Implant Removal in Orthopaedics

Definition

Classification of Implants Removed

Indications for Implant Removal

1. Absolute (Mandatory) Indications

• Deep infection around metallic hardware is a major absolute indication
• Biofilm formation on implant surfaces makes eradication of infection impossible without removal
• For acute infections where bone union has NOT yet occurred, irrigation and debridement with retention may be attempted
• Once union is confirmed, the implant should be removed
• Intramedullary nails with peri-implant infection: nail removal, reaming, and placement of antibiotic-impregnated cement rods are performed to eradicate infection (Rockwood & Green's, p.2860)

• A broken intramedullary nail or plate indicates implant fatigue, usually at the non-union site, transitional zones, or interlocking screw holes
• Broken screws must be removed before re-nailing or replating
• Broken IMN removal techniques: extraction bolt / conical bolt threaded into nail; using a long hook down the cannulated portion; stacking multiple guidewires for interference fit; small cortical window approach from the far end (Rockwood & Green's, p.2860)

• Migrating K-wires from the shoulder, wrist, or hip can penetrate vital structures (lung, vessels, spinal canal)
• Must be removed urgently

• Prominent hardware causes persistent skin irritation, bursitis, or wound breakdown
• Subcutaneous hardware (e.g., ulnar plate, clavicle plate, K-wires at the elbow) is particularly symptomatic because there is minimal muscle coverage
• Ulnar plates are at highest risk because the bone is subcutaneous; plates should be placed on the dorsal or volar surface to allow some muscle coverage (Rockwood & Green's, p.415)

• Misplaced screws penetrating articular cartilage (e.g., ankle, knee, hip)
• Hardware impinging on tendons or nerves

• Implants crossing physeal plates can cause premature physeal arrest and angular deformity
• Must be removed before significant growth disturbance occurs

• A sinus tract with purulent discharge implies implant involvement - this is an absolute indication for implant removal (Firestein & Kelley's Textbook of Rheumatology)

2. Relative Indications

• Patients with recurrent deep pain at the surgical site, especially in cold weather, related to hardware presence
• Removal should only be performed after weighing risks

• Most common reason for elective removal after fracture healing
• Discomfort, restriction of movement, palpable/visible hardware

• Hardware removal before joint arthroplasty, osteotomy, or revision surgery in the same region
• Plated clavicle before shoulder arthroplasty; plated pelvis before total hip arthroplasty

• Implant removal + re-fixation with fresh bone grafting
• Broken plates at non-union site

• Syndesmotic screws in ankle fractures are often removed at 8-12 weeks to restore syndesmotic motion before weight-bearing, though suture buttons may not require removal

3. Controversial / Prophylactic Indications

• Routine removal in patients under 16 years is advocated by ~60% of surgeons (to accommodate bone growth and remodeling)
• Routine removal in adults aged 16-35 years: supported by only ~12% of surgeons
• Routine removal in patients over 35 years: only ~3% of surgeons advocate this
• Cosmetically disturbing hardware in subcutaneous locations

Timing of Implant Removal

• Key principle: Hardware removal from the forearm should be delayed by at least 12-18 months to allow adequate remodeling and reduce refracture risk. Protective external support (splint/brace) for 4-6 weeks post-removal is recommended (Rockwood & Green's, p.415)
• Implant removal should only be considered once fracture union is radiologically confirmed

Contraindications

• Patient medically unfit for surgery
• Implant deeply embedded with high risk of neurovascular injury on extraction
• Asymptomatic implants in elderly patients (risk-benefit unfavorable)
• Unconfirmed fracture union
• Active anticoagulation without proper bridging plan

