Plates and Screws After Fracture: When to Consider Removal
Key Takeaway
This article provides essential research regarding Plates and Screws After Fracture: When to Consider Removal. The removal of orthopedic plates and screws after fracture healing is decided by weighing potential benefits against surgical risks. Removal is typically recommended for pain, infection, device failure, or allergic reactions. However, this second surgery carries risks such as bleeding, new infections, or weakening of the bone. If no issues arise, plates and screws are often safely retained.
Introduction and Epidemiology
Hardware removal, formally termed implant extraction, remains one of the most frequently performed orthopedic procedures worldwide. Historically, the routine removal of internal fixation devices was standard practice, driven by theoretical concerns regarding stress shielding, long term metallurgical degradation, and the potential for late onset implant related malignancies. However, contemporary orthopedic philosophy has shifted significantly toward a symptom directed approach.
Epidemiological data suggests that implant removal accounts for approximately five to fifteen percent of all elective orthopedic operations, with significant regional variations influenced by healthcare systems and cultural expectations. The highest rates of removal are typically observed following fixation of the ankle, clavicle, and forearm. Despite its frequency, the procedure is not benign. It carries a distinct complication profile, consumes substantial healthcare resources, and presents unique technical challenges, particularly with the widespread adoption of titanium alloys and locking plate technology.
The decision to remove orthopedic hardware requires a nuanced understanding of fracture healing, implant biomechanics, and the patient specific risk benefit ratio. The contemporary orthopedic surgeon must be adept not only at the indications for removal but also at the complex surgical techniques required to extract osseointegrated, cold welded, or mechanically failed implants.
Surgical Anatomy and Biomechanics
The rationale for hardware removal, as well as the technical difficulty of the procedure, is deeply rooted in the biomechanical interaction between the implant and the host bone, alongside the specific anatomical characteristics of the operative site.
Metallurgical Properties and Implant Integration
Modern orthopedic implants are primarily fabricated from medical grade stainless steel (316L) or titanium alloys (Ti-6Al-4V). The choice of material dictates the long term biological and mechanical behavior of the hardware. Stainless steel exhibits a higher Youngs modulus (approximately 200 GPa), which is significantly stiffer than cortical bone (15 to 20 GPa). This modulus mismatch can lead to stress shielding, wherein the rigid implant unloads the underlying bone, potentially leading to osteopenia beneath the plate.
Conversely, titanium alloys possess a lower elastic modulus (approximately 110 GPa), reducing the degree of stress shielding. However, titanium is highly biocompatible and prone to extensive osseointegration. Bone frequently grows over the plate margins and directly into the screw threads. Furthermore, titanium is highly susceptible to galling, or cold welding. This phenomenon occurs when the titanium screw head mechanically locks into the titanium plate hole during insertion or physiological loading, making subsequent extraction exceptionally difficult.
Anatomical Considerations and Soft Tissue Envelopes
The anatomical location of the implant is a primary driver for symptomatic hardware. Implants placed in regions with an attenuated soft tissue envelope are far more likely to cause mechanical irritation, bursitis, and tendinopathy. High risk anatomical zones include the medial malleolus, the lateral malleolus, the olecranon, the anterior tension band of the patella, and the superior surface of the clavicle.
In these regions, the prominence of a screw head or plate margin can cause direct friction against overlying tendons or subcutaneous tissues. For instance, volar locking plates for distal radius fractures can irritate the flexor pollicis longus tendon, potentially leading to delayed rupture if not addressed. Understanding the local neurovascular anatomy is critical during the removal approach, as the original internervous planes may be obscured by dense scar tissue, placing structures like the superficial peroneal nerve or the radial nerve at significant risk during re-exploration.
Indications and Contraindications
The decision matrix for implant removal must be strictly evidence based, balancing the objective relief of symptoms against the inherent risks of a secondary surgical intervention. Routine removal in asymptomatic adult patients is generally discouraged in contemporary practice.
| Clinical Scenario | Operative Indication for Removal | Non Operative Management |
|---|---|---|
| Infection | Deep periprosthetic infection, chronic osteomyelitis, sinus tract formation. | Superficial cellulitis responding to oral antibiotics. |
| Implant Prominence | Painful bursa, tendon irritation, impending skin breakdown over hardware. | Asymptomatic palpable hardware. |
| Mechanical Failure | Broken plate or screws associated with nonunion or malunion requiring revision. | Asymptomatic broken screws in a fully healed, stable fracture. |
| Joint Penetration | Intra articular screw penetration causing cartilage damage or mechanical block. | Extra articular hardware with full range of motion. |
| Pediatric Patients | Hardware crossing open physes, plates restricting normal bone growth. | Hardware distant from physes in nearing skeletal maturity. |
| Syndesmotic Fixation | Routine removal of static syndesmotic screws prior to full weight bearing (controversial). | Retained syndesmotic screws in asymptomatic patients. |
| Deep Pelvic or Spinal Fixation | Rarely indicated unless catastrophic failure or deep chronic infection occurs. | Routine retention due to extreme surgical morbidity of removal. |
Pre Operative Planning and Patient Positioning
Thorough preoperative planning is the cornerstone of successful hardware removal. The surgeon must never underestimate the potential difficulty of extracting seemingly straightforward implants.
