Removal of deep extremity implants in children

Implants removal in children: results of a survey among Italian orthopaedic surgeons

In the treatment of paediatric limb disorders, the use of metal implants has been increasing over the last decades. Recent studies have addressed the decision of orthopaedic surgeons regarding the removal of implants after the treatment of fracture, and there is a growing consensus within the scientific community supporting the choice of not removing implants in children. This survey aimed to investigate the rationale behind the Italian orthopaedic community's decision regarding metal implant removal in paediatric patients. An electronic questionnaire was sent to all members of the Italian Paediatric Orthopaedic and Traumatology Society, Italian Orthopaedic and Traumatology Society, Italian Club of Osteosynthesis, and South Italy Society of Orthopaedic and Traumatology. The survey comprised 34 questions about hardware removal after the treatment of long bone fractures, epiphyseal growth plate injuries, slipped capital femoral epiphysis (SCFE), and flat foot. Of the 3500 orthopaedic surgeons who received the questionnaire, 5.5% responded. The leading indications for implant removal were the patient's intolerance, pain, ROM limitations, and hardware breakage. Removal of elastic nails for long bone fractures, cannulated screws for growth plate injuries, and SCFE and screws for arthroereisis for flat foot correction were analysed in detail. The consensus among Italian Orthopaedic Surgeons is to remove elastic nails and cannulated screws in cases of pain, intolerance, or breakage and to reduce further risks during patient growth. An increasing number of physicians, however, are endorsing and advocating the growing trend in the literature of not routinely removing the hardware.

Burden of routine orthopedic implant removal a single center retrospective study

BACKGROUND

Open reduction and internal fixation represent prevalent orthopedic procedures, sparking ongoing discourse over whether to retain or remove asymptomatic implants. Achieving consensus on this matter is paramount for orthopedic surgeons. This study aims to quantify the impact of routine implant removal on patients and healthcare facilities. A retrospective analysis of implant removal cases from 2016 to 2022 at King Fahad Hospital of the University (KFHU) was conducted and subjected to statistical scrutiny. Among these cases, 44% necessitated hospitalization exceeding one day, while 56% required only a single day. Adults exhibited a 55% need for extended hospital stays, contrasting with 22.8% among the pediatric cohort. The complication rate was 6%, with all patients experiencing at least one complication. Notably, 34.1% required sick leave and 4.8% exceeded 14 d. General anesthesia was predominant (88%). Routine implant removal introduces unwarranted complications, particularly in adults, potentially prolonging hospitalization. This procedure strains hospital resources, tying up the operating room that could otherwise accommodate critical surgeries. Clearly defined institutional guidelines are imperative to regulate this practice.

AIM

To measure the burden of routine implant removal on the patients and hospital.

METHODS

This is a retrospective analysis study of 167 routine implant removal cases treated at KFHU, a tertiary hospital in Saudi Arabia. Data were collected in the orthopedic department at KFHU from February 2016 to August 2022, which includes routine asymptomatic implant removal cases across all age categories. Nonroutine indications such as infection, pain, implant failure, malunion, nonunion, restricted range of motion, and prominent hardware were excluded. Patients who had external fixators removed or joints replaced were also excluded.

RESULTS

Between February 2016 and August 2022, 360 implants were retrieved; however, only 167 of those who met the inclusion criteria were included in this study. The remaining implants were rejected due to exclusion criteria. Among the cases, 44% required more than one day in the hospital, whereas 56% required only one day. 55% of adults required more than one day of hospitalization, while 22.8% of pediatric patients required more than one day of inpatient care. The complication rate was 6%, with each patient experiencing at least one complication. Sick leave was required in 34.1% of cases, with 4.8% requiring more than 14 d. The most common type of anesthesia used in the surgeries was general anesthesia (88%), and the mean (SD) surgery duration was 77.1 (54.7) min.

CONCLUSION

Routine implant removal causes unnecessary complications, prolongs hospital stays, depletes resources and monopolizing operating rooms that could serve more critical procedures.

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.].

Controversies in the management of pediatric neck femur fractures- a systematic review

Purpose

To review controversies systematically in the management of pediatric neck femur fracture from the literature and to develop consensus for the optimum management.

