Do orthopaedic surgeons need a policy on the removal of metalwork? A descriptive national survey of practicing surgeons in the United Kingdom
Introduction
Internal fixation in the management of fractures has increased in frequency in recent times.19 This inevitably leads to increasing numbers of patients with indwelling metallic implants. Simultaneously operations for removal of these implants have also increased.6 In a Finnish study, nearly all (81%) implants inserted for fracture fixation were eventually removed.6 In addition, concerns about local and systemic effects of retained metalwork have lead many patients to request elective hardware removal.6 Current literature highlights the risk of complications associated with metalwork removal.2, 8, 12, 16, 18, 19, 21, 22 It has been suggested in adults that these implants should not be removed unless the patient has symptoms.19 However, Sanderson et al.22 suggest that internal fixation devices are removed once a fracture has healed, especially in weight-bearing bones. Controversy continues to shroud the issue of metalwork removal and surgical practice is diverse as a consequence.
No universal agreement or clear guidelines exist with regards to removal of metalwork. In this article we evaluate the current practice of orthopaedic surgeons in the United Kingdom with regards to implant removal in asymptomatic patients, who have previously required internal fixation for limb trauma. Our aim was to ascertain the policy that surgeons were adhering to and their reasoning for such practice.
Section snippets
Methods
We wanted to estimate (I) the current state of practice of orthopaedic surgeons in the United Kingdom regarding implant removal for limb trauma in asymptomatic patients, (II) to make known any concerns with the long-term retention of metalwork, (III) to reveal any variation in routine removal rates between differing age groups and (IV) to ascertain if departmental policies existed regarding removal of metalwork.
In this study we distributed a clinical questionnaire concerning removal of
Results
We achieved an 81% response rate (407/500). Of these 69% (345/500) were deemed suitable for analysis as exclusion criteria barred patients who had not suffered from trauma in the first instance requiring their internal fixation; those who had undergone spinal procedures and the responses received from retired surgeons or those surgeons who no longer were involved with trauma patients.
In the upper limb, routine removal of metalwork was most commonly performed for internal fixation of the
Discussion
Metalwork removal is a common procedure and is increasing in frequency in trauma patients.19 Although the issue of metalwork removal remains controversial there are a number of common clinical indications for removal (Table 2). Pain is commonly cited as an indication for removal. However, following metalwork removal, pain persists in almost 50% of cases.24 Some have therefore questioned the validity of pain as a clinical indicator.5 Sanderson et al.22 found 65% of patients were listed for
Conclusion
The routine removal of metalwork following surgery for fractures remains controversial. Although potential complications and morbidity associated with such procedures are well recognised, the question of whether removal of metalwork in adults should be pursued remains unanswered. 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.
Conflict of interest
No benefits in any form have been received or shall be received from any commercial party related directly or indirectly to the subject of this article.
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