Removal Of Implants Research Articles

Metal implants in children.

Metal implants are increasingly used in children for trauma and deformity correction. This review outlines the current knowledge on the types of metals used and explores reasons for removal and the potential for long-term health issues of metal implants. The literature pertaining to these aspects was studied and summarised in this review. Types of metals used have evolved as well as the development of children-specific implants. Improvements in deformity correction are measurable with likely improved outcomes and reduced health costs. Indications for metal implant removal following successful treatment remain ill-defined; however, the risks of removal are known with a minimum 6% complication rate. Health costs could be reduced by around 6% by judicious decisions to leave metal in place. Implant removal should only be encouraged in the presence of infection, mechanical failure or symptoms that are truly attributable to the implant. In the domain of spinal implants, there is evidence of significant metal ion release, most notably titanium which remains elevated to many times baseline levels beyond 2 years. The detection of titanium at low levels requires special techniques. The long-term health effects on patients and/or their offspring are not well defined, although well described in animal models. The risks of metal removal are significant. Clinicians need to be aware of potential health risks in the use of metal implants and the potential for covert toxicity effects in children especially with their long life ahead. There is a need for greater awareness of metal alloy composition and implant design to minimise risks. Level V.

A good index surgery for congenital pseudarthrosis of the tibia minimizes complications following surgery.

Congenital pseudarthrosis of the tibia (CPT) has traditionally been a difficult condition to treat, with high complication rates, including nonunion, refractures, malalignment, and leg length discrepancy. Surgical approaches to treatment of CPT include intramedullary rodding, external fixation, combined intramedullary rodding and external fixation, vascularized fibular graft, and most recently cross-union. The current study aims to compare the outcomes and complication rates of cross-union versus other surgical approaches as an index surgery for the management of CPT. Our hypothesis was that a good index surgery for CPT achieves union and minimizes complications such as refractures and limb length discrepancy. A multicentre study was conducted involving two institutions in Singapore and China. All patients with CPT who were surgically managed between January 2009 and December 2021 were included. The patients were divided based on their index surgery. Group 1 included patients who underwent excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for their index surgery. Group 2 included patients who underwent all other surgical procedures for their index surgery, including excision of hamartoma, intramedullary rodding, and/or external fixation, without cross-union of the tibia and fibula. Comparisons of the rates of union, refracture, limb length discrepancy, reoperations, and other complications were performed between the two groups. A total of 36 patients were included in the study. Group 1 comprised 13 patients, while Group 2 comprised 23 patients. The mean age at index surgery was four years (1 to 13). The mean duration of follow-up was 4.85 years (1.75 to 14). All patients in Group 1 achieved bony union at a mean of three months (1.5 to 4), but ten of 23 patients in Group 2 had nonunion of the pseudarthrosis (p = 0.006). None of the patients in Group 1 had a refracture, while seven of 13 patients who achieved bony union in Group 2 suffered a refracture (p = 0.005). None of the patients in Group 1 had a limb length discrepancy of more than 2 cm, while ten of 23 patients in Group 2 have a limb length discrepancy of more than 2 cm (p = 0.006). In Group 1, four of 13 patients had a complication, while 16 of 23 patients in Group 2 had a complication (p = 0.004). Excluding removal of implants, four of 13 patients in Group 1 had to undergo additional surgery, while 18 of 23 patients in Group 2 had to undergo additional surgery following the index surgery (p = 0.011). A good index surgery of excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for CPT achieves union and minimizes complications such as refractures, limb length discrepancy, and need for additional surgeries.

Ultrasound-guided minimally invasive removal of deep contraceptive implants: outcomes and challenges.

