The removal of metalwork in children

Outcomes of Hardware Removal Surgery for Children

Hardware removal is among the most common orthopedic procedures performed in the United States. The goal of this study was to report the outcomes of deep hardware removal for children. This study received institutional review board approval. Patients younger than 18 years who underwent deep hardware removal between 2007 and 2017 were studied. We reviewed 227 procedures involving 132 boys and 95 girls. Mean follow-up was 25 months (range, 14-36 months). Mean age at the time of surgery was 12.8 years (range, 2-17 years). Mean time from initial surgery to hardware removal was 8.4 months (range, 1-72 months). Of the 227 cases, 75 used a tourniquet. Mean tourniquet time was 30.1 minutes (range, 1-118 minutes). Mean length of surgery was 44.0 minutes (range, 4-173 minutes). Mean resident level performing the surgery was postgraduate year 3 (range, postgraduate year 2 to fellow). There were 3 complications. Locations of the implanted hardware included: femur, 85; humerus, 49; tibia, 46; hip/pelvis, 17; ulna, 11; miscellaneous foot, 10; radius, 6; and fibula, 3. Indications for surgery included surgeon recommendations in 122 cases; symptomatic hardware in 68 cases, and parent wishes in 37 cases. Hardware removal for children was safe, and the outcomes were excellent. Complications of hardware removal at a teaching hospital can be minimized when a more senior resident is the primary surgeon. Despite the challenging and historically troublesome nature of deep hardware removal, the current study shows that hardware removal for children is safe and effective. [Orthopedics. 2022;45(2):e91-e95.].

Implant removal of osteosynthesis. Results of a survey among Spanish orthopaedic surgeons

INTRODUCTION

The indications on extraction of osteosynthesis material are not well defined in the current literature deriving in relative indications, depending on experiences, customs or patient's request. The aim of this article is to assess the beliefs, indications, usual practice and perceived complications of surgeons in Spain regarding on extraction of osteosynthesis material.

METHODS

We conducted a questionnaire of 44 questions covering general demographics, general and subjective opinion on implant removal, specific attitudes by implant type and anatomical location, and personal habits.

RESULTS

164 questionnaires were received. The most frequent indications are patellar and olecranon cerclage wires and elastic nails in children. 56% remove the implant at the patient's request, 31% always remove it in children, 28% do it in asymptomatic patients to avoid possible surgical problems, 14% to avoid a possible peri-implant fracture and 9% by simple preference. The most frequent intraoperative complications are surgery longer than expected, bone growth over the implant, rounded screw head core, cold fusion, difficulty in finding the implant and impossibility to remove part of the implant. The most frequent postoperative complication was persistence of symptoms 39.8%.

CONCLUSION

The results provide information to advise the patient regarding the expected clinical outcome and intra and postoperative complications. The surgeon should cautiously indicate extraction in the asymptomatic patient given the high rate of complications.

The Effect of Diclofenac Sodium-Loaded PLGA Rods on Bone Healing and Inflammation: A Histological and Histomorphometric Study in the Femur of Rats

Implants made of poly(lactide-co-glycolide) (PLGA) are biodegradable and frequently provoke foreign body reactions (FBR) in the host tissue. In order to modulate the inflammatory response of the host tissue, PLGA implants can be loaded with anti-inflammatory drugs. The aim of this study was to analyze the impact of PLGA 80/20 rods loaded with the diclofenac sodium (DS) on local tissue reactions in the femur of rats. Special emphasis was put on bone regeneration and the presence of multinucleated giant cells (MGCs) associated with FBR. PLGA 80/20 alone and PLGA 80/20 combined with DS was extruded into rods. PLGA rods loaded with DS (PLGA+DS) were implanted into the femora of 18 rats. Eighteen control rats received unloaded PLGA rods. The follow-up period was of 3, 6 and 12 weeks. Each group comprised of six rats. Peri-implant tissue reactions were histologically and histomorphometrically evaluated. The implantation of PLGA and PLGA+DS8 rods induced the formation of a layer of newly formed bone islands parallel to the contour of the implants. PLGA+DS rods tended to reduce the presence of multi-nucleated giant cells (MGCs) at the implant surface. Although it is known that the systemic administration of DS is associated with compromised bone healing, the local release of DS via PLGA rods did not have negative effects on bone regeneration in the femora of rats throughout 12 weeks.