Surgical Technique - General Principles

1. Pre-operative planning: Identify the implant system and have the appropriate extraction set (matching screwdrivers, extraction bolts, conical bolts, carbide-tipped drill bits)
2. Imaging: Fluoroscopy should be available intraoperatively
3. Expose the implant adequately: Debride adherent soft tissue and bone overlying the implant-bone interface
4. Screw extraction: Use the correct driver to engage the screw head fully; use a cannulated drill to clear bone overgrowth from screw heads; for stripped screw heads - use a trephine, screw extractor, reverse torque device, or a carbide burr to cut a new slot
5. Cold welding: Titanium screws in titanium plates are prone to cold welding; use an anti-seize agent during insertion to prevent this at index surgery
6. Broken screw removal: Use hollow mill drill over the screw, then reverse-torque extractor; leave if asymptomatic and deeply buried

Specific Techniques

• Standard approach over previous incision
• Remove screws before the plate
• If screws are stripped: carbide-tipped drill to remove head, or trephine around the screw and leave the shaft if not prominent

• Access the nail at the insertion site (antegrade/retrograde)
• Remove end cap, insert guidewire
• Attach extraction bolt / handle to nail
• Back-slap extractor to disengage nail
• Broken nail: conical bolt method; hook technique; cortical window method; stacking guidewires for interference fit

• Usually done in OPD or under local anesthesia
• Cut wire flush with skin if buried; use wire pulling pliers

• More complex - requires full exposure
• Debride bone-implant interface with fine chisels and osteotomes
• For total ankle arthroplasty: disengage polyethylene liner first, then remove tibial and talar components with chisels; care to avoid malleolar fracture (Campbell's Operative Orthopaedics, p.3752-3768)

Complications of Implant Removal

1. Refracture (Most Important Complication)

• Overall rate: up to 18-22% for forearm plates
• Mechanisms:
  • Stress riser effect of empty screw holes: empty screw holes act as stress concentration points
  • Stress shielding: the underlying cortex becomes osteoporotic under the plate due to stress shielding during the period of fixation
  • Cortical defect less than 10% of bone diameter: no change in torsional strength
  • Defect 10%-20% diameter: 34% drop in torsional strength
  • Defects >20%: linear further decrease in strength
  • Unicortical defect reduces torsional strength by 22%; bicortical defect by 26% (Rockwood & Green's, p.424-428)
• Sites: through the original fracture site OR through empty screw holes
• Early series with 4.5-mm plates reported refracture rates of 22%; later series with 3.5-mm compression plates showed lower rates
• Prevention: delay removal by 12-18 months; use a protective splint/brace for 4-6 weeks after removal; avoid torsional activities for 3-6 months

2. Infection

• Post-removal wound infection reported in up to 21% of cases
• Risk increases with deep dissection, lengthy surgical time, and poor tissue handling

3. Nerve Injury

• Particularly at risk: radial nerve (in posterior forearm), superficial peroneal nerve (lateral ankle), sural nerve (posterior ankle)
• Reported in up to 8-21% of forearm plate removals (Rockwood & Green's, p.431)

4. Vascular Injury

• Rare but serious; relevant when implants are adjacent to major vessels (e.g., pelvic fixation near iliac vessels)

5. Retained Hardware / Incomplete Removal

• Stripped screws, broken drill bits, fragment of broken nail
• Most frequent complication in large series; may be asymptomatic and left in situ if deeply buried and not causing problems

6. Hematoma / Wound Complications

• Wound dehiscence, seroma, hematoma

7. Prolonged Disability

• Hospital stay may range from 3 to 168 hours; average absence from work: 3.4 weeks (Rockwood & Green's, p.431)

8. Anesthetic Risks

• General anesthesia or regional anesthesia complications

9. Peri-implant Fracture (Intraoperative)

• Occurs especially during forceful extraction of a well-ingrown implant
• Aggressive use of osteotomes during prosthesis removal can cause malleolar fractures during ankle arthroplasty revision

Considerations by Anatomical Region

Implant Removal in Special Situations

Infection-Related Removal

• For periprosthetic joint infection: one-stage or two-stage revision
• For fracture-fixation infection: removal + antibiotic cement spacer + re-fixation after infection control
• Biofilm necessitates hardware removal as antibiotics alone cannot penetrate biofilm