Contraceptive arm implants, such as Implanon NXT®/Nexplanon®, are reversible methods of birth control that have gained global popularity, with over 20 million worldwide users. While palpable implants can be easily removed, deep or non-palpable implants pose complications during extraction, often requiring open surgery. This ultrasound-guided removal technique offers a minimally invasive, safe, and effective alternative, providing real-time control over the implant and neurovascular structures. Our study aims to evaluate the effectiveness and challenges of this implant removal method. In this retrospective observational study, all cases referred to our institution for ultrasound-guided removal of contraceptive implants, from June 2022 to December 2023, were reviewed. Our facility serves as a referral center for handling challenging implants. Twenty-nine women with contraceptive implants were referred for implant removal in this period of time. Thirty implants were sent for removal in total (one patient had a double implant). Data specific to the patients were collected: age and body mass index (BMI). Data specific to the implant were also collected: time since implant insertion (months), history of a previous removal attempt, type of implant (single or double rod), implant palpability, laterality of the implant, supra or subfascial location, success or failure of the ultrasound-guided removal procedure and presence of complications in the post-procedure. Statistical analysis was conducted to determine the relationship between the procedure success rate and these variables, and also between these variables and the supra or subfascial location of the implant. Twenty-six of the 30 implants (86.67%) were successfully removed with this fully ultrasound-guided technique. In cases where the implant could not be removed, there was a higher rate of subfascial implant location (75%), while in cases where the removal was successful, the rate of subfascial implant location was significantly lower at 19.23% (P=0.048). Patients whose implants could be removed had a median BMI of 23.71 kg/m2, which was higher than the BMI of patients whose implants could not be removed (20.82 kg/m2), with a P=0.022. No complications were registered. Percutaneous real-time ultrasound-guided implant removal is effective, safe and offers a minimally-invasive alternative to open surgery. The removal of subfascial implants is also feasible but more challenging, leading to a reduction of success rate in this group. These positive outcomes suggest its potential as a standard initial approach for deep contraceptive implant removal.

Indications, outcomes, and complications of orthopaedic implant removal: a prospective observational study

Background: Orthopaedic implant removal is a common procedure, but its indications and outcomes remain debated. This study aimed to examine the indications, outcomes, and complications of implant removal in a tertiary care center. Methods: A prospective observational study was conducted on 66 patients undergoing implant removal between February 2022 and February 2024. Patient demographics, indications for removal, time to removal, and complications were recorded. Follow-ups were conducted at 6 weeks, 3 months, and 6 months post-removal. Results: The study included 47 males and 19 females, with 74% adults and 26% paediatric patients. Pain was the most common indication for removal (42%), followed by elective removal (36%). Most implants (33%) were removed after 2 years. Complications were minimal, with 4.5% incomplete removals and 1.5% failure to remove. No intraoperative fractures or postoperative infections were observed. Patients generally reported improvement in symptoms or psychological well-being following implant removal. Conclusion: Implant removal should be approached selectively, with careful consideration of indications and potential complications. Pain relief and improved function were common outcomes, but risks such as incomplete removal should be considered. The study supports individualized decision-making in implant management, emphasizing the need for thorough preoperative planning and skilled surgical execution.

Removal of the Metaphyseal Screw From Tension Band Constructs After Hemiepiphysiodesis: High Rates of Physeal Tethering and Subsequent Implant Removal.

