Hardware Removed Research Articles

Intraparenchymal Cysts Following Deep Brain Stimulation: Variable Presentations and Clinical Courses.

The development of cysts at the electrode lead is a rare complication of deep brain stimulation (DBS), with only 3 cases reported in the literature. A better understanding of the variable clinical presentations and courses of these cysts may help increase awareness of this potentially life-threatening complication. To review the clinical presentation of patients with intraparenchymal cysts following DBS implantations. We report 3 patients who developed a cyst along the course of the DBS lead. These patients received DBS for different indications and in different brain locations. Clinical courses differed considerably with 1 asymptomatic patient followed conservatively, 1 mildly symptomatic patient who had the DBS hardware removed for insidious worsening over months, and 1 who had it emergently removed for acute development of hydrocephalus. Serial imaging revealed spontaneous reduction in cyst size over time in the asymptomatic patient, and following removal in 1 of the symptomatic patients. This report highlights the variable clinical presentation and course of patients who develop cysts along the DBS lead. It suggests that some cases can be followed clinically without removal of hardware but that ongoing vigilance is required given the potential for serious adverse events.

Outcomes of Lisfranc Injuries Treated with Joint Preserving Fixation

Category: Midfoot/Forefoot Introduction/Purpose: Open reduction and internal fixation with transarticular screws to stabilize Lisfranc injuries may increase the risk of arthritis or affect outcomes. Extra-articular or bridge plating to stabilize these injuries avoids this articular damage. This study analyzes the functional outcomes and complications in patients who underwent this type of joint preserving fixation for Lisfranc injuries. Methods: A retrospective review of all patients treated for a Lisfranc injury at a level 1 trauma center from July 2008 to October 2015 was conducted. Patients over 18 years of age who were not incarcerated and did not have any concomitant procedures in the lower extremities were included. Patient electronic medical records were reviewed. Outcomes were analyzed with AOFAS scores. Results: There were 16 patients included in the study with an average follow up time of 57 months (15 - 102 months). Average AOFAS score was 79 (SD 16) and time to return to regular activities was 35 weeks (SD 25 weeks). Seven patients (44%) had their hardware removed during the follow up period. There was 1 complication which comprised of a screw backing out and needing to be removed. Conclusion: In the present case series, joint preserving fixation for Lisfranc injuries offered similar AOFAS scores as those reported for ORIF with transarticular screws, but with a decreased rate of hardware removal and need for mid-foot fusion.

Plate fixation of midshaft clavicular fractures: patient-reported outcomes and hardware-related complications

Recent studies report high hardware removal rates after plate fixation of midshaft clavicular fractures. Precontoured clavicle plates may decrease hardware-related complications while improving healing rates and patient-reported outcomes (PROs). Using a private-payer national database, we identified 7826 patients who underwent clavicle open reduction and internal fixation (ORIF) in 2007 to 2011. Database patients were tracked for 2years to assess hardware removal and revision fixation. In addition, we retrospectively identified 73 patients who underwent plate fixation of midshaft clavicular fractures at our institution. These patients completed the Disabilities of Arm, Shoulder and Hand (DASH) assessment, the EQ-5D (EuroQol, Rotterdam, The Netherlands) quality of life assessment, and a hardware-related outcomes survey. Among 7826 database patients, 994 (12.7%) underwent hardware removal and 78 (1%) required revision ORIF. The annual incidence of clavicle ORIF increased 61.5% between 2007 and 2011. In our institutional cohort, 56 patients (77%) were fixed with precontoured plates and 17 (23%) with standard plates. At a mean follow-up of 4.2years, 11 patients (15%) underwent hardware removal and 1 patient (1.4%) experienced nonunion. Patients reported excellent outcomes, with average DASH of 4.0±8.9 and EQ-5D of 0.89±0.19. There were no differences in PROs, hardware removal, or union rate between plate types, although our study was underpowered for these outcomes. Patients who underwent hardware removal reported lower DASH, EQ-5D, satisfaction, and shoulder function compared with patients with hardware retained. Women were more likely to undergo hardware removal in the institutional (P=.009) and the database (P<.001) cohorts. Displaced midshaft clavicle fractures have high union rates with precontoured plate fixation. Women are 4 times more likely than men to have hardware removed. Patients undergoing clavicle hardware removal report worse long-term outcomes than patients with hardware retained.