Trans-Metaphyseal Screws Placed in Children: An Argument for Monitoring and Potentially Removing the Implants

BACKGROUND

Surgeons frequently use trans-metaphyseal screws in children to achieve osteosynthesis after fractures or stability after reconstructive osteotomies. Screws that were initially inserted below the cortex of bone can become prominent and symptomatic due to the process of funnelization that narrows the wide metaphysis to the diameter of the thinner diaphysis.

METHODS

Case series presentation of 11 children who presented with screw prominence after the cutback process range in age from 19 to 169 months. We used the screws as radiographic markers to quantitate the amount of bone "cutback" or lost during the process of funnelization.

RESULTS

The average length of screw protrusion beyond the edge of the bone when symptomatic was 8.7 mm (range, 3.3 to 14.3 mm). Time from implantation to the last radiograph averaged 40 months (range, 19 to 84 mo). The average loss of bone width at the time of presentation was 21% (range, 7% to 36%).

CONCLUSIONS

These cases suggest that orthopaedic surgeons should consider monitoring children after implantation of trans-metaphyseal screws and informing parents and patients about the possibility of screw prominence necessitating removal due to the process of metaphyseal funnelization.

LEVEL OF EVIDENCE

Level IV.

Outcomes after slipped capital femoral epiphysis: a population-based study with three-year follow-up

PURPOSE

To evaluate outcomes three years after treatment for slipped capital femoral epiphysis (SCFE): development of avascular necrosis (AVN), subsequent surgery, hip function and the contralateral hip.

METHODS

This prospective cohort study included a total national population of 379 children treated for SCFE between 2007 and 2013. A total of 449 hips treated for SCFE and 151 hips treated with a prophylactic fixation were identified. The Barnhöft questionnaire, a valid patient-reported outcome measure (PROM), was used.

RESULTS

In all, 90 hips had a severe slip, 61 of these were clinically unstable. AVN developed in 25 of the 449 hips. Six of 15 hips treated with capital realignment developed AVN. A peri-implant femur fracture occurred in three slipped hips and in two prophylactically pinned hips. In three of these five hips technical difficulties during surgery was identified. In 43 of 201 hips scheduled for regular follow-up a subsequent SCFE developed in the contralateral hip. Implant extraction after physeal closure was performed in 156 of 449 hips treated for SCFE and in 51 of 151 prophylactically fixed hips. Children with impaired hip function could be identified using the Barnhöft questionnaire.

CONCLUSION

Fixation in situ is justified to remain as the primary treatment of choice in SCFE. Overweight is more common in children with SCFE than in the average population. Prophylactic fixation is a safe procedure when performed using a correct technique. The number of patients who developed AVN after capital realignment is of concern. We recommend rigorous follow-up of both hips, including PROM evaluation, until physeal closure.

LEVEL OF EVIDENCE

II - prospective cohort study.

Easy and Inexpensive Technique for Removal of Round Headed, Jammed Locking Screws in Distal Tibial Interlocking Plate

Introduction:

The advent of locking plates has brought new problems in implant removal. Difficulty in removing screws from a locking plate is well-known. These difficulties include cold welding between the screw head and locking screw hole, stripping of the recess of the screw head for the screwdriver, and cross-threading between threads in the screw head and screw hole. However, there are cases in which removal is difficult. We describe a new technique for removing a round headed, jammed locking screws from a locking plate.

