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Routine Removal of Orthopaedic Implants in Pediatric Trauma Patients With Fracture Union: Who, When, and Why
Stephanie Ihnow1, Brittany Raymond, MaryBeth Horodyski
1Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL.
Insights
Routine removal of pediatric orthopedic implants after fracture union varies widely by implant type and location. Surgeons are less likely to remove implants in older children, with minimal consensus on the reasons for removal.
Area of Science:
- Orthopaedic surgery
- Pediatric trauma
- Implant removal
Background:
- Routine removal of metallic implants in pediatric fracture treatment is controversial.
- Limited randomized trials exist to guide decisions on implant retention versus removal.
- Previous studies explored general preferences but lacked specifics on timing, location, and patient age.
Purpose of the Study:
- To survey members of the Pediatric Orthopaedic Society of North America (POSNA) regarding their practices for routine removal of orthopaedic implants after fracture union.
- To gather data on specific factors influencing implant removal decisions, including patient age, implant type, and timing.
Main Methods:
- An IRB-approved online survey was distributed to POSNA members.
- The questionnaire covered demographics, implant removal practices based on patient age and time since implantation, reasons for removal, and common complications.
- Data from 285 POSNA members were analyzed.
Main Results:
- Flexible nails were most frequently removed (84.6%-90.8%), while clavicle plates and screws were least likely (31.6%).
- Implant removal likelihood decreased in patients older than nine years.
- Upper extremity implants were removed earlier (7-9 months) than lower extremity implants (10-12 months).
Conclusions:
- Routine implant removal rates in pediatric trauma patients vary significantly, from over 90% for flexible nails to 31.6% for clavicle plates.
- Implant removal timing ranges from 7 to 12 months post-implantation, with less frequent removal in older children.
- There is a lack of consensus among surgeons regarding the rationale for routine implant removal.
Purpose:
While the indications and options expand for treatment of pediatric fractures with metallic implants, routine removal of implants remains controversial. There is a paucity of randomized prospective trials to determine the risk of retention versus removal. Prior studies provided insight into the preferences of POSNA members versus their nonpediatric counterparts; however, they did not capture specifics regarding timing, anatomic location, implant type, or patient age. This study aims to report POSNA members' practice habits regarding the routine removal of orthopaedic implants after fracture union.
Methods:
This is an IRB-approved online survey of POSNA members regarding the routine removal of orthopaedic trauma implants after fracture union. The questionnaire consisted of 6 parts: demographics, implant removal with consideration of patient age and time since implantation, the most common reason for removal, the most common complications of removal, and a comment section.
Results:
Two hundred eighty-five POSNA members responded to at least 1 implant-related question. Flexible nails were the most commonly removed implants (90.8% for the forearm, 87.3% for the femur, 86.3% for the tibia, and 84.6% for the humerus), followed by femur plates and screws (79.9%). The least likely implants to be routinely removed were clavicle plates and screws (31.6%), femur rigid nails (32.6%), and tibial tubercle screws (37.1%). There was a lower likelihood of implant removal in patients older than nine. Upper extremity implants tended to be removed earlier than lower extremity implants (between 7 and 9 mo vs. 10 and 12 mo postimplantation). The most cited reasons for removal included routine practice (mean 43%) and symptomatic hardware (mean 32%), while the least selected reason was evidence-based research (mean 10%).
Conclusions:
Rates of routine implant removal in pediatric trauma patients after fracture union range from 90.8% for flexible forearm nails to 31.6% for clavicle plates and screws. Removal typically occurs between 7 and 12 months postimplantation. As patients age, surgeons are less inclined to remove implants. There was minimal consensus on the rationale for routine removal.
Level Of Evidence:
Level V.
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