Our study shows that the current practice and attitude toward implant removal, amongst trauma and orthopaedic surgeons in the Netherlands, varies in our relatively small single European country. Similar variations have also been described in few other European countries. In Finland, implant removal is more or less routinely done, resulting in a removal rate of approximately 80% [14
], whereas in Norway removal is merely done in patient with complaints (removal rate around 50%) [15
]. For Great Britain, the total percentage of removals is quite low at about 20% [16
]. These percentages suggest that the daily practice of implant removal is determined by expert-based or cultural factors instead of evidence-based knowledge about the true functional outcomes of this surgical procedure.
Practice is mostly based on personal beliefs of benefit for the patient. In our survey there seems to be consensus that specific hardware related complaints like pain and pressure on the skin or soft tissue irritation can be improved by implant removal, as these are the most frequently mentioned reasons to take an implant out (e.g. tension bands on olecranon or patella and plates on clavicle or tibia). Dodenhoff et al.
] investigated the relief of pain after the removal of femoral nails. Although there was some uncertainty as to whether pain stemmed from the femoral nail or was due to heterotrophic ossification, the majority of patients were relieved. Removal of tibial nails in patients with anterior knee pain relieves pain in 45-88% [18
]. However, in one of these studies 3 out of 18 patients who were asymptomatic before implant removal, developed long term complaints afterwards [19
Implant removal in young patients because of prophylactic reasons, especially in the lower extremity, is frequently advocated in view of potential future surgeries, such as joint replacement or operative treatment of new fractures. These operations will be more difficult to perform if metal implants remain in situ. Another reason for implant removal in young patients, according to some authors, is the possible risk of a refracture due to the implant itself, for example in the forearm, whereas removal after many years can be more difficult due to bone overgrowth [11
]. One can suppose that removing the material at an earlier time point is therefore of benefit to avoid such situations. Currently, there is no evidence on this specific issue. Although a majority of the Dutch surgeons believes that implants should be routinely removed in children, for adult patients - including those under the age of 40
years - routine removal is not advocated. Particularly the Dutch orthopaedic surgeons appear more reticent.
One of the main outcomes of implant removal after fracture healing includes implant removal related complications. The estimated risks for these adverse events vary in the literature from 1% for postoperative bleeding, 0 to 14% for wound infection, 1 to 29% for nerve damage, 1 to 30% for a refracture up to 9% for obtaining an unpleasant scar [10
]. Unfortunately, most of the data originate from older publications and there are very few recent studies reporting on these specific complications. The most commonly mentioned postoperative complications in our survey were wound infection (37%), unpleasant scarring (24%) and postoperative hemorraghe (19%), though these numbers estimated.
Another reason for the wide variance in the (international) practice of implant removal might be the associated costs. It is a fact that each operation has its costs, and implies a recovery period and temporary employment loss with social consequences [1
]. In the absence of evidence based guidelines, the availability of workers compensation might affect patient’s opinion to implant removal. On the other hand, the compensation for direct costs for the doctor and hospital and the availability of requested hospital resources might also influence the removal rate. Some surgeons from our collective find that the procedure is not adequately paid for. This could be a reason not to remove metal implants unless a patient suffers a lot of complaints, though these financial incentives did not appeared to play a significant role in the decision making.
Comparing our survey to that of Hanson et al.
], the demographic profile of the respondents differed slightly. The interviewees in Hanson’s study were more frequently residents (34%) as can be expected in an AO-course, and came from 65 different countries all over the world, mostly with a general orthopaedic background. Our study population originated from a single, westeuropean country and contained a lot of staff surgeons dedicated to and experienced in fracture surgery. The large majority (92%) of the Dutch trauma and orthopaedic surgeons decide to remove implants in symptomatic patients, whereas in the surgeon collective of Hanson et al.
patients’ requests and complaints were of less importance in the decision-making process (69%). Remarkably, surgeons in that study were less enthusiastic about the beneficial effect of implant removal in ‘symptomatic’ patients. In our study, orthopaedic surgeons were less likely to agree that implants should always be removed under the age of 40
years compared to trauma surgeons with a general surgical background. A similar majority of all surgeons in both studies did not favour routine implant removal in asymptomatic patients, though more surgeons in our study felt that removing material was of greater risk to soft tissues than leaving it in situ (84% versus 50% in Hanson’s study). Overall, the variety of views reported is indicative for the large differences in opinion and attitude about implant removal between surgeons from different backgrounds and countries. Despite the demographic differences between both studies, the results are quite comparable.
Our study only describes personal opinions and habits regarding implant removal of the practicing surgeons in the Netherlands. Although effort was made to make the survey as complete as possible, it is generally known that questionnaire surveys are prone to multiple sources of bias [31