Surgical screws left in bone after fracture repair are one of the most common sources of ongoing orthopedic pain, and the discomfort they cause is the leading reason patients request a second surgery to have hardware taken out. In one prospective study of patients with symptomatic implants, pain was present in about 60% of cases scheduled for removal. The pain can range from a dull ache that flares in cold weather to sharp discomfort that limits movement, and its causes are more varied than most people realize.
How Common Is Implant-Related Pain After a Fracture Heals?
The short answer is that a meaningful fraction of people who receive plates, screws, or rods during fracture surgery end up bothered by the hardware once the bone itself has healed. Across the literature, pain and “prominent material” (hardware you can feel pressing under the skin) are the most frequently cited reasons patients seek removal, well ahead of concerns like planned future surgery or routine protocol-based removal.1PubMed. Indications for implant removal after fracture healing: a review of the literature In a prospective cohort of symptomatic patients, pain was the single most common complaint, present in roughly 60% of cases, with an average pain score of about 3.6 out of 10 before surgery.2PubMed Central. Is Elective Implant Removal after Fracture Healing Beneficial? – A Prospective Cohort Study
Some locations are worse than others. After surgical repair of a kneecap (patella) fracture, about one in three patients needed a second operation specifically because of implant-related symptoms, and among patients younger than 60 the rate climbed to 40%.3PubMed. Implant removal following surgical stabilization of patella fracture That is a striking number, and it underscores a reality that surgeons sometimes gloss over when counseling patients before fracture surgery: the hardware that fixes the bone can become a problem of its own.
Mechanical Reasons Screws Hurt
The most straightforward explanation is physical irritation. Screws can protrude slightly beyond the far side of the bone, and when they do, the protruding tip presses into soft tissue, tendons, or nearby nerves and blood vessels.4PubMed Central. Incidence and complications of orthopaedic screw protrusion Even when a screw sits exactly where it was intended, it can create a hard bump under thin skin. In the ankle, the shin, or the wrist, where there is not much soft tissue padding between bone and skin, patients often report being able to feel the screw head when they press on the area or when shoes or clothing rub against it.
Another mechanical issue is stress shielding. Metal is far stiffer than bone, so a plate and screw construct carries most of the load during healing. Once the fracture has united, the hardware continues to bear a disproportionate share of mechanical stress, and the bone underneath can gradually thin from disuse. Computational modeling has shown that commercially available screws can reduce the load on surrounding bone by 55 to 70% over three years, which eventually weakens the bone and can contribute to loosening.5PubMed. Computational simulations of stress shielding and bone resorption around existing and computer-designed orthopaedic screws A loose screw is a painful screw: it micro-moves inside the bone, irritating surrounding tissue with every step or twist.
Screw loosening is an especially well-studied concern in spinal surgery, where pedicle screws anchor rods to the vertebrae. Loosening there can undermine the fusion, cause back pain to return, and sometimes require revision surgery.6PubMed Central. Risk factors for pedicle screw loosening: a comprehensive review Patients with osteoporosis, diabetes, or a history of smoking tend to be at higher risk, because all of those factors slow or impair the bone’s ability to integrate tightly around the screw threads.
The Cold-Weather Connection
If you have ever heard someone with a plate in their leg say they can “feel the weather changing,” they are not imagining things. A recent study comparing implant-related pain in cold versus warm conditions found that roughly 60% of patients experienced pain in cold weather, compared with about 18% in warm weather.7PubMed. A myth: orthopedic implant pain in cold weather About a third of patients also reported a persistent cold sensation around the implant site and difficulty warming the area up. A quarter took preventive measures against the cold, such as layering clothing or using heating pads.
The mechanism is not entirely settled, but the leading explanation involves the difference in thermal conductivity between metal and bone. Metal conducts heat away from surrounding tissue far more efficiently than bone does, so when the ambient temperature drops, the tissue closest to the implant cools faster than surrounding tissue. That localized cooling can stimulate pain-sensing nerve endings and may increase stiffness in the joint capsule or surrounding scar tissue. Whatever the exact pathway, the clinical finding is clear: cold weather and implant pain go hand in hand for a majority of people with retained hardware.
Infection and Metal Allergy
Not all implant pain is mechanical. A low-grade bacterial infection can simmer around hardware for months or years without causing the dramatic redness and fever that people associate with infection. In a database study of patients undergoing revision spinal surgery, about 29% of cases tested positive for bacteria on infection screening, most commonly Staphylococcus and Propionibacterium species. Patients who tested positive were more likely to have loose screws on imaging, and removing the infected hardware produced significant pain relief.8PubMed. Pedicle screw loosening is correlated to chronic subclinical deep implant infection: a retrospective database analysis This kind of chronic subclinical infection is easy to miss because blood tests and X-rays can look normal. It tends to be discovered only when someone undergoes revision surgery and cultures are taken directly from the tissue around the implant.