Preoperative Radiographic Evaluation
Recent, high quality orthogonal radiographs are mandatory. The surgeon must confirm solid clinical and radiographic union of the fracture before considering removal, unless the removal is part of a revision for nonunion. The radiographs must be scrutinized to identify the exact type of implant, the manufacturer, the number of screws, and the presence of any previously broken or bent hardware.
Equipment and Instrumentation
The operative theater must be equipped with the specific extraction instruments corresponding to the original implant. Identifying the screw head recess (hexagonal, star drive, cruciate) is essential. However, because specialized screwdrivers may fail, a universal broken screw extraction set must be available in the room before the incision is made. This set should include:
* Sharp conical extraction screws with reverse cutting threads.
* Hollow reamers or trephines sized to the core diameter of the screws.
* Carbide drill bits capable of drilling through titanium and stainless steel.
* High speed burrs and metal cutting wheels.
* Gouge forceps and heavy needle nosed pliers.
Patient Positioning
Patient positioning mirrors the original surgical approach. A radiolucent table is required, and intraoperative fluoroscopy must be readily available to locate buried hardware or confirm the complete extraction of broken screw fragments. A pneumatic tourniquet is highly recommended for extremity hardware removal to ensure a bloodless field, which is critical for identifying small screw heads obscured by fibrous tissue or heterotopic ossification.
Detailed Surgical Approach and Technique
The execution of hardware removal requires meticulous soft tissue handling, precise identification of the implant, and a systematic approach to extraction.
Soft Tissue Dissection and Exposure
The previous surgical scar should be utilized. If the scar is hypertrophic or widened, an elliptical excision of the old scar can be performed to improve the final cosmetic result. Dissection must proceed cautiously through the subcutaneous tissues, as normal anatomical planes are frequently obliterated by dense, avascular scar tissue.
The surgeon must identify and protect superficial nerves that may be tethered to the scar. Once the deep fascia is incised, the hardware is often encased in a thick pseudocapsule. This fibrous layer must be sharply excised over the plate. Periosteal elevators are used to define the margins of the plate. It is imperative to completely clear the soft tissue and any bony overgrowth from the screw heads. Even a millimeter of retained fibrous tissue in the screw recess will prevent the screwdriver from fully seating, drastically increasing the risk of stripping the screw head. A sharp dental pick or a fine curette is highly effective for clearing the screw recess.
Standard Hardware Extraction Protocols
Once the screw heads are meticulously cleared, the appropriate screwdriver is engaged. The surgeon must ensure the driver is perfectly collinear with the long axis of the screw. Axial pressure is applied to seat the driver firmly before applying rotational torque.
For locking plates, it is advisable to loosen all locking screws slightly before completely removing any single screw. This prevents the plate from rotating or shifting, which can bind the final remaining screws in their locking threads. If a screw demonstrates significant resistance, alternating between slight forward (clockwise) and backward (counterclockwise) rotation can help break the osseous integration along the screw threads.
Management of the Stripped Screw Head
Stripping the recess of a screw head is a common intraoperative complication, particularly with titanium locking screws. When the standard driver fails, the surgeon must escalate through a systematic salvage algorithm:
1. Re-clear and Re-seat: Ensure no debris is preventing full engagement. Sometimes, a slightly larger driver or a different geometry (e.g., a star drive in a stripped hex hole) can gain enough purchase.
2. Conical Extraction Screw: A reverse threaded conical extraction screw is driven into the stripped recess. As it is turned counterclockwise, the left handed threads bite into the damaged recess, eventually locking in place and transmitting torque to back the screw out.
3. Screw Head Drilling: If the extraction screw fails, the screw head must be drilled off to disengage the plate. A carbide drill bit matching the core diameter of the screw is used to drill through the head until it separates from the shaft. Once all heads are removed, the plate can be lifted off. The remaining screw shafts protruding from the bone can then be grasped with heavy pliers or a specialized chuck and backed out.
Management of the Broken Screw
Screws that are broken below the surface of the cortex present a significant challenge. If the broken screw is asymptomatic and deeply buried, it is often most prudent to leave it in situ, documenting its presence.
If removal is mandatory (e.g., in the setting of infection or to clear the path for revision fixation), a hollow reamer or trephine is utilized. The trephine is placed over the broken screw shaft and advanced over a wire or under fluoroscopic guidance, cutting a cylindrical core of bone around the screw. Once the trephine has advanced sufficiently, the screw and the surrounding bone core are extracted together. This technique leaves a significant cortical defect and must be used judiciously.
