Hardware Removal:

Indications and
Expectations

Matthew L. Busam, MD*

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.
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;14:113120
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.

Volume 14, Number 2, February 2006

Abstract
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.

ardware removal is frequently

undertaken for symptoms attributed to the presence of hardware.
In addition, concerns about systemic and local effects of retained implants have led many patients to request elective hardware removal.
Although many orthopaedic surgeons view the procedure as a routine part of care, it is sometimes
more challenging and prone to complications than the initial surgery.
Although there is little debate
that hardware should be removed in
the setting of implant failure, infection, nonunion, and soft-tissue compromise, there is little consensus on
routine hardware removal in the setting of healed fracture. Neither is
there consensus on whether implants represent a risk for the patient
whose vocation or avocation requires impact loading at that site.

Furthermore, it is not clear how long

patients should be protected from
significant loads after hardware removal.
Important considerations in determining whether to remove hardware include the potential for complications 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 detection by security devices reported in
the orthopaedic literature.

Frequency and Cost

Although there are not extensive
data outlining occurrence of hardware removal, most sources identify
113

Hardware Removal

it as a common procedure, accounting for approximately 5% of all orthopaedic procedures done in the
United States.1 In a Finnish study,
nearly all implants inserted for fracture fixation (81%) were removed after fracture healing.2 Removal of the
implant accounted for 29% of elective procedures and 15% of total orthopaedic procedures performed at
that institution during a 7-year period, compared with a removal rate of
6% of all orthopaedic cases in Finland for the duration of that study.
Despite the significant number of
hardware removals performed, there
is little published information regarding the full cost of the procedure. In addition to the direct costs
(ie, physician and hospital fees), indirect costs include patient lost work
and productivity. These costs have
not been quantified, and only a few
studies of implant removal document patient time away from work.
One study of removal of lower extremity 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 research into practice variations regarding hardware removal in the
United States.

Peri-implant Fracture
and Refracture
Internal fracture fixation with either
intramedullary or extramedullary
implants creates a biologic environment that leads to adaptive changes
in bone, with the principal desired
effect of fracture healing. Direct fracture healing does not produce fracture callus; the new osseous channels form across the fracture site in
the environment of rigid internal fixation, which is most commonly
achieved with compression plating.
Indirect fracture healing with callus
formation occurs in the setting of
less rigid fixation, such as intramed114

ullary or external fixation.

During the initial months of healing after plate fixation, some bone
mass loss is observed at the boneplate interface. Some authors attribute this to stress shielding, in
which the plates shield the bones
from normal, functional stresses
leading to bone loss.4 Perren et al5 attribute this osteopenia to the disruption of blood supply caused by contact between the plate and the bone.
They showed that osteopenia was
temporary, produced even by flexible
plastic plates, and occurred less often and for a shorter time when the
vascular supply to the bone was less
disturbed. This work led to the development of low-contact plates and
locked plates, which cause less periosteal and cortical vascular disruption.
Multiple reports on implant removal demonstrate lower rates of refracture when implants are retained
longer, possibly further supporting
the idea that osteoporosis is a selflimited, vascular phenomenon.
Beaupr and Csongradi6 retrospectively reviewed seven studies to examine the refracture rate in 401 patients from whom 459 forearm
plates were removed after successful
union. They reported higher rates of
refracture with the use of largefragment dynamic compression
plates (DCPs) (21%), compared with
one-third tubular plates (0%), smallfragment DCPs (5.6%), and semitubular plates (6.6%).6 Removing a
plate before complete fracture consolidation increased the rate of refracture.
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 energyabsorbing 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 occurred in calcanei after drilling with
a 6.0-mm pin, the size commonly
used when placing ankle-spanning

external fixators for tibial pilon fractures.8 However, Burstein et al9 reported that radiographic evidence of
a screw hole remained after the hole
began to fill in with new bone. New
woven bone eliminated the stressconcentrating effect of the hole
within 4 weeks in a canine model,
even though the hole was still radiographically present. Using single
photon absorptiometry, Rosson et
al10 found that bone mass in young
adult men returned to close to normal 18 weeks after screw removal,
leading them to recommend avoidance of contact activity for 4 months
after screw removal.
Although refracture after plate removal cannot be completely prevented, the available data lead to
several conclusions that can be used
to minimize the risk. (1) Achieving
complete union and remodeling before implant removal decreases the
risk of refracture. (2) Avoiding unnecessary disruption of the vascular
supply to the bone decreases osteopenia. Furthermore, allowing sufficient time for the vascular supply
to recover may correct the initial osteopenia. (3) Screw holes may remain as stress risers for as long as 4
months.
Refracture is rarely reported after
removal of an intramedullary implant. 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 original 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 addition to radiographic evidence of cir-

