Skip to main content

Advertisement

SpringerLink
Log in

Indications for implant removal after fracture healing: a review of the literature

  • Review Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Introduction

The aim of this review was to collect and summarize published data on the indications for implant removal after fracture healing, since these are not well defined and guidelines hardly exist.

Methods

A literature search was performed.

Results

Though there are several presumed benefits of implant removal, such as functional improvement and pain relief, the surgical procedure can be very challenging and may lead to complications or even worsening of the complaints. Research has focused on the safety of metal implants (e.g., risk of corrosion, allergy, and carcinogenesis). For these reasons, implants have been removed routinely for decades. Along with the introduction of titanium alloy implants, the need for implant removal became a subject of debate in view of potential (dis)advantages since, in general, implants made of titanium alloys are more difficult to remove. Currently, the main indications for removal from both the upper and lower extremity are mostly ‘relative’ and patient-driven, such as pain, prominent material, or simply the request for removal. True medical indications like infection or intra-articular material are minor reasons.

Conclusion

This review illustrates the great variety of view points in the literature, with large differences in opinions and practices about the indications for implant removal after fracture healing. Since some studies have described asymptomatic patients developing complaints after removal, the general advice nowadays is to remove implants after fracture healing only in symptomatic patients and after a proper informed consent. Well-designed prospective studies on this subject are urgently needed in order to form guidelines based on scientific evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Hanson B, van der Werken C, Stengel D. Surgeons’ beliefs and perceptions about removal of orthopaedic implants. BMC Musculoskelet Disord. 2008;9:73.

    Article  PubMed  Google Scholar 

  2. Busam ML, Esther RJ, Obremskey WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg. 2006;14(2):113–20.

    PubMed  Google Scholar 

  3. Loder RT, Feinberg JR. Orthopaedic implants in children: survey results regarding routine removal by the pediatric and nonpediatric specialists. J Pediatr Orthop. 2006;26(4):510–9.

    Article  PubMed  Google Scholar 

  4. Böstman O, Pihlajamäki H. Routine implant removal after fracture surgery: a potentially reducible consumer of hospital resources in trauma units. J Trauma. 1996;41(5):846–9.

    Article  PubMed  Google Scholar 

  5. Mølster A, Behring J, Gjerdet NR, Ekeland A. Removal of osteosynthetic implants. Tidsskr Nor Laegeforen. 2002;122(23):2274–6.

    PubMed  Google Scholar 

  6. Jamil W, Allami M, Choudhury MZ, Mann C, Bagga T, Roberts A. Do orthopaedic surgeons need a policy on the removal of metalwork? A descriptive national survey of practicing surgeons in the United Kingdom. Injury. 2008;39(3):362–7.

    Article  PubMed  CAS  Google Scholar 

  7. AWMF online (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften). Implantatentfernung. 2010. http://www.awmf.org/leitlinien/detail/ll/012-004.html.

  8. Black J. Does corrosion matter? J Bone Joint Surg Br. 1988;70(4):517–20.

    PubMed  CAS  Google Scholar 

  9. Levine DL, Staehle RW. Crevice corrosion in orthopedic implant metals. J Biomed Mater Res. 1977;11(4):553–61.

    Article  PubMed  CAS  Google Scholar 

  10. Thomas KA, Cook SD, Harding AF, Haddad RJ Jr. Tissue reaction to implant corrosion in 38 internal fixation devices. Orthopedics. 1988;11(3):441–51.

    PubMed  CAS  Google Scholar 

  11. Grogan CH. Experimental studies in metal cancerigenesis. VIII. On the etiological factor in chromate cancer. Cancer. 1957;10(3):625–38.

    Article  PubMed  CAS  Google Scholar 

  12. Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg Am. 2001;83-A(3):428–36.

    PubMed  CAS  Google Scholar 

  13. Thomas P, Thomsen M. Allergy diagnostics in implant intolerance. Orthopade. 2008;37(2):131–5.

    Article  PubMed  CAS  Google Scholar 

  14. Müller A, Allgöwer M, Schneider R, Willenegger H, editors. Manual of internal fixation. 2nd ed. New York: Springer; 1979.

    Google Scholar 

  15. Kettunen J, Kröger H, Bowditch M, Joukainen J, Suomalainen O. Bone mineral density after removal of rigid plates from forearm fractures: preliminary report. J Orthop Sci. 2003;8(6):772–6.