Case Report:

55 years old male patient received a locking distal tibial plate along with distal fibular plate 3years back from UAE. Now patient came with complaint of non-healing ulcer over medial aspect of lower 1/3rd of right leg from past 1 year. Non operative management did not improve the symptoms. The patient consented to implant removal, with the express understanding that implant removal might be impossible because already one failed attempt had been performed at some other hospital six months back. We then decided to proceed with the new technique. The rest of the proximal screws were removed using a technique not previously described. We used stainless steel metal cutting blades that are used to cut door locks or pad locks to cut the remaining stripped headed screws.

Conclusion:

This technique is very quick, easy to perform and inexpensive because the metal cutting blades which are used to cut the screws are very cheap. Yet it is very effective technique to remove the stripped headed or jammed locking screws. It is also very less destructive because of very less heat production during the procedure there is no problem of thermal necrosis to the bone or the surrounding soft tissue.

Peri-implant fracture of the femur in an 11-year-old: a case report

Fracture of the femur in the area of a pre-existing implant is not common in an adolescent. We report the case of a fracture, in the area of a pre-existing implant in an 11-year-old boy, after a fall from a bike. We are not aware of any similar reports in the literature.

Implant removal of osteosynthesis: the Dutch practice. Results of a survey

Background

The aim of this survey study was to evaluate the current opinion and practice of trauma and orthopaedic surgeons in the Netherlands in the removal of implants after fracture healing.

Methods

A web-based questionnaire consisting of 44 items was sent to all active members of the Dutch Trauma Society and Dutch Orthopaedic Trauma Society to determine their habits and opinions about implant removal.

Results

Though implant removal is not routinely done in the Netherlands, 89% of the Dutch surgeons agreed that implant removal is a good option in case of pain or functional deficits. Also infection of the implant or bone is one of the main reasons for removing the implant (> 90%), while making money was a motivation for only 1% of the respondents. In case of younger patients (< 40 years of age) only 34% of the surgeons agreed that metal implants should always be removed in this category. Orthopaedic surgeons are more conservative and differ in their opinion about this subject compared to general trauma surgeons (p = 0.002). Though the far majority removes elastic nails in children (95%).

Most of the participants (56%) did not agree that leaving implants in is associated with an increased risk of fractures, infections, allergy or malignancy. Yet in case of the risk of fractures, residents all agreed to this statement (100%) whereas staff specialists disagreed for 71% (p < 0.001). According to 62% of the surgeons titanium plates are more difficult to remove than stainless steel, but 47% did not consider them safer to leave in situ compared to stainless steel. The most mentioned postoperative complications were wound infection (37%), unpleasant scarring (24%) and postoperative hemorraghe (19%).

Conclusion

This survey indicates that there is no general opinion about implant removal after fracture healing with a lack of policy guidelines in the Netherlands. In case of symptomatic patients a majority of the surgeons removes the implant, but this is not standard practice for every surgeon.

Complications and associated risk factors at screw removal in slipped capital femoral epiphysis treated by cannulated stainless steel screws

PURPOSE

The aim of our study is to report our complication rate and analyze the associated risk factors when removing cannulated stainless steel screws for SCFE fixation.

METHODS

This was a multicenter retrospective study of patients who underwent removal of cannulated stainless steel screws after a mean time of 2.03 years of implantation. Thirty-two patients were included (38 hips) with a mean of 13.7 years of age during screw removal surgery. The mean post-removal follow up time was 1.6 years. In all cases the removal of screws was done systematically. Demographic data, possible risk factors related to removal failure, as well as post-removal complications such as post-removal fractures, infections and scar issues were recorded.

RESULTS

A removal failure rate of 15.79 % (6/38) was found. The removal surgical time was longer than the initial fixation time but without statistical significance (70.78 vs 61.84 m, p = 0.196). However, the duration of screw implantation (r (2): 7.09; IC: 1.12-13.06) and screw head bony coverage (r (2): 21.32; IC: 5.58-37.06) were both related to this prolonged time. Multivariant analysis revealed that a fully threaded cannulated screw had the lowest removal failure risk (OR: 0.3; IC: 0.14-0.61). There were no postremoval complications recorded.