Methods

Authors searched literature by using keywords of pediatric neck femur fracture, proximal femur fracture, complications, management by following PRISMA guidelines. A common dilemma was listed.

Results

Age, mechanism of injury, fracture type, presentation, treatment method, implant, and nature of complications were compared. Inference from recent literature was extracted for optimum management.

Conclusion

Immediate anatomical reduction with stable fixation must be accomplished. Complications continue to happen despite the best efforts and a longer follow-up is important.

Implant removal associated complications after ESIN osteosynthesis in pediatric fractures

PURPOSE

ESIN (elastic stable intramedullary nailing) is considered the gold standard for various pediatric fractures. The aim of this study was to analyze the incidence and type of complications during or after TEN (titanium elastic nail) removal.

METHODS

A retrospective data analysis was performed. Metal removal associated complications and preoperative extraosseous length/outlet angle of TENs as possible causes of complications were assessed.

RESULTS

The complication rate in 384 TEN removals was 3.1% (n = 12). One major complication (rupture of M. extensor pollicis brevis) was documented. One refracture at the forearm occurred, however, remodeling prior TEN removal was completed. Ten minor complications were temporary or without irreversible restrictions (3 infections, 5 scaring/granuloma, 2 temporary paraesthesia). In 38 cases (16 forearms, 10 femora, 9 humeri, 3 lower legs), intra-operative fluoroscopy had to be used to locate the implants. In patients with forearm fractures, extraosseous implant length was relatively shorter than in cases without fluoroscopy (p = 0.01), but outlet angle of TENs was not significantly different in these two groups (28.5° vs 25.6°). In patients with femur fractures, extraosseous implant length and outlet angle were tendentially shorter, respectively, lower, but this did not reach statistical significance.

CONCLUSION

Removal of TENs after ESIN is a safe procedure with a low complication rate. Technically inaccurate TEN implantation makes removal more difficult and complicated. To prevent an untimely removal and patient discomfort, nail ends must be exactly positioned and cut. Intraoperative complications may be minimized with removal of TENs before signs of overgrowth.

EVIDENCE

Level III, retrospective.

Should Proximal Femoral Implants be Removed Prophylactically or Reactively in Children With Cerebral Palsy?

BACKGROUND

Implants are commonly used to stabilize proximal femoral osteotomies in children with cerebral palsy (CP). Removal of implants is common practice and believed to avoid infection, fracture, or pain that might be associated with retained hardware. There is little evidence to support a prophylactic strategy over a reactive approach based on symptoms. The aim of this study was to compare the outcomes of prophylactic and reactive approaches to removal of proximal femoral implants in children with CP.

METHODS

An intention-to-treat model was used to compare 2 institutions that followed a prophylactic (within ∼1 y) and reactive (following complication/symptoms) approach to hardware removal, respectively. Patients with CP who had femoral implants placed at or before age 16, and had ≥2-year postsurgical follow-up were included. Demographics, surgical details, reasons for removal, and complications were recorded. χ and t tests were used.

RESULTS

Six hundred twenty-one patients (prophylactic=302, reactive=319) were followed for an average of 6 years (range, 2 to 17 y). Two hundred eighty-seven (95%) implants were removed in the prophylactic group at 1.2 years. In the reactive group, 64 (20%) implants were removed at an average of 4.2 years. Reasons for removal included pain; infection; fracture; or for repeat reconstruction. The rate of unplanned removals due to fracture or infection was higher in the reactive group (4.7% vs. 0.7%, P=0.002), but there was no difference in the rate of complications during/after removal between the 2 groups (1.7% vs. 3.1%; P=0.616). No specific risk factor associated with unplanned removal could be identified; but children under 8 years old seemed more likely to undergo later removal (odds ratio 1.98; 95% confidence interval, 0.99-3.99).

CONCLUSIONS

Eighty percent of patients in the reactive removal strategy avoided surgery. This group did have a 4% higher rate of fracture or infection necessitating unplanned removal but these were successfully treated at time of removal with no difference in complication rates associated with removal between both groups. One would need to remove implants from 25 patients to avoid 1 additional complication, providing some support for a reactive approach to removal of proximal femoral implants in this population.