Removal of the metaphyseal screw from tension band plate constructs after correction of angular deformity in patients treated with hemiepiphysiodesis has been suggested as an alternative to removing the plate and both screws. While this has the potential benefit of easier implant removal and reinsertion in the event of rebound, there is debate in the literature regarding the benefits and risks of leaving the epiphyseal screw and plate in place. Patients treated with hemiepiphysiodesis at the distal femur and/or proximal tibia with tension band plates and screws who underwent subsequent removal of the metaphyseal screw after correction were included. Charts and radiographs were reviewed for the need for metaphyseal screw reinsertion, subsequent removal of deep implants, and evidence of physeal tethering. Tethering was defined as progressive overcorrection in the treated bone segment after removal of the metaphyseal screw with the mechanical axis moving one full mechanical axis zone or more. Patients with tethering were compared with those without. A total of 215 patients with 387 limbs treated met inclusion criteria. Of those, 175 patients were treated for idiopathic genu valgum, while 40 were treated for other conditions. Fifty-nine individuals (27%) underwent replacement of the metaphyseal screw for repeat angular correction. Fifty-one percent of patients underwent secondary procedures for reasons other than metaphyseal screw reinsertion (74 symptomatic implant removal, 7 elective implant removal, 29 due to tethering). There were 44 cases of tethering in 36 patients (17%). In cases of tethering, 7 patients were treated with observation, 11 with implant removal only, 16 with hemiepiphysiodesis on the opposite side, and 2 with osteotomy. Patients with tethering were significantly younger, more likely to be male, and more likely to have had the metaphyseal screw removed more than once (P < 0.05). Removal of only the metaphyseal screw after hemiepiphysiodesis has high rates of tethering and further surgery for iatrogenic deformity correction and implant removal. This technique is not recommended. Therapeutic Level III, case-control study.

12372 A Rare Case Of Silicon Granulomatosis Induced Hypercalcemia In A Transgender Female

Abstract Disclosure: O.A. Aluko: None. I. Singh: None. Introduction: Hypercalcemia has been described in patients with most granulomatous disorders, of which sarcoidosis and tuberculosis are the most common. Granuloma formation is a rare, however well known complication of silicon implants and injections. We present a case of silicon granulomatosis induced hypercalcemia in a transgender female. Case Report 60-year-old transgender female, with past medical history of HIV on HAART was referred to Endocrinology for evaluation of hypercalcemia. She Bloodwork done a few weeks prior revealed elevated calcium 12.3 and low PTH of 9. Reported symptoms include worsening abdominal pain similar to prior gastritis flare, insomnia and significant weight loss. Denied any constipation, joint pain, mood changes, no history of bone fractures or kidney stones. Admitted to significant dairy intake - half a gallon of milk within 3 days and daily yogurt consumption. Endorsed inadequate daily fluid intake and she was not taking oral calcium or Vitamin D supplementation. Quit tobacco 9 years ago. Vitals were significant for tachycardia with HR 120/min, BP stable. Patient was referred to the ER for IV hydration and further evaluation with initial suspicion of malignancy. Repeat corrected calcium was 14.7, ionized calcium 6.8, PTHrP undetectable &amp;lt;2, borderline high 1,25 dihydroxyvitamin D 74.5, low vitamin D 17.9 and normal free T4 1.5. ACE, SPEP, UPEP levels within normal limits. Vitamin A low. CT chest/abdomen/pelvis revealed innumerable soft tissue foci in the subcutaneous adipose tissue of the flanks and lateral gluteal areas; nodular liver, suspected cirrhosis and portal hypertension. Imaging findings prompted further discussion regarding prior procedures. She endorsed history of silicone fillers in hips and breast implants 30 years ago. Images reviewed with radiology confirmed calcification around bilateral breast implants, with intracapsular rupture. Calcium improved with IV Fluids, bisphosphonates and steroids. The most probable cause of hypercalcemia was believed to be secondary to silicone granulomatosis. Innumerable granulomas were deemed irresectable, removal of the breast implants considered however not performed. She was later diagnosed with hepatitis B, cirrhosis and succumbed to sepsis and multiorgan failure. Conclusion Eliciting a detailed history, physical exam and correlating with imaging findings is imperative to establishing an uncommon diagnosis. PTHrP was low and there were no bony metastases making the possibility of malignancy related hypercalcemia less likely. FDG-PET if performed would reveal hypermetabolic nodules, often an initial indication to the underlying etiology. Presentation: 6/2/2024