CONCLUSIONS

We recommend to use full threaded cannulated stainless steel screws and to perform the procedure as soon as the physis are closed to decrease the surgical time. It is a safe procedure based on a low rate of complications such as post-removal fractures, infection and scar issues.

Focal adhesions in osteoneogenesis

As materials technology and the field of tissue engineering advance, the role of cellular adhesive mechanisms, in particular, interactions with implantable devices, becomes more relevant in both research and clinical practice. A key tenet of medical device technology is to use the exquisite ability of biological systems to respond to the material surface or chemical stimuli in order to help to develop next-generation biomaterials. The focus of this review is on recent studies and developments concerning focal adhesion formation in osteoneogenesis, with an emphasis on the influence of synthetic constructs on integrin-mediated cellular adhesion and function.

Removal of deep extremity implants in children

We have reviewed our experience of the removal of deep extremity orthopaedic implants in children to establish the nature, rate and risk of complications associated with this procedure. A retrospective review was performed of 801 children who had 1223 implants inserted and subsequently removed over a period of 17 years. Bivariate analysis of possible predictors including clinical factors, complications associated with implant insertion and indications for removal and the complications encountered at removal was performed. A logistical regression model was then constructed using those predictors which were significantly associated with surgical complications from the bivariate analyses. Odds ratios estimated in the logistical regression models were converted to risk ratios.

The overall rate of complications after removal of the implant was 12.5% (100 complications in 801 patients), with 48 (6.0%) major and 52 (6.5%) minor. Children with a complication after insertion of the initial implant or with a non-elective indication for removal, a neuromuscular disease associated with a seizure disorder or a neuromuscular disease in those unable to walk, had a significantly greater chance of having a major complication after removal of the implant. Children with all four of these predictors were 14.6 times more likely to have a major complication.

Outcomes analysis after routine removal of implants in healthy pediatric patients

Routine removal of nonspinal, orthopedic implants from pediatric patients is a debated practice. The purpose of this study was to compare preremoval and postremoval outcome measures in children. Twenty-five patients, mean age 11.6 years, completed a pain scale and the Pediatric Outcomes Data Collection Instrument (PODCI). Many patients scored in the normal range of the PODCI before and after removal. Higher postoperative PODCI scores were found in patients without preoperative pain, and in patients with upper extremity versus lower extremity implants. In summary, routine removal of implants in children was carried out without complications and with some functional benefits.

OSTEOSYNTHESIS WITH INTRAMEDULLARY NAILS IN CHILDREN

The authors present a comprehensive review of the literature emphasizing the use of flexible intramedullary nails in the treatment of fractures in children, focusing the treatment of femoral shaft and forearm fractures and emphasizing the importance of the non-surgical approach. Children's age and weight threshold are not well defined for the use of the method. The removal of implants is a controversial matter in the literature, with a trend towards keeping the implants.

Fracture incidence following plate removal in Legg-Calvé-Perthes disease: a 32-year study

PURPOSE

The decision of whether or not to remove pediatric metallic implants remains a controversial issue. Many factors have been cited both in favor and against routine removal of metallic implants. The purpose of this study was to determine the fracture rate following the routine removal of hardware from patients with Legg-Calvé-Perthes (LCP) disease treated by proximal femoral varus osteotomy (PFVO) and to determine if there is an optimal time to remove hardware in this population.

METHODS

We performed a retrospective chart review of children who had PFVO with subsequent hardware removal from March 1973 to May 2005 performed by a single surgeon. A total of 196 hips in 184 patients were included. Data was analyzed using logistic regression. Inverse prediction was also used to obtain estimates of the time needed to produce probabilities of no fracture.