Journal of the American Academy of Orthopaedic Surgeons

Matthew L. Busam, MD, et al

cumferential bridging external callus, they recommend retaining the

implant for at least 12 months postoperatively.12 Although union occurs
before 12 months, the additional
time allows bone remodeling for hypertrophy and strength before hardware removal.
Patients and physicians are often
concerned about the risk of fracture
in proximity to a retained implant.
Because implants may biomechanically function as stress risers, theoretically they may predispose a patient to peri-implant fracture (Figure
1). However, few data exist indicating an increased overall fracture risk
caused by a retained implant. McKee
et al13 reported three cases of fracture
occurring at the tip of a locked humeral nail, all as a result of lowenergy 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 implants end in metaphyseal bone. An
analogous femoral implant is the intramedullary hip screw, such as the
original Gamma nail (Stryker,
Kalamazoo, MI), a device reported to
have a risk of diaphyseal periimplant 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%, respectively.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 fracture caused by a motorcycle accident
in a patient with a retained unlocked
intramedullary nail. The tibial intramedullary nail was reduced back
into the distal metaphysis and relocked without having to place a
new one (Figure 2, B).
There is no consensus concerning
the necessary amount of protection,
weight-bearing limits, or activity
modification after implant removal.
The available data seem to support
Volume 14, Number 2, February 2006

Figure 1

Oblique-lateral radiograph demonstrating a peri-implant ulnar fracture caused by a

retained implant. The implant served as a stress riser.

Figure 2

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
cortex of the distal tibia. B, The retained nail simplified treatment by allowing
reimplantation and relocking of the nail in the distal tibia without the need to replace
the intramedullary device.
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 acknowledging lack of data to support
their recommendation, allowed patients to participate in sports activity with an intramedullary nail in
place for the first athletic season after fracture healing, provided the interlocking screws had been removed.
They recommended nail removal
upon completion of the first season
of competition. Evans and Evans16 reported 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, periimplant fracture after having open reduction and internal fixation (ORIF)
with plating for a both-bone forearm
fracture. A second patient was symptomatic in the area of a tension-band
fixation for a patellar fracture. The
authors recommended allowing early
return to competitive sports with retained implants because the minimal
risk is offset by competitive and financial rewards.16
The current orthopaedic literature regarding fracture risk from retained implants does not support either universal retention or removal
of hardware. There appears to be no
significant risk of peri-implant fracture when hardware is left in place,
even when the patient resumes contact 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 factors ought to be considered.

Painful Hardware
Persistent pain after radiographic evidence of fracture union commonly
leads to implant removal. Rates of
implant removal vary based on ana116

tomic location and implant selection. In one study of 55 patients undergoing tension band wiring of
olecranon fractures, 61% required
revision surgery for painful hardware.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 fractures and found lower pain scores and
lower scores on the Medical Outcomes Study 36-Item Short Form for
patients with pain overlying the lateral hardware. Of the 39 patients reporting 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 improvement after hardware removal in
75% of patients who had previously
undergone ORIF of the ankle.
Pain relief following femoral intramedullary nail removal is similarly unpredictable. In their retrospective review of 80 patients with
femoral fractures, Dodenhoff et al21
noted that 11 of 17 who underwent
implant removal experienced pain relief. With tibial implants, knee pain
is a common indicator for nail removal. Keating et al22 showed a 45%
rate of complete relief of knee pain
after tibial nail removal; 35% of patients experienced partial relief and
20%, no relief. In a retrospective review of 169 patients, Court-Brown et
al23 noted complete pain relief in
27% and marked relief in 69% after
nail removal. However, 3.2% reported worsening pain after hardware
removal. In another study, 17% of patients noted an increase in knee pain
after tibial nail removal.3 Because the
extent of pain relief varies after hardware removal, the surgeon must exercise caution in attributing persistent pain to retained implants. No
patient should be guaranteed complete pain relief.

Fixation Across Joints

Preventing implant failure is a common indication for removal. The cyclic loading associated with fixation
across joints often leads to fatigue
failure of metallic implants. Because
of this concern, hardware is often removed from the distal tibiofibular
syndesmosis after ankle injury fixation as well as from the midfoot after fixation of Lisfranc joint injuries.
Removal versus retention of ankle
syndesmosis transfixion screws remains controversial. There are no
prospective, randomized studies
comparing the results of retention
versus removal of syndesmosis
screws. Some authors routinely remove the implant before unrestricted 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 immobility created by fixation across pelvic
joints. Displaced fractures of the anterior and posterior pelvic ring routinely require fixation spanning the
symphysis pubis and the sacroiliac
joints. Displaced pelvic fractures in
female patients have been associated
with negative effect on genitourinary and reproductive function.27 To
date, no studies have been able to determine the ability of a female patient to have a vaginal delivery after
undergoing pelvic fracture fixation.
However, obstetricians are generally
unwilling to have their patients attempt vaginal delivery in the setting
of symphyseal or sacroiliac fixation.
This concern may be an indication
for hardware removal in young female patients.

