Ankle Fracture Surgery: Plates, Screws, and What Patients Should Expect
- sarangndesai
- Aug 8
- 16 min read
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Ankle Fracture Surgery: Plates, Screws, and What Patients Should Expect
By Sarang Desai, DO — Fellowship-Trained Orthopedic Foot and Ankle Surgeon
Sports Medicine | McKinney and Flower Mound, Texas
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If you've been told you need surgery for an ankle fracture, one of the first questions that comes to mind is: "What are they actually putting inside my ankle?"
Fair question. You're about to have metal implanted in your body, and you deserve a clear explanation of what it is, why it's there, how it works, and whether it ever needs to come out.
As someone who does this operation regularly in McKinney and Flower Mound, I've had this conversation thousands of times. Here's everything I'd tell you if you were sitting across from me in clinic.
For the full overview of ankle fractures: The Complete Guide to Ankle Fractures · Do All Ankle Fractures Need Surgery?
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WHY HARDWARE IS NEEDED
The ankle joint is unforgiving. Even 1–2 millimeters of displacement — a shift you can barely see with the naked eye — changes how weight distributes across the joint and increases long-term arthritis risk. The goal of surgery is to put every piece of bone back exactly where it belongs and hold it there while healing occurs.
That's what the plates and screws do. They are not replacements for bone. They are temporary scaffolding — holding the fracture in anatomic position while your body does the actual healing. Once the bone has healed, the hardware's job is done.
The operation is called ORIF — open reduction and internal fixation. "Open reduction" means making an incision to directly see and reposition the bones. "Internal fixation" means using implants (plates, screws, wires) placed under the skin to hold them there. Ankle ORIF Surgery: What to Expect
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WHAT ARE PLATES AND SCREWS MADE OF?
Nearly all modern ankle fracture hardware is made of either stainless steel or titanium alloy (Ti-6Al-4V).
Titanium
- Superior corrosion resistance and biocompatibility — titanium alloys are better than stainless steel and cobalt-chrome alloys in this regard, with a lower modulus of elasticity that reduces stress shielding of surrounding bone
- Lower metallic ion release — stainless steel implants release significantly more iron, chromium, molybdenum, and nickel into surrounding tissue compared to titanium
- MRI compatible — produces less artifact on MRI, which matters if you ever need imaging of the ankle after surgery
- Lighter
Stainless steel
- Long track record of success
- Slightly stronger, which matters in some constructs
- Less expensive
- Easier to remove — this is a real consideration, because titanium screws can occasionally cold-weld to the plate, making removal harder. A study of 157 titanium plate removal procedures found 1.1% of screws stripped, 0.6% cold-welded, and 1.0% broken during removal, with 7.6% of surgeries requiring advanced tools — more likely when implants had been in place longer (3.7 vs. 1.1 years)
Neither material triggers a foreign body reaction in local tissues. Both are well tolerated.
Bottom line: both work extremely well. Most fellowship-trained surgeons today preferentially use titanium for its biocompatibility and imaging advantages, but the clinical outcomes are comparable.
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THE HARDWARE, PIECE BY PIECE
Every ankle fracture is different, but here are the implants I may use and why:
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LATERAL MALLEOLUS (FIBULA) — THE MOST COMMON FIXATION SITE
The fibula is the bone on the outside of the ankle, and it breaks in the majority of ankle fractures. Fixing it is the cornerstone of the operation, because it sets the width and alignment of the ankle mortise. The standard technique uses a plate and screws:
Lag screw — A screw placed perpendicular to the fracture line that compresses the two pieces together. This is the first step: close the crack.
Neutralization plate — A metal plate laid along the fibula, secured with screws above and below the fracture. It protects the lag screw from bending and rotational forces while you heal. Without it, the lag screw alone would fail under normal loading.
This combination — lag screw plus neutralization plate — is the standard AO fixation technique taught to every orthopedic resident and has been the gold standard for decades.
