|Year : 2018 | Volume
| Issue : 1 | Page : 12-16
Orthopaedic implant removal: Epidemiology and outcome analysis
Chikwendu Nwosu, Taofeek Olanrewaju Adeyemi, Oni Nasiru Salawu, Joseph Olorunsogo Mejabi, Abidemi Abiola Fadimu
Department of Surgery, Federal Medical Centre, Birnin Kebbi, Kebbi State, Nigeria
|Date of Web Publication||30-Jul-2018|
Dr. Chikwendu Nwosu
Department of Surgery, Federal Medical Centre, Birnin Kebbi, Kebbi State
Source of Support: None, Conflict of Interest: None
Background: Implant removal represents one of the most common operations in bone and joint surgery. After fracture union, the implant loses its purpose and continues to exist only as a foreign object inside the patient's body and the question arises whether the implant should be removed, and if so, why and when. While early implant removal increases the risk of re-fracture, delayed removal may result in more difficult and extensive operating procedures, due to a stronger bony integration and overgrowth on implants. This will provide essential information needed for hospital policy formulation. Aims and Objectives: The aim of this study is to determine the prevalence, indications and outcomes following orthopaedic implant removal and to proffer appropriate solutions. This will provide essential information needed for hospital policy formulation. Patients and Methods: This is a retrospective study of all cases of implant removal performed in the Orthopedic Unit of Federal Medical Center and Surgery Department of Sir Yahaya Memorial Hospital all in Birnin Kebbi, Kebbi State, North-western Nigeria from January 2011 to December 2017. Case notes of the patients were retrieved and relevant information was extracted and analysed. Results: A total of 113 implants were removed from 111 patients. There were 78 males and 33 females, with a male to female ratio of 2.4:1. The peak age group is the 36–45 years. The longest duration of implant was from 13 to 18 months. Plate and screws constituted 76 (67%) of all implants removed. The femur was involved in 49 (43.3%) cases. Patient's request constituted 46 (41.5%) of the indications. There was retained hardware in 6 (5.4%) cases while external fixation (17, 15.3%) was the most common additional procedure performed. Conclusion: Most of the implants stayed for more than a year. Plate and screws were the most common implants removed. The femur was the most involved bone. Patient's request was the most common indication for removal. Retained hardware was the most common post-operative complication while external fixation was mostly performed as an additional procedure.
Keywords: Orthopaedic implant, outcome, removal
|How to cite this article:|
Nwosu C, Adeyemi TO, Salawu ON, Mejabi JO, Fadimu AA. Orthopaedic implant removal: Epidemiology and outcome analysis. Niger J Orthop Trauma 2018;17:12-6
|How to cite this URL:|
Nwosu C, Adeyemi TO, Salawu ON, Mejabi JO, Fadimu AA. Orthopaedic implant removal: Epidemiology and outcome analysis. Niger J Orthop Trauma [serial online] 2018 [cited 2018 Nov 15];17:12-6. Available from: http://www.njotonline.org/text.asp?2018/17/1/12/237837
| Introduction|| |
Implant removal represents one of the most common operations in bone and joint surgery. Surgical stabilisation has become integral to the management of orthopaedic trauma, and most options for the repair of orthopaedic injury involve the application of some type of implant. Titanium alloys and stainless steel are generally employed for the manufacture of orthopaedic implants.
The removal of orthopaedic implants after fracture had healed has always been a topical issue for the following reasons; first, because the science of biomechanics of internal fixation is highly dynamic with the development of newer and better fixation devices, and second, because the criteria for removal have not been clearly documented. After fracture union, the implant loses its purpose and continues to exist only as a foreign object inside the patient's body and the question arises whether the implant should be removed, and if so, why and when? While early implant removal increases the risk of re-fracture, delayed removal may result in more difficult and extensive operating procedures, due to a stronger bony integration and overgrowth on implants.
The most common indication for implant removal is patient's request, which could be due to existing cultural and religious beliefs, in which individuals consider the implant as a foreign body which should be removed. For patients who have had internal fixation, most wonder if and when such metallic hardware will be removed. In addition, concerns about local and systemic effects of retained implants have led many patients to request elective hardware removal.
