Should I have Tibia Hardware Removed after Healing?

@don34 Don, along with my fellow mentor, John, I welcome you to Connect. I had so much to tell you, that there will be a second post following this one.

I wanted to offer some experience about removal of surgical hardware after an ankle fracture. I had mine removed 9 months ago. My fracture happened 2 years ago with surgery and internal hardware fixation done at Mayo. I had pain all the time (like I was getting kicked in the ankle) from the titanium plates and the skin would be warm to the touch. Sometimes it throbbed a bit, and the skin over the plates was starting to develop some pigment. About 6 months after the injury, I developed chronic hives and had to stay on antihistamines all the time or I would have large patches of hives on my body anywhere, and it was worst where my clothing was tighter such as where elastic made contact. The surgeon didn't connect this with my hardware, although I did, and since the hardware was removed, I have not had the hives at all.

I am in my recovery period from hardware removal and I have had tightness, ankle swelling after walking, and some sharp pains related to the swelling, and my ankle would sometimes collapse under me with a sharp pain when I took a step particularly when I was fatigued, and I wouldn't be able to walk unless I held my ankle like it was fixed in a cast.

There are several factors in all of this. My injury was a fracture, a dislocation, and a bad sprain all at the same time, and it was compound with the broken fibula protruding through the skin. This injury was significant enough to cause nerve damage and at the time it happened, I could feel a nerve firing and pulsing repeatedly although at that time because of shock, it wasn't horribly painful. I straightened my dislocated ankle just enough to back off the nerve that was firing, and didn't straighten it completely because I didn't want to cause more damage, and it was put in a splint by the paramedic who took me to the hospital. During my healing after surgery it felt like I had something under my foot in the cast and I would get sharp pains through my toes. I got that same pain when my ankle swelled even long after the cast was removed.

I used a lace up ankle brace. My tendons and ligaments would take turns hurting, and some of that is caused by a muscle spasm. My calf would get tight a lot. I would work out the muscle kinks by massaging it out with a hard plastic ball or let my leg rest on that ball under its own weight on a painful muscle. These are things my physical therapist recommended. If a tendon hurt, it was because the muscle attached to it was in a knot, and loosening that helped. Muscles work in opposition so the inside of my calf was stronger than the outside that had been rolled during the injury. After sitting with my leg elevated for a couple years, I lost a lot of muscle and strength from atrophy due to non use and babying my ankle.

I had custom orthotics from a podiatrist and I got new ones made since the injury and surgery. I had been circling my ankle around to keep it moving and it would crunch a lot, and that seemed to be helping if I did this first thing when I got up each day. It was a conversation with my PT about this that was a light bulb moment. She did a mobilization and showed me a modified way that I could do this at home to get the talus moving because it can get stuck and lock up the ankle. I wondered if the ankle brace I had been wearing for 2 years was adding to the problem, so I took it off and any time I felt ankle pain, I did the mobilization technique. For the first time in 2 years, I am walking without my ankle collapsing. I have been able to be on my feet longer and up to the point of being so fatigued by it, that I collapsed when I got home and couldn't stay awake. Then after 2 days of recovery, I am stronger. I also went trail riding on my horse for 4 hours which does use leg strength, and again I was trashed by that, but then everything including my back gets stronger a few days later. I was weak from 2 years of sitting most of the time, and only now am I strong enough to not need to sit and rest so much. An ankle injury is a very difficult recovery after which you are weak and it takes a very long time to rebuild strength. My podiatrist told me it took me years to build that body strength as I grew to be an adult, so it doesn't come back so fast. I do not have ankle pain now, and removing the hardware was a good thing.

Another good thing is I have a very good physical therapist with a doctorate who is also an expert in myofascial release which is a way to release tight tissue. Here is our discussion about MFR which can help relieve tightness and scar tissue after surgery part of which is from the surgical path itself.
Myofascial Release Therapy (MFR) for treating compression and pain: https://connect.mayoclinic.org/discussion/myofascial-release-therapy-mfr-for-treating-compression-and-pain/

Have you heard of myofascial release before?