Journal of the American Academy of Orthopaedic Surgeons

Matthew L. Busam, MD, et al

Metal Allergy
Implants with nickel or chromium
composition cause allergic responses in a small segment of the population. A review of approximately 50
studies shows the prevalence of metal sensitivity in the general population 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 sensitivity 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 implant. An example of clinical information that may suggest a metal
sensitivity is the presence of symptoms in a fair-skinned, red-haired
woman with a history of earlobe irritation caused by earrings that are
not 14-carat gold or caused by costume jewelry. The patient also may
be sensitive to medications and
have multiple allergies. Patients
with sensitivity or allergy will express significant relief almost immediately 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 causeand-effect relationship between
metal sensitivity and implant loosening. Currently, there is no evidence 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 require insertion of metal implants,
the carcinogenic risk of these implants must be assessed. The association between metallic implants and
tumors has been established in experimental animals.31 In the absence
of chronic infection, the pathogenesis of metal-induced carcinogenesis
may fall into two general categories:
(1) metal-ion binding to DNA and (2)
alteration of DNA and protein synthesis. Because binding is reversible,
other effects are likely to be involved
in carcinogenesis. Evidence points to
reactive oxygen species created during corrosion and their effects on
DNA and proteins as the likely second culprit in metal-induced carcinogenesis.32 Although basic science 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 denominator is not known, making it impossible to quantify risk. Moreover,
it is extremely difficult to differentiate correlation from causation when
trying to establish a relationship between implants and tumors. Generally, 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 significant risk for local tumor development. The overall risk, if any, appears 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% increase in hematopoietic cancers over
the general population in their retrospective 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

study to date, Signorello et al35 conducted 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 cancer. Long-term follow-up (>15 years)
showed an increase in multiple myeloma and a statistically insignificant 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 emergency departments and high schools, patients 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 implants with sufficiently high iron
content would be detected and that
because modern implants have little, if any, iron, detection is unlikely. In 1994, Beaupre37 corrected that
earlier assertion, explaining that
316L stainless steel is actually 60%
iron. Detection depends on an objects permeability (ability to temporarily disrupt a magnetic field) and
conductivity. Because modern processing techniques limit permeability and conductivity, the potential
for detection is very low.
The incidence of implant detection during security screening may
be low, but many orthopaedic surgeons provide their patients with
wallet cards containing a short
statement providing documenta117

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 appropriate 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 attention to an implant card. Given the
low likelihood of detection by security measures, removing metallic
implants to avoid travel concerns is
not warranted at this time.

Pediatric Patients
The general practice at many institutions is to offer removal of implants
118

to pediatric patients. The reasons

cited for removing pediatric implants
include difficulty in removing implants later because of exuberant callus overlying the implant, stress
shielding, risk of corrosion, metal allergy, and potential carcinogenesis.
Concern about degenerative processes and the consequences of retained hardware when addressing
later fractures also has driven the
routine removal of implants in children. The same concerns may be expressed in adults, but adults have
fewer expected years of risk for complications. No data are available concerning the frequency of a retained
implants posing a technical problem
in the patient undergoing surgery for
a second fracture or for joint degeneration in that extremity.
Flexible intramedullary rods used
for treating pediatric fractures are
routinely removed after bony union.
There are no data in the literature regarding whether these implants
should be removed or what the consequences are if they are left in
place. In a recent review of flexible
nailing of pediatric femoral fractures, hardware removal was not undertaken routinely.38 Removal of
flexible intramedullary nails in children 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 complication is blood loss and surgical time
exceeding that of the original procedure. He noted such difficulty in 11
of 18 cases of SCFE hardware removal (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-

plant or intraoperative fracture.40

Kahle41 reported an overall complication rate of 13% in pediatric hardware removal but a 42% rate in
SCFE hardware removal. Based on
these numbers, some surgeons question 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 asymptomatic internal fixation devices.
There are no clear data in the literature regarding routine removal of
pediatric implants. Chapman states,
in the orthopaedic textbook that he
edited, In children we advise routine removal of implants.42 However, 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 reconstructive 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 inherent risks, including wound complications, iatrogenic injury, and anesthetic complications. In their report
on implant removal in 86 patients,
Richards et al44 noted a 3% complication rate, including one refracture,
one radial nerve injury, and one hematoma. Sanderson et al45 reported
an overall 20% complication rate in
their series of 188 patients. The
most common complication was infection, followed by nerve injury.
They recommend senior surgeon supervision of forearm hardware removal; unsupervised junior surgeons
produced three permanent nerve injuries.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,

