Hardware Removal:

Indications and
Expectations

Matthew L. Busam, MD* Abstract

Robert J. Esther, MD, MSc*
William T. Obremskey, MD,
MPH
*Dual first authorship
Dr. Busam is Resident, Department of
Orthopaedics and Rehabilitation,
Vanderbilt University, Nashville, TN.
Dr. Esther is Resident, Department of
Orthopaedics, University of North
Carolina, Chapel Hill, NC.
Although hardware removal is commonly done, it should not be
considered a routine procedure. The decision to remove hardware
has significant economic implications, including the costs of the
procedure as well as possible work time lost for postoperative
recovery. The clinical indications for implant removal are not well
established. There are few definitive data to guide whether implant
removal is appropriate. Implant removal may be challenging and
lead to complications, such as neurovascular injury, refracture, or
recurrence of deformity. When implants are removed for pain relief
alone, the results are unpredictable and depend on both the implant
type and its anatomic location. Current literature does not support
the routine removal of implants to protect against allergy,
carcinogenesis, or metal detection. Surgeons and patients should be
aware of appropriate indications and have realistic expectations of
the risks and benefits of implant removal.

Dr. Obremskey is Assistant Professor,
Department of Orthopaedics and
Rehabilitation, Division of Orthopaedic
Trauma, Vanderbilt University.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Busam, Dr. Esther, and Dr.
Obremskey.
Reprint requests: Dr. Obremskey,
Division of Orthopaedic Trauma,
Vanderbilt University, Medical Center
East, South Tower, Suite 4200,
Nashville, TN 37232-8774.
J Am Acad Orthop Surg 2006;14:113-
120
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.
H
ardware removal is frequently
undertaken for symptoms at-
tributed to the presence of hardware.
In addition, concerns about system-
ic and local effects of retained im-
plants have led many patients to re-
quest elective hardware removal.
Although many orthopaedic sur-
geons view the procedure as a rou-
tine part of care, it is sometimes
more challenging and prone to com-
plications than the initial surgery.
Although there is little debate
that hardware should be removed in
the setting of implant failure, infec-
tion, nonunion, and soft-tissue com-
promise, there is little consensus on
routine hardware removal in the set-
ting of healed fracture. Neither is
there consensus on whether im-
plants represent a risk for the patient
whose vocation or avocation re-
quires impact loading at that site.
Furthermore, it is not clear how long
patients should be protected from
significant loads after hardware re-
moval.
Important considerations in de-
termining whether to remove hard-
ware include the potential for com-
plications and the economic impact.
To make the best decision regarding
implant removal, the orthopaedic
surgeon must be familiar with the
potential risk of refracture or neural
injury, pain caused by implants,
metal sensitivity, carcinogenesis,
and the possibility of implant detec-
tion by security devices reported in
the orthopaedic literature.
Frequency and Cost
Although there are not extensive
data outlining occurrence of hard-
ware removal, most sources identify

Volume 14, Number 2, February 2006 113

Hardware Removal
it as a common procedure, account-
ing for approximately 5% of all or-
thopaedic procedures done in the
United States.1 In a Finnish study,
nearly all implants inserted for frac-
ture fixation (81%) were removed af-
ter fracture healing.2 Removal of the
implant accounted for 29% of elec-
tive procedures and 15% of total or-
thopaedic procedures performed at
that institution during a 7-year peri-
od, compared with a removal rate of
6% of all orthopaedic cases in Fin-
land for the duration of that study.
Despite the significant number of
hardware removals performed, there
is little published information re-
garding the full cost of the proce-
dure. In addition to the direct costs
(ie, physician and hospital fees), indi-
rect costs include patient lost work
and productivity. These costs have
not been quantified, and only a few
studies of implant removal docu-
ment patient time away from work.
One study of removal of lower ex-
tremity intramedullary nails found
that patients required a mean of 11
days of sick leave.3 Given the finite
resources available for medical care,
research is needed on the economic
costs of elective implant removal.
Additionally, there is a need for re-
search into practice variations re-
garding hardware removal in the
United States.
Peri-implant Fracture
and Refracture
Internal fracture fixation with either
intramedullary or extramedullary
implants creates a biologic environ-
ment that leads to adaptive changes
in bone, with the principal desired
effect of fracture healing. Direct frac-
ture healing does not produce frac-
ture callus; the new osseous chan-
nels form across the fracture site in
the environment of rigid internal fix-
ation, which is most commonly
achieved with compression plating.
