Elective removal vs. retaining of hardware after osteosynthesis in asymptomatic patients – A scoping review.

Abstract

Background Osteosynthesis is the internal fixation of fractures or osteotomy by mechanical devices (also called hardware). After bone healing there are two options: One is to remove the hardware the other is to leave it in place. The elective removal of the hardware in asymptomatic patients is controversially discussed. We performed a scoping review to assess if there is evidence on the removal of hardware in patients without medical indication (elective) compared to retaining of the hardware. In addition we wanted to find out which type of evidence is available. Methods A systematic literature search was performed in Pubmed, Embase, EconLit and Cinahl (11/2019). We included studies comparing asymptomatic patients with an internal fixation in the lower or upper extremities whose internal fixation was electively (without medical indication) removed or retained. We did not restrict inclusion to any effectiveness/safety outcome and considered any comparative study design as eligible. Study selection and data extraction was performed by two reviewers. Results We identified 13476 titles/abstracts. Of these we obtained 115 full-text publications which were assessed in detail against the inclusion criteria. We included 13 studies (1 RCT, 4 cohort studies, 8 before-after studies) and identified two ongoing RCTs. Nine assessed the removal of the internal fixation in the lower extremities (six of these syndesmotic screws in ankle fractures only) and two in the upper extremities. One study analysed the effectiveness of hardware removal in children in all types of extremity fractures. Outcomes reported included various scales measuring functionality, pain and clinical assessments (e.g. range of motion) and health-related quality of life. Conclusions We identified 13 studies that evaluated the effectiveness/safety of hardware removal in the extremities. Moreover we found two ongoing RCTs. The follow up times were short, the patient groups small and the ways of measurement differed. In general clinical heterogeneity was high. Evidence on selected topics e.g. syndesmotic screw removal is available nevertheless not sufficient to allow a meaningful assessment of effectiveness.

Mechanical and numerical investigations of biodegradable magnesium alloy screws for fracture treatment

“…A recent review showed high heterogeneity in patient outcome for asymptomatic implant removal. 6 Overall, an individual risk-benefit analysis is recommended 7 as the remaining material carries risks like a possible infection, allergisation 8,9 or resulting difficulties in radiological imaging. Especially when using MRI imaging, the peri-implant region might be difficult to evaluate, as titanium leads to imaging artifacts around it.…”

“…Additional risks like aspiration, shock, and hyperthermia (general anesthesia) and neural damage or infections (regional anesthesia) 5 require careful assessment. A recent review showed high heterogeneity in patient outcome for asymptomatic implant removal 6 . Overall, an individual risk–benefit analysis is recommended 7 as the remaining material carries risks like a possible infection, allergisation 8,9 or resulting difficulties in radiological imaging.…”