The impact of cosmetic tourism across one year on an NHS breast surgery unit

BackgroundThis is a review of patients managed by our single-site breast surgery service for complications of cosmetic surgeries performed abroad and within the UK, across September 2022-2023. MethodsA retrospective review of outpatient clinic and emergency theatre lists was used to identify patients; data was collected from their electronic records. Results25 patients (23 female) were identified, 20 had surgery abroad. Turkey was the most common destination that patients travelled to (n=15), with bilateral breast augmentation being the most common procedure (n=15). Post-operative infection and wound dehiscence (n=10 and n=8 respectively) were the most common complications; 72% (n=18) of patients presented within 8 weeks of their surgery. There was incomplete recording of surgical details including precise date (recorded for 48%), clinic name (8%), and name of the surgeon (0%). 17 microbiological samples were sent, with 11 resulting in a named organism - Staphylococcus Aureus was most common (n=5). 17 (68%) cases were treated conservatively, without radiological or surgical interventions. When surgical management occurred (n=6), it was for removal of breast implants (n=5) or evacuation of haematoma (n=1). The cost of managing these complications was at least £37,000. ConclusionComplications from cosmetic tourism present more commonly to the NHS than those resulting from private surgery performed in the UK. This has significant financial implications for the NHS. More accurate recording of relevant data, engagement in audits, and disseminating findings may help raise awareness of the risks and complications of cosmetic surgery performed abroad.

Ankle Fractures Treated with Locked Fibular Intramedullary Nailing: Description and Outcomes of a Minimally Invasive Open Technique

OBJECTIVES: To describe and report outcomes of a minimally invasive open intramedullary (IM) fibular nailing technique for fixation of ankle fractures. METHODS: Design: Case Series Setting: Urban Level 1 trauma center Patient Selection Criteria: Adult patients with ankle fractures (OTA 44A-C) treated with locked fibular IM nailing via a minimally invasive open technique for fracture and syndesmotic reduction between 2021 and 2024. Outcome Measures and Comparisons: Quality of reduction, complications, and patient-reported outcomes (PRO). RESULTS: A total of 150 consecutive patients operated by a single surgeon were included. Mean age was 53.3 (17-97) years, and mean BMI was 30.6 ± 7.4 kg/m2. 93(62%) patients were female, and 78 (52%) patients were Caucasian. 72 (48%) patients were obese, 40 (27.7%) patients were current/former smokers, 39 (26%) patients were diabetic, and 23 (15.3%) patients had open fractures. 37 (24.7%) patients had isolated lateral malleolus fractures, 48 (32%) had bimalleolar fractures, and 65(43.3%) had trimalleolar fractures. 123 (82%) patients had 2 syndesmotic screws placed, 26 (17.3%) had 1 screw, and 1 (0.7%) had none. Quality of reduction was good for 98%, fair for 2%, and poor for none per McLennan’s criteria. 113 patients (75.3%) were followed until clinical and radiographic union for a mean of 7.6 months (range 3-22) months). 110 patients (97.3%) went on to successful clinical and radiographic union following the index procedure. No patient had a superficial surgical-site infection, and 3 (2.6%) had deep surgical-site infections. 3 patients had a loss of reduction, and 6 patients had implant failure (5 broken syndesmotic screws, and 1 medial malleolus screw). 9 (8%) patients had unplanned reoperations (3 for debridement, 2 for loss of reduction, and 4 for removal of symptomatic implants). Mean ankle range of motion at final follow-up visit was 12.9° (0-40) of dorsiflexion, 39.6° (10-70) of plantarflexion, 23.5° (5-40) of inversion, and 18.2° (5-50) of eversion. Mean PROs at final follow-up visit were: Global Physical Health: 42.4 (23.5-67.6), Global Mental Health: 47.5 (21-67.6), Physical Function: 37.5 (14.7-57.8), Pain: 54.9 (22-72) and Mobility: 36.9 (16-65.3). CONCLUSIONS: Minimally invasive open fibular IM nailing allowed for excellent reduction and results in union with low rates of complications and good patient reported outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical complications after immediate implant-based breast reconstruction for breast cancer in women over 65 years.