Indirect fracture healing with callus
formation occurs in the setting of
less rigid fixation, such as intramed-
114
ullary or external fixation.
During the initial months of heal-
ing after plate fixation, some bone
mass loss is observed at the bone-
plate interface. Some authors at-
tribute this to stress shielding, in
which the plates shield the bones
from normal, functional stresses
leading to bone loss.4 Perren et al5 at-
tribute this osteopenia to the disrup-
tion of blood supply caused by con-
tact between the plate and the bone.
They showed that osteopenia was
temporary, produced even by flexible
plastic plates, and occurred less of-
ten and for a shorter time when the
vascular supply to the bone was less
disturbed. This work led to the de-
velopment of low-contact plates and
locked plates, which cause less peri-
osteal and cortical vascular disrup-
tion.
Multiple reports on implant re-
moval demonstrate lower rates of re-
fracture when implants are retained
longer, possibly further supporting
the idea that osteoporosis is a self-
limited, vascular phenomenon.
Beaupré and Csongradi6 retrospec-
tively reviewed seven studies to ex-
amine the refracture rate in 401 pa-
tients from whom 459 forearm
plates were removed after successful
union. They reported higher rates of
refracture with the use of large-
fragment dynamic compression
plates (DCPs) (21%), compared with
one-third tubular plates (0%), small-
fragment DCPs (5.6%), and semitu-
bular plates (6.6%).6 Removing a
plate before complete fracture con-
solidation increased the rate of re-
fracture.
A second area of concern is the
stress riser at the cortical defect after
screw removal. In a study of drilled
dog femurs, Brooks et al7 reported a
mean 55% reduction in energy-
absorbing capacity in the presence of
a single 2.8- or 3.6-mm drill hole. In
a cadaveric study, a 22% reduction
in compressive load to failure oc-
curred in calcanei after drilling with
a 6.0-mm pin, the size commonly
used when placing ankle-spanning
Journal of the American Academy of Orthopaedic Surgeons
external fixators for tibial pilon frac-
tures.8 However, Burstein et al9 re-
ported that radiographic evidence of
a screw hole remained after the hole
began to fill in with new bone. New
woven bone eliminated the stress-
concentrating effect of the hole
within 4 weeks in a canine model,
even though the hole was still radio-
graphically present. Using single
photon absorptiometry, Rosson et
al10 found that bone mass in young
adult men returned to close to nor-
mal 18 weeks after screw removal,
leading them to recommend avoid-
ance of contact activity for 4 months
after screw removal.
Although refracture after plate re-
moval cannot be completely pre-
vented, the available data lead to
several conclusions that can be used
to minimize the risk. (1) Achieving
complete union and remodeling be-
fore implant removal decreases the
risk of refracture. (2) Avoiding un-
necessary disruption of the vascular
supply to the bone decreases os-
teopenia. Furthermore, allowing suf-
ficient time for the vascular supply
to recover may correct the initial os-
teopenia. (3) Screw holes may re-
main as stress risers for as long as 4
months.
Refracture is rarely reported after
removal of an intramedullary im-
plant. Wolinsky et al11 reported on
551 fractures managed with reamed
intramedullary femur fixation. They
removed 131 nails and reported no
refractures. In a study of femoral
fractures in patients treated with
static interlocked stainless steel
nails, Brumback et al12 compared
111 fractures managed with retained
implants with 103 from which the
implant was removed. No fractures
occurred about the nail or locking
screws in the first group, and only
one patient refractured at the origi-
nal fracture site in the second group.
The authors concluded that stress
shielding from intramedullary nail
fixation was not clinically evident
once the fracture had united. In addi-
tion to radiographic evidence of cir-
 Matthew L. Busam, MD, et al

cumferential bridging external cal- Figure 1

lus, they recommend retaining the
implant for at least 12 months post-
operatively.12 Although union occurs
before 12 months, the additional
time allows bone remodeling for hy-
pertrophy and strength before hard-
ware removal.
Patients and physicians are often
concerned about the risk of fracture
in proximity to a retained implant.