It is important to assess the main reason for implant removal and the extent to which a surgeon and a patient are willing to go to do so. Infection, non-union, migration of the implant, unremitting pain, deformity or re-fracture requiring fixation are the indications for nail removal. The concerns with retaining metal implants include deep late infection, metal allergy or toxicity, tumorigenicity, hardware migration, metal failure and secondary fracture at plate ends. On the one hand, issue of pain relief, local irritating symptoms, ease of management if re-fracture occurs, benefits to the residents in developing operative proficiency and surgical skills favour implant removal procedures; however, on the other hand, potential complications associated with the removal such as neurovascular injuries, re-fracture, anaesthesia and surgery-related complications, economic burden to the patient, increased workload to the hospitals and ethical issues discourage the routine procedure.
During removal cases, however, hardware, especially screws, can break leading to difficult and prolonged surgery with possibility of retained hardware.
In children, it may be necessary to remove implants early to avoid disturbances to the growing skeleton, to prevent bony ingrowth making later removal technically difficult or impossible and to allow planned reconstructive surgery after skeletal maturation (in case of hip dysplasia). Implant removal is often left to the junior members of a surgical team, at the end of the list when many of the experienced members of the team have already left; This results in a high incidence of minor or serious complications leading to a prolonged period of recuperation.
Hardware removal is cost-consuming for both hospitals and healthcare resources and also affects the society's labour force due to post-operative absence from work. A routine policy on the removal of orthopaedic fixation devices after fracture healing remains an issue of debate as there is a paucity of evidence-based guidelines available.
The incidence, indications and outcome analysis for orthopaedic implant removal for patients that had internal fixation of their fractures are important for the trauma systems, resource and management planning. The aim of this study was to determine the incidence, indications and outcomes following orthopaedic implant removal after internal fixation of fractures and to proffer solutions towards a better outcome. This will provide essential information needed for hospital policy formulation on implant removal.
| Patients and Methods|| |
This is a retrospective study of all cases of implant removal performed in the Orthopedic Unit of Federal Medical Center and Surgery Department of Sir Yahaya Memorial Hospital all in Birnin Kebbi, Kebbi State, North-western Nigeria, from January 2011 to December 2017. Data were extracted from the operation register and patients' case folders on bio-data, diagnosis, type of surgical procedure, site of surgery, dates of surgery and removal of implant, indication for removal as well as presence of complications. Only files of patients with complete medical records were included in this study. All information obtained was treated with strict confidentiality. Data collected were analysed using the Statistical Package for the Social Sciences for Windows version 22 (SPSS Inc., Chicago, IL, USA). Results were presented with descriptive statistics. The Chi-square test was used in accessing the significance of association between categorical variables. The relationship of reason for implant removal with other variables was assessed using bivariate analysis and multivariate logistic regression analysis. A P < 0.05 was considered statistically significant.
| Results|| |
During the 7-year period, 119 patients had metallic implants removed, out of which eight had incomplete data and were excluded from the study. A total of 113 implants were removed from 111 patients. Two patients had implants removed from two different bones. Over the period under review, 78 (70.3%) patients were recruited from Federal Medical Centre, while 33 (29.7%) patients were recruited from Sir Yahaya Memorial Hospital, all in Birnin Kebbi. Among the patients were 82 males and 29 females with male to female ratio of 2.8:1. Sex was significantly associated with reason for implant removal on bivariate analysis (χ2 = 25.306, P < 0.0001). This association was independently significant on further analysis (odds ratio [OR] = 3.47, confidence interval [CI] = 0.482–1.296, P < 0.0001). The age range of the patients was from 7 to 82 (mean 31.4). 68 (61.2%) of the patients were in the 26–45 years age group, while children were 8 (7.2%) [Table 1]. Age was statistically significant on bivariate analysis (χ2 = 61.099, P < 0.0001). This association was independently not significant on further analysis (OR = 0.07, CI = 0.026–2.684, P = 0.116). Thirty-two (28.8%) of the patients had no formal education, 23 (20.7%) had primary education, 34 (30.6%) had secondary education, while 22 (19.9%) had tertiary education. This association was not clinically significant (χ2 = 4.063, P = 0.255).
Thirty-six (32.4%) of the patients had their implant in situ for 13–18 months, while 27 (24.3%) of the patients had theirs for 7–12 months [Table 2]. The duration of implant was significantly associated on bivariate analysis (χ2 = 39.027, P < 0.001). This association was independently significant on further logistic regression analysis (OR = 1.839, CI = 0.098–0.329, P = 0.017).
