Updated: 4/30/2021

Symptomatic Hardware and Implant Removal

Review Topic
Videos / Pods
  • summary
    • Removal of hardware can be technically difficult and have it's own associated complications
    • Unpredictable results when removed solely for pain relief and even less so for function.
    • Orthopaedic hardware symptoms can be common and some hardware may require removal.
  • Epidemiology
    • Incidence
      • 5-16% overall
        • large geographical variation
      • common sites of hardware removal
        • olecranon tension band wiring: 30-61%
        • TMTJ arthrodesis: 15%
        • clavicle: 6% (anteroinferior plating) - 60% (superior)
        • patellar tension band wiring: 10%
        • distal radius: 10%
    • Risk factors
      • low body weight/thin soft tissue envelope
      • females
      • litigation
      • metal allergy/sensitivity
        • difficult to differentiate from non-specific pain
        • consider in fair-skinned, red-haired females with history of sensitivity to specific jewelery items with deep generalised pain about an implant
    • Economics
      • average cost of syndesmosis screw removal is US$3500
      • significant economic and clinical implications
  • Etiology
    • Pathophysiology
      • Empty screw holes may remain as stress risers for up to 4 months
      • Complete union and remodelling recommended prior to elective removal
  • Presentation
    • History
      • nature and timing of initial injury
        • neurovascular compromise
        • open fractures and soft tissue injury
      • timing, nature and location of surgical treatment (obtain operative records)
      • peri-operative wound problems and infection
      • previous non- or delayed-union
    • Symptoms
      • foregin body sensation
      • irritability/sensitivity such as when touched or knocked
      • stiffness
      • patients may demand removal in absence of symptoms
    • Physical exam
      • inspection
        • location of incisions
        • skin healing
        • prominence of hardware
      • palpation
        • tenderness
        • confirm pain is at a site of hardware
        • generalised pain distant to implants is less likely to improve with removal
      • motion
        • carefully document pre- and post- removal of hardware
      • neurovascular
        • carefully document pre- and post- removal of hardware
  • Imaging
    • Radiographs
      • indications
        • ensure union
        • assess for signs of infection
        • assist implant identification
        • identify hardware breakage(s)
    • CT
      • indications
        • union uncertain on plain films
        • assess location of complex hardware for approach considerations
    • MRI
      • indications
        • suspected adverse tissue reaction to hardware
    • Bone scan
      • indications
        • further investigate pain/non-union
  • Studies
    • Assess for infection as per wound & hardware infection
  • Prevention
    • Reduce need for removal
      • careful soft tissue coverage with layered closure
      • alternate implant options and configurations
      • pre-operative counselling about expected hardware retention
    • Prevent difficulties in future hardware removal
      • careful use of targeting guides with locking plates
      • torque-limiting driver for locking screws
      • deliberate drill and screw insertion technique, avoid thread and head damage
      • document location of neurovascular structures with reference to implant landmarks
  • Treatment
    • Nonoperative
      • reassurance and hardware retention
        • indications
          • no medical indication for removal of hardware (see below)
          • mild symptoms
          • symptoms unlikely to be directly caused by hardware nor improved by its removal
    • Operative
      • hardware removal
        • indications
          • wound & hardware infection
          • implant failure with symptomatic fracture instability
          • symptomatic non-union
          • potential for damage to structures
            • ACJ hook plates
        • relative indications
          • healed fracture with ongoing pain
            • results unpredictable
          • implant mechanical issues
            • impingement against structures
            • tendon irritation
          • joint-spanning fixation
            • TMTJ bridge plating
            • rigid ankle syndesmotic fixation
              • controversial
            • pubic symphysis and SIJ plates
              • consider in females prior to vaginal delivery
          • paediatric patients
            • concerns for callus, corrosion, allergy, carcinogenesis, future surgery
            • little evidence to guide decision
          • metal sensitivity
  • Techniques
    • Pre-operative preparation
      • identify implants in situ, from most to least reliable
        • implant sticker chart from records
        • operative note from records
        • hospital or regional implant registries
        • experienced colleague radiograph identification
        • surgeon's previous preferences
      • order equipment
        • correct screwdrivers +/- spares
        • cannulated driver and guidepin for any cannulated screws
          • helps align driver with screw head
        • difficult screw removal set (standby)
        • implant-specific devices
      • surgical technique guide for the implant for its removal technique
    • Intra-operative
      • prophylactic pre-operative antibiotic dose does not reduce the high surgical site infection rate in removal of hardware but is often administered
      • exposure
        • clear any tissue and bone overlying hardware
        • minimally invasive retractors available for stab incisions
        • expose all screw heads and implants before starting removal
          • medullary bleeding may obscure view
      • removal of intact screws that can be loosened by hand
        • ensure recess completely clear with scalpel, diathermy and sharp hooks
        • clear any overlying bone over any part of the metal for removal