Because implants may biomechani-
cally function as stress risers, theo-
retically they may predispose a pa-
tient to peri-implant fracture (Figure
1). However, few data exist indicat- Oblique-lateral radiograph demonstrating a peri-implant ulnar fracture caused by a
ing an increased overall fracture risk retained implant. The implant served as a stress riser.
caused by a retained implant. McKee
et al13 reported three cases of fracture
occurring at the tip of a locked hu- Figure 2
meral nail, all as a result of low-
energy trauma. These injuries were
attributed to the type of bone in
which the implants were inserted:
humeral nails end in diaphyseal
bone, whereas femoral and tibial im-
plants end in metaphyseal bone. An
analogous femoral implant is the in-
tramedullary hip screw, such as the
original Gamma nail (Stryker,
Kalamazoo, MI), a device reported to
have a risk of diaphyseal peri-
implant fracture as high as 3.1%.14
Periprosthetic fracture rates about
the hip and knee have been reported
to be as high as 2.3% and 1.2%, re-
spectively.15
Patients are often concerned
about the consequences of a new
fracture near a retained implant, but
a retained implant may be beneficial
if a second fracture occurs. Figure 2,
A, demonstrates a distal tibia frac-
ture caused by a motorcycle accident
in a patient with a retained unlocked
intramedullary nail. The tibial in-
tramedullary nail was reduced back
into the distal metaphysis and re-
locked without having to place a
new one (Figure 2, B).
There is no consensus concerning A, Lateral radiograph in a patient with a prior tibial fracture that was managed with
an intramedullary nail. A repeat injury caused the nail to break out of the anterior
the necessary amount of protection,
cortex of the distal tibia. B, The retained nail simplified treatment by allowing
weight-bearing limits, or activity
reimplantation and relocking of the nail in the distal tibia without the need to replace
modification after implant removal. the intramedullary device.
The available data seem to support

Volume 14, Number 2, February 2006 115

Hardware Removal
limiting impact and torsional loading
for up to 4 months.10 The timing of
resuming contact activity, whether
occupational or recreational, is a
common question of patients and
their families. Brumback et al,12 ac-
knowledging lack of data to support
their recommendation, allowed pa-
tients to participate in sports activ-
ity with an intramedullary nail in
place for the first athletic season af-
ter fracture healing, provided the in-
terlocking screws had been removed.
They recommended nail removal
upon completion of the first season
of competition. Evans and Evans16 re-
ported no clinical problems in 13 of
15 professional rugby players (87%)
who returned to participation with a
variety of implants in situ. However,
one player reported a new, peri-
implant fracture after having open re-
duction and internal fixation (ORIF)
with plating for a both-bone forearm
fracture. A second patient was symp-
tomatic in the area of a tension-band
fixation for a patellar fracture. The
authors recommended allowing early
return to competitive sports with re-
tained implants because the minimal
risk is offset by competitive and fi-
nancial rewards.16
The current orthopaedic litera-
ture regarding fracture risk from re-
tained implants does not support ei-
ther universal retention or removal
of hardware. There appears to be no
significant risk of peri-implant frac-
ture when hardware is left in place,
even when the patient resumes con-
tact activity. The local bone seems
to adequately remodel to correct any
deficit within 2 to 4 months after
hardware removal. The decision to
remove or retain hardware cannot be
clearly decided solely on the basis of
refracture risk; therefore, other fac-
tors ought to be considered.
Painful Hardware
Persistent pain after radiographic ev-
idence of fracture union commonly
leads to implant removal. Rates of
implant removal vary based on ana-
116
tomic location and implant selec-
tion. In one study of 55 patients un-
dergoing tension band wiring of
olecranon fractures, 61% required
revision surgery for painful hard-
ware.17 In a retrospective review of
surgically treated patellar fractures,
9 of 87 patients underwent removal
of symptomatic hardware.18
It is important to consider whether
the patient may reliably expect pain
relief after hardware removal. Brown
et al19 examined functional outcomes
after internal fixation of ankle frac-
tures and found lower pain scores and
lower scores on the Medical Out-
comes Study 36-Item Short Form for
patients with pain overlying the lat-
eral hardware. Of the 39 patients re-
porting pain, 22 underwent removal
of hardware, but only 11 (50%) of
those had improved lateral ankle
pain. These data contrast with that of
Jacobsen et al,20 who reported im-
provement after hardware removal in
75% of patients who had previously
undergone ORIF of the ankle.
Pain relief following femoral in-
tramedullary nail removal is simi-
larly unpredictable. In their retro-
spective review of 80 patients with
femoral fractures, Dodenhoff et al21
noted that 11 of 17 who underwent
implant removal experienced pain re-
lief. With tibial implants, knee pain
is a common indicator for nail re-
moval. Keating et al22 showed a 45%
rate of complete relief of knee pain
after tibial nail removal; 35% of pa-
tients experienced partial relief and
20%, no relief. In a retrospective re-
view of 169 patients, Court-Brown et
al23 noted complete pain relief in
27% and marked relief in 69% after
nail removal. However, 3.2% re-
ported worsening pain after hardware
removal. In another study, 17% of pa-
tients noted an increase in knee pain
after tibial nail removal.3 Because the
extent of pain relief varies after hard-
ware removal, the surgeon must ex-
ercise caution in attributing persis-
tent pain to retained implants. No
patient should be guaranteed com-
plete pain relief.
