Elsevier

Injury

Volume 39, Issue 3, March 2008, Pages 362-367
Injury

Do orthopaedic surgeons need a policy on the removal of metalwork? A descriptive national survey of practicing surgeons in the United Kingdom

https://doi.org/10.1016/j.injury.2007.10.028Get rights and content

Summary

Introduction

Routine metalwork removal, in asymptomatic patients, remains a controversial issue. Current literature emphasises the potential hazards of implant removal and the financial implications encountered from these procedures. However, there is little literature guidance and no published research on current practice.

Aim

To estimate the current state of practice of orthopaedic surgeons in the United Kingdom regarding implant removal in asymptomatic patients.

Methods

An analysis, by two independent observers, was performed on the postal questionnaire replies of 36% (500 out of 1390), randomly selected UK orthopaedic consultants.

Results

Four hundred and seven (81%) replies were received. A total of 345 (69%) were found to be suitable for analysis. The most significant results of our study (I) 92% of orthopaedic surgeons stated that they do not routinely remove metalwork in asymptomatic skeletally mature patients; (II) 60% of trauma surgeons stated that they do routinely remove metalwork in patients aged 16 years and under; (III) 87% of the practicing surgeons indicated that they believe it is reasonable to leave metalwork in for 10 years or more; (IV) only 7% of practicing trauma surgeons who replied to this questionnaire have departmental or unit policy.

Conclusion

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. Such a policy should include guidelines specific to age groups and level of surgeon who should be performing the removal procedure. Such a document would require further validated studies but would eventually serve to steer surgeons in achieving best practice.

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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