While immediate breast reconstruction rates in breast cancer are increasing, they remain low in women over 65 years old. The aim was to investigate surgical outcomes in women older than 65 years receiving implant-based immediate breast reconstruction. The population-based Stockholm Breast Reconstruction Database includes all adult women with breast cancer receiving an implant-based immediate breast reconstruction in Stockholm, Sweden, 2005-2015. Primary outcomes within 30 days from immediate breast reconstruction were: infection requiring antibiotics and reoperation on. Implant removal was a secondary outcome. Women more than 65 years were compared with younger age groups. Chi-square tests and multivariable logistic regression were applied for the primary outcomes, and Kaplan-Meier analysis for the secondary outcome. Among 1749 cases of immediate breast reconstruction, 140 (8.0%) were in women more than 65 years. Median follow-up was 74 months (1-198). Postoperative infection was not more common in women older than 65 years old (22 of 140, 15.7%) than in women under 65 years old (303 of 1609, 18.8%; P = 0.221). Reoperation on was more frequent in women older than 65 years than in other age groups (more than 65: 8.6%; 50-64: 6.5%; 40-49: 3.5%; less than 40: 1.6%; P < 0.001), however, age older than 65 years was not an independent risk factor in the multivariable analysis (OR 1.00, 95% c.i. 0.44 to 2.28). Overall, 6-year probability of implant removal was 11.4%, (8.1% due to complications and 3.3% due to patient preference). There was no statistically significant difference between age groups for either reason (P = 0.085 and P = 0.794 respectively). Older age alone was not associated with worse surgical outcomes after implant-based immediate breast reconstruction in highly selected patients older than 65 years when compared with their younger counterparts.

Lateral open wedge tibial osteotomy for posttraumatic deformity

Correction of pseudoinstability and tibial malalignment by re-establishment of the pretraumatic tibial axis. Posttraumatic valgus malalignment accompanied by pseudoinstability. Infections, significant inhibition of movement and multidirectional ligament instability. Standard anterolateral approach to the proximal tibial head. Lateral open wedge high tibial osteotomy above (supra) the tibiofibular joint and opening until the pseudoinstability of the lateral collateral ligament is levelled. Partial weight bearing for 4weeks, after radiological control full body weight loading is allowed. Implant removal after full bony consolidation. There is limited evidence in the current literature but the available results show good results in 70% of the cases in long-term follow-up.

Removal of infected bone in-growth pelvic fixation implants and microcomputed tomography analysis of osseous integration: illustrative case.

A novel pelvic fixation screw fusion device (iFuse Bedrock Granite implant) was designed to promote bony fusion through self-harvesting fenestrations throughout the outer screw shank. Bone on-growth and in-growth using this design have been demonstrated in a sheep model, but data from human subjects have not been reported. A 66-year-old medically complex female with 2 prior spine fusions developed spondylodiscitis cephalad to a prior fusion, requiring the removal of instrumentation, which included screw fusion devices. Within this case report, the authors present a novel bone-preserving technique for the removal of well-fixed screw fusion devices. One screw backed out with a driver, and the other 3 had to be trephined out. One screw sheared off the T30 torque driver, implying a removal torque greater than 270 inch-lbs (30.5 Nm). In addition, the removed implants were analyzed using microcomputed tomography (micro-CT) and demonstrated bone on-growth, in-growth, and through-growth in all 4 screws. Micro-CT clearly demonstrated osseous integration of the screw fusion devices and provided significant support for the use of these implants for lumbopelvic fixation. The authors' hope is that the novel bone-preserving technique will help other surgeons when faced with the difficult removal of well-fixed screw fusion devices. https://thejns.org/doi/10.3171/CASE24274.

Iatrogenic Intraoperative Fracture in Patients With Osteogenesis Imperfecta.

