the time.


Hope your inflammation gets better soon. Good luck.
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replied April 11th, 2013
ankle hardware problems
just came upon this site and after reading your reply I am curious to hear your thoughts. I too had fracture of both ankle bones in September 2011. After much pain and being unable to walk without severe limp I was able to get dome testing approved. Turns out that both inside and outside bone screws were (are) tearing the tendons causing nerve damage. I had the inside (larger) bone screws removed as of last week. Doctor is saying not to have any weight far at least 2 weeks and when he takes the 13 screws out of the outside bone he says at least 8 weeks. What are the chances of this really fixing the problem. My foot more tomes than not feels like it is in a bucket of ice and is always swollen and very sore. Any comments would be welcome. Thanks. Susan
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replied April 12th, 2013
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Susan,

If is can be shown that the orthopedic fixation devices are actually causing your discomfort, then taking out the hardware usually helps the situation.

However, removal of the hardware does not remove the fact that you fractured your ankles and you will most likely always have some residuals from the injury.


But, again, if it can be shown that the hardware is causing problems, then its removal should help some, but it is doubtful that it will take all of your pain away. But, if it helps significantly, great.

Good luck.
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replied April 16th, 2013
Hardware removed after 8 months
Ectomorph7 wrote:

I think you really have to give it a good year before discussing pin removal.


I am a 55 year old female and VERY physically active (hike, bike, snowboard, golf, snowshoe, etc). I suffered a comminuted bimalleolar fracture/dislocation in July 2012 (hiking), ORIF same day, 7 screws and a plate on the fib, two long screws in the tib. Once the swelling from the injury/surgery started to subside, it was apparent the hardware was proud and I could see every screw along the length of the plate. I could also 'feel' the hardware - always 'aware' it was there and it was VERY uncomfortable and painful (electric shock, jump out of my skin painful) to the touch. After 6 months I was begging for it to be removed. My OS agreed to remove it after 8 months (not the same OS who did the ORIF surgery).

Everything was removed on March 19, 2013 and the difference was striking! I no longer have discomfort anywhere along the outer edge of the fib, and only minor tenderness on the tib which is already subsiding. Come to find out, not only were the screw heads proud on the outer edge of the fib, but the sharp ends of the screws were peeking out of the bone on the inside edge and into the muscles! No wonder I was always in pain!

Since the removal I have been nearly pain free and getting a much better range of motion. Word to the wise, if the hardware really hurts, don't wait a year to get it removed. Conventional wisdom only applies if you feel satisfied your recovery is conventional.
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replied October 11th, 2013
Lunatiq - I am so glad I am not alone...shattered fib November 2012 - 8 screws and a plate later I am in constant pain and feels like I have a cheese grater in my leg. I used to be twice as active as I am now, but can no longer run or trail hike due to the hardware pain.. You have given me hope that my decision to remove the hardware (3 weeks from now) is the right decision. will let everyone know my experience... (Is it wrong to be looking so forward to surgery? ) Smile
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replied May 21st, 2013
I fractured my Fibula in four places and had a plate and screws put in December 2009. I haven't had any problems until about a year ago. I'm a bigger guy at 6'2" 275 lbs and my job requires me to be on my feet a lot. Now if i spend a lot of time on my feet, my ankle and heel hurt so bad I can barely walk by the end of the day. Also, I can no longer wear boots or high top sneakers due to anything touching the incision sigt causing severe pain. I feels like maybe the screws are backing out. Is this possible? and would hardware removal be a good idea considering my size?
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