LEVEL OF EVIDENCE

Level III-therapeutic.

Complications in a Young Adult Attributable to a Retained Pediatric Dynamic Hip Screw

Introduction

Orthopedic implants are used for many different conditions in the pediatric population. The literature on hardware removal is controversial and vague.

Case Report

We highlight a young adult male who underwent a dynamic hip screw (DHS) due to a motor vehicle accident at 11 years old. He healed the fracture and did well for years. He was lost to follow-up and the hardware was never removed. The patient presented to our facility with a periprosthetic subtrochanteric proximal femur fracture just distal to the retained hardware. The DHS was removed and the fracture fixed with an intramedullary nail. The patient healed the fracture and did well.

Discussion

A literature review was performed to highlight the benefits and complications of hardware removal vs. retention. We hope to equip the orthopedic surgeon with the reasons for or against hardware removal to optimize treatment to each patient. In this instance, we recommend hardware removal due to the serious consequences of retained hardware in the adolescent/young adult population.

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.

Tibial Rotation Osteotomies in a Matched Cohort of Myelodysplasia and Cerebral Palsy Children

BACKGROUND

The purpose of this study is to examine the frequency of complications in children with myelodysplasia (MD) undergoing tibial rotational osteotomies with a matched cohort of children with cerebral palsy (CP). It was postulated that because of the unique health issues facing children with MD more complications would be observed.

METHODS

A retrospective chart review was performed to identify children with MD who underwent primary tibial rotational osteotomy between 1997 and 2012 and had a minimum 2-year follow-up. The 15 children thus identified were matched for age, body mass index, and functional ability with 15 children with CP. Outcome measures were complications that occurred within a year of osteotomy or hardware removal. Major complications were defined as nonunions or malunions, hardware failures, deep infections, fractures, and stage III or IV decubiti. Recurrence of rotational deformity requiring revision osteotomy at any time was also defined as a major complication. Minor wound problems healing within 6 weeks with only local care were considered minor complications.

RESULTS

Fifteen children with MD, who underwent 21 tibial derotational osteotomies, were available for review with a mean 7-year follow-up. The 15 children with CP underwent 22 tibial derotational osteotomies with a mean of 6 years of follow-up. In each cohort there were 3 children classified as GMFCS I, 3 children as GMFCS II, 4 children as GMFCS III, and 5 as GMFCS IV. Three (20%) of the children with MD experienced major complications (1 infected nonunion and 2 children who experienced bilateral malunions requiring revisions). One child with a major complication was classified as GMFCS II and the other 2 as GMFCS IV. None of the children with CP experienced a major complication.

CONCLUSIONS

The majority of children in both groups experienced good results, but children with MD have more frequent major complications. More frequent complications were seen in children with less functional ability.

LEVEL OF EVIDENCE

Level III-prognostic study, case-control study.

Elastic stable intramedullary nailing in paediatric forearm fractures: the rate of open reduction and complications

The aim of this study was to evaluate the rate of open reduction and complications of elastic stable intramedullary nailing (ESIN) in treating unstable diaphyseal forearm fractures in children. We performed a retrospective review of a consecutive series of 102 paediatric patients with a mean age of 9 years (range: 7-14 years) who underwent ESIN of unstable closed forearm fractures at three different centres. Closed reduction of one or both bones was achieved in 68 (67%) patients and open reduction was required in 34 (33%) patients. The rate of open reduction in single-bone fractures (52.2%) was significantly higher than that in both-bone fractures (27.8%) (P=0.04, Fisher's exact test). All the fractures united within 3 months. There were six refractures following nail removal. Five patients had superficial wound infections. Seven patients developed neuropraxia of the sensory branch of the radial nerve. All resolved spontaneously within 3 months of the surgery. ESIN is an effective technique in treating unstable diaphyseal forearm fractures. The need for open reduction should be decided promptly following failed attempts of closed reduction. Single-bone fractures are more likely to require open reduction than both-bone fractures. The radius should be reduced and stabilized first. If open reduction is required, this should be performed through a volar approach rather than a dorsal one.

