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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 31-34

Indications of implant removal: A retrospective study in a government tertiary care hospital


Department of Orthopaedics, Mandya Institute of Medical Sciences, Mandya, Karnataka, India

Date of Submission19-Nov-2021
Date of Decision17-Dec-2021
Date of Acceptance18-Dec-2021
Date of Web Publication15-Mar-2022

Correspondence Address:
G Prashanth
Department of Orthopaedics, 601 B, Doctors Quarters, Mandya Institute of Medical Sciences, Mandya-571401, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_34_21

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  Abstract 


Introduction: Metallic implant inserted for orthopedic fracture fixation may be removed for a variety of reasons. There is little consensus if such implant be removed routinely after fracture union. Hence, in our study, we would like to determine the indications for implant removal. Materials and Methods: This is a retrospective study of all cases of implant removal at the Orthopaedic Department of Mandya Institute of Medical Sciences, Mandya, Karnataka, India, from January 2019 to December 2020. Relevant information of patients were extracted and analyzed. Results: The study included 217 patients; there are 161 males and 56 females with a male-to-female ratio of 2.87. The peak age group is 16–30 years with a mean age group of 36.2 years. Distal tibia/ankle (15.66%) is the most common site for implant removal. Tibia (35.4%) is the most common bone. Plates and screws (38.7%) is the most common implant. Patients' request (31.7%) is the most common indication followed by surgeon request (25.8%), prominent hardware (21.6%), infection (17.5%), and failure (3.4%). About 37.7% of implants were removed before 12 months. Conclusion: Patients' request was the most common indication as they wanted implant to be removed and long-term effects of internal implant were not known. Surgeon request is the second most common indication, especially in the pediatric age. Prominent hardware was the third most common indication group as implants were impinging. Infection and implant failure were the other mandatory indications for implant removal.

Keywords: Implant, implant removal, orthopedic implant, patient request


How to cite this article:
Prashanth G, Mahendra Kumar K L, Shivaprakash S S, Dushyantha M C. Indications of implant removal: A retrospective study in a government tertiary care hospital. J Orthop Dis Traumatol 2022;5:31-4

How to cite this URL:
Prashanth G, Mahendra Kumar K L, Shivaprakash S S, Dushyantha M C. Indications of implant removal: A retrospective study in a government tertiary care hospital. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 May 24];5:31-4. Available from: https://www.jodt.org/text.asp?2022/5/1/31/339680




  Introduction Top


Fracture management has improved along with the advance of technology. For different bone and site of fracture, precontoured plates and nails are available. Hardware after fracture union may be detected as a foreign object by the body itself and produce reaction against it.[1] Metallic implant inserted for orthopedic fracture fixation may be removed for a variety of reasons. There is little consensus if such implant be removed routinely after fracture union.[2]

To avoid disturbances to the growing skeleton, it may be necessary to remove implants early in children. Most patients wonder when metallic hardware will be removed. Infection, nonunion, migration of the implant, deformity or refracture requiring fixation, issue of pain relief, and local irritating symptoms favor implant removal procedures. Deep late infection, metal allergy or toxicity, tumorigenicity, hardware migration, metal failure, and secondary fracture at plate ends are the concerns with retaining metal implant.[3]

The (medical) indications for surgical removal of these metal implants are not well defined and a variety of viewpoints with large differences in opinions and practices between surgeons, countries, patients, anatomical locations, and implant materials exist.[2]

Hence, in our study, we would like to determine the indications for orthopedic implant removal used for internal fixation.


  Materials and Methods Top


The study was undertaken after taking approval from institutional ethics committee and scientific committee. This is a retrospective record-based study. The patient who underwent orthopedic implant removal surgery in the study period between January 1, 2019, and December 31, 2020, a period of 2 years were included in the study. The records were obtained from operation theater register and case sheets were obtained from record section and analyzed. Two hundred and seventeen patients whose records were found and who underwent orthopedic implant removal used for internal fixation at the Department of Orthopaedics, Mandya Institute of Medical Sciences (MIMS) were included in the study. Only those patients who were admitted and operated for implant removal were included. The records were analyzed for demographic data, clinical diagnosis and treatment, type of bone with implant, indication for implant removal, duration of implant before removal, and type of implant removed.

The total number of patients is 217.

Inclusion criteria

  1. Patients who underwent implant removal in the Orthopaedic Department at MIMS, Mandya, Karnataka, India, between January 1, 2019, and December 31, 2020
  2. Implant used for internal fixation or replacement
  3. Patients whose records are obtained.


Exclusion criteria

  1. Oromaxillary and dental implants
  2. Implant used for external fixation
  3. Implant removal done without admission and outside the operation theater.