Plate and screws constitute 76 (67%) of implants removed followed by intramedullary nails [Table 3]. Two patients had plate and screws removed from two different long bones. The type of implant removed was significantly associated with the reason for implant removal on bivariate analysis (χ2 = 21.148, P < 0.001). This association was independently significant on further analysis (OR = 0.415, CI = 0.034–0.061, P = 0.030).
The most common bone involved was the femur 49 (43.3%) followed by the tibia 24 (21.2%) [Table 4]. The bone involved was significantly associated with the reason for implant removal on bivariate analysis (χ2 = 100.53, P < 0.001). This association was independently not significant on further logistic regression analysis (OR = 4.163, CI = 0.018–4.776, P = 0.107).
Patient's request is the most common indication for removal in 46 (41.5%) cases followed by infection in 31 (27.9%) cases [Table 5].
There were no post-operative complications in 98 (88.3%) cases, while the most common complication was retained hardware (6, 5.4%) followed by fracture (4, 3.7%) [Table 6]. Post-operative complications were not significantly associated with reason for implant removal on bivariate analysis (χ2 = 32.439, P = 0.054). Loss of contour of the screw head slot was also commonly encountered preventing the engagement of the driver in the screw head. Screw heads had to be cut-off to remove the plate in two patients because of this complication and the shank left in the bone. In one patient, the screw of the dynamic hip screw could not be removed due to extensive bony growth after 9 years of fixation. The hardware was left in the bone to avoid extensive bony damage from difficult extraction.
External fixation was the most common procedure performed following implant removal in 17 (15.3%) patients; this was followed by intramedullary nailing in 12 (10.8%) patients. Further operative procedure was significantly associated with reason for implant removal on bivariate analysis (χ2 = 18.986, P < 0.001). This was independently significant on further logistic regression analysis (OR = 0.361, CI = 0.820–1.322, P = 0.021). There were two cases of radial nerve injury during extraction of plate and screws from the humerus through a posterior approach. These were identified intra-operatively, and they had epineural repair of the radial nerve. They were subsequently followed up postoperatively, and they had return of normal function after 6 months [Table 7]. All the surgical procedures were performed by a consultant orthopaedic surgeon. The mean duration of hospital stay for all the patients (n = 111) was 7 days with the mode at 10 days.
| Discussion|| |
Removal of orthopaedic implant can pose a formidable challenge to the surgeon, especially in the presence of bony overgrowth, worn out screw threads and heads, stuck nails, broken implants and ingress of bone into all possible crevices of the implants. Currently, there is no single hardware removal technique that is uniformly successful, and several different methods may be employed during the same case. Obtaining prior knowledge of the type of implant and the duration of implantation is the useful information in the preoperative planning of hardware removal procedures, thus saving precious operative time.
This study showed a male preponderance which is similar to the findings of Kuubiere et al., Kadir et al. and Shrestha et al. However, it is at variance with the findings of Onche et al., who reported female preponderance. This is probably due to the fact that males are more involved in trauma being breadwinners. There were more patients in the productive age group. This is similar to the findings of other similar studies.,,, This may be as a result of them being more active and hence more predisposed to trauma.
Plate and screws were the most common implant removed in this study. This is similar to the findings of Onche et al., Haseeb et al. and Kadir et al. However, it is at variance with the findings of Shrestha et al., who reported intramedullary nail as the most common. This may be due to the type of implant readily available during the period of study.
The average duration of implants before removal in this study was between 13 and 18 months. This is similar to the findings of Ogundele et al. but contrasts with the findings of Kuubiere et al., who reported 6–12 months. The most common bone involved in this study is the femur. This is similar to the findings of Ogundele et al., Shrestha et al. and Kadir et al. It contrasts with the findings of Haseeb et al. and Reith et al., who reported tibia and ankle, respectively.
Patient's request is the most common indication for the removal in this study. This is similar to the findings of Onche et al. and Kuubiere et al. but is at variance with the findings of Haseeb et al., Reith et al. and Ogundele et al., who reported pain, doctor's recommendation and implant failure, respectively, as the most common indication for removal. This may be due to cultural and religious beliefs. It may also be psychological due to the presence of the implant.