Journal of the American Academy of Orthopaedic Surgeons

Matthew L. Busam, MD, et al

and 2 refractures. They recommended leaving asymptomatic hardware

in place and not delegating the procedure to inexperienced surgeons.
They reported complication rates of
13%, 60%, and 100% in cases performed by experienced surgeons,
moderately experienced surgeons,
and inexperienced surgeons, respectively.
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 consider intraoperative fluoroscopy to confirm that no new fracture has occurred. Furthermore, informing the
patient about the possible risks of
nail removal remains paramount.

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.

2.

3.

4.

Summary
Hardware removal, although a common operation, should not be undertaken 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 patients reporting implant-related
pain, removal of that implant does
not guarantee relief and may be associated with further complications,
including infection, refracture, nerve
damage, and worsening pain. Additionally, patients may request or surgeons may recommend removal on
unproved grounds, such as protection from neoplasm or reduction of
stress shielding. No data suggest
that implant removal accomplishes
these objectives or that retained implants increase the risk of neoplasm
or cause stress shielding. As with
any surgical procedure, it is important to understand the expected benefits from the procedure as well as to
know the inherent risks. More research is needed regarding the timing and expected benefits of removing implants as well as the direct and
indirect costs of the procedure.
Volume 14, Number 2, February 2006

5.

6.

7.

8.

9.

10.

11.

12.

Rutkow IM: Orthopaedic operations

in the United States, 1979 through
1983. J Bone Joint Surg Am 1986;68:
716-719.
Bostman O, Pihlajamaki H: Routine
implant removal after fracture surgery: A potentially reducible consumer of hospital resources in trauma
units. J Trauma 1996;41:846-849.
Boerger TO, Patel G, Murphy JP: Is
routine removal of intramedullary
nails justified? Injury 1999;30:79-81.
Harkness JW, Ramsey WC, Harkness
JW: Principles of fractures and dislocations, in Rockwood CA, Green DP,
Bucholz RW, Heckman JD (eds): Fractures in Adults, ed 4. Philadelphia,
PA: Lippincott-Raven, 1996, vol 1, pp
3-120.
Perren SM, Cordey J, Rahn BA, Gautier E, Schneider E: Early temporary porosis of bone induced by internal fixation implants: A reaction to necrosis,
not to stress protection? Clin Orthop
Relat Res 1988;232:139-151.
Beaupr GS, Csongradi JJ: Refracture
risk after plate removal in the forearm.
J Orthop Trauma 1996;10:87-92.
Brooks DB, Burstein AH, Frankel VH:
The biomechanics of torsional fractures: The stress concentration effect
of a drill hole. J Bone Joint Surg Am
1970;52:507-514.
Juliano PJ, Yu JR, Schneider DJ, Jacobs
CR: Evaluation of fracture predilection in the calcaneus after external
fixator pin removal. J Orthop
Trauma 1997;11:430-434.
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.
Rosson J, Murphy W, Tonge C, Shearer J: Healing of residual screw holes after plate removal. Injury 1991;22:
383-384.
Wolinsky PR, McCarty E, Shyr Y,
Johnson K: Reamed intramedullary
nailing of the femur: 551 cases.
J Trauma 1999;46:392-399.
Brumback RJ, Ellison TS, Poka A,
Bathon GH, Burgess AR: Intramedullary nailing of femoral shaft fractures:
III. Long-term effects of static inter-