The total number of surgeries was noted in the 2-year period and the number of implants removed. This was divided into period before coronavirus lockdown and after coronavirus lockdown. The duration between January 1, 2019, and March 24, 2020, was considered before coronavirus lockdown. The sex of the patient was noted. The age was noted and divided into five groups of <15, 16–30, 31–45, 46–60, and above 60 years. The site of implant was noted. The implant removed was divided into plate and screws, interlocking intramedullary nail with screws, K wire with or without SS wire, titanium elastic nail, and screws only and bipolar.

The indication of implant removal was categorized into patient request, prominent hardware/pain, surgeon request, and infection and implant failure. Patients' request was the indication when no other absolute cause was found. Prominent hardware/pain was the indication when the implant was prominent and impinging. Surgeon request was the indication for implant removal, especially in the pediatric population. Infection was the indication when infection warranted implant removal. Implant failure was the indication when failure warranted implant removal and redoing the fixation. When there were two or more causes, the main indication for implant removal was taken.

The main implant responsible for each case was taken into account. The duration was divided into <6 months, 6–12 months, 1–2 years, and >2 years. These data were analyzed using mean, percentage, and proportions.


  Results Top


Two hundred and seventeen patients underwent implant removal during the study and constituted 11.1% of total orthopedic surgeries. One hundred and ninety-seven patients underwent implant removal before coronavirus lockdown constituting 12.23% of total orthopedic surgeries. Twenty patients underwent implant removal after coronavirus lockdown constituting 6% of total orthopedic surgeries [Table 1].
Table 1: Impact of coronavirus lockdown on implant removal

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Among 217 patients, there were 161 males and 56 females with a male-to-female ratio of 2.87 [Table 2].
Table 2: Sex relation to implant removal

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The mean age was 36.2 years. The youngest age was 4 years and oldest age was 95 years [Table 3].
Table 3: Age relation to implant removal

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Distal tibia/ankle is the most common site for implant removal. Tibia is the most common bone for implant removal [Table 4].
Table 4: Site relation to implant removal

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Plates and screws were the most common implant to be removed. Titanium elastic nail was the next most common implant. Intramedullary interlocking nails were the third most common implant followed by K wire/SS wire, screws only and bipolar were the least [Table 5].
Table 5: Type of implant relation to removal

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Patient request is the most common indication followed by surgeon request for implant removal. Prominent hardware is the third common indication followed by infection and finally implant failure [Table 6].
Table 6: Indication for implant removal

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Eighty-two (37.7%) cases of implant removal occurred during the 1st year [Table 7].
Table 7: Duration of implant before removal

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  Discussion Top


Implant removal surgery constituted around 12% of orthopedic surgeries during normal times, but after coronavirus lockdown, it was reduced to 6%. Implant removal is an elective procedure and most indications for implant removal are “relative.” They are driven by patients' complaints and symptoms. Pain, prominent material, functional impairment, possible future problems, and the patients' requests are the main examples of “relative” indications for removal.[4] Infection, broken material, avascular necrosis, intraarticular material, tendon rupture, and tenosynovitis can be considered “absolute” indications for hardware removal. Of 20 cases, 85% were due to indicated causes, 11 cases were due to infection, 5 cases were in children (surgeon request), and 1 case was due to prominent hardware. Three cases were due to patient request. Implant removal being routine elective surgery, so there was reduction during coronavirus pandemic and those who underwent implant removal during coronavirus pandemic were mainly of indicated causes especially infected implant.

About 74.2% of implant removal occurred in males in our study. Similar findings were found, one study showed a male preponderance 189 of 275 (68) patients[5] and another study showed 71 (85%) were males of 83 patients.[6] This is probably related to males being more involved in outdoor activities and consequent fractures resulting in more implant removal.

There were more patients in the productive age group. About 48% of implant removal occurred in the age group of 16–45 years. This is similar to the findings of other studies.[7],[8],[9],[10] This may be as a result of them being more active and hence more predisposed to trauma resulting in more implant removal.

Distal tibia/ankle is the most common site of implant removal. This is similar to the findings of Reith et al.[11] and Haseeb et al.,[7] Shrestha et al.,[5] Ogundele et al.,[12] and Kadir et al.[8] reported femur as the most common bone. This may be distal tibia/ankle being more prone for injury, being injured even on less velocity injuries, and also being more subcutaneous may result in impingement. These factors may result in implant removal.