RESULTS

Ten out of the 196 hips included (5.1%) sustained a fracture after plate removal. The time from osteotomy to plate removal averaged 10.4 months in the nonfracture group and 4.8 months in the fracture group. This was statistically significant (P < 0.0001). Using the logistic regression model, the predicted time to plate removal corresponding to a 95% probability of no fracture was between 5.1 and 8.4 months.

CONCLUSIONS

Plate removal remains a reasonable choice but questions remain as to the timing of removal. These data suggest that patients may benefit from extending the time to hardware removal beyond radiographic union to at least six months or more after the osteotomy.

Do orthopaedic surgeons need a policy on the removal of metalwork? A descriptive national survey of practicing surgeons in the United Kingdom

INTRODUCTION

Routine metalwork removal, in asymptomatic patients, remains a controversial issue. Current literature emphasises the potential hazards of implant removal and the financial implications encountered from these procedures. However, there is little literature guidance and no published research on current practice.

AIM

To estimate the current state of practice of orthopaedic surgeons in the United Kingdom regarding implant removal in asymptomatic patients.

METHODS

An analysis, by two independent observers, was performed on the postal questionnaire replies of 36% (500 out of 1390), randomly selected UK orthopaedic consultants.

RESULTS

Four hundred and seven (81%) replies were received. A total of 345 (69%) were found to be suitable for analysis. The most significant results of our study (I) 92% of orthopaedic surgeons stated that they do not routinely remove metalwork in asymptomatic skeletally mature patients; (II) 60% of trauma surgeons stated that they do routinely remove metalwork in patients aged 16 years and under; (III) 87% of the practicing surgeons indicated that they believe it is reasonable to leave metalwork in for 10 years or more; (IV) only 7% of practicing trauma surgeons who replied to this questionnaire have departmental or unit policy.

CONCLUSION

Our results demonstrate that most practicing trauma surgeons do comply with the evidence presented in the little literature available. However, we do believe that a general policy for metalwork removal is essential. Such a policy should include guidelines specific to age groups and level of surgeon who should be performing the removal procedure. Such a document would require further validated studies but would eventually serve to steer surgeons in achieving best practice.

Retention of flexible intramedullary nails following treatment of pediatric femur fractures

INTRODUCTION

Flexible intramedullary nails are commonly used for the treatment of diaphyseal femur fractures in children. Although, their removal after fracture healing is advocated by some, there are no definitive studies to support the routine removal of these implants. The purpose of this study is to determine the natural history of children with diaphyseal fractures of the femur treated with flexible intramedullary nails and no scheduled nail removal.

MATERIAL AND METHODS

We performed a retrospective case series of 24 consecutive children treated at our tertiary pediatric referral center for closed diaphyseal femur fractures. All children had intramedullary fixation with flexible titanium nails. The main outcomes measured are fracture healing, incidence of hardware removal, and pain assessment with the use of a follow-up telephone questionnaire.

RESULTS

All the patients healed their fractures. The average follow-up time was 3.6 years. A total of six patients had removal of nails for any reason at an average of 15 months post-injury. The survivorship free of revision due to persistent pain was 72% at 5 years of follow-up. Twenty-two patients were reached by phone for a final follow-up questionnaire. There was no difference in reports of residual symptoms of pain among those who did have nails removed and those who did not (P = 0.626).

CONCLUSIONS

Among children with femur fractures treated with flexible intramedullary nailing without scheduled implant removal, about a quarter may ultimately require a second procedure for nail removal due to persistent discomfort. Moreover, up to half of patients can have residual non-debilitating pain at 2-5 years post-injury regardless of presence or absence of the implant. Whether this is a previously unrecognized adverse outcome of this injury or treatment approach, or due to routinely leaving nails in will have to be assessed in future controlled trials.