Metal allergy is rarer but real. Orthopedic implants are made from stainless steel, titanium, or cobalt-chromium alloys, and a small number of people develop a hypersensitivity reaction to one of these metals. The reaction can cause persistent pain, swelling, and skin changes around the implant site. In some cases it leads to loosening, formation of inflammatory tissue masses around the hardware, or outright device failure.9PubMed Central. Metal Hypersensitivity Reactions to Orthopedic Implants If there is no obvious mechanical explanation for persistent pain and infection has been ruled out, patch testing for metal allergy is sometimes the next diagnostic step.
Locations Where Screws Are Especially Troublesome
The ankle is a frequent offender. Syndesmotic screws, placed across the joint between the tibia and fibula to hold the ankle mortise together, can restrict normal ankle motion even after the ligaments heal. When an intact syndesmotic screw limits dorsiflexion or causes ongoing discomfort, removal after four to six months is often recommended.10PubMed Central. To retain or remove the syndesmotic screw: a review of literature If the screw breaks inside the bone, the situation can become more complicated. Broken screw fragments trapped within bone have been linked to higher rates of eventual hardware removal due to pain.11PubMed. Syndesmotic Screw Breakage May Be More Problematic Than Previously Reported
In the lumbar spine, pedicle screws that violate an adjacent facet joint can impair outcomes. When a screw encroaches on the facet joint at the vertebral level above or below the fusion, patients tend to have less improvement in back pain and disability scores compared to those whose screws are well-positioned.12PubMed Central. Pedicle Screw-Associated Violation of the Adjacent Unfused Facet Joint: Clinical Outcomes and Fusion Rates Facet joint violations have also been studied as a contributor to adjacent segment disease, the gradual breakdown of spinal segments next to a fusion, which can cause new pain years after the original surgery.13PubMed Central. Superior facet joint violation after lumbar pedicle screw placement: a scoping review
Beyond those two areas, the kneecap and the forearm are also well-known trouble spots, largely because the hardware sits close to the skin surface and rubs against tendons during movement. As noted earlier, kneecap fracture hardware has some of the highest removal rates in the body.
How Doctors Figure Out Whether the Screw Is the Problem
Diagnosing hardware-related pain is not as straightforward as it might seem. A patient might have pain near the hardware, but that does not automatically mean the hardware is to blame. Scar tissue, nerve damage from the original injury, or arthritis in a nearby joint can all mimic implant pain. Imaging helps narrow it down, but each modality has limits.
Standard X-rays are good for spotting obvious problems like a broken screw or a plate that has shifted, but they miss subtler issues. CT scans do a better job of detecting screw loosening: in a prospective trial comparing imaging methods for pedicle screws in the spine, CT had the highest sensitivity at about 65%, compared with roughly 54% for X-rays and 44% for MRI.14PubMed. Value of standard radiographs, computed tomography, and magnetic resonance imaging of the lumbar spine in detection of intraoperatively confirmed pedicle screw loosening MRI has traditionally been limited by metal artifact, the distortion that metallic implants create on the images. Newer metal-artifact-reduction MRI sequences improve diagnostic confidence for complications like soft-tissue inflammation and nerve compression near hardware.15PLoS ONE. Comparison Study between Conventional Sequence and Slice-Encoding Metal Artifact Correction (SEMAC)
In practice, surgeons often rely on a combination of clinical clues and imaging. If pressing directly on the screw head reproduces the patient’s pain, if the pain started only after the fracture healed, or if symptoms worsen in cold weather or with specific movements, those patterns build the case that hardware is the culprit. When infection is suspected, blood markers like CRP and ESR can help, but definitive diagnosis sometimes requires tissue cultures taken during surgery.
When Hardware Removal Helps, and When It Does Not
The good news is that taking out painful hardware usually works. In one study tracking patients for a year after implant removal, pain scores dropped by about 76%, and more than half of patients had complete resolution of pain by 12 months. Every patient in that cohort said they were satisfied and would do it again.16Journal of Bone and Joint Surgery. Removal of Painful Orthopaedic Implants After Fracture Union A large patient survey found that 95% of those who had hardware removed because of pain reported subjective improvement afterward.17PubMed Central. Metal implant removal: benefits and drawbacks – a patient survey
But those numbers deserve some nuance. The same survey found that about 42% of all patients felt no change in pain after removal, even when the surgery went smoothly. And roughly 5% of patients who had pain beforehand said it actually got worse after the hardware came out.17PubMed Central. Metal implant removal: benefits and drawbacks – a patient survey When surgeons themselves were surveyed about how effective implant removal is for symptomatic patients, they rated its effectiveness as moderate, averaging about 5.8 out of 10.18PubMed Central. Surgeons’ beliefs and perceptions about removal of orthopaedic implants That measured optimism reflects a genuine clinical reality: sometimes the pain is not coming from the hardware itself but from nerve damage, scar tissue, or changes in the joint that removal surgery cannot reverse.
The distinction matters for your expectations going in. If the pain is clearly localized to the hardware, reproducible by pressing on the screw, and worse with specific motions that load the implant, removal tends to produce good results. If the pain is more diffuse, has a burning or shooting quality (suggesting nerve involvement), or is accompanied by significant psychological distress, the odds of complete relief with hardware removal are lower.
