The use of internal fixation, such as plates, screws, rods, and pins, is a common technique in orthopedic surgery to stabilize fractured bones or correct deformities, a process known as Open Reduction Internal Fixation (ORIF). These devices temporarily hold the bone fragments in correct alignment, allowing the body’s natural healing process to create a solid union. The central question for many patients is whether this hardware must be removed once the bone has fully healed. The decision to remove or retain the hardware is highly individualized and is determined by a thorough medical assessment of the patient’s specific circumstances.
Factors Determining Hardware Retention
Modern orthopedics often favors retaining plates and screws if they are not causing problems. Contemporary fixation devices, typically made from biocompatible materials like titanium or surgical stainless steel, are designed to remain in the body indefinitely. Retaining the hardware avoids the inherent risks and expense associated with a second surgical procedure.
The anatomical location significantly influences the retention decision. Hardware situated deep within muscle tissue or in non-weight-bearing bones is frequently left untouched, as it is unlikely to interfere with function or cause pain. Conversely, superficial hardware, such as near the ankle, collarbone, or wrist, is more prone to soft tissue irritation and is removed more often.
Patient-specific factors, including age and overall health, also play a role. For older patients, the risks of a second surgery, including complications from anesthesia or prolonged recovery, often outweigh the benefits of removing asymptomatic hardware. The complexity of the initial surgery is also considered, as a challenging removal procedure with a high risk of nerve damage may favor retention.
Specific Reasons for Hardware Removal
Specific medical indications often necessitate secondary surgery for hardware removal. Pain or discomfort is the most common reason, often resulting from the implant’s prominence or irritation of surrounding soft tissues. For instance, a screw head might rub against a tendon or be easily palpable under thin skin, causing bursitis or localized tenderness.
Infection represents a definitive and urgent reason for removal. Bacteria can colonize the implant surface, forming a protective biofilm that shields them from the immune system and antibiotics. The infection often cannot be cleared until the foreign material is taken out. Both acute and chronic infections require prompt surgical intervention, often involving antibiotic treatment alongside hardware extraction.
Functional interference is another clear indication for removal, especially when the hardware restricts joint movement or impedes growth. In children and adolescents, plates and screws near growth plates are routinely removed to prevent growth abnormalities. For adults, hardware that bridges a joint may limit the full range of motion, and its removal is necessary to restore optimal function.
Although rare, a metal sensitivity or allergic reaction to the implant material (typically nickel or cobalt) is a definitive reason for removal. Symptoms may include chronic skin inflammation, persistent pain, or poorly healing wounds. Furthermore, hardware failure, such as breaking or loosening, requires removal, as it loses stability and can cause pain.
The Timing and Procedure of Removal
Hardware removal surgery (HWR) is generally elective unless there is an urgent complication, such as a deep infection. The consensus is to wait until the underlying bone has achieved complete structural healing, typically taking between 12 and 18 months depending on the fracture’s complexity. Removing the implant too early, before the bone has fully remodeled, significantly increases the risk of a refracture through the screw holes or at the plate site.
The removal procedure is often shorter than the initial fixation surgery, though it carries its own risks. The surgeon usually utilizes the original incision, or a slightly modified one, to access the embedded hardware. Specialized instruments are used to unscrew and extract the plates and screws, which can be challenging if dense scar tissue has formed around the implant.
Potential complications of HWR include the risk of nerve or blood vessel damage, which can be heightened due to altered anatomy and scarring from the initial injury. Post-removal, patients face a temporary risk of refracture, particularly in the weeks following the surgery, until the bone fills the empty screw holes. Recovery is typically less intensive than the initial healing period, though limited weight-bearing or activity restrictions may be necessary for several weeks to mitigate this risk.