Types of Fibula Plates — What the Surgeon Chooses and Why
One-third tubular plate
The original workhorse. Thin, lightweight, conforms well. A 2025 meta-analysis of 14 studies (2,802 patients) found one-third tubular plates had significantly shorter operative time and significantly lower overall wound complications compared to anatomical precontoured plates, with no differences in functional scores, union rates, hardware irritation, or hardware removal rates. And they cost a fraction of the price — $91 vs. $747 per plate in one economic analysis, which extrapolates to potential savings of nearly $40 million annually across the United States.
Anatomical precontoured plates (locking)
Pre-shaped to match the distal fibula anatomy, with locking screw technology. More expensive, but useful in certain scenarios:
- Osteoporotic bone — locking screws grip the plate rather than relying on friction with bone, providing better fixation in soft bone. A comparison found patients with osteoporosis achieved earlier partial weight-bearing with locking plates (4.7 vs. 7.8 weeks, P=0.03), though AOFAS scores at 6 and 12 months were similar
- Comminuted (shattered) fractures where a bridging construct is needed
- Very distal fractures where there isn't enough bone for standard screws
Locked vs. non-locked plating: A 442-patient study found both had low reoperation rates (6.3% locked vs. 11.3% non-locked). Non-locked plates placed laterally had more symptomatic hardware, while locked plates had higher infection-related reoperations. Both techniques work; the choice depends on bone quality and fracture pattern.
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WHERE THE PLATE GOES — LATERAL VS. POSTERIOR (AND WHY IT MATTERS TO YOU)
This is something most patients never think about, but it meaningfully affects whether the hardware bothers you:
Lateral plate — placed on the outer surface of the fibula. This is the most common position. The skin is thin here, and the plate sits directly under it. This is why many patients feel the plate through the skin, especially in boots, cleats, or ski boots.
Posterior antiglide plate — placed on the back of the fibula. A systematic review and meta-analysis of 1,122 patients found:
- Two-fold greater odds of needing hardware removal with lateral plating vs. posterior plating (OR 2.48; 95% CI 1.58–3.91; P<0.0001)
- Three-fold greater odds of hardware discomfort with lateral plating (OR 2.96; 95% CI 1.83–4.80; P<0.0001)
- No difference in peroneal tendon irritation, infection, wound complications, or operative time
A separate study confirmed this: among non-locked plates, 72.2% of hardware removals for symptomatic implants were laterally positioned vs. 27.8% posteriorly (P<0.01).
In a true antiglide technique, no screws are placed in the distal fragment at all — the plate acts as a buttress. This produced a 15.2% hardware removal rate vs. 38.1% when distal screws were added (P=0.02), with equivalent union and alignment.
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What this means for you: the position of the plate — not just the type — significantly affects whether you'll feel it and whether you'll eventually want it removed. Posterior placement is associated with substantially less hardware-related discomfort.
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Biomechanically, the posterior antiglide plate was stronger than the lateral locking plate in osteoporotic bone, with significantly greater torque to failure and construct stiffness (P=0.01 and P=0.005).
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ALTERNATIVE FIBULA FIXATION — INTRAMEDULLARY DEVICES
For some fracture patterns, the fibula can be fixed with a nail or screw placed inside the bone rather than a plate on the outside. Think of it like a dowel inside a broken stick instead of a splint taped to the outside.
Advantages:
- No prominent hardware under the skin — significantly less symptomatic hardware irritation (P<0.001) in one comparative study
- Smaller incision, less soft tissue stripping
- Lower delayed implant removal rate (8.7% vs. 23.6%) in a separate case-control study
Where the evidence stands:
- A meta-analysis of 4 RCTs (359 patients) found intramedullary nail fixation had significantly better functional outcomes at 3 months and fewer wound-related complications
- However, a prospective RCT of 120 patients aged ≥60 found significantly more complications and secondary operations after nail fixation than plate fixation (P=0.024 and P=0.028), with equivalent functional scores
- Functional outcomes at 12+ months are equivalent between approaches
Bottom line: intramedullary fixation is a viable option, particularly for patients with soft tissue concerns, diabetes, or peripheral vascular disease. But plate fixation remains the standard of care and the most studied technique.
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MEDIAL MALLEOLUS — THE INSIDE OF THE ANKLE
When the bump of bone on the inside of the ankle breaks, it's typically fixed with two partially threaded cannulated screws.