Osteogenesis imperfecta (OI) is a genetic defect in collagen type I, phenotypically characterized by bony fragility and a propensity to high rates of childhood fracture. Fragility fractures in patients with OI have been reported with routine hospital care. In addition, there is a nonzero rate of iatrogenic fracture during orthopaedic surgery directly related to the technical steps of the procedure itself. The rate of this latter has never been explicitly investigated. A review of all patients at a single OI referral center was conducted, including all patients with a diagnosis of OI seen between 2013 and 2023, inclusive. All patients who underwent orthopaedic surgery of any kind were reviewed, and clinical and radiographic details of all procedures were extracted. Among the details examined were the OI subtype, surgery details, any implants used, intraoperative and hospital stay complications, modified Clavien-Dindo classification of complications, and ultimate outcome. Eleven of 60 patients experienced an unplanned, iatrogenic intraoperative fracture during orthopaedic surgery (11/60 = 18.3%). This comprised 15 fractures among 356 total orthopaedic surgical episodes (15/356 = 4.2%). All but one fracture occurred on the operative long bone segment, all were a direct result of surgical steps, and 11 of 15 fractures occurred in the femur. Most fractures were secondary to the removal, insertion, or exchange of intramedullary implants in the lower extremity (11 of 15 fractures), most often the femur. Thirteen of 15 injuries were classified as modified Clavien-Dindo II or III, requiring modification of postop rehabilitation, additional treatments, or surgical intervention (87%). Overall, iatrogenic fracture was the most common intraoperative complication experienced in the cohort. Iatrogenic fracture during orthopaedic surgery for patients with OI is not uncommon. A sizeable minority of patients with OI undergoing orthopaedic surgery will experience unplanned fractures, most commonly in the femur, and care is altered in most instances. The risk of intraoperative fracture can be discussed with families of children with OI as part of informed consent and shared decision-making. Level IV-retrospective cohort series.

Posterior Malleolus Fracture Fixation In Lateral Decubitus Position: Surgical Technique and Results in 60 Patients

The present study shows how posterior malleolus fractures (PMFs) and distal fibular fractures were fixed using the posterolateral approach with the patient in lateral decubitus position, not previously described in the literature. This technique has been used in 60 consecutive patients (42 women and 18 men; mean age 54.7; range 21-92 years), 33 of which presented as fracture dislocations from March, 2021 to December, 2023. After PMFs fixation in lateral decubitus position, release of the sacral support allowed patients to be placed supine (without de-sterilizing the operative field), in order to proceed with medial malleolus or posteromedial fragment fixation. Fractures were classified according to the Lauge Hansen classification as SER4 (n = 50), PER4 (n = 7), SAD (n = 1), and PAB (n = 2). Fractures were classified according to Rammelt & Bartonicek, as type B (n = 40), C (n = 13), and D (n = 7). During the same period of time 14 fractures involving the PM, classified as type A, were treated with indirect fixation, whilst 6 geriatric and/or poor mobility patients with fracture dislocations were treated with retrograde hindfoot nail fixation. Follow-up period ranged from 4-36 months (mean = 14.4; SD = 8.8). Complications occurred in 5 patients (8.3%; 3 had delayed (medial) wound healing, one developed CRPS and one required implants removal and arthroscopy because of metal irritation and stiffness). No deep infections, thromboembolic events, fracture malreductions or malunions were recorded and all patients returned to the preinjury mobilization status. In conclusion, PM fracture fixation was feasible and safely performed with patients in lateral decubitus position.

Successful surgical management of a Salter-Harris type I fracture of the accessory carpal bone in a dog.