I had a titanium nail in my left tibia from a whitewater accident in ‘05. I could FEEL the nail (or maybe the screws) in my knee, caused some pain. I also worried about the “if you break this leg again with the nail in it will get…complicated.”! As soon as I was fully healed (about 18 months) I asked for removal. That surgery is indeed as traumatic as insertion! However, the pain resolved and I felt much better knowing it was out. I also have numb spots on knee and foot (prob. Compounded by nerve pinch) but no other issues. YMMV.

@don34 Don, along with my fellow mentor, John, I welcome you to Connect. I had so much to tell you, that there will be a second post following this one.

I wanted to offer some experience about removal of surgical hardware after an ankle fracture. I had mine removed 9 months ago. My fracture happened 2 years ago with surgery and internal hardware fixation done at Mayo. I had pain all the time (like I was getting kicked in the ankle) from the titanium plates and the skin would be warm to the touch. Sometimes it throbbed a bit, and the skin over the plates was starting to develop some pigment. About 6 months after the injury, I developed chronic hives and had to stay on antihistamines all the time or I would have large patches of hives on my body anywhere, and it was worst where my clothing was tighter such as where elastic made contact. The surgeon didn't connect this with my hardware, although I did, and since the hardware was removed, I have not had the hives at all.

I am in my recovery period from hardware removal and I have had tightness, ankle swelling after walking, and some sharp pains related to the swelling, and my ankle would sometimes collapse under me with a sharp pain when I took a step particularly when I was fatigued, and I wouldn't be able to walk unless I held my ankle like it was fixed in a cast.

There are several factors in all of this. My injury was a fracture, a dislocation, and a bad sprain all at the same time, and it was compound with the broken fibula protruding through the skin. This injury was significant enough to cause nerve damage and at the time it happened, I could feel a nerve firing and pulsing repeatedly although at that time because of shock, it wasn't horribly painful. I straightened my dislocated ankle just enough to back off the nerve that was firing, and didn't straighten it completely because I didn't want to cause more damage, and it was put in a splint by the paramedic who took me to the hospital. During my healing after surgery it felt like I had something under my foot in the cast and I would get sharp pains through my toes. I got that same pain when my ankle swelled even long after the cast was removed.

I used a lace up ankle brace. My tendons and ligaments would take turns hurting, and some of that is caused by a muscle spasm. My calf would get tight a lot. I would work out the muscle kinks by massaging it out with a hard plastic ball or let my leg rest on that ball under its own weight on a painful muscle. These are things my physical therapist recommended. If a tendon hurt, it was because the muscle attached to it was in a knot, and loosening that helped. Muscles work in opposition so the inside of my calf was stronger than the outside that had been rolled during the injury. After sitting with my leg elevated for a couple years, I lost a lot of muscle and strength from atrophy due to non use and babying my ankle.

I had custom orthotics from a podiatrist and I got new ones made since the injury and surgery. I had been circling my ankle around to keep it moving and it would crunch a lot, and that seemed to be helping if I did this first thing when I got up each day. It was a conversation with my PT about this that was a light bulb moment. She did a mobilization and showed me a modified way that I could do this at home to get the talus moving because it can get stuck and lock up the ankle. I wondered if the ankle brace I had been wearing for 2 years was adding to the problem, so I took it off and any time I felt ankle pain, I did the mobilization technique. For the first time in 2 years, I am walking without my ankle collapsing. I have been able to be on my feet longer and up to the point of being so fatigued by it, that I collapsed when I got home and couldn't stay awake. Then after 2 days of recovery, I am stronger. I also went trail riding on my horse for 4 hours which does use leg strength, and again I was trashed by that, but then everything including my back gets stronger a few days later. I was weak from 2 years of sitting most of the time, and only now am I strong enough to not need to sit and rest so much. An ankle injury is a very difficult recovery after which you are weak and it takes a very long time to rebuild strength. My podiatrist told me it took me years to build that body strength as I grew to be an adult, so it doesn't come back so fast. I do not have ankle pain now, and removing the hardware was a good thing.

