Hardware removal halts the majority of postoperative foot and ankle pain

Patients’ reconstructions fared best if pain decreased after elective hardware removal.

Issue: September 2009

Many orthopedists offer hardware removal to patients undergoing foot and ankle reconstructive or trauma surgery, but patients frequently do not take advantage of it. For those who do, this practice can play a positive role in their pain management, according to Tampa-area investigators.

To better understand the factors affecting pain in these patients, Dolfi Herscovici Jr., DO, and Julia Scaduto, ARNP, prospectively enrolled 28 patients in a study to evaluate hardware removal outcomes in terms of how greatly and quickly pain levels improved.

According to Herscovici, “94% of patients had a decrease in pain postoperatively. The best results appeared to occur in the reconstructive patients.” Those with the next best results: trauma patients without workers’ compensation claims.

“You can get a decrease in pain to occur in almost all these patients, but it is unlikely you will be able to eliminate all of their pain,” Herscovici said at the American Academy of Orthopaedic Surgeons annual meeting.

Two groups

They investigated 26 patients who elected to undergo hardware removal at the investigators’ institution between January 2006 and December 2007. The majority were women and the average age for the group was 51 years. Exclusion criteria were infection, nonunion, skeletal immaturity, planned removal of implants and neurogenic-based pain.

Investigators analyzed outcomes using the pain Visual Analog Scale (VAS), SF-36 general health scale and Short Form Musculoskeletal Functional Assessment (SMFA) questionnaire preoperatively and 6 months postoperatively.

Eighteen patients underwent open reduction internal fixation (ORIF) and constituted the trauma group, with eight patients in the reconstructive group. Herscovici said the groups were similar demographically, and their body mass index (BMI), all were obese. The BMIs for the groups were approximately 28 for the reconstructive and 30 for trauma group.

Average preoperative scores for both groups were VAS 5.1, SF-36 43.1 and SMFA 38.6 compared to VAS 3.6, SF-36 45.6 and SMFA 23.1, average, after hardware removal surgery.

Lingering pain

According to the abstract, preoperative VAS scores of 4.5 dropped to 3.2 for the reconstructive group. Their preoperative SF-36 scores of 55.4 were 49.3 after hardware removal, and their SMFA score decreased from 43.0 to 33.5. The trauma group’s VAS scores changed from 6.7 to 2.2. Their SF-36 scores went from 42.2 preop to 43.1 postop, and preoperative SMFA scores of about 45 decreased to 18 postoperatively.

Among workers’ compensation patients, “There was little or no change between preoperative and postoperative evaluation,” Herscovici said.

Two patients in each group ended up pain-free.

“We feel the factors that probably contribute to pain are the high BMI, the waits, the compensation for pain,” as well as time elapsed between implant placement and removal, he said.

For more information:

Dolfi Herscovici Jr., DO, can be reached at the Florida Orthopaedic Institute, 13020 Telecom Parkway North, Tampa, FL 33637; 813-978-9700; e-mail: fixbones@aol.com. He has no direct financial interest in any products or companies mentioned in this article.

Reference:

Herscovici D, Scaduto J. Removal of hardware in the foot and ankle: How successful are we in managing pain? #239. Presented at the American Academy of Orthopaedic Surgeons 76th Annual Meeting. Feb. 25-28, 2009. Las Vegas.