    Article  PubMed  Google Scholar 

  16. Rosson JW, Petley GW, Shearer JR. Bone structure after removal of internal fixation plates. J Bone Joint Surg Br. 1991;73(1):65–7.

    PubMed  CAS  Google Scholar 

  17. Rosson J, Murphy W, Tonge C, Shearer J. Healing of residual screw holes after plate removal. Injury. 1991;22(5):383–4.

    Article  PubMed  CAS  Google Scholar 

  18. du Preez LA, Bütow KW, Swart TJ. Implant failure due to titanium hypersensitivity/allergy?—Report of a case. SADJ. 2007;62(1):22, 24–5.

    PubMed  Google Scholar 

  19. Krischak GD, Gebhard F, Mohr W, Krivan V, Ignatius A, Beck A, et al. Difference in metallic wear distribution released from commercially pure titanium compared with stainless steel plates. Arch Orthop Trauma Surg. 2004;124(2):104–13.

    Article  PubMed  CAS  Google Scholar 

  20. Serhan H, Slivka M, Albert T, Kwak SD. Is galvanic corrosion between titanium alloy and stainless steel spinal implants a clinical concern? Spine J. 2004;4(4):379–87.

    Article  PubMed  Google Scholar 

  21. Ehlinger M, Adam P, Simon P, Bonnomet F. Technical difficulties in hardware removal in titanium compression plates with locking screws. Orthop Traumatol Surg Res. 2009;95(5):373–6.

    Article  PubMed  CAS  Google Scholar 

  22. Richards RG. The effect of surface roughness on fibroblast adhesion in vitro. Injury. 1996;27(Suppl 3):SC38–43.

    PubMed  Google Scholar 

  23. Meredith DO, Riehle MO, Curtis AS, Richards RG. Is surface chemical composition important for orthopaedic implant materials? J Mater Sci Mater Med. 2007;18(2):405–13.

    Article  PubMed  CAS  Google Scholar 

  24. Hayes JS, Seidenglanz U, Pearce AI, Pearce SG, Archer CW, Richards RG. Surface polishing positively influences ease of plate and screw removal. Eur Cell Mater. 2010;19:117–26.

    PubMed  CAS  Google Scholar 

  25. Pearce AI, Pearce SG, Schwieger K, Milz S, Schneider E, Archer CW, et al. Effect of surface topography on removal of cortical bone screws in a novel sheep model. J Orthop Res. 2008;26(10):1377–83.

    Article  PubMed  Google Scholar 

  26. Hayes JS, Vos DI, Hahn J, Pearce SG, Richards RG. An in vivo evaluation of surface polishing of TAN intermedullary nails for ease of removal. Eur Cell Mater. 2009;18:15–26.

    PubMed  CAS  Google Scholar 

  27. Sanderson PL, Ryan W, Turner PG. Complications of metalwork removal. Injury. 1992;23(1):29–30.

    Article  PubMed  CAS  Google Scholar 

  28. Richards RH, Palmer JD, Clarke NM. Observations on removal of metal implants. Injury. 1992;23(1):25–8.

    Article  PubMed  CAS  Google Scholar 

  29. Minkowitz RB, Bhadsavle S, Walsh M, Egol KA. Removal of painful orthopaedic implants after fracture union. J Bone Joint Surg Am. 2007;89(9):1906–12.

    Article  PubMed  Google Scholar 

  30. Müller-Färber J. Metal removal after osteosyntheses. Indications and risks. Orthopade. 2003;32(11):1039–57. quiz 58.

    Article  PubMed  Google Scholar 

  31. Krettek C, Müller C, Meller R, Jagodzinski M, Hildebrand F, Gaulke R. Is routine implant removal after trauma surgery sensible? Unfallchirurg. 2012;115(4):315–22.

    Article  PubMed  CAS  Google Scholar 

  32. Raney EM, Freccero DM, Dolan LA, Lighter DE, Fillman RR, Chambers HG. Evidence-based analysis of removal of orthopaedic implants in the pediatric population. J Pediatr Orthop. 2008;28(7):701–4.

    Article  PubMed  Google Scholar 

  33. Morshed S, Humphrey M, Corrales LA, Millett M, Hoffinger SA. Retention of flexible intramedullary nails following treatment of pediatric femur fractures. Arch Orthop Trauma Surg. 2007;127(7):509–14.