Outcomes of Cutaneous Scar Revision During Surgical Implant Removal in Children with Cerebral Palsy

BACKGROUND

Children who have had surgery involving the placement of an implant frequently undergo a subsequent surgery for hardware removal. The cosmesis of surgical scars following initial and subsequent surgeries is unpredictable. Scar incision (subsequent surgical incision through the initial scar) or excision (around the initial scar) is selected on the basis of the quality of the initial scar. The outcomes following these techniques have not been determined.

METHODS

This prospective, consecutive case series was designed to compare outcomes following surgical scar incision versus excision at the time of implant removal in children with cerebral palsy. Photographs of the scars were made preoperatively and at 6 and 12 months following implant removal and were graded for scar quality utilizing the modified Stony Brook Scar Evaluation Scale (SBSES). Parental assessment of scar appearance was performed at the same time points utilizing a visual analog cosmetic scale (VACS).

RESULTS

The scars that were selected for incision had significantly worse SBSES scores at 6 and 12 months following the second surgery compared with preoperative values. However, parents' VACS scores of the incised scars, although worse at 6 months, were comparable with preoperative scores at 12 months. Scars that were selected for excision had significantly worse SBSES scores at 6 months but scores that were comparable with preoperative values at 12 months. VACS scores for the excised scars were comparable at the 3 time points.

CONCLUSIONS

Surgical incisions that initially healed with good scar quality generally healed well (from the parents' perspective) following subsequent incision through the previous scar. Surgical incisions that initially healed with poor scar quality did not heal better following excision of the previous scar. In such situations, surgical excision of the existing scar should occur in conjunction with additional adjuvant therapies to improve cosmesis.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Indications for implant removal following intra-articular calcaneal fractures and subsequent complications

INTRODUCTION

Implant removal following operative calcaneal fracture treatment has received little attention in the literature. The aim of the current retrospective cohort study was to assess the indications and number of wound complications following calcaneal plate removal.

METHODS

All consecutive adult patients who had their plate and screws removed following the operative treatment of a closed uni- or bilateral intra-articular calcaneal fracture using a stainless steel nonlocking calcaneal plate between 2000 and 2011 were included.

RESULTS

In 102 patients (46% of the total number of operated calcaneal fractures) implants were removed. Implant removal was performed in 75 patients for symptomatic reasons, in 10 patients due to implant malposition and in 19 patients because of a persistent wound infection or fistula. Following implant removal 17 (16%) patients had a wound complication (2 wound dehiscence, 15 culture positive wound infections). In 6 patients (9%) a wound complications was seen following implant removal after uncomplicated fracture surgery. Implant removal for active infection or plate fistula displayed an infection rate of 8 out of 19 (42%).

CONCLUSION

Implant removal after an intra-articular calcaneal fracture treated with open reduction and internal fixation via an extended lateral approach was followed by a wound complication in 1 of every 10 patients without a preexisting wound infection. Infection rates were especially high in patients in whom the implants were removed for an active wound problem.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A novel technique for pediatric femoral locked submuscular plate removal: the 'push-pull' technique

Submuscular and minimally invasive plate insertion is gaining popularity reducing the need for large open approaches and resulting in a smaller operative ‘footprint.’ With pediatric fractures and titanium implants, fibrous and osseous ingrowth to the implant and osseous implant integration may interfere with implant removal. Therefore, the small minimally invasive implant insertion procedure may require a large maximally invasive exposure for implant removal after fracture healing. To reduce soft tissue damage, bleeding, scarring, and pain associated with implant removal, a minimally invasive procedure utilizing the pre-existing incisions while controlling the implant is efficient and beneficial. The surgical technique is described, and a case series of 21 treated pediatric femoral fractures illustrates the successful performance of the procedure and its limitations.

Implant removal in children

PURPOSE

Implant removal in children is still a standard procedure. Implants may disturb function, and some theoretical long-term risks like growth disturbance, foreign body reaction, chronic infection and corrosion are used as arguments for removal. Implant migration or interference with any other orthopaedic treatment over the later course of life is also a matter of debate. On the other hand, the difficulty in removing single implants as well as possible perioperative complications has induced discussion about the retention of implants in childhood.

METHODS

The current procedures are exposed and the available literature on implant removal in children reviewed.