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

locking fixation. J Bone Joint Surg

Am 1992;74:106-112.
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.
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.
Mabrey JD, Wirth MA: Periprosthetic
fractures, in Rockwood CA, Green
DP, Bucholz RW, Heckman JD (eds):
Rockwood and Greens Fractures in
Adults, ed 4. Philadelphia, PA:
Lippincott-Raven, 1996, vol 1, pp 539603.
Evans NA, Evans RO: Playing with
metal: Fracture implants and contact
sport. Br J Sports Med 1997;31:319321.
Romero JM, Miran A, Jensen CH:
Complications and re-operation rate
after tension-band wiring of olecranon fractures. J Orthop Sci 2000;5:
318-320.
Smith ST, Cramer KE, Karges DE,
Watson JT, Moed BR: Early complications in the operative treatment of patella fractures. J Orthop Trauma
1997;11:183-187.
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 fractures. J Orthop Trauma 2001;15:271274.
Jacobsen S, de Lichtenberg MH, Jensen CM, Torholm C: Removal of internal fixationthe effect on patients complaints: A study of 66 cases
of removal of internal fixation after
malleolar fractures. Foot Ankle 1994;
15:170-171.
Dodenhoff RM, Dainton JN, Hutchins PM: Proximal thigh pain after femoral nailing: Causes and treatment.
J Bone Joint Surg Br 1997;79:738-741.
Keating JF, Orfaly R, OBrien PJ: Knee
pain after tibial nailing. J Orthop
Trauma 1997;11:10-13.
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.
Meyer TL Jr, Kumler KW: A.S.I.F.
technique and ankle fractures. Clin
Orthop 1980;150:211-216.
de Souza LJ, Gustilo RB, Meyer TJ: Results of operative treatment of displaced external rotation-abduction

119

Hardware Removal

26.

27.

28.

29.

30.

31.

fractures of the ankle. J Bone Joint

Surg Am 1985;67:1066-1073.
Kuo RS, Tejwani NC, DiGiovanni
CW, et al: Outcome after open reduction and internal fixation of Lisfranc
joint injuries. J Bone Joint Surg Am
2000;82:1609-1618.
Copeland CE, Bosse MJ, McCarthy
ML, et al: Effect of trauma and pelvic
fracture on female genitourinary, sexual, and reproductive function.
J Orthop Trauma 1997;11:73-81.
Jacobs JJ, Goodman SB, Sumner DR,
Hallab NJ: Biologic response to orthopaedic implants, in Buckwalter JA,
Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and
Biomechanics of the Musculoskeletal
System, ed 2. Rosemont, IL: American
Academy of Orthopaedic Surgeons,
2000, pp 401-426.
Swiontkowski MF, Agel J, Schwappach J, McNair P, Welch M: Cutaneous metal sensitivity in patients with
orthopaedic injuries. J Orthop
Trauma 2001;15:86-89.
Hallab N, Merritt K, Jacobs JJ: Metal
sensitivity in patients with orthopaedic implants. J Bone Joint Surg
Am 2001;83:428-436.
Memoli VA, Urban RM, Alroy J, Galante JO: Malignant neoplasms associated with orthopedic implant materi-

120

32.

33.

34.

35.

36.

37.

38.

39.

als in rats. J Orthop Res 1986;4:346355.

Wang S, Shi X: Molecular mechanisms
of metal toxicity and carcinogenesis.
Mol Cell Biochem 2001;222:3-9.
Keel SB, Jaffe KA, Petur Nielsen G,
Rosenberg AE: Orthopaedic implantrelated sarcoma: A study of twelve
cases. Mod Pathol 2001;14:969-977.
Gillespie WJ, Frampton CM, Henderson RJ, Ryan PM: The incidence of cancer following total hip replacement.
J Bone Joint Surg Br 1988;70:539-542.
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.
Pearson WG, Matthews LS: Airport
detection of modern orthopaedic implant metals. Clin Orthop 1992;280:
261-262.
Beaupre GS: Letter: Airport detection
of modern orthopedic implant metals.
Clin Orthop 1994;303:291-292.
Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE:
Complications of titanium elastic
nails for pediatric femoral shaft fractures. J Pediatr Orthop 2003;23:443447.
Swiontkowski MF: Slipped capital
femoral epiphysis: Complications

40.

41.

42.

43.

44.

45.

46.

47.

related
to
internal
fixation.
Orthopedics 1983;6:705-712.
Jago RD, Hindley CJ: The removal of
metalwork in children. Injury 1998;
29:439-441.
Kahle WK: The case against routine
metal removal. J Pediatr Orthop
1994;14:229-237.
Chapman MW: Principles of internal
and external fixation, in Chapman
MW (ed): Chapmans Orthopaedic
Surgery, ed 3. Philadelphia, PA: Lippincott Williams and Wilkins, 2001,
vol 1, pp 375-376.
Green NE, Swiontkowski MF: Skeletal Trauma in Children, ed 3. Philadelphia, PA: Saunders, 2003, vol 3, pp
388-398.
Richards RH, Palmer JD, Clarke NM:
Observations on removal of metal implants. Injury 1992;23:25-28.
Sanderson PL, Ryan W, Turner PG:
Complications of metalwork removal. Injury 1992;23:29-30.
Langkamer VG, Ackroyd CE: Removal of forearm plates: A review of the
complications. J Bone Joint Surg Br
1990;72:601-604.
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.

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