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Is it bad to leave metalwork in the body? by Jonathan Bell

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Fracture surgery usually means using plates, screws and rods to fix fractures. A huge increase in the use of metal fixation over the last three decades has greatly improved the outcome for many fractures. The decision to remove or leave metalwork is not always easy. So let’s look at some of the facts that may help you to make a decision.

Metalwork that should always be removed?

This includes smooth wires often known as K wires.  They have a habit of loosening and migrating. This occurs regardless of whether they are left buried or protruding. The second fixation that is almost always removed is any metalwork that it fixed across a joint. Occasionally a screw is positioned across a joint to help hold that joint in place whilst it heals and it should be removed before moving the joint again to prevent breakage of the metalwork.  Infected metalwork should always be removed preferably after the fracture has healed.

Metalwork that could be left behind?

Most metalwork that is put in for fracture surgery is deeply buried under both the skin and muscle and unless protruding into the muscle or adjacent structures can usually be very safely left.

Metal rods

One particular case would be an intramedullary nail which is a metal rod placed in the marrow cavity of the bone. These rods are often “locked” into position by screws to go through the bone and the rod. If a rod is buried in the marrow cavity of the bone it is unlikely to cause any trouble. Occasionally rods protrude a little at the end of the bone. Logic would suggest that if protruding a little it would make sense to remove it. Studies have shown that removal of intramedullary nails doesn’t guarantee that the pain will disappear. The cross-locking screws are often awkwardly positioned around the ankle or knee where they may be prominent.  It is sometimes worth just removing the locking screw as this is a minor job when compared to removing the whole rod.

Plates and Screws

Some plates and screws are rather more superficial. Examples include those around the knee, ankle, clavicle and elbow. This metalwork often sits just beneath the skin and as a result can be uncomfortable. It is easily knocked when it becomes noticeably tender. If metalwork is prominent around the ankle it can rub. This is particularly a problem when fitting ski boots. However, a good boot fitter maybe able to fit a boot without resorting to removal of the plate and screws. If the metalwork remains tender then it should be removed.Some discomfort around a healed fracture may be from the expanded and irregular shape to the bone. Many fractures will take for up to 3 years to stop aching.

So why is so much metalwork removed?

One should not forget that surgeons are paid to remove metal and the cynics may believe that that is a primary driver. There are other reasons that some choose to remove metalwork. Some surgeons believe that the metal will shield the bone from normal day-to-day stress. Others believe that the presence of metalwork may make future operations more difficult or put the sportsman at risk if they have a further fracture. In 25 years of orthopaedic practice I have seen less than half a dozen people fracture around previously inserted metalwork. In a couple of examples it did make management of the fracture a little more tricky, but not impossible. There doesn’t seem to be a great deal of evidence that the presence of metalwork causes progressive harm to the bone.

If metalwork is removed there is a concern that the bone will then be very weak. Certainly the bone will be less strong immediately after removal of metalwork but the holes will gradually fill in. In an adult they probably never quite fully fill in. It will take many months for the bone to regain normal strength and for that reason high impact sports should be avoided for perhaps 3 to 6 months after removal of metal in weight bearing bones.

So as you can see I’ve made a fairly strong case for leaving the majority of metalwork in place but it is quite clear that some people will benefit from removal of their plates screws or rods.

Can someone choose to have the metalwork taken out?

The short answer is yes. Some people struggle to get closure on the experience of having a fracture. The removal of the metalwork can help them “complete “ their treatment and move on from the experience. For this reason I do think personal preference can be a good reason to remove metalwork.

Who should remove metalwork?

When I was a trainee removal of metalwork was often left to the most junior surgeon. In my experience it can be an extremely difficult and at times unpredictable operation. When the metalwork is placed in the body it is not uncommon for screws to be damaged as they are tightened. The top of the majority of screws used in trauma accept a screwdriver that is more like an Allen key and because of the hex shaped hole in the screw head it is easily damaged. These screws can prove impossible to remove with the supplied screwdriver. They can then only be removed by drilling the screw out which is slow and demanding of the surgeon. So when embarking on removal of metalwork I always have a backup plan for what to do if it is impossible to remove one or more of the screws. In my view it is not an operation to be left to the inexperienced. Surgical operations tend to be very carefully planned and fortunately almost always run smoothly and to plan. Removal of metalwork is one operation that is most likely not to go to plan. That means the surgeon has to be able to adapt the plan and think on his or her feet.  In the past I have decided to abandon removal, drill out damaged screws and even cut off plates using a diamond cutter. By removing only the metalwork that needs removal this sort of problem can be kept to a minimum.

How to find out if you should have your metalwork removed?

If you want to discuss removal of metalwork would be very happy to help. We offer fixed-price packages for surgery or just single consultations. We are happy for you to bring your own x-rays if they are of good quality.

For further information please call   0208 944 0665 or click here