The most common complication following implant removal in this study is retained hardware. This is similar to the findings of Haseeb et al. but is at variance with the findings of Kadir et al., Shrestha et al. and Reith et al., who reported wound infection, nerve injury and impaired wound healing, respectively. The rate and nature of the complications will probably depend on the experience of the surgeon.
The most common further surgical procedure in this study is external fixation following infected osteosynthesis with non-union. This is in contrast with the findings of Haseeb et al., who reported sequestrectomy as the most common.
The limitations of this study lie in the fact that it is a retrospective study with limited data.
| Conclusion|| |
The most common indication for implant removal is patient's request which may be due to cultural or psychological reasons. Plate and screws were the most common implants removed. The surgeon should be thorough during the primary surgery to prevent the occurrence of post-operative complications that may lead to implant removal. Retained hardware was the most common complication following implant removal. The patient should be informed about the presence and reason for the retained hardware. External fixation was the most common procedure performed following implant removal.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Sidky A, Buckley RE. Hardware removal after tibial fracture has healed. Can J Surg 2008;51:263-8.
Zbigniew G, Ronald WL. Removal versus retention of orthopedic trauma implants. Orthop Knowl Online J 2015;13:2.
Vos DI, Verhofstad MH. Indications for implant removal after fracture healing: A review of the literature. Eur J Trauma Emerg Surg 2013;39:327-37.
Onche II, Osagie OE, INuhu S. Removal of orthopaedic implants: Indications, outcome and economic implications. J West Afr Coll Surg 2011;1:101-12.
Haseeb M, Butt MF, Altaf T, Muzaffar K, Gupta A, Jallu A, et al.
Indications of implant removal: A study of 83 cases. Int J Health Sci (Qassim) 2017;11:1-7.
Marintschev I, Rausch S, Fujak A, Klos K, Hofmann GO, Gras F, et al.
Removal of a femoral nail with osseous overgrowth at the end-cap: A navigated and cannulated minimally invasive technique. Comput Aided Surg 2013;18:41-6.
Kuubiere CB, Mogre V, Alhassan A. Incidence and indications for orthopedic implant removal: A retrospective analysis. J Life Sci Res 2015;2:76-86.
Kadir BM, Ibraheem GH, Yakub S, Onuchukwu NS, Olawepo K, Babalola OM, et al
. Removal of orthopedic hardware: A five year review. Niger J Orthop Trauma 2013;12:113-8.
Busam ML, Robert RJ, Obremsky WT. Hardware removal: Indications and outcome. J Am Acad Orthop Surg 2006;14:113-20.
Varunjikar MD, Joshi SC, Varunjikar AM, Joshi CR. Implant removal: An unsolved challenge to the orthopedician. J Evol Med Dent Sci 2014;3:4282-6.
Jung HG, Kim JI, Park JY, Park JT, Eom JS, Lee DO, et al.
Is hardware removal recommended after ankle fracture repair? Biomed Res Int 2016;2016:5250672.
Shrestha R, Shrestha D, Dhoju D, Parajuli N, Bhandari B, Kayastha SR, et al.
Epidemiological and outcome analysis of orthopedic implants removal in Kathmandu university hospital. Kathmandu Univ Med J (KUMJ) 2013;11:139-43.
Bachoura A, Yoshida R, Lattermann C, Kamineni S. Late removal of titanium hardware from the elbow is problematic. ISRN Orthop 2012;2012:256239.
Hanson B, van der Werken C, Stengel D. Surgeons' beliefs and perceptions about removal of orthopaedic implants. BMC Musculoskelet Disord 2008;9:73.
Twaddle B. Implant removal. AO Trauma Operating Room Personnel Handbook. Davos Switzerland: AO Publishers; 2013. p. 1-15.
Reith G, Schmitz-Greven V, Hensel KO, Schneider MM, Tinschmann T, Bouillon B, et al.
Metal implant removal: Benefits and drawbacks – A patient survey. BMC Surg 2015;15:96.
Mue DD, Yongu WT, Elachi IC, Salihu MN. Surgeons' perception about removal of orthopedic implants. IOSR J Dent Med Sci 2014;13:8-13.
Hak DJ, McElvany M. Removal of broken hardware. J Am Acad Orthop Surg 2008;16:113-20.
Ogundele OJ, Ifesanya AO, Adesanya AA, Alonge TO. Removal of orthopaedic implants from patients at the university college hospital, Ibadan. Afr J Med Med Sci 2013;42:151-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]