Journal of the American Academy of Orthopaedic Surgeons
Fixation Across Joints
Preventing implant failure is a com-
mon indication for removal. The cy-
clic loading associated with fixation
across joints often leads to fatigue
failure of metallic implants. Because
of this concern, hardware is often re-
moved from the distal tibiofibular
syndesmosis after ankle injury fixa-
tion as well as from the midfoot af-
ter fixation of Lisfranc joint injuries.
Removal versus retention of ankle
syndesmosis transfixion screws re-
mains controversial. There are no
prospective, randomized studies
comparing the results of retention
versus removal of syndesmosis
screws. Some authors routinely re-
move the implant before unrest-
ricted weight bearing,24 but DeSouza
et al25 reported no complications
from screw retention and removed
screws only from those patients who
were symptomatic on palpation or
who requested removal. Kuo et al26
followed 48 patients who underwent
ORIF for Lisfranc joint injuries for an
average of 52 months (range, 13 to
144). Twenty-eight patients required
hardware removal secondary to pain,
but the remainder demonstrated no
clinical problems with the retained
hardware.
Another concern is the immobil-
ity created by fixation across pelvic
joints. Displaced fractures of the an-
terior and posterior pelvic ring rou-
tinely require fixation spanning the
symphysis pubis and the sacroiliac
joints. Displaced pelvic fractures in
female patients have been associated
with negative effect on genitouri-
nary and reproductive function.27 To
date, no studies have been able to de-
termine the ability of a female pa-
tient to have a vaginal delivery after
undergoing pelvic fracture fixation.
However, obstetricians are generally
unwilling to have their patients at-
tempt vaginal delivery in the setting
of symphyseal or sacroiliac fixation.
This concern may be an indication
for hardware removal in young fe-
male patients.

Metal Allergy
Implants with nickel or chromium
composition cause allergic respons-
es in a small segment of the popula-
tion. A review of approximately 50
studies shows the prevalence of met-
al sensitivity in the general popula-
tion to be 10% to 15%.28 In fracture
surgery, the incidence of sensitivity
to any of the three ions in stainless
steel (ie, chromium, nickel, cobalt)
seems to be low (0.2%, 1.3%, and
1.8%, respectively).29 Because of
concerns about hypersensitivity to
any of these ions, some authors have
proposed using titanium implants in
patients known to be allergic to the
components of stainless steel.
A patient who has metal sensitiv-
ity or a nickel allergy may report
nonspecific deep generalized pain
over the area of injury and implant.
It is very difficult to differentiate
this nonspecific pain from either
pain caused by the local injury or
mechanical pain related to the im-
plant. An example of clinical infor-
mation that may suggest a metal
sensitivity is the presence of symp-
toms in a fair-skinned, red-haired
woman with a history of earlobe ir-
ritation caused by earrings that are
not 14-carat gold or caused by cos-
tume jewelry. The patient also may
be sensitive to medications and
have multiple allergies. Patients
with sensitivity or allergy will ex-
press significant relief almost im-
mediately after hardware removal.
It is not yet known whether metal
sensitivity plays a notable role in
implant failure in fracture surgery,
or whether it is merely an unusual
complication for a limited number
of patients. Additionally, it is not
known whether there is a cause-
and-effect relationship between
metal sensitivity and implant loos-
ening. Currently, there is no evi-
dence of an increased risk of implant
failure in patients with positive skin
patch testing sensitivity.30
Volume 14, Number 2, February 2006
Carcinogenicity
Because younger patients may re-
quire insertion of metal implants,
the carcinogenic risk of these im-
plants must be assessed. The associ-
ation between metallic implants and
tumors has been established in ex-
perimental animals.31 In the absence
of chronic infection, the pathogene-
sis of metal-induced carcinogenesis
may fall into two general categories:
(1) metal-ion binding to DNA and (2)
alteration of DNA and protein syn-
thesis. Because binding is reversible,
other effects are likely to be involved
in carcinogenesis. Evidence points to
reactive oxygen species created dur-
ing corrosion and their effects on
DNA and proteins as the likely sec-
ond culprit in metal-induced car-
cinogenesis.32 Although basic sci-
ence and animal studies may point
to a correlation between metallic
implants and cancer, one must be
careful not to ascribe carcinogenesis
to retained implants.
