The Most Difficult Orthopedic Surgery

hip fracture plate
Metal plates and screws are often used to repair broken bones.. 3D Clinic / Getty Images

While removing old hardware implanted in the body may seem straightforward, it can be one of the more challenging orthopedic procedures.  In fact, many orthopedic surgeons describe hardware removal to new trainees and residents to be "The Most Difficult Procedure."

In reality, hardware removal is probably not the most difficult surgery--complex spine surgery, correction of congenital deformities, reconstruction of damaged joints--are all difficult, time-consuming surgical procedures.

  However, hardware removal surgery often lulls the unsuspecting surgeon, and patient, into thinking the surgery will be quick and easy.  While it may turn out to be simple, hardware removal surgery has a propensity to be much more challenging the anticipated. 

Why Remove Hardware?

This is an excellent question, because in the vast majority of patients with metal in the body, there is no need to remove the metal.  Metal implants are generally designed to remain in place forever.  There are some circumstances where metal should be removed.  These include temporary metal devices only intended to be in the body for a short time, loose metal, or metal that may need to be removed to allow for additional surgery.

The bottom line is, there should always be a good reason to remove metal from the body, because needless hardware removal can open the door to possible complications of surgery.

Complications of Hardware Removal

  • Infection: The most obvious reason to avoid an unnecessary surgical procedure is the possibility of infection.  While infection is rare when removing hardware (and infection may be a reason to remove metal), it is certainly possible, and whenever a surgery is not necessary, you should consider if you should be having surgery at all.
  • Weakening on Bone: Most metal implants are secured in the bone.  In order to remove the implant from the bone, there is typically a weakening of the bone.  Screws removed leave a hole in the bone, plates may leave a deformity in the bone.  Removing these implants may weaken the bone where the implant was used.
  • Damage to the Body: In order to remove an implant, tissues and bone surrounding the implant must be moved.  This can damage skin, muscle, and other tissues in the body.  Often bone and soft-tissue grow into and around implants making them more difficult to remove.
  • Inability to Remove the Implant: This is the most concerning issue, and a concern any orthopedic surgeon who has been working for more than a short time has faced.  Difficulty removing an implant can occur if the implant is difficult to locate, if the implant breaks, or in some cases, if it is simply stuck.  While you can always do more to remove the implants, sometimes the damage to normal bone and soft-tissue becomes not worthwhile to remove the old metal.  In these rare circumstances, the effort to remove an implant may be abandoned and the implant left behind.

Bottom Line

The reality is, most metal implants can be removed.  However, there is always potential that what is seemingly going to be a simple, straight-forward surgical procedure may become much more complicated.

  For that reason, surgeons always should be wary of a hardware removal surgery, as these procedures can become more challenging than anticipated.

Sources:

Busam ML, et al. "Hardware removal: indications and expectations" J Am Acad Orthop Surg. 2006 Feb;14(2):113-20.

Brown OL, et al. "Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures." J Orthop Trauma. 2001 May;15(4):271-4.

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