Cannulated means the screws are hollow — they slide over a guidewire that's been placed across the fracture first, ensuring perfect trajectory. Partially threaded means the threads only grab the fragment, pulling it back to the tibia and compressing the fracture.
In some fractures — particularly vertical shear patterns — a buttress plate is used instead, placed on the medial surface to prevent the fragment from displacing.
Why the medial side can be annoying: The skin over the medial malleolus is paper-thin. Hardware here is often palpable, and screw heads can be felt through the skin. This is one of the most common sites for hardware-related discomfort.
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POSTERIOR MALLEOLUS — THE BACK OF THE ANKLE
Trimalleolar fractures include a fragment off the back of the tibia. How it's fixed depends on its size and displacement:
Anterior-to-posterior (A-to-P) screws — for smaller fragments, screws placed from the front of the tibia into the posterior fragment. No additional incision needed — the screws go through the anterior skin.
Posterior buttress plate — for larger fragments, a plate placed directly on the back of the tibia through a posterolateral incision. A meta-analysis of 2 RCTs and 6 cohort studies found posterior plating achieved better articular step-off and gap reduction (RR 0.28; 95% CI 0.11–0.76; P=0.01) compared to A-to-P screws, with no differences in AOFAS scores, arthritis rates, or total complications.
The clinical implication: better articular reduction means a smoother joint surface, which theoretically reduces arthritis risk over time. For larger posterior fragments, direct fixation with a plate tends to be more anatomic.
For fracture type comparisons: Bimalleolar vs. Trimalleolar vs. Lateral Malleolus Fractures Explained
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SYNDESMOTIC FIXATION — HOLDING THE TWO LEG BONES TOGETHER
About 20% of ankle fractures damage the syndesmosis — the ligament complex between the tibia and fibula above the ankle joint. When it's unstable, it must be fixed.
There are two main options:
Syndesmotic screw (rigid fixation) — a screw through the fibula into the tibia, locking the two bones together. Works well but:
- Can delay weight-bearing
- May break if loaded too early
- Often needs to be removed (22.4% removal rate)
- Can malreduce the joint (11.5%)
Suture button (flexible fixation) — high-strength suture with cortical buttons, allowing physiologic motion. A meta-analysis of 5 RCTs found:
- Higher AOFAS scores (95.3 vs. 86.7, P<0.001)
- 0% broken implants vs. 25.4% with screws
- Less malreduction (0.8% vs. 11.5%)
- Earlier weight-bearing and lower implant removal rate (6% vs. 22.4%)
At 5-year follow-up of a randomized trial, suture button maintained better functional scores (AOFAS 100 vs. 90, P=0.006) and was associated with lower incidence of ankle osteoarthritis (35% vs. 65%; OR 3.4; P=0.009).
I covered this in detail in: Ankle Fracture Surgery Recovery Timeline: Week by Week
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TENSION BAND WIRES AND K-WIRES
Occasionally used for specific fracture patterns:
Tension band wiring — two K-wires plus a figure-of-eight wire, most commonly for small medial malleolus fragments. Converts tensile forces to compression during ankle motion. Less common than screw fixation but occasionally the right choice for small avulsion-type fragments.
K-wires (Kirschner wires) — thin, smooth wires used for provisional fixation (holding things temporarily during surgery) or occasionally as definitive fixation in very small fragments. These can sometimes be left outside the skin and removed in clinic without another surgery.
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THE TYPICAL HARDWARE CONSTRUCT — PUT IT ALL TOGETHER
Here's what the hardware looks like for the three most common fracture patterns:
Isolated lateral malleolus fracture (Weber B):
- 1 lag screw across the fracture
- 1 neutralization plate (4–6 holes) along the fibula with 4–6 screws
- Total: ~1 plate, 5–7 screws
Bimalleolar fracture:
- Fibula: lag screw + neutralization plate (as above)
- Medial malleolus: 2 partially threaded cannulated screws
- Total: ~1 plate, 7–9 screws
Trimalleolar fracture with syndesmotic injury:
- Fibula: lag screw + neutralization plate
- Medial malleolus: 2 screws
- Posterior malleolus: 1–2 screws or a posterior plate
- Syndesmosis: 1–2 syndesmotic screws or suture button
- Total: 1–2 plates, 9–14 screws, ± suture button device
All of this is visible on your postoperative X-rays, which is why those films can look alarming. It's a lot of metal. But every piece has a specific job.