There are fewer than 30 human
cases of implant-associated tumors
in the literature. The limitations of
such case reports is that the denom-
inator is not known, making it im-
possible to quantify risk. Moreover,
it is extremely difficult to differenti-
ate correlation from causation when
trying to establish a relationship be-
tween implants and tumors. Gener-
ally, sarcomas related to implants
tend to be high-grade and occur
many years after initial placement of
the device.33 There is no consensus,
however, that implants pose a signif-
icant risk for local tumor develop-
ment. The overall risk, if any, ap-
pears to be very low.
The great majority of data related
to cancer risk and metallic implants
is found in the total joint literature.
Gillespie et al34 reported a 70% in-
crease in hematopoietic cancers over
the general population in their retro-
spective review of 1,358 total joint
patients over a 10-year period. Those
results have not been duplicated in
other studies, however. In the largest
Matthew L. Busam, MD, et al
study to date, Signorello et al35 con-
ducted a nationwide cohort study in
Sweden to examine cancer incidence
in 116,727 patients who underwent
total hip replacement from 1965
through 1994. Overall, they found
no increased risk of cancer compared
with the general population, but
they did note slight increases in
prostate cancer and melanoma as
well as a reduction in stomach can-
cer. Long-term follow-up (>15 years)
showed an increase in multiple my-
eloma and a statistically insignifi-
cant increase in bladder cancer. The
authors found no increase in bone or
connective tissue cancer in either
sex in any follow-up period.35 The
risk of carcinogenicity associated
with metallic implants appears to be
very small and does not warrant the
routine removal of hardware.
Metal Detection
In this era of heightened security at
venues ranging from airports and
sporting events to hospital emergen-
cy departments and high schools, pa-
tients frequently inquire about the
possibility that an implant will set
off a metal detector. In 1992, Pearson
and Matthews36 tested a variety of
arthroplasty and fracture implants.
They postulated that only those im-
plants with sufficiently high iron
content would be detected and that
because modern implants have lit-
tle, if any, iron, detection is unlike-
ly. In 1994, Beaupre37 corrected that
earlier assertion, explaining that
316L stainless steel is actually 60%
iron. Detection depends on an ob-
ject’s permeability (ability to tempo-
rarily disrupt a magnetic field) and
conductivity. Because modern pro-
cessing techniques limit permeabil-
ity and conductivity, the potential
for detection is very low.
The incidence of implant detec-
tion during security screening may
be low, but many orthopaedic sur-
geons provide their patients with
wallet cards containing a short
statement providing documenta-
117
Hardware Removal
Figure 3
Anteroposterior view of a retained
flexible intramedullary nail after
management of a pediatric femur
fracture.
tion of a metallic implant as well as
a telephone number that appropri-
ate authorities may use to further
confirm the presence of implanted
metal. Our experience with a joint
arthroplasty and airport travel is
that the screeners do not pay atten-
tion to an implant card. Given the
low likelihood of detection by secu-
rity measures, removing metallic
implants to avoid travel concerns is
not warranted at this time.
Pediatric Patients
The general practice at many institu-
tions is to offer removal of implants
118
to pediatric patients. The reasons
cited for removing pediatric implants
include difficulty in removing im-
plants later because of exuberant cal-
lus overlying the implant, stress
shielding, risk of corrosion, metal al-
lergy, and potential carcinogenesis.
Concern about degenerative pro-
cesses and the consequences of re-
tained hardware when addressing
later fractures also has driven the
routine removal of implants in chil-
dren. The same concerns may be ex-
pressed in adults, but adults have
fewer expected years of risk for com-
plications. No data are available con-
cerning the frequency of a retained
implant’s posing a technical problem
in the patient undergoing surgery for
a second fracture or for joint degen-
eration in that extremity.
Flexible intramedullary rods used
for treating pediatric fractures are
routinely removed after bony union.
There are no data in the literature re-
garding whether these implants
should be removed or what the con-
sequences are if they are left in
place. In a recent review of flexible
nailing of pediatric femoral frac-
tures, hardware removal was not un-
dertaken routinely.38 Removal of
flexible intramedullary nails in chil-
dren is frequently as difficult as or
more difficult than implantation and
requires larger incisions (Figure 3).
Of the two major complications in
the study by Luhmann et al,38 one
was a septic knee following implant
removal.