    Article  PubMed  Google Scholar 

  34. Gorter EA, Vos DI, Sier CF, Schipper IB. Implant removal associated complications in children with limb fractures due to trauma. Eur J Trauma Emerg Surg. 2011;37(6):623–7.

    Article  PubMed  Google Scholar 

  35. Berkes M, Obremskey WT, Scannell B, Ellington JK, Hymes RA, Bosse M; Southeast Fracture Consortium. Maintenance of hardware after early postoperative infection following fracture internal fixation. J Bone Joint Surg Am. 2010;92(4):823–8.

    Article  PubMed  Google Scholar 

  36. Rightmire E, Zurakowski D, Vrahas M. Acute infections after fracture repair: management with hardware in place. Clin Orthop Relat Res. 2008;466(2):466–72.

    Article  PubMed  Google Scholar 

  37. Trampuz A, Widmer AF. Infections associated with orthopedic implants. Curr Opin Infect Dis. 2006;19(4):349–56.

    Article  PubMed  CAS  Google Scholar 

  38. Trampuz A, Zimmerli W. Diagnosis and treatment of infections associated with fracture-fixation devices. Injury. 2006;37(Suppl 2):S59–66.

    Article  PubMed  Google Scholar 

  39. Vos D, Hanson B, Verhofstad M. Implant removal of osteosynthesis: the Dutch practice. Results of a survey. J Trauma Manag Outcomes. 2012;6(1):6.

    Article  PubMed  Google Scholar 

  40. Hidaka S, Gustilo RB. Refracture of bones of the forearm after plate removal. J Bone Joint Surg Am. 1984;66(8):1241–3.

    PubMed  CAS  Google Scholar 

  41. Deluca PA, Lindsey RW, Ruwe PA. Refracture of bones of the forearm after the removal of compression plates. J Bone Joint Surg Am. 1988;70(9):1372–6.

    PubMed  CAS  Google Scholar 

  42. Rumball K, Finnegan M. Refractures after forearm plate removal. J Orthop Trauma. 1990;4(2):124–9.

    Article  PubMed  CAS  Google Scholar 

  43. Labosky DA, Cermak MB, Waggy CA. Forearm fracture plates: to remove or not to remove. J Hand Surg Am. 1990;15(2):294–301.

    Article  PubMed  CAS  Google Scholar 

  44. Langkamer VG, Ackroyd CE. Removal of forearm plates. a review of the complications. J Bone Joint Surg Br. 1990;72(4):601–4.

    PubMed  CAS  Google Scholar 

  45. Rosson JW, Shearer JR. Refracture after the removal of plates from the forearm. an avoidable complication. J Bone Joint Surg Br. 1991;73(3):415–7.

    PubMed  CAS  Google Scholar 

  46. Chia J, Soh CR, Wong HP, Low YP. Complications following metal removal: a follow-up of surgically treated forearm fractures. Singapore Med J. 1996;37(3):268–9.

    PubMed  CAS  Google Scholar 

  47. Gyuricza C, Carlson MG, Weiland AJ, Wolfe SW, Hotchkiss RN, Daluiski A. Removal of locked volar plates after distal radius fractures. J Hand Surg Am. 2011;36(6):982–5.

    Article  PubMed  Google Scholar 

  48. Lovald S, Mercer D, Hanson J, Cowgill I, Erdman M, Robinson P, et al. Complications and hardware removal after open reduction and internal fixation of humeral fractures. J Trauma. 2011;70(5):1273–7. discussion 1227–8.

    Article  PubMed  Google Scholar 

  49. Boerger TO, Patel G, Murphy JP. Is routine removal of intramedullary nails justified. Injury. 1999;30(2):79–81.

    Article  PubMed  CAS  Google Scholar 

  50. Husain A, Pollak AN, Moehring HD, Olson SA, Chapman MW. Removal of intramedullary nails from the femur: a review of 45 cases. J Orthop Trauma. 1996;10(8):560–2.

    Article  PubMed  CAS  Google Scholar 

  51. Brumback RJ, Ellison TS, Poka A, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part III: long-term effects of static interlocking fixation. J Bone Joint Surg Am. 1992;74(1):106–12.