Complications and Management
Hardware removal is associated with a distinct set of complications. Thorough preoperative counseling is required to manage patient expectations, and the surgeon must be prepared to manage these intraoperative and postoperative challenges.
| Complication | Estimated Incidence | Etiology and Risk Factors | Salvage and Management Strategies |
|---|---|---|---|
| Inability to Remove Implant | 5 to 10 Percent | Cold welding of titanium, stripped screw heads, deeply buried broken screws. | Utilize universal extraction set. If extraction fails and hardware is asymptomatic, leave retained fragments and burr flush with cortex. Document thoroughly. |
| Iatrogenic Fracture | 1 to 3 Percent | Excessive torque during removal, aggressive use of osteotomes, large trephine defects. | Immediate intraoperative recognition via fluoroscopy. Proceed to revision Open Reduction and Internal Fixation (ORIF) with new hardware bypassing the defect. |
| Postoperative Refracture | 2 to 5 Percent | Stress risers from empty screw holes, premature return to unprotected weight bearing. | Treat as a new fracture. Often requires surgical stabilization depending on displacement and anatomical location. |
| Surgical Site Infection | 2 to 10 Percent | Poor soft tissue envelope, prolonged operative time, hematoma formation in dead space. | Aggressive irrigation and debridement, targeted culture specific antibiotic therapy. Leave wound open if necessary. |
| Nerve Injury | 1 to 5 Percent | Scar tissue tethering, altered anatomy obscuring internervous planes during exposure. | Meticulous dissection. If transected, primary microsurgical repair. If neuropraxia, observation and neuropathic pain management. |
| Hematoma | 3 to 8 Percent | Dead space left by plate removal, inadequate hemostasis. | Meticulous hemostasis prior to closure. Consider closed suction drainage for large dead spaces. Compressive dressings. |
Post Operative Rehabilitation Protocols
The postoperative rehabilitation protocol following hardware removal must account for the temporary biomechanical vulnerability of the bone. The removal of a plate and screws leaves behind cortical defects that act as significant stress risers.
Biomechanics of the Empty Screw Hole
From a biomechanical perspective, an empty screw hole represents a critical stress concentration factor. Experimental data demonstrates that a single cortical hole can reduce the torsional strength of a long bone by up to fifty percent. The bone remains structurally compromised until the defect undergoes the process of intramembranous ossification and subsequent remodeling.
Woven bone typically fills the empty screw tract within four to six weeks, providing initial mechanical support. However, the complete remodeling of this woven bone into organized, load bearing osteons can take twelve weeks or longer.
Weight Bearing and Activity Modification
Due to the risk of postoperative refracture through these stress risers, rehabilitation must be carefully phased.
* Immediate Postoperative Phase (0 to 2 weeks): Focus is on wound healing and edema control. For lower extremity hardware removal, patients are typically restricted to partial or touch down weight bearing with assistive devices. Range of motion exercises for adjacent joints are initiated immediately to prevent stiffness.
* Intermediate Phase (2 to 6 weeks): Weight bearing is progressively advanced based on radiographic evidence of early bone filling and clinical absence of pain. Torsional loads and high impact activities must be strictly avoided.
* Late Phase (6 to 12 weeks and beyond): Gradual return to full activities, including sports, is permitted once the patient is pain free and the cortical defects show substantial radiographic consolidation. High level athletes may require functional bracing during the initial return to play.
Summary of Key Literature and Guidelines
The academic consensus regarding hardware removal has evolved, heavily influenced by large scale retrospective reviews and prospective trials evaluating patient outcomes and cost effectiveness.
Current guidelines from major orthopedic organizations, including the AO Foundation, emphasize that routine removal of asymptomatic hardware is not indicated. The literature demonstrates that while symptomatic hardware removal yields high patient satisfaction rates (often exceeding eighty percent improvement in localized pain), up to twenty percent of patients may experience no change or an exacerbation of symptoms following removal.
Specific attention has been given to syndesmotic screw removal. Recent prospective randomized trials (such as the SYNDOC trial) have challenged the historical dogma of routine syndesmotic screw removal prior to weight bearing. The literature increasingly supports retaining these screws unless they become symptomatic or cause mechanical restriction, as routine removal exposes the patient to unnecessary surgical risks without demonstrating definitive long term functional superiority.
In conclusion, implant removal is a complex surgical intervention requiring rigorous preoperative planning, advanced technical proficiency in extraction techniques, and a deep understanding of bone biomechanics. The decision to proceed must be highly individualized, carefully weighing the objective clinical indications against the documented risks of iatrogenic injury and postoperative refracture.