Removal of implants used for
treating a slipped capital femoral
epiphysis (SCFE) is also routinely
done, but not without risk
of complications. According to
Swiontkowski,39 a major complica-
tion is blood loss and surgical time
exceeding that of the original proce-
dure. He noted such difficulty in 11
of 18 cases of SCFE hardware remov-
al (61%). In another series of implant
removal in patients with SCFE, four
of seven patients (57%) undergoing
implant removal had complications,
such as breakage of the retained im-
Journal of the American Academy of Orthopaedic Surgeons
plant or intraoperative fracture.40
Kahle41 reported an overall compli-
cation rate of 13% in pediatric hard-
ware removal but a 42% rate in
SCFE hardware removal. Based on
these numbers, some surgeons ques-
tion the practice of routine hardware
removal in children. Kahle41 stated
that “there is very little clinical or
experimental evidence to support a
policy of routinely removing asymp-
tomatic internal fixation devices.”
There are no clear data in the lit-
erature regarding routine removal of
pediatric implants. Chapman states,
in the orthopaedic textbook that he
edited, “In children we advise rou-
tine removal of implants.”42 Howev-
er, Green and Swiontkowski43 do not
recommend (and even discourage)
routine removal of implants except
in the pelvis and proximal femur,
where retained hardware could be
problematic during secondary recon-
structive procedures. As with any
elective procedure, parents need to
be aware of the risks and benefits of
hardware removal in the pediatric
population.
Surgical Complications
Any surgical procedure carries inher-
ent risks, including wound compli-
cations, iatrogenic injury, and anes-
thetic complications. In their report
on implant removal in 86 patients,
Richards et al44 noted a 3% compli-
cation rate, including one refracture,
one radial nerve injury, and one he-
matoma. Sanderson et al45 reported
an overall 20% complication rate in
their series of 188 patients. The
most common complication was in-
fection, followed by nerve injury.
They recommend senior surgeon su-
pervision of forearm hardware re-
moval; unsupervised junior surgeons
produced three permanent nerve in-
juries.45 Langkamer and Ackroyd46
reported on 55 patients who had
forearm plate removal. They noted a
40% complication rate, including 4
infections, 5 poor scars, 17 nerve
problems, 1 delay in wound healing,

and 2 refractures. They recommend-
ed leaving asymptomatic hardware
in place and not delegating the pro-
cedure to inexperienced surgeons.
They reported complication rates of
13%, 60%, and 100% in cases per-
formed by experienced surgeons,
moderately experienced surgeons,
and inexperienced surgeons, respec-
tively.
Takakuwa et al47 reported on four
intraoperative fractures of the tibia
during elective removal of a slotted
intramedullary tibial nail. Given
this risk, the surgeon should consid-
er intraoperative fluoroscopy to con-
firm that no new fracture has oc-
curred. Furthermore, informing the
patient about the possible risks of
nail removal remains paramount.
Summary
Hardware removal, although a com-
mon operation, should not be under-
taken lightly and should not be a
routine procedure. Although it is
clearly indicated in some instances,
the habitual removal of implants is
not supported by the literature and
exposes the patient to unnecessary
costs and complications. Even in pa-
tients reporting implant-related
pain, removal of that implant does
not guarantee relief and may be asso-
ciated with further complications,
including infection, refracture, nerve
damage, and worsening pain. Addi-
tionally, patients may request or sur-
geons may recommend removal on
unproved grounds, such as protec-
tion from neoplasm or reduction of
stress shielding. No data suggest
that implant removal accomplishes
these objectives or that retained im-
plants increase the risk of neoplasm
or cause stress shielding. As with
any surgical procedure, it is impor-
tant to understand the expected ben-
efits from the procedure as well as to
know the inherent risks. More re-
search is needed regarding the tim-
ing and expected benefits of remov-
ing implants as well as the direct and
indirect costs of the procedure.
Volume 14, Number 2, February 2006
References
Evidence-based Medicine: There are
no level I or level II evidence-based
studies in the articles referenced.
Citation numbers printed in bold
type indicate references published
within the past 5 years.
1. Rutkow IM: Orthopaedic operations
in the United States, 1979 through
1983. J Bone Joint Surg Am 1986;68:
716-719.
2. Bostman O, Pihlajamaki H: Routine
implant removal after fracture sur-
gery: A potentially reducible consum-
er of hospital resources in trauma
units. J Trauma 1996;41:846-849.
3. Boerger TO, Patel G, Murphy JP: Is
routine removal of intramedullary
nails justified? Injury 1999;30:79-81.