Incidence of Hardware Removal Following Volar Plate Fixation of Distal Radius Fracture

To assess the risk of tendon rupture or plate removal after volar plate fixation of distal radius fractures and to determine the incidence of hardware removal. We searched the surgical database of 5 attending hand surgeons at a single institution from 2009 to 2014. All patients who had undergone volar plate fixation were included. Patients were excluded if they underwent an alternate form of fixation, had less than 1 year of follow-up, or could not be reached for follow-up. Postoperative radiographs were examined for Soong grade, plate distance to the critical line, and plate distance to the volar rim. If patients had hardware removed, the reason for plate removal was identified. For all patients who did not have documented hardware removal at our institution, we placed a follow-up call to determine whether they had hardware removed elsewhere. A total of 517 patients underwent volar plate fixation, 143 of whom did not have their hardware removed at our institution but could not be reached for follow-up. Of the remaining 374 patients, 37 (10%) had hardware removed. For group 1 (hardware retained), Soong grades were 13% grade 0, 85% grade 1, and 2% grade 2. For group 2 (hardware removed) the proportions were 11%, 76%, and 5%, respectively, and 8% undetermined. Mean plate distance to the critical line was significantly greater for group 2 (1.9 mm) compared with group 1(1.2 mm). Mean plate distance to the volar rim did not differ (5.1mm vs 5.3 mm). The incidence of hardware removal in our series was 10%. The vast majority of patients had Soong grade 1 prominence. Patients who had hardware removed had a greater plate prominence volar to the critical line. Plate distance to the volar rim was not associated with removal. Prognostic II.

Symptomatic Hardware Removal After First Tarsometatarsal Arthrodesis

Severe hallux valgus deformity with proximal instability creates pain and deformity in the forefoot. First tarsometatarsal joint arthrodesis is performed to reduce the intermetatarsal angle and stabilize the joint. Dorsomedial locking plate fixation with adjunctive lag screw fixation is used because of its superior construct strength and healing rate. Despite this, questions remain regarding whether this hardware is more prominent and more likely to need removal. The purpose of the present study was to determine the incidence of symptomatic hardware at the first tarsometatarsal joint and to determine the incidence of hardware removal resulting from prominence and/or discomfort. A review of 165 medical records of consecutive patients who had undergone first tarsometatarsal joint arthrodesis with plate fixation was conducted. The outcome of interest was the incidence of symptomatic hardware removal in patients with clinical union. The mean age was 55 (range 18.4 to 78.8) years. The mean follow-up duration was 65.9 ± 34.0 (range 7.0 to 369.0) weeks. In our cohort, 25 patients (15.2%) had undergone hardware removed because of pain and irritation. Of these patients, 18 (72.0%) had a locking plate and lag screw removed, and 7 (28.0%) had crossing lag screws removed. The fixation of a first tarsometatarsal joint fusion poses a difficult situation owing to minimal soft tissue coverage and the inherent need for robust fixation to promote fusion. Hardware can become prominent postoperatively and can become painful and/or induce cutaneous compromise. The results of the present observational investigation imply that surgeons can reasonably inform patients that the incidence of symptomatic hardware removal after first tarsometatarsal arthrodesis is approximately 15% within a median duration of 9.0 months after surgery.

Functional outcome of displaced intra-articular calcaneal fractures

The purpose of this study is to assess the clinical results of a minimally invasive treatment featured the concept of internal compression, including an anatomic plate and multiple compression bolts compared with open reduction and internal fixation for displaced intra-articular calcaneal fractures (DIACFs). We retrospectively analyzed 329 patients (383 feet) who were identified from trauma inpatient database in our hospital for DIACFs from January 2004 to December 2009. Of them, 148 patients (170 feet) were treated with open reduction and internal fixation (OR group), which involved using a traditional L-shaped extended lateral approach, and fractures were fixed by plate and screws from January 2004 to December 2006; 181 patients (213 feet) were treated with a minimally invasive approach featured the concept of calcaneal internal compression (CIC group), which was achieved by an anatomic plate and multiple compression bolts through a small lateral incision from January 2007 to December 2009. Postoperative complications were recorded. During follow-up, pain and functional outcome were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) scores and compared between the two groups. Subsequent subtalar arthrodesis and early implant removal were performed when indicated. Routine hardware removal was scheduled for all patients at 1-year follow-up. There were no significant differences in sex, age, and fracture classification (Sanders classification) between the two groups. Wound healing complications were 4 of 213 (1.88%) in CIC group and 20 of 170 (11.76%) in OR group. Subtalar arthrodesis had to be performed in one case in OR group. Four cases in CIC group and four cases in OR group had the hardware removed earlier due to complications. The average time after surgery to start weight-bearing exercise is 5.64 weeks in CIC group and 9.38 weeks in OR group (p < 0.001). The mean AOFAS score is higher in CIC group than in OR group, although the difference is not statistically significant (87.53 vs. 84.95; p = 0.191). The overall results according to the AOFAS scoring system were good or excellent in 185 of 213 (86.85%) in CIC group and 144 of 170 (84.71%) in OR group. The subjective portion of the AOFAS survey answered by patients showed statistically significant difference in activity limitation and walking surface score (7.31 vs. 7.02 and 3.72 vs. 3.42; p < 0.05) but not in pain and walking distance between the two groups (32.72 vs. 32.29 and 4.37 vs. 4.42; p > 0.05). The study results suggest that this minimally invasive approach featured the concept of the calcaneal internal compression can achieve functional outcome as good as, if not better than the open techniques. It is proved to be an effective alternative treatment for DIACFs. Therapeutic study, level IV.