RESULTS

Actually, a clear recommendation does not exist. The current line of action still includes routine removal, as it is preferred by some authors, whereas others argue for a selective procedure. K-wires as well as intramedullary nails are usually removed because the ends may interfere with the surrounding tissue. Screws and plates can be retained if there are no local problems. The removal of external fixators is non-controversial.

CONCLUSIONS

Benefits have to outweigh the risks and complications in the individual case and the procedure should not require a more extensive procedure than insertion. It has to be an individual decision in view of the lack of evidence to support routine removal as well as to refute it.

Acute complications associated with removal of flexible intramedullary femoral rods placed for pediatric femoral shaft fractures

BACKGROUND

The American Academy of Orthopaedic Surgeons position statement on the treatment of pediatric femoral shaft fractures could not comment on the safety of flexible intramedullary (IM) rod removal because of a lack of published evidence. This study reviews the acute complications of flexible IM rod removal from pediatric patients treated for femoral shaft fractures.

METHODS

A retrospective clinical and radiographic analysis at a single institution over a 5-year period. Demographic and radiographic parameters were analyzed to determine their influence on intraoperative and immediate postoperative complications.

RESULTS

One hundred sixty-three subjects (133 males, 30 females), mean age of 9.3±2.8 years (range, 2.7 to 14.8 y) and mean weight of 34.4±15.3 kg (range, 14.0 to 139.0 kg), underwent femoral flexible IM rod removal a mean 12.4±10.8 months (range, 2.4 to 63.8 mo) after placement with mean operative time of 51.1±22.3 minutes (range, 10 to 131 min). One hundred fifty-one subjects (92.6%) had stainless-steel Ender rods and the remaining nails were titanium. There were no significant demographic, intraoperative, or radiographic differences comparing subjects with Ender versus titanium rods. Indications for rod removal were pain at insertion site, family request, or surgeon's recommendation. There were 4 (2.5%) minor intraoperative difficulties, including the inability to remove 1 of 2 rods secondary to IM migration (n=1) and complete bone overgrowth at insertion site resulting in prolonged extraction time (n=3). Three of the 4 subjects had the rods placed >60 months before removal. Immediately postoperative (n=134), there were 4 (3.0%) complications, including superficial wound infection (n=3, 2.2%) and knee contracture (n=1, 0.8%). Subjects were released to full activities at a mean 4.7±1.8 weeks postoperatively with no known postoperative fractures.

CONCLUSIONS

The rate of intraoperative and immediate postoperative complications is low. Neither patient demographics, fracture characteristics, nor operative technique influenced the complication rate. Intraoperative difficulties may be minimized with removal of rods before signs of overgrowth.

LEVELS OF EVIDENCE

Level IV, intervention case series.

Atypical tibial tuberosity fracture in an adolescent

Avulsion fractures of the tibial tuberosity are typically sustained by adolescent males during sporting activities. Tibial tuberosity avulsions with simultaneous proximal tibial epiphyseal fractures are rare injuries. We present an unusual case of Ogden type IIIA avulsion fracture of tibial tuberosity with a Salter Harris type IV posterior fracture of proximal tibial epiphysis in a 13-year-old boy. We believe that the patient sustained the tibial tuberosity avulsion during the take-off phase of a jump while playing basketball due to sudden violent contraction of the quadriceps as the knee was extending. This was then followed by the posterior Salter Harris type IV fracture of proximal tibial physis as he landed on his leg with enormous forces passing through the knee. Although standard radiographs were helpful in diagnosing the complex fracture pattern, precise configuration was only established by computed tomography (CT) scan. The scan also excluded well-recognized concomitant injuries including ligament and meniscal injuries. Unlike other reported cases, our patient did not have compartment syndrome. Anatomic reduction and stabilization with a partially threaded transepiphyseal cannulated screw and a metaphyseal screw followed by early mobilization ensured an excellent recovery by the patient.Our case highlights the importance of vigilance and a high index of suspicion for coexisting fractures or soft tissue injuries when treating avulsion fractures of tibial tuberosity. A CT scan is justified in such patients to recognize complex fracture configurations, and surgical treatment should be directed appropriately to both the fractures followed by early rehabilitation. Patients with such injuries warrant close monitoring for compartment syndrome during the perioperative period.