4. Harkness JW, Ramsey WC, Harkness
JW: Principles of fractures and dislo-
cations, in Rockwood CA, Green DP,
Bucholz RW, Heckman JD (eds): Frac-
tures in Adults, ed 4. Philadelphia,
PA: Lippincott-Raven, 1996, vol 1, pp
3-120.
5. Perren SM, Cordey J, Rahn BA, Gauti-
er E, Schneider E: Early temporary po-
rosis of bone induced by internal fix-
ation implants: A reaction to necrosis,
not to stress protection? Clin Orthop
Relat Res 1988;232:139-151.
6. Beaupré GS, Csongradi JJ: Refracture
risk after plate removal in the forearm.
J Orthop Trauma 1996;10:87-92.
7. Brooks DB, Burstein AH, Frankel VH:
The biomechanics of torsional frac-
tures: The stress concentration effect
of a drill hole. J Bone Joint Surg Am
1970;52:507-514.
8. Juliano PJ, Yu JR, Schneider DJ, Jacobs
CR: Evaluation of fracture predilec-
tion in the calcaneus after external
fixator pin removal. J Orthop
Trauma 1997;11:430-434.
9. Burstein AH, Currey J, Frankel VH,
Heiple KG, Lunseth P, Vessely JC:
Bone strength: The effect of screw
holes. J Bone Joint Surg Am 1972;54:
1143-1156.
10. Rosson J, Murphy W, Tonge C, Shear-
er J: Healing of residual screw holes af-
ter plate removal. Injury 1991;22:
383-384.
11. Wolinsky PR, McCarty E, Shyr Y,
Johnson K: Reamed intramedullary
nailing of the femur: 551 cases.
J Trauma 1999;46:392-399.
12. Brumback RJ, Ellison TS, Poka A,
Bathon GH, Burgess AR: Intramedul-
lary nailing of femoral shaft fractures:
III. Long-term effects of static inter-
Matthew L. Busam, MD, et al
locking fixation. J Bone Joint Surg
Am 1992;74:106-112.
13. McKee MD, Pedlow FX, Cheney PJ,
Schemitsch EH: Fractures below the
end of locking humeral nails: A report
of three cases. J Orthop Trauma
1996;10:500-513.
14. Docquier PL, Manche E, Autrique JC,
Geulette B: Complications associated
with gamma nailing: A review of 439
cases. Acta Orthop Belg 2002;68:
251-257.
15. Mabrey JD, Wirth MA: Periprosthetic
fractures, in Rockwood CA, Green
DP, Bucholz RW, Heckman JD (eds):
Rockwood and Green’s Fractures in
Adults, ed 4. Philadelphia, PA:
Lippincott-Raven, 1996, vol 1, pp 539-
603.
16. Evans NA, Evans RO: Playing with
metal: Fracture implants and contact
sport. Br J Sports Med 1997;31:319-
321.
17. Romero JM, Miran A, Jensen CH:
Complications and re-operation rate
after tension-band wiring of olecra-
non fractures. J Orthop Sci 2000;5:
318-320.
18. Smith ST, Cramer KE, Karges DE,
Watson JT, Moed BR: Early complica-
tions in the operative treatment of pa-
tella fractures. J Orthop Trauma
1997;11:183-187.
19. Brown OL, Dirschl DR, Obremskey
WT: Incidence of hardware-related
pain and its effect on functional
outcomes after open reduction
and internal fixation of ankle frac-
tures. J Orthop Trauma 2001;15:271-
274.
20. Jacobsen S, de Lichtenberg MH, Jen-
sen CM, Torholm C: Removal of in-
ternal fixation—the effect on pa-
tients’ complaints: A study of 66 cases
of removal of internal fixation after
malleolar fractures. Foot Ankle 1994;
15:170-171.
21. Dodenhoff RM, Dainton JN, Hutch-
ins PM: Proximal thigh pain after fem-
oral nailing: Causes and treatment.
J Bone Joint Surg Br 1997;79:738-741.
22. Keating JF, Orfaly R, O’Brien PJ: Knee
pain after tibial nailing. J Orthop
Trauma 1997;11:10-13.
23. Court-Brown CM, Gustilo T, Shaw
AD: Knee pain after intramedullary
tibial nailing: Its incidence, etiology,
and outcome. J Orthop Trauma 1997;
11:103-105.
24. Meyer TL Jr, Kumler KW: A.S.I.F.
technique and ankle fractures. Clin
Orthop 1980;150:211-216.