Poster 70: Internal Hardware Removal After Treatment of Maxillofacial Fractures

Facial fractures are commonly treated by oral and maxillofacial surgeons. Many methods exist for the treatment of fractures and most fractures are treated with a type of internal fixation and rigid fixation. After the treatment of the fractures with internal rigid fixation the hardware has to be removed on occasion. The aim of this study is to identify the rates and reasons for plate removal for patients that were treated for facial fractures and to investigate for methods of prevention. This experiment was a retrospective review of patient information to identify reasons for hardware removal for patients treated for maxillofacial fractures. Patient information was gathered on facial fractures treated by the Oral and Maxillofacial Surgery Team. Patient data was collected over a 5-year period from January 1, 2006, to December 31, 2010. Data were gathered from 3 busy trauma hospitals—Loma Linda University, a level 1 trauma center, Arrowhead Regional Medical Center and Riverside County Regional Medical center, both level 2 trauma centers. Study variables included age, sex, diagnosis, type of fracture, approach to the facial skeleton, presence of teeth in the line of fracture, site of hardware, use of maxillomandibular fixation postoperatively, and reasons for plate removal. There were 1,748 patients with facial fractures treated in the 5-year period in the operating room. There were 183 patients that had hardware removed during the same time period. Descriptive and quantitative statistics were undertaken. The reasons for hardware removal were gathered and included pain, palpation by the patient, temperature sensitivity, and infection. Infection was the most common cause for removal. The mandibular angle fracture was the most common location to remove the plate from. Mandible fractures treated with maxillomandibular fixation for at least 2 weeks after open reduction internal fixation had a lower incidence of plate removal. Selection of favorable plate location, infection control, close follow-up of patients, and consideration of maxillomandibular fixation may reduce plate removal rates in patients treated for maxillofacial fractures.

Infections and Hardware Salvage after Deep Brain Stimulation Surgery: A Single-Center Study and Review of the Literature

Aims: Infection of hardware is a serious complication after deep brain stimulation (DBS), as this may result in additional surgery, cost and loss of treatment benefit for the patient. We report the incidence and management of infections after DBS in a single institution over the past 11 years. Methods: A database of 270 patients with 484 implants was used in the study. Incidence, clinical characteristics and management of infections were analyzed. Results: The overall infection rate was 9.3% (25/270) by patients and 6.8% (33/484) by episode/implants. The median time of infection after implantation was 64 days. Only 7/33 episodes (21.2%) occurred within 30 days after surgery, 22/33 episodes (66.7%) within 6 months and 28/33 episodes (84.8%) within 12 months. There was no age difference between infected and noninfected patients, while comorbidities were more frequent in the former. Infection rates before and after January 2003 were 14.3 and 4.9%, respectively. The rate of complete and partial hardware salvage was 30.3 and 21.2% while that of complete hardware removal was 48.5%. Patients with deep purulent infections and patients with Staphylococcus aureus as the causative organism were more likely to have their hardware removed. Conclusions: The incidence of hardware infections declined significantly over time. Improvements in hardware and implantation techniques may be responsible. Hardware can often be completely or partly saved in infected patients.

Fracture healing

In a review of five case series and two retrospective cohort studies, nearly 50% of patients had their hardware removed without a clear indication. Approximately half of patients who underwent hardware removal for pain experienced pain relief, although some patients did experience increased pain after removal. It is unclear whether the indication for hardware removal affects resultant pain relief. Improved function was also observed in a few select studies. While generally safe, the available evidence does not support a general recommendation for hardware removal after fracture healing. Well-designed comparative studies are needed to determine whether there is any benefit of hardware removal for patients, particularly those without a clear indication for removal.

Semitubular Plates for Acutely Displaced Midclavicular Fractures: A Retrospective Study of 111 Patients Followed for 2.5 to 6 Years

We designed this study to determine the usefulness of semitubular plates for acute displaced or comminuted fractures of the midclavicle. Nonrandomized retrospective study. A secondary transfer hospital specializing in orthopaedics. From May 1997 to July 2001, 121 patients were treated with a 92% (111) follow-up rate. The mean follow-up time was 3.5 years (range, 2.5 to 6 years). Semitubular plates using 4.5-mm cortical or 6.5-mm cancellous screws and wire as necessary. The functional result was evaluated by the Disabilities of the Arm, Shoulder and Hand (DASH) score at the time of admission for implant removal in 82 patients or at the end of follow-up by telephone in 29 patients. Most (107 of 111) fractures healed within 6 months. Three patients with implant failure due to backing out of the screws healed after surgical revision. One patient had an infected nonunion with a poor result. The other 110 patients had good results. No implant breakage was noted. No other major complications were noted except for 1 deep infection. No bone graft was needed, even with comminution at the fracture site. Of the 107 patients with uneventful union, 82 had hardware removal. The other 25 were diagnosed as having union both radiographically and clinically and did not have their hardware removed. Overall, 95% of patients were satisfied with the surgical procedure. We suggest that a semitubular plate with 4.5-mm cortical and 6.5-mm cancellous screws with wire augmentation if necessary is a reliable procedure for acute severely displaced or comminuted midclavicular fractures.