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WHAT TO EXPECT WITH HARDWARE IN YOUR ANKLE
Feeling the hardware: This is the most common patient concern, and it's real. 89.4% of patients with internally fixed ankle fractures report some form of discomfort — soreness over implants, scar tissue sensitivity, reduced motion, or strain-related pain. This doesn't mean something is wrong. It means you have metal under thin skin.
Where it's felt most:
- Lateral fibula plate (especially if placed laterally rather than posteriorly)
- Medial malleolus screws
- The plate edge, where it contacts soft tissue during ankle motion
What makes it worse:
- Tight shoes, boots, cleats, ski boots, ice skates
- Cold weather
- Direct pressure (kneeling, sitting cross-legged)
- Swelling (which pushes tissue against the hardware)
What helps:
- Supportive shoes with room in the ankle area
- Compression for swelling management
- Silicone scar pads over prominent hardware
- Time — most hardware discomfort improves over the first 12–18 months as soft tissue settles
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DOES THE HARDWARE EVER NEED TO COME OUT?
This is one of the most debated questions in orthopedic trauma.
The short answer: not routinely, but it's common.
The data:
- In a Finnish nationwide registry of 83,666 ankle fracture surgeries, the most common reason for reoperation beyond 4 months was fixation device removal, with a cumulative incidence of 17% within 3 years
- In a 997-patient study, 17% had implant removal — 144 for complaints and 26 for infection
- Hardware removal was more common in younger patients and those with bimalleolar or trimalleolar fractures
- Risk factors for removal due to complaints: female sex, younger age, no syndesmosis screw, longer operation
- Risk factors for removal due to infection: older age, current smoking (HR 3.15, P=0.005)
Does removal help?
A study of 80 consecutive hardware removal cases found:
- Pain score decreased from 3.4 to 1.3 after removal
- 72.5% had improved ankle stiffness
- 81.3% had less discomfort walking on uneven ground
- 80.8% were satisfied with hardware removal
These benefits held even when the pre-removal hardware-related pain was minimal. The authors concluded that routine hardware removal after bony union could improve daily activities and patient satisfaction.
My approach: I don't recommend routine removal for every patient. But if hardware is limiting your shoe options, causing pain during activity, or bothering you at 12+ months despite healing, removal is a reasonable outpatient procedure with high satisfaction rates.
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COMPLICATIONS — WHAT CAN GO WRONG WITH THE HARDWARE
The overall short-term complication rate after ankle fracture surgery in the Finnish national registry was 7.2%:
- Infection: 4.4%
- Thromboembolic complications: 1.6%
- Mechanical complications (hardware failure): 0.4%
- Other: 0.9%
- Mortality within 4 months: 0.6% (in an elderly-heavy population)
Risk factors for complications: age >75 (OR 1.53, P<0.001), diabetes, chronic pulmonary disease, kidney or liver disease, and peripheral vascular disease.
Hardware-specific issues:
- Symptomatic hardware — the most common "complication," though it's really an expected occurrence in a percentage of patients
- Hardware failure (broken screw, bent plate) — rare with modern implants when weight-bearing protocols are followed
- Infection — diabetes was the dominant risk factor (83.3% of infection-related reoperations occurred in diabetic patients). Smoking tripled the risk (HR 3.15, P=0.005)
- Screw penetration into the joint — avoidable with careful intraoperative fluoroscopy and proper technique
- Peroneal tendon irritation — can occur with posterior plating if the plate extends too far distally
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WILL THE HARDWARE SET OFF METAL DETECTORS?
A question every patient asks. Usually not for ankle hardware. Airport security metal detectors are calibrated for weapons, and the amount of metal in an ankle fracture construct is typically below the threshold. TSA body scanners may occasionally flag it. You won't need to carry a card, but you can request one from your surgeon if it makes you feel better.
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CAN I GET AN MRI WITH HARDWARE?
