Radiographic Evaluation of Foot Hardware

Standard Radiographic Protocol

The American College of Radiology recommends obtaining standard three-view radiographs consisting of anteroposterior (AP), medial oblique, and lateral projections, ideally performed weight-bearing, to provide sufficient radiographic evaluation of the osseous anatomy and hardware positioning in the foot 1
Weight-bearing radiographs are preferred over non-weight-bearing films because they detect dynamic abnormalities such as hardware loosening, joint malalignment, and implant displacement that may not be apparent when the foot is unloaded 1, 2
Non-weight-bearing radiographs are an acceptable alternative if the patient cannot bear weight due to pain, limited mobility, or risk of further displacement, though they provide less functional information 1

For hardware in the calcaneus, an axial Harris-Beath view should be added to the standard three views to optimally evaluate the posterior foot and assess hardware position relative to the subtalar joint 3, 4
The standard three-view series adequately visualizes midfoot hardware without additional projections 3, 2
Bilateral comparison views can be helpful when evaluating subtle malalignment or hardware positioning, particularly in the midfoot where anatomic relationships are complex 2
The standard three views are generally sufficient for metatarsal and phalangeal hardware 3, 5

The American College of Radiology advises against relying solely on non-weight-bearing films when assessing hardware stability or alignment, as this can miss clinically significant displacement or loosening that only manifests under physiologic load 1, 2
Consistent positioning between serial studies is crucial, as inconsistent cassette-side positioning or weight-bearing status can make comparison difficult and obscure subtle hardware migration 6

The American College of Radiology recommends considering CT for evaluating complex hardware positioning, assessing bone quality around implants, or when plain radiographs are equivocal regarding hardware complications 3, 1
MRI should be considered if there is clinical concern for soft tissue complications (infection, tendon injury) around hardware, though it is not routinely used for initial hardware assessment 3, 1