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