        • ensure correct alignment of driver and full seating in recess
        • partial turn clockwise prior to anti-clockwise may assist removal by re-engaging thread
        • break screw-plate bond of last locking screw while second-last screw in still situ
          • avoids spinning the plate in locked constructs
      • damaged screw recess (socket)
        • conical extraction screw (cone shaped reverse-threaded head)
      • missing screw head
        • fine tip or 'needle nose' screw removal pliers may grasp exposed screw body
        • trephine drill to remove bone around outer screw body if needed, some have centring pin
        • lavage with fluid to cool bone during trephine use, consider drill irrigation-suction device
        • use extraction bolt to remove the screw body
        • combined ream, grip and extraction with extraction reamers
      • screw fused to plate
        • high speed burr to open screw hole and destroy screw head, use irrigation or water-based lubricant (see below - sectioning hardware)
        • or extraction drill bit to drill through head
      • sectioning hardware
        • for planned partial removal of hardware such as plates, nails, screws or as a bail out
        • cover bone and tissue in packs
        • cover packs and cutting site with water-based lubricant (translucent) or emollient
        • high speed burr (e.g. tungsten burr) to section plate ideally through empty hole
        • lubricant/emollient captures metal shards
      • use non-absorbable interrupted sutures as wounds are higher risk for delayed healing and dehiscence
    • Specific implant removals
      • intramedullary nails
        • original nail jig with backslap attachment
        • nail extractor hook
          • can place in most proximal locking hole if nail thread difficult to access (expose more length of proximal nail)
        • steinman pins can punch broken locking screws through far cortex and out of nail
        • guidewire bouquet
          • olive tip into nail core first
          • pass as many guidewires or k-wires as able into nail around olive tip wire
          • backslap on olive tip which jams and expands other wires
        • extractor screw heads (conical threaded head threads into nail)
        • consider use of a cannulated hip stem revision trephine to remove bone above buried nails and replace the core after nail removal
        • failure to progress on removal
          • ensure cross bolts are all out
          • drill through unused locking holes to remove bone bridge
          • can try to drill a guidewire down nail core to break islands
          • abandon and cut nail at removed depth or leave in situ
          • if required osteotomy may be performed but significant morbidity
      • Kuntscher nail (K nail)
        • large punch
          • advancing nail first prior to removal is easier and may break interface
        • K-nail removal set if available
        • olive and guide wires for bouquet technique
        • mole grip fine nose pliers or hook with backslap
        • revision hip stem trephines
          • overream proximally to break bone ongrowth and expose nail
        • drill down centre of nail especially if slotted
        • be prepared to use a high speed burr and transect partially removed nail as bail out
        • corticotomy e.g. with Gigli saw possible but significant morbidity
      • bone staples
        • often not as simple to remove as they appear
        • osteotome or small instruments may pry it free
        • some bone removal often required
        • can attach manufacturer staple removal device and backslap
      • dynamic hip screw
        • if converting to arthroplasty consider hip dislocation prior to removal
          • avoid uncontrolled fracture
          • relocate then removal of metal prior to neck cut
        • remove shaft screws then plate/barrell
        • backout lag screw
          • use manufacturer driver if available
          • if not plate/barrel can be used to unwind the lag screw once freed from shaft
      • blade plate
        • order in specific removal set if able
          • attaches to blade for backslapping
        • mole grip wrench with backslap useful alternative
        • older systems may have phillips-head screws
    • Post operative
      • no consensus on protection and weight-bearing limits
  • Complications
    • Overall
      • 3-20% (8%) complication rate
      • 4% revision surgery rate
      • Liver disease, pilon fractures and pelvic fractures increased risk
    • Surgical Site Infection
      • incidence 3-14%, slightly higher for foot and ankle
      • treatment
        • antibiotics
          • uncomplicated, no abscess, healed wound
        • +/- debridement
          • presence of necrosis, collection, dehiscence
    • Neurovascular injury
      • more difficult to identify neurovascular structures within scar
      • senior surgeon supervision recommended for forearm plate removal
    • Refracture
      • intra- or post-operative
      • rare, particularly for intramedullary nails
      • theoretical inceased risk of peri-prosthetic fracture if implant retained
      • no evidence to support retention nor removal from fracture risk perspective
      • confirm fracture healed prior to removal - obtain CT if in doubt
  • Prognosis
    • stiffness may or may not improve
      • mechanical impingement of hardware may limit movement
      • further surgical scarring post removal may limit movement
    • outcomes variable
      • ensure patient does not expect guaranteed pain relief after removal
      • females and patients with fewer co-morbidities have better improvement
      • higher risk of complications for non-medically indicated removal
      • rates of pain relief/satisfaction after implant removal
        • overall 40-70%
        • ankle: 50-75%
        • femoral nail: 65%
        • tibial nail (knee pain): 35-45%, and may even increase in some
Flashcards (4)
1 of 4
Evidence (16)
Private Note