Broken Nail (Intramedullary)

• Most common site of nail failure: non-union site, transitional zones, interlocking holes
• Removal techniques as described above
• Filling interlocking holes with screws may reduce stress concentration

Pediatric Considerations

• ~60% of surgeons recommend routine removal in children under 16
• Implants crossing the physis: mandatory removal
• K-wires: 3-6 weeks; flexible IMN: 6-12 months after union
• Growth implications, remodeling potential, and risk of growth arrest must guide timing

Post-Operative Care After Implant Removal

1. Protective splinting / bracing for 4-6 weeks (especially forearm, tibia)
2. Gradual return to weight-bearing / activity
3. Avoid contact sports and torsional activities for 3-6 months
4. Radiological follow-up at 6 weeks to assess for refracture
5. Wound care and monitoring for infection

Economic Considerations

• Implant removal carries significant economic burden: revision surgeries, prolonged hospitalization, and work absenteeism
• Particularly significant in low-income countries
• Only 7% of hospital units have a formal guideline on implant removal, highlighting variation in practice

Current Evidence & Guidelines

• The JAAOS 2022 review found a 10% overall complication rate from a pooled review of 871 patients across 10 case series; reported complications included fracture, infection, hematoma, wound dehiscence, and retained hardware
• The International Orthopaedics 2025 review notes that implant removal is "far more than a resident's simple task" - requiring thorough pre-operative planning, the appropriate extraction instruments, and experienced surgical handling
• Evidence-based literature on the expected improvement of symptoms after removal (especially in the upper extremity) remains limited and mostly retrospective

Summary

• The nature and severity of the indication (absolute vs. relative)
• The timing (adequate fracture union, minimum 12-18 months for forearm plates)
• The risks, particularly refracture, nerve injury, and infection
• The patient's age, activity level, and overall health

• Rockwood and Green's Fractures in Adults, 10th ed. 2025 - "Implant Removal and Refracture" (forearm chapter, p.415-431); "Hardware Removal and Fracture Risk" (p.424-428); "Broken Nails" (p.2860)
• Campbell's Operative Orthopaedics, 15th ed. 2026 - "Implant Removal" (total ankle revision chapter, p.3752); "Fixation and Implant Removal" (ankle syndesmosis chapter)
• International Orthopaedics 2025 - Implant removal review
• JAAOS Global 2022 - Indications and risks of implant removal

Anterior (Henry's) Approach to the Radial Shaft

Introduction / Overview

Indications

• Fractures of the radial shaft (ORIF)
• Galeazzi fracture-dislocation (radial shaft fracture + distal radioulnar joint disruption)
• Distal radius fractures (volar plating)
• Radial osteotomy (malunion correction)
• Tumours or biopsy of the radial shaft
• Compartment syndrome decompression (volar forearm)
• Exploration/repair of radial artery

Internervous Plane

Position

• Patient supine
• Arm abducted on a hand/arm table
• Forearm supinated (palm facing upward)

Fig. 42-25A,B,C - Patient positioning supine with the forearm supinated on a hand table. The incision runs from the lateral aspect of the distal biceps tendon to the radial styloid (Rockwood & Green's, p.1789)

Incision

• A straight or gently curved incision is drawn along a line connecting the lateral aspect of the biceps tendon proximally to the radial styloid distally
• This places the incision along the ulnar border of the brachioradialis
• The incision can be centered over the fracture site when only partial exposure is needed
• The skin and subcutaneous fat are incised and the deep fascia is identified

Superficial Dissection

• Interval between brachioradialis (lateral) and pronator teres (medial)

• Interval between brachioradialis (lateral) and flexor carpi radialis (medial)

Fig. 42-25D - Interval between brachioradialis and FCR identified, with radial artery visible on the medial aspect (Rockwood & Green's, p.1790)