25. de Souza LJ, Gustilo RB, Meyer TJ: Re-
sults of operative treatment of dis-
placed external rotation-abduction
119
Hardware Removal
fractures of the ankle. J Bone Joint
Surg Am 1985;67:1066-1073.
26. Kuo RS, Tejwani NC, DiGiovanni
CW, et al: Outcome after open reduc-
tion and internal fixation of Lisfranc
joint injuries. J Bone Joint Surg Am
2000;82:1609-1618.
27. Copeland CE, Bosse MJ, McCarthy
ML, et al: Effect of trauma and pelvic
fracture on female genitourinary, sex-
ual, and reproductive function.
J Orthop Trauma 1997;11:73-81.
28. Jacobs JJ, Goodman SB, Sumner DR,
Hallab NJ: Biologic response to ortho-
paedic implants, in Buckwalter JA,
Einhorn TA, Simon SR (eds): Ortho-
paedic Basic Science: Biology and
Biomechanics of the Musculoskeletal
System, ed 2. Rosemont, IL: American
Academy of Orthopaedic Surgeons,
2000, pp 401-426.
29. Swiontkowski MF, Agel J, Schwap-
pach J, McNair P, Welch M: Cutane-
ous metal sensitivity in patients with
orthopaedic injuries. J Orthop
Trauma 2001;15:86-89.
30. Hallab N, Merritt K, Jacobs JJ: Metal
sensitivity in patients with ortho-
paedic implants. J Bone Joint Surg
Am 2001;83:428-436.
31. Memoli VA, Urban RM, Alroy J, Gal-
ante JO: Malignant neoplasms associ-
ated with orthopedic implant materi-
120
als in rats. J Orthop Res 1986;4:346-
355.
32. Wang S, Shi X: Molecular mechanisms
of metal toxicity and carcinogenesis.
Mol Cell Biochem 2001;222:3-9.
33. Keel SB, Jaffe KA, Petur Nielsen G,
Rosenberg AE: Orthopaedic implant-
related sarcoma: A study of twelve
cases. Mod Pathol 2001;14:969-977.
34. Gillespie WJ, Frampton CM, Hender-
son RJ, Ryan PM: The incidence of can-
cer following total hip replacement.
J Bone Joint Surg Br 1988;70:539-542.
35. Signorello LB, Ye W, Fryzek JP, et al:
Nationwide study of cancer risk
among hip replacement patients in
Sweden. J Natl Cancer Inst 2001;93:
1405-1410.
36. Pearson WG, Matthews LS: Airport
detection of modern orthopaedic im-
plant metals. Clin Orthop 1992;280:
261-262.
37. Beaupre GS: Letter: Airport detection
of modern orthopedic implant metals.
Clin Orthop 1994;303:291-292.
38. Luhmann SJ, Schootman M, Schoe-
necker PL, Dobbs MB, Gordon JE:
Complications of titanium elastic
nails for pediatric femoral shaft frac-
tures. J Pediatr Orthop 2003;23:443-
447.
39. Swiontkowski MF: Slipped capital
femoral epiphysis: Complications
Journal of the American Academy of Orthopaedic Surgeons
related to internal fixation.
Orthopedics 1983;6:705-712.
40. Jago RD, Hindley CJ: The removal of
metalwork in children. Injury 1998;
29:439-441.
41. Kahle WK: The case against routine
metal removal. J Pediatr Orthop
1994;14:229-237.
42. Chapman MW: Principles of internal
and external fixation, in Chapman
MW (ed): Chapman’s Orthopaedic
Surgery, ed 3. Philadelphia, PA: Lip-
pincott Williams and Wilkins, 2001,
vol 1, pp 375-376.
43. Green NE, Swiontkowski MF: Skele-
tal Trauma in Children, ed 3. Phila-
delphia, PA: Saunders, 2003, vol 3, pp
388-398.
44. Richards RH, Palmer JD, Clarke NM:
Observations on removal of metal im-
plants. Injury 1992;23:25-28.
45. Sanderson PL, Ryan W, Turner PG:
Complications of metalwork remov-
al. Injury 1992;23:29-30.
46. Langkamer VG, Ackroyd CE: Remov-
al of forearm plates: A review of the
complications. J Bone Joint Surg Br
1990;72:601-604.
47. Takakuwa M, Funakoshi M, Ishizaki
K, Aono T, Hamaguchi H: Fracture
on removal of the ACE tibial
nail. J Bone Joint Surg Br 1997;79:
444-445.