Yes. Both titanium and stainless steel implants used in modern ankle fracture surgery are MRI-safe at standard clinical field strengths (1.5T and 3T). The hardware creates artifact — a dark area on the image around the metal — which can limit interpretation of nearby structures. Titanium produces less artifact than stainless steel, which is one reason many surgeons prefer it.
If you ever need an MRI of your ankle after surgery — for example, to evaluate cartilage, tendons, or ligaments — the hardware won't prevent the study. It may limit what the radiologist can see immediately adjacent to the metal.
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FREQUENTLY ASKED QUESTIONS
1. What kind of metal is in my ankle?
Almost always titanium alloy or stainless steel. Both are well tolerated with no foreign body reaction. Titanium has superior biocompatibility, corrosion resistance, and MRI compatibility.
2. How many screws will I have?
Depends on the fracture. A simple lateral malleolus: 5–7 screws and 1 plate. A trimalleolar fracture with syndesmotic fixation: 9–14 screws, 1–2 plates, ± suture button.
3. Are the screws permanent?
They can be. The hardware is designed to be left permanently unless it causes symptoms. 17% of patients have hardware removed within 3 years, most for discomfort, not failure.
4. Will I feel the plate?
Many patients feel it to some degree, especially on the outside and inside of the ankle where skin is thin. 89.4% report some form of implant awareness. This typically improves over 12–18 months.
5. Does plate position matter?
Yes — significantly. Posterior plate placement on the fibula is associated with 2.5× less hardware removal and 3× less hardware discomfort compared to lateral placement.
6. What is a locking plate? Is it better?
A locking plate has threaded screw holes that lock the screw to the plate, creating a fixed-angle construct. It's useful in osteoporotic bone and comminuted fractures. For standard fractures in good bone, outcomes are similar to non-locking plates, but locking plates cost about 4× more.
7. What is an antiglide plate?
A plate placed posteriorly on the fibula that acts as a buttress — the fracture pushes against the plate and can't slide. It often requires no screws in the distal fragment, which reduces hardware prominence and halves the hardware removal rate.
8. What is a lag screw?
A screw placed perpendicular to the fracture that compresses the bone fragments together. It's the foundation of fibula fixation — the plate protects it.
9. What is a cannulated screw?
A hollow screw that slides over a guidewire. Used mainly for the medial malleolus. The guidewire ensures perfect aim before you commit to the screw trajectory.
10. What is a suture button for the syndesmosis?
A flexible fixation device using high-strength suture with buttons on each side of the bone. Allows physiologic motion and is associated with better functional scores, earlier weight-bearing, and lower arthritis risk at 5 years compared to syndesmotic screws.
11. Will the syndesmotic screw need to come out?
Often yes — 22.4% required removal in a meta-analysis. This is typically done as a short outpatient procedure at 8–12 weeks.
12. Can screws break?
Rarely. Syndesmotic screws break more often than other screws (25.4% breakage rate in a meta-analysis), which is one reason suture buttons have gained popularity (0% breakage).
13. Can plates break?
Very rarely with modern plates when protocols are followed. This usually indicates the bone hasn't healed (nonunion) and the hardware is absorbing forces the bone should be carrying.
14. What if I'm allergic to metal?
True metal allergy is rare but real. Nickel is the most common culprit, and stainless steel contains nickel. Titanium allergy is exceedingly rare. Commercially pure titanium has been shown to contain trace impurities of nickel, but clinical reactions are very uncommon. If you have a documented metal allergy, tell your surgeon — titanium is the safer choice.
15. Do plates and screws cause arthritis?
The hardware itself does not cause arthritis. Post-traumatic arthritis comes from the original cartilage damage at the time of injury, not from the hardware. Ankle Arthritis Treatment in DFW: What the 2026 AAOS Guidelines Mean for You
16. Will I need to modify my shoes?
Possibly for the first year while swelling settles. Most patients return to normal shoe wear. Those with prominent lateral hardware may prefer boots and shoes with a wider ankle collar. Tight-fitting ski boots, ice skates, and cleats can be uncomfortable until hardware is removed.