Plates and screws are the most common implant removed. This is similar to the findings of Haseeb et al.,[7] Kadir et al.[8] and Onche et al.[9] However, it is at variance with the findings of Shrestha et al.[5] who reported intramedullary nail as the most common. This may be the result of plates and screws being most commonly used implants with precontoured plates and locking plates being available easily for various sites. Consequently more implant removal of plates and screws.

Patient request (31.7%) is the most common indication for the removal in this study. This is similar to the findings of Onche et al.[9] and Kuubiere et al.[10] However, is at variance with the findings of Reith et al.,[11] Haseeb et al.[7] and Ogundele et al.[12] who reported doctor's recommendation, pain, and implant failure, respectively, as the most common indication for removal. It may also be psychological factor due to the presence of the implant. The long-term effects of metallic implant are not known resulting in apprehension among patients and also readily availability of implant removal devices resulting in implant removals. Patients' request was the most common indication in which there was no other absolute indication for implant removal and was more common for plates and screws (59.4%).

Surgeon request (25.8%) was commonly seen in implants used for fracture fixation in the pediatric age group. It may be due to the fear of growth arrest in children. Titanium elastic nail (62.5%) is the common implant being removed. These set of implants were removed after fracture union and mostly within a year of insertion.

Prominent hardware was the common reason in patients with the use of implants for fixation of fracture of subcutaneous bone and used for principle of tension band wiring. K wires and SS wires caused prominence resulting in implant removals (42.5%).

Infection was the mandatory cause of implant removal and most implants were removed within the first 6 months (68.4%). Six bipolar were removed due to infection. Bipolar implantation is usually done in elderly patients with multiple comorbidities.

Seven cases of implant failure were other mandatory causes for implant removal.

With regards to the duration of implants before removal, majority of the patients had their implants removed within 12 months of insertion (37.7%). This compares favorably to published reports which indicate that most patients get their implants removed within the 1st year of insertion.[5],[13],[14] Most of these implants were used in the pediatric age group, infection, and implant failure.


  Conclusion Top


Patients' request was the most common indication as they wanted implant to be removed and long-term effects of implants were not known. Surgeon request is the second-most common indication, especially in the pediatric age group. Prominent hardware was the third most common indication as implants were impinging. Infection and implant failure were the other mandatory indications for implant removal.

Limitation is a retrospective study with limited data. Long-term and multiple studies are required to know the long-term effects of retained implant and whether routine removal of implant is necessary, especially when there is no defined indication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Girish P, Sundararajan T, Varman JM, Khader FA. Study of implant removal due to various indications in a tertiary care hospital – A retrospective study. Indian J Orthop Surg 2020;6:322-7.  Back to cited text no. 1
    
2.
Jain RK, Patel Y, Jayaswal A, Verma A. Indications for implant removal; a prospective study. Int J Res Orthop 2019;5:1-7.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
  [Full text]  
4.
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.  Back to cited text no. 4
    
5.
Shrestha R, Shrestha D, Dhoju D, Parajuli N, Bhandari B, Kayastha SR. Epidemiological and outcome analysis of orthopedic implants removal in Kathmandu University Hospital. Kathmandu Univ Med J (KUMJ) 2013;11:139-43.  Back to cited text no. 5
    
6.
Abidi SA, Umer MF, Ashraf SM, Mehdi SH, Ahmed SK, Shaikh IA, et al. Outcome of painful implant removal after fracture union. Pak J Surg 2012;28:114-21.  Back to cited text no. 6
    
7.
Haseeb M, Butt MF, Altaf T, Muzaffar K, Gupta A, Jallu A. Indications of implant removal: A study of 83 cases. Int J Health Sci (Qassim) 2017;11:1-7.  Back to cited text no. 7
    
8.
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;12:1138.  Back to cited text no. 8
    
9.
Onche II, Osagie OE, INuhu S. Removal of orthopaedic implants: Indications, outcome and economic implications. J West Afr Coll Surg 2011;1:101-12.  Back to cited text no. 9
    
10.
Kuubiere CB, Mogre V, Alhassan A. Incidence and indications for orthopedic implant removal: A retrospective analysis. J Life Sci Res 2015;2:7686.  Back to cited text no. 10
    
11.
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.  Back to cited text no. 11
    
12.
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.  Back to cited text no. 12
    
13.
Boulos A, DeFroda SF, Kleiner JE, Thomas N, Gil JA, Cruz AI Jr. Inpatient orthopaedic hardware removal in children: A cross-sectional study. J Clin Orthop Trauma 2017;8:270-5.  Back to cited text no. 13
    
14.
Rana ZA. The incidence and indications for removal of osteosynthesis devices in adult trauma patients: A retrospective study. Ann Pak Inst Med Sci 2012;8:184-7.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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