Introduction
Materials and methods
Systematic review
PICO
Systematic search
Inclusion/exclusion
Case control study
Patients
Baseline characteristics
Metalwork insertion
Metalwork removal
Long-term follow-up
Statistical analysis
Results
Systematic review
Study inclusion
Characteristic | Description | Group A: metalwork not removed | Group B: metalwork removed | P value |
---|---|---|---|---|
Patients | Number | 19 | 36 | |
Age | Years (mean, range) | 45.9, 23–75 | 42.1, 12–67 | 0.363 (Fisher exact) |
Sex | Male:female (%) | 13:6 (68.4:31.6) | 15:21 (41.7:58.3) | 0.089 (Fisher exact) |
Charlson index | Mean, (range) | 0.51 (0–3) | 0.84 (0–3) | 0.245 (Fisher exact) |
Injury level | Number of patients T, TLJ, L (%) | 2, 12, 5 (10.5, 63.2, 26.3) | 5, 21, 10 (13.9, 58.3, 27.8) | 0.960 (Fisher exact) |
AO classification | Number of patients A, B, C (%) | 16, 2, 1 (84.2, 10.5, 5.3) | 22, 12, 2 (61.1, 33.3, 5.6) | 0.142 (Fisher exact) |
Mechanism of injury | Number of patients Fall < 2 m, fall > 2 m, RTA, other (%) | 3, 10, 6, 0 | 7, 18, 9, 2 | 0.862 (Fisher exact) |
Vertebrae fixed | 2, 3, 4/number of patients (%) | 12, 2, 5 | 14, 3, 19 | 0.185 (Fisher exact) |
Spinal fixation | Litres blood loss < 0.1, 0.1, 0.2, 0.3 (%) | 13, 0, 4, 2 (68.4, 0.0, 21.1, 10.5) | 25, 1, 9, 1 (69.4, 2.8, 25.0, 2.8) | 0.710 (Fisher exact) |
Mean (range) days length of stay | 8.4 (3–19) | 7.9 (3–20) | 0.716 (t-test) | |
Follow-up from injury | Mean (range) months | 44.9 (10–83) | 43.3 (11–76) | 0.807 (t-test) |
Case control study
Patient characteristics
Comparative analysis of parameters between systematic review and case–control study
Timing of metalwork removal
Neurologically intact | ||||
Study | Class of evidence | Population and surgery | Outcomes | Summary/conclusions |
Lorente et al. 202110 | II—prospective multicentre cohort | n = 31. All T11-L5 type A, AO classification fractures. Metalwork removal after 24 months | VAS, ODI, CL, FA, SI, C%, DD, DA | • Metalwork removal safe in type A fractures, good clinical results, no loss of correction • VAS, ODI improved post-removal but not significant • Post-removal: CL, FA, SI, kyphosis, C%, DD, DA not significantly different • 2 superficial wound infections (oral antibiotics, no sequelae) |
Sasagawa et al. 202111 | III—retrospective series | n = 24. 2 groups of n = 12 (+ residual back pain, no residual back pain). Metalwork removal: mean 14.4 months (5 – 27) post index surgery | Patient satisfaction, NRS-B/L, ODI, local kyphosis, disc degeneration | • 13 extremely satisfied, 8 moderately satisfied, 3 neither, 0 dissatisfied • Patient satisfaction post removal high independent of residual back pain or occupation • No difference in disc degeneration or local kyphosis in patients with/without back pain • No complications reported |
Manson et al. 202012 | II—prospective study | n = 32. (In 26, metalwork retained; in 6, metalwork removed). n = 26 neurologically intact (N0); n = 6 had deficit (1 N1, 2 N2, 3 N3). Removal at 16–45 months post insertion | Operative time, blood loss, LOS, patient satisfaction, NRS-B/L, ODI, RTW | • 26 (81.25%) with metalwork retention: minimal disability, mild pain, satisfaction and RTW (mean 6 months) with moderate back and leg pain until removal • 6 had removal of metalwork due to prominence of construct / screw loosening causing symptoms (removal at 16–45 months). RTW mean 7 months • After removal, minimal disability and mild pain reported • No complications after metalwork removal |
Oh and Seo 201913 | III—retrospective series | n = 30. TLICS > 4. All neurologically intact. Metalwork removal at mean 12.8 months post index surgery | Optimal removal time assessed using: VAS, ODI, ROM, CA, AVHR, complications | • Metalwork removal group within 12 months had better ROM recovery than those removed after 12 months • No significant difference in VAS, ODI, AVHR or CA between groups • 2 cases of screw breakage—satisfactory outcomes at last follow-up |