Another good thing is I have a very good physical therapist with a doctorate who is also an expert in myofascial release which is a way to release tight tissue. Here is our discussion about MFR which can help relieve tightness and scar tissue after surgery part of which is from the surgical path itself.
Myofascial Release Therapy (MFR) for treating compression and pain: https://connect.mayoclinic.org/discussion/myofascial-release-therapy-mfr-for-treating-compression-and-pain/

Have you heard of myofascial release before?

@don34 Don, I do not think removing hardware or partially removing it will change anything with tightness and numbness unless your tibia and fibula have been screwed together. That is a discussion to have with your surgeon after you have an opinion from the new specialist and/or a good physical therapist about what is possible. My surgeon would not remove any hardware until it had been in place at least a year, and I was at 16 months post op when it was removed. It takes longer for the ligaments and tendons to heal.

The numbness may be from nerve damage. Sometimes peripheral nerves can heal, but that takes a long time, and can be more than a year. I still have some stiffness in my ankle, but it is not tight anymore and keeping the parts moving correctly helps that a lot. The tightness comes a lot from the muscles on the stronger side beating up the weaker side because they can't counteract the strength. With physical therapy you stretch, but also need to rebuild strength on the weaker side as best you can. My difficulty with that was walking on uneven ground and having to stabilize my ankle in mud when I was out doing horse feeding chores. I was doing the least amount of steps as possible and getting a lot of fatigue and pain. It was a long winter being careful on ice and snow, then the months of mud in the spring and frequent rains. I wasn't sure how long this recovery can be to get back to my maximum recovery and my podiatrist couldn't really answer that either as it must vary with a lot of individual factors. I have wondered if it could be as much as 5 years.

I am encouraged and happy about my recent advances just in the last few weeks without the brace and want to try walking and hiking more to build endurance. What I can tell you is that when you have a high impact fracture with some added speed from a bicycle or moving horse, it tends to be a worse fracture. Mine was what they call a bimalleolar fracture, in simple terms, the "knobs" on both sides of the ankle (formed by the tibia and fibula) were sheared off. The front of my tibia was like puzzle pieces because of compression of flexing my foot into the ground on impact. If your surgeon were to remove hardware, he may not want to leave some of it there, and there is a reason there are at least 3 screws with plates so they can't move; he would probably remove the entire plate instead of leaving too few screws in place. That could also depend on how difficult it is to remove. The tricky part on mine was a screw inside my fibula, but he did get it out. The plates screwed to the outside of the tibia were easy to remove.

Knee problems come when you have alignment problems in your leg because something changes and you start walking differently. MFR therapy can help a lot with body alignment and more normal movement. If you get any pain in the knee, talk to a physical therapist or specialists about it, because if it is left alone, it can lead to uneven wear an tear, and this is what causes problems that can lead to knee replacements. It is possible that surgical hardware can limit your movement and lead to other joint problems, so do ask that question if that could happen to you. The recovery after hardware removal was not nearly as hard as the recovery right after the injury, so don't let that influence your decision. I'm thinking it seems to be about half the time at least in my case.

Second opinions are good. Would you let me know what you find out? I think I can help. Would you like to talk about the fear?

Hi Jennifer,

Your input has been helpful. My common sense tells me your right about the screws having very little to do about the tightness. It’s been a little over a year so I need to give it some more time. My surgeon said he thinks the tightness will improve however the numbness may be a different story. I will give that time, however most of time I don’t dwell on that and can live with it. I just hope the tightness resolves. As for my knee it stiff but improving and there is pain just below the knee cap due to one of the screws at the top of the rod that was inserted through my tibia. My surgeon said that can be removed easily in an outpatient procedure, a 15 minute operation, so I’m thinking of asking him about that. It certainly sounds like you have been on a long journey in your healing process. Right now I am gathering as much information as possible so I make the best decisions. As far as fear goes you have helped me step back and try and be a little more patient with my recovery. Thanks!