To describe the successful surgical management of a previously unreported Salter-Harris type I fracture of the accessory carpal bone in a dog. An 11-week-old intact female Golden Retriever-Poodle cross presented with a history of a marked left forelimb lameness following a suspected fall from a height. On physical examination, the patient demonstrated a severe left forelimb lameness and pain on palpation and range of motion of the left carpus. Orthogonal radiographs of the distal left forelimb demonstrated a type I Salter-Harris fracture of the accessory carpal bone with proximal displacement of the palmar fragment. The patient underwent open reduction and internal fixation wherein the fracture was reduced and stabilized with two 1.1-mm Kirschner wires. Postoperatively, the patient was initially managed with a carpal flexion bandage for 2 weeks and then a soft padded bandage was maintained until 4 weeks postoperatively. The patient recovered well and was walking and weight-bearing comfortably following removal of the carpal flexion bandage. Repeat radiographs performed 4 and 8 weeks postoperatively demonstrated adequate fracture healing but showed mild proximocaudal implant displacement. Implant removal was not performed, as the patient was doing well at home and the implant migration appeared static and was not causing clinical morbidity. To the authors' knowledge, this was the only reported case of a Salter-Harris fracture of the accessory carpal bone in a dog and the only described case of successful surgical stabilization.

Characterization of Cochlear Implant Artifact and Removal Based on Multi-Channel Wiener Filter in Unilateral Child Patients.

Cochlear implants (CI) allow deaf patients to improve language perception and improving their emotional valence assessment. Electroencephalographic (EEG) measures were employed so far to improve CI programming reliability and to evaluate listening effort in auditory tasks, which are particularly useful in conditions when subjective evaluations are scarcely appliable or reliable. Unfortunately, the presence of CI on the scalp introduces an electrical artifact coupled to EEG signals that masks physiological features recorded by electrodes close to the site of implant. Currently, methods for CI artifact removal have been developed for very specific EEG montages or protocols, while others require many scalp electrodes. In this study, we propose a method based on the Multi-channel Wiener filter (MWF) to overcome those shortcomings. Nine children with unilateral CI and nine age-matched normal hearing children (control) participated in the study. EEG data were acquired on a relatively low number of electrodes (n = 16) during resting condition and during an auditory task. The obtained results obtained allowed to characterize CI artifact on the affected electrode and to significantly reduce, if not remove it through MWF filtering. Moreover, the results indicate, by comparing the two sample populations, that the EEG data loss is minimal in CI users after filtering, and that data maintain EEG physiological characteristics.

Use of an Osseointegrated Intraosseous Transcutaneous Amputation Prosthesis for Amputated Fingers Is Followed by Frequent Infection and Implant Removal

ABSTRACT Introduction We report on the outcomes of using a custom-built osseointegrated (OI) intraosseous transcutaneous amputation prosthesis (ITAP) as a bone anchor for prosthetic reconstruction of a series of amputated fingers. The aim of ITAP was to reduce the risk of failure due to infection by creating a biological seal at the skin-implant interface. Methods and Results A total of 14 patients who suffered from amputations of their digits at a variety of different levels were recruited. Eleven patients (20 implants) underwent treatment with an implant based on the ITAP principle. With the exception of one patient (1 implant), all implants were removed by 9 years after insertion. Patients requested removal because of recurrent infections, exposure of the flange structure (unique to ITAP), loosening of the implant, and inability to secure a prosthesis to the implant. Conclusions The ITAP principle does not work when used as part of the design of an OI bone anchor for prosthetic reconstruction after finger amputation. Clinical Relevance Statement This study suggests that there are major problems with the principles underlying the design of the ITAP implant when used in humans. Future studies of OI implants using the principles of ITAP may be at risk of similar problems.

Technical Pearls and Pitfalls of Facial Feminization Surgery: A Review of Techniques From a Single Institutional Practice.

Facial feminization surgery (FFS) is an emerging practice that falls under the broader umbrella of gender-affirming surgery. Various approaches exist to feminize the face, yet few published articles describe in detail the techniques of each component procedure. Considering the diversity of interventions employed, the objective of this manuscript is to highlight FFS techniques utilized by the senior author and create a corresponding media gallery. All patients with the diagnosis of gender dysphoria that were referred to the senior author for FFS consultation between June 2017 and August 2022 were reviewed. Data were retrospectively collected from electronic medical records according to the