• In the proximal and middle third, the radial artery and its venae comitantes run under brachioradialis, between FCR and brachioradialis
• In the distal third, the radial artery assumes a position between FCR and brachioradialis
• To allow ulnar retraction of the radial artery with FCR: several vascular branches from the radial artery to brachioradialis must be identified and ligated or cauterized

• The superficial sensory (cutaneous) branch of the radial nerve runs on the undersurface of brachioradialis, lateral to the radial vascular bundle
• It is retracted laterally along with brachioradialis - never cut

• The terminal branch of the musculocutaneous nerve, running along the lateral forearm, should be identified and protected at the proximal end of the incision

Deep Dissection - By Level

• Pronator quadratus (PQ) - distal third
• Flexor digitorum superficialis (FDS) - middle third
• Pronator teres (PT) - middle third
• Supinator - proximal third

Fig. 42-25I - Deep dissection: periosteal incision with retractors demonstrating the pronator teres insertion and supinator proximally. Forearm supination pushes the PIN posteriorly away from the surgical field (Rockwood & Green's, p.1793)

Proximal Third - Supinator

• To expose the proximal radial shaft, the supinator muscle must be released from its radial origin
• The posterior interosseous nerve (PIN) runs within the substance of supinator
• Critical step: fully supinate the forearm to rotate the PIN into a posterior and ulnar position, away from the surgical field. Retraction around the radial neck must be avoided
• The supinator is then elevated subperiosteally from its radial origin
• If access to the very proximal radius / radial head and neck is needed, the bicipital bursa is incised lateral to the distal biceps tendon - this avoids the brachial artery and its bifurcation (located medial to the tendon)
• Leash of Henry: the radial recurrent artery (branch of radial artery) and its accompanying veins must be ligated to allow medial retraction of the proximal radial artery and access to the proximal radius

Middle Third - Pronator Teres & FDS

• Pronate the forearm to bring the pronator teres insertion into view on the lateral aspect of the radius
• The radial origins of PT and FDS (distal to the supinator) are incised subperiosteally
• Complete detachment of PT should be avoided where possible - preserve the distal ulnar attachment

Distal Third - Pronator Quadratus

• The flexor pollicis longus (FPL) is swept ulnarly to expose the underlying PQ
• Supinate the forearm to rotate the PQ into view
• PQ is released from its radial origin and reflected ulnarly
• The distal border of PQ is sharply incised along the watershed line (just proximal to the volar wrist capsule) to allow complete elevation
• The distal radius can alternatively be approached through a window medial to the radial artery through the floor of the FCR tendon sheath

Summary of Forearm Positions During Deep Dissection

Intraoperative photo

Intraoperative view of the Henry anterior approach - ORIF of a Galeazzi fracture with a volar radial plate in position

Structures at Risk and How to Protect Them

Advantages of the Anterior Approach

1. True internervous plane (radial / median) - safe, reproducible
2. Extensile - entire radius from bicipital tuberosity to radial styloid accessible
3. Excellent for distal radius volar plating (FCR approach variant)
4. Lower risk of tendon irritation compared to dorsal (Thompson) approach
5. Radial artery is identifiable as a reliable landmark throughout
6. Forearm pronation/supination can be used to improve access at each level

Disadvantages / Limitations

• Proximal radius (radial head, proximal neck) access is limited
• PIN at risk during proximal exposure if supination not maintained
• Radial artery must be mobilized and protected throughout
• Not ideal when combined dorsal approach is needed

Closure

• Subperiosteal muscles (supinator, PT, FDS, FPL, PQ) are reapproximated to bone using absorbable sutures through drill holes or bone anchors, or directly to periosteum
• Deep fascia and subcutaneous tissues closed in layers
• Skin closure

• Rockwood and Green's Fractures in Adults, 10th ed. 2025 - "Volar Approach of Henry," Figs. 42-25A through K (p.1787-1794)
• Miller's Review of Orthopaedics, 9th ed. - "Anterior (Henry) Approach," Surgical Approaches to the Forearm (p.171-172)