    PubMed  CAS  Google Scholar 

  52. Toms AD, Morgan-Jones RL, Spencer-Jones R. Intramedullary femoral nailing: removing the nail improves subjective outcome. Injury. 2002;33(3):247–9.

    Article  PubMed  CAS  Google Scholar 

  53. Dodenhoff RM, Dainton JN, Hutchins PM. Proximal thigh pain after femoral nailing. causes and treatment. J Bone Joint Surg Br. 1997;79(5):738–41.

    Article  PubMed  CAS  Google Scholar 

  54. Gösling T, Hufner T, Hankemeier S, Zelle BA, Muller-Heine A, Krettek C. Femoral nail removal should be restricted in asymptomatic patients. Clin Orthop Relat Res. 2004;423:222–6.

    Article  PubMed  Google Scholar 

  55. Hui C, Jorgensen I, Buckley R, Fick G. Incidence of intramedullary nail removal after femoral shaft fracture healing. Can J Surg. 2007;50(1):13–8.

    PubMed  Google Scholar 

  56. Kukla C, Gaebler C, Mousavi M, Vécsei V, Heinz T. Indications for implant removal in healed proximal femoral fractures. Acta Chir Austriaca. 2000;32:196–8.

    Google Scholar 

  57. Krettek C, Mommsen P. Implant removal after intramedullary osteosyntheses. Literature review, technical details, and tips and tricks. Unfallchirurg. 2012;115(4):299–314.

    Article  PubMed  CAS  Google Scholar 

  58. Keating JF, Orfaly R, O’Brien PJ. Knee pain after tibial nailing. J Orthop Trauma. 1997;11(1):10–3.

    Article  PubMed  CAS  Google Scholar 

  59. Karladani AH, Ericsson PA, Granhed H, Karlsson L, Nyberg P. Tibial intramedullary nails—should they be removed? A retrospective study of 71 patients. Acta Orthop. 2007;78(5):668–71.

    Article  PubMed  Google Scholar 

  60. Leliveld MS, Verhofstad MH. Injury to the infrapatellar branch of the saphenous nerve, a possible cause for anterior knee pain after tibial nailing? Injury. 2012;43(6):779–83.

    Article  PubMed  CAS  Google Scholar 

  61. Sidky A, Buckley RE. Hardware removal after tibial fracture has healed. Can J Surg. 2008;51(4):263–8.

    PubMed  Google Scholar 

  62. Gösling T, Hüfner T, Hankemeier S, Müller U, Richter M, Krettek C. Indication for removal of tibial nails. Chirurg. 2005;76(8):789–94.

    Article  PubMed  Google Scholar 

  63. Im GI, Lee KB. Difficulties in removing ACE tibial intramedullary nail. Int Orthop. 2003;27(6):355–8.

    Article  PubMed  Google Scholar 

  64. Seligson D, Howard PA, Martin R. Difficulty in removal of certain intramedullary nails. Clin Orthop Relat Res. 1997;340:202–6.

    Article  PubMed  Google Scholar 

  65. Brown OL, Dirschl DR, Obremskey WT. Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma. 2001;15(4):271–4.

    Article  PubMed  CAS  Google Scholar 

  66. Williams AA, Witten DM, Duester R, Chou LB. The benefits of implant removal from the foot and ankle. J Bone Joint Surg Am. 2012;94(14):1316–20.

    Article  PubMed  Google Scholar 

  67. Georgiadis GM. Percutaneous removal of buried antegrade femoral nails. J Orthop Trauma. 2008;22(1):52–5.

    Article  PubMed  Google Scholar 

  68. Jago ER, Hindley CJ. The removal of metalwork in children. Injury. 1998;29(6):439–41.

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Surgery, Amphia Hospital Breda, P.O. Box 90158, 4800 RK, Breda, The Netherlands

    D. I. Vos

  2. Department of Trauma Surgery, Erasmus University Medical Centre, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands

    M. H. J. Verhofstad

Authors
  1. D. I. Vos
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. H. J. Verhofstad
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to D. I. Vos.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Vos, D.I., Verhofstad, M.H.J. Indications for implant removal after fracture healing: a review of the literature. Eur J Trauma Emerg Surg 39, 327–337 (2013). https://doi.org/10.1007/s00068-013-0283-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-013-0283-5

Keywords

Search

Navigation