The effects of nanoscale pits on primary human osteoblast adhesion formation and cellular spreading

Current understanding of the mechanisms involved in ossesoinegration following implantation of a biomaterial has led to an emphasis being placed on the modification of material topography to control interface reactions. Recent studies have inferred nanoscale topography as an important mediator of cell adhesion and differentiation. Biomimetic strategies in orthopaedic research aim to exploit these influences to regulate cellular adhesion and subsequent bony tissue formation. Here experimental topographies of nanoscale pits demonstrating varying order have been fabricated by electron-beam lithography in (poly)carbonate. Osteoblast adhesion to these nanotopographies was ascertained by quantification of the relation between adhesion complex formation and total cell area. This study is specifically concerned with the effects these nanotopographies have on adhesion formation in S-phase osteoblasts as identified by BrdU incorporation. Nanopits were found to reduce cellular spreading and adhesion formation.

Complications at screw removal in slipped capital femoral epiphysis treated by cannulated titanium screws

INTRODUCTION

Various modes of fixation are proposed for the treatment of slips of the capital femoral epiphysis (SCFE). We describe our experience with the use and removal of a new, cannulated titanium screw (Asnis III, Stryker, Howmedica).

PATIENTS AND METHODS

Single cannulated titanium screws had been inserted in 101 hips of 65 patients in the 3-year period from 2001 to 2003. These pins were used for in situ fixation of minor chronic slips in 41 patients and for prophylactic fixation on the contralateral side in patients with open physis in 60 patients.

RESULTS

The insertion of these screws was achieved without any real problem. The mean surgical time was 25 min (13-46 min). Problems came up when we started to remove the pins. Hardware retrieval was attempted in 27 patients with 43 pins. The mean surgical time for removal was double the average time of insertion with 51 min (26-107 min). The hexagonal Allen sockets proved to be too weak to overcome the necessary torque for loosening the pin from bone and applying the reverse-cutting-force, necessary to extract the pin. Eleven patients needed extensive chiselling. Two adolescents sustained a subtrochanteric fracture 5 and 7 weeks after hardware removal. Seven pins could not be totally removed.

CONCLUSION

Due to the considerable disadvantages encountered in our series we conclude that Asnis III cannulated screws should be suspended from further use in SCFE.

Removal of flexible titanium nails in children

Removal of hardware in children after orthopaedic procedures is controversial. The authors retrospectively reviewed hospital charts and radiographs of 143 children who underwent removal of flexible titanium nails from the femur and the forearm. In 16 children the nails were removed because of protrusion, skin irritation, and some discomfort. Most of the patients were asymptomatic and underwent nail removal electively, according to the authors' policy for routine hardware removal in children. Complications included unsuccessful nail removal in three children and refractures after nail removal in two. Although the authors are still inclined to remove flexible titanium nails in most of the patients, the need for routine elective execution of this procedure may be questionable.

Hardware removal: indications and expectations

Although hardware removal is commonly done, it should not be considered a routine procedure. The decision to remove hardware has significant economic implications, including the costs of the procedure as well as possible work time lost for postoperative recovery. The clinical indications for implant removal are not well established. There are few definitive data to guide whether implant removal is appropriate. Implant removal may be challenging and lead to complications, such as neurovascular injury, refracture, or recurrence of deformity. When implants are removed for pain relief alone, the results are unpredictable and depend on both the implant type and its anatomic location. Current literature does not support the routine removal of implants to protect against allergy, carcinogenesis, or metal detection. Surgeons and patients should be aware of appropriate indications and have realistic expectations of the risks and benefits of implant removal.

Technique for removal of cannulated screws

Cannulated screws can become incarcerated or stripped during the process of initial open-reduction internal fixation or at the time of hardware removal. In addition, many different sizes and brands of cannulated screws exist, and the appropriate size or type of screwdriver may not be available. We describe a simple technique for cannulated screw removal that works for all types of screws and can be performed percutaneously using only a Steinmann pin and T- handle chuck or pin driver.