Kim et al. 201414 | III—retrospective series | n = 16 undergoing metalwork removal at 12 months. All neurologically intact. Two groups (A, B) depending on presence of osteoporosis. Metalwork removal at 12 months post index surgery | VAS, VH, ROM | • Significant pain relief in both groups • Significant improvement in VH post-op despite some VH post-removal • ROM improved significantly pre-removal and at last follow-up post-removal (10.5° and 10.2° in groups A and B at last follow-up) • Removal of metalwork preserves motion regardless of osteoporosis • No major complications from metalwork removal |
Cox et al. 201315 | IV—case series | n = 3 with severe pain refractory to analgesia/bracing following percutaneous fracture fixation | Pain relief, radiographic fusion, complication rate | • All had significant pain reduction facilitating rapid mobilization • Radiographic fracture healing at 6 months • No complications |
With neurological deficit | ||||
Study | Class of evidence | Population and surgery | Outcomes | Summary/conclusions |
Han et al. 202116 | III—retrospective series | n = 31. AO Neurologic status: 18 (58%) N0, 1 (3%) N1, 3 (10%) N2, 9 (29%) N3. Metalwork removal at median 13.7 months (6–56) post index surgery | CA, ODI, VAS, VBH, SMA | • Back pain relieved and ODI improved post metalwork removal (p < 0.001) irrespective of radiological outcomes • Less CA (1.58°), VBH (0.52 mm) • SMA preservation in 58.1%—significant if screw removal < 12 months • Kyphotic recurrence in 12.9%; but pain improved, no further surgery |
Chen et al. 202017 | III—retrospective review | n = 84 with neurologic deficit. Decompression + intracorporeal bone grafting (minimal-access tubular-assisted) + percutaneous short segment pedicle screw fixation. Metalwork removal at 12 months post index surgery | ASIA, VAS, ODI, CSI, KA, CA, AVH, SI | • AIS: 14 (16.7%) did not improve 33 (39.3%) recovered to grade E. 5/9 AIS B improved by ≥ 1 grade. 32/44 (72.7%) recovered by 1 grade, 4 reached grade E. All grade D recovered to E At final follow-up post metalwork removal: • VAS and ODI decreased • Incidence of kyphosis recurrence limited—VBH and SI maintained • One pull-out screw, one broken rod |
Proietti et al. 201918 | III—retrospective review | n = 36. Metalwork removal at mean 10 months | SF-12, ODI VAS, loss of correction, residual mobility (Dvorak) | • Clinically significant decrease in VAS + ODI at 1-month post-removal • Preserved mobility of treated segments post-removal at 12 months • Non-fused segment included in pedicle instrumentation maintains mobility if metalwork removed < 10 months • Post-removal in 12 months, normal ROM restored in proximal and distal segment of fracture, no significant loss of correction • No complications reported |
Pain outcomes
Disability
Return to work
Predictor | Values | Odds ratio | 95% C.I | P value |
---|---|---|---|---|
Univariate | ||||
Screws removed | Yes = 1, No = 0 | 5.000 | 1.399–18.868 | 0.013* |
Age | Years | 0.999 | 0.959–1.041 | 0.969 |
Charlson | Comorbidity | 0.658 | 0.361–1.198 | 0.171 |
Injury level | T = 1, TLJ = 2, L = 3 | 0.880 | 0.326–2.377 | 0.801 |
Vertebra | Number of levels | 0.829 | 0.442–1.554 | 0.559 |
Deformity
Complications
Detail | Mean (range) |
---|---|
Months from fixation to removal (range) | 13.3 (5–27) |
Litres blood loss < 0.1, 0.1, 0.2, 0.3 (%) | 30, 1, 0, 1 (93.8, 3.1, 3.1) |
Mean (range) length of surgery in minutes | 69.5 (30–120) |
Number (%) patients with complications | 3/33 (9.1)* |
Mean (range) length of stay in days | 1.3 (0–4) |
Mean (range) months follow-up from metalwork removal | 31.8 (4–71) |