Risks of the Removal Procedure Itself
Hardware removal is generally considered minor surgery, but it carries its own set of complications. A large analysis found that wound-healing problems occurred in about 2% of cases, infections in about 1.6%, and unexpected reoperations in about 2.5%. Nerve injury occurred in roughly 0.6% of removals, and bone re-fracture at the old fracture site occurred in about 0.5%.19PubMed. Complications of Hardware Removal
Refracture is the risk that concerns surgeons most, particularly in children. Bone that has been shielded by a plate for months or years may not be strong enough to handle full load immediately after the plate comes off.20PubMed Central. Indications for and Risks Associated With Implant Removal After Pediatric Trauma Activity restrictions for several weeks after removal are standard practice to give the bone time to remodel.
The removal itself can also be technically challenging. Locking screws in modern plates sometimes become jammed or have their drive recesses stripped, making extraction difficult. A multicenter study of locking-screw removal found that jammed and stripped screws were the most common technical complications, and in one case the humerus fractured during plate removal.21PubMed. Technical complications during removal of locking screws from locking compression plates These situations require specialized instruments and sometimes turn a routine operation into a longer, more complicated procedure.
Children and Adolescents
Hardware removal is more common in pediatric patients than in adults, and for good reason. Growing bones change shape over time, and an implant that fit well at age 10 may be in the wrong position by age 13. Surgeons also remove hardware in children to prevent it from interfering with future growth or becoming buried under new bone, which would make later removal much harder. About 88% of pediatric patients who had hardware removed specifically for pain experienced relief afterward, a slightly better rate than in adult populations.22Journal of Pediatric Orthopaedics. Complications of Hardware Removal in Pediatric Orthopaedic Surgery
The trade-off is that removal in children carries its own challenges. In guided-growth procedures for ankle deformity, where screws and staples are used to temporarily steer bone growth, complicated hardware extraction occurred in about 37% of extremities. Hardware that had been left in longer (averaging 1.8 years versus 1.4 years) was significantly more likely to be difficult to remove, and in a small number of cases screws could not be fully extracted at all.23Journal of Pediatric Orthopaedics. Guided Growth for Ankle Valgus Deformity: The Challenges of Hardware Removal The lesson for parents is that planned removal should not be indefinitely postponed once the treating surgeon recommends it, because bone overgrowth around hardware makes the procedure progressively harder.
Bioabsorbable Screws and the Future of Fixation
One way to avoid hardware pain entirely is to use screws that dissolve on their own. Bioabsorbable screws, made from polymers that gradually break down and are replaced by bone, eliminate the need for a second removal surgery. A study comparing bioabsorbable and metallic screws for tibial tubercle fractures in adolescents found that both types were equally effective for healing, but the bioabsorbable screws produced less hardware irritation, earlier recovery of knee range of motion, and lower rates of joint stiffness.24PubMed Central. Comparison of bioabsorbable screw versus metallic screw fixation for tibial tubercle fractures in adolescents
Bioabsorbable fixation is not a universal replacement for metal, though. These screws are weaker than their metallic counterparts, which limits their use to fractures that do not bear heavy loads during healing. They also occasionally cause a local inflammatory reaction as they degrade, producing a painful swelling that can be confused with infection. For high-demand applications like spinal fusion or complex lower-limb fractures, metal remains the standard. Newer screw designs with graded stiffness, intended to reduce stress shielding by allowing more load to transfer to the bone, have shown promising results in computer simulations, potentially decreasing bone loss around the screw from over 55% down to about 15% over three years.5PubMed. Computational simulations of stress shielding and bone resorption around existing and computer-designed orthopaedic screws Whether those laboratory results translate into fewer painful loose screws in real patients is still an open question.
Living With Hardware You Are Keeping
Not everyone with implant-related discomfort needs or wants removal surgery. For some people the pain is manageable, the hardware is in a location where removal carries high surgical risk, or medical conditions make another operation inadvisable. In those cases, practical management strategies can make a real difference.
Cold sensitivity is one of the most common ongoing complaints. Wearing thermal sleeves or insulated braces over the hardware site during winter, using microwaveable heat wraps, and keeping the affected limb warm during outdoor activities can reduce flares. For pain driven by soft-tissue irritation over a prominent screw head, silicone scar pads or gel cushions placed inside shoes or under clothing can buffer the pressure. Physical therapy focused on strengthening the muscles around the implant site can also help, because stronger surrounding musculature offloads some of the mechanical stress that gets transmitted to the hardware.
Over-the-counter anti-inflammatory medications manage flares for many people. If the pain is more persistent, a conversation with your surgeon about whether the hardware has served its purpose and can safely come out is worth having. Surgeons tend to counsel patience in the first year after fracture surgery, because some implant-related discomfort fades as swelling resolves and soft tissues settle around the hardware. Pain that persists or worsens beyond 12 to 18 months, though, is less likely to resolve on its own and more likely to represent a structural issue worth investigating.