17. How long does hardware removal surgery take?
Usually 30–60 minutes, outpatient, under anesthesia. Recovery is much shorter than the original operation — most patients are weight-bearing immediately in a boot and back to normal within 2–4 weeks.
18. Is titanium harder to remove?
Slightly. 1.1% of titanium screws stripped and 0.6% cold-welded during removal in a 157-patient study. Longer in-vivo time increased difficulty (3.7 vs. 1.1 years). But overall, 92.4% of titanium removals were straightforward.
19. Can I play sports with hardware in my ankle?
Yes. Once the fracture has healed and you've completed rehabilitation, the hardware does not prevent return to sport. Professional athletes routinely compete with plates and screws in their ankles. A Pro Sports Team Physician's Guide to Foot and Ankle Sports Injuries
20. My friend said they only had screws, no plate. Why do I need a plate?
Different fracture patterns require different constructs. Some medial malleolus or posterior malleolus fractures need only screws. Most fibula fractures need a plate because the forces acting on the fibula during walking are primarily rotational — screws alone can't resist that.
21. What does "open reduction" actually mean?
It means making a surgical incision to directly see and realign the broken bones. This is opposed to "closed reduction," which is setting the bones through the skin without an incision. For most displaced ankle fractures, direct visualization gives a better result.
22. How big are the incisions?
Typically 6–10 cm on the outside of the ankle and 3–5 cm on the inside, depending on the fracture. Posterior approaches add a third incision if the posterior malleolus needs direct fixation.
23. Can the surgery be done with smaller incisions?
Some techniques — including intramedullary fibula fixation and minimally invasive plate osteosynthesis (MIPO) — use smaller incisions. These reduce soft tissue stripping but are not appropriate for every fracture pattern.
24. What happens if I smoke?
Tobacco use adversely affects direct bone healing (P<0.001) and increases postoperative complications (P=0.050). Smoking tripled the risk of infection-related hardware removal (HR 3.15, P=0.005). Quit before surgery if at all possible.
25. I have diabetes. Does that change things?
Yes. Diabetes was the only comorbidity associated with a higher rate of infection-related reoperations (83.3% vs. 15.6%, P<0.01) in a 442-patient study. Good blood sugar control before and after surgery directly affects outcomes.
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THE BOTTOM LINE
- Modern ankle fracture hardware is safe, well-tolerated, and effective
- Titanium and stainless steel both work; titanium has advantages in biocompatibility and imaging
- Plate position matters — posterior placement reduces hardware discomfort and removal rates significantly
- Suture button (flexible) syndesmotic fixation outperforms syndesmotic screws on most outcome measures
- 17% of patients have hardware removed within 3 years, mostly for discomfort — and over 80% are satisfied with removal
- Complications are uncommon (7.2% overall) but are higher in smokers, diabetics, and elderly patients
- The hardware is not the limiting factor in your recovery — your bone healing, rehabilitation, and overall health are
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RELATED READING
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ABOUT THE AUTHOR
Dr. Sarang Desai is a fellowship-trained orthopedic foot and ankle surgeon with particular expertise in sports medicine. With over 15 years of experience, Dr. Desai serves as a professional sports team physician and treats the full spectrum of foot and ankle conditions — including ankle fractures, syndesmotic injuries, Achilles tendon injuries, chronic ankle instability, cartilage injuries, peroneal tendon disorders, bunions, foot and ankle arthritis, total ankle replacement, and complex revision surgery.
He is a published researcher, an orthopedic implant inventor, a national lecturer, and a former University of Texas All-American athlete.
Offices in McKinney and Flower Mound, Texas, serving patients throughout Plano, Frisco, Denton, Lewisville, Southlake, Dallas, Fort Worth, Arlington, and the greater Dallas–Fort Worth metroplex and beyond.
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📞 (972) 547-0047
📍 McKinney, TX | Flower Mound, TX
If you've broken your ankle and want an expert opinion on surgical options — or if you've already had surgery and have questions about your hardware — bring your X-rays, operative report, and a list of questions. The goal is straightforward: an anatomic reduction, stable fixation, and getting you back to your life.
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This article is for educational purposes only and does not constitute personal medical advice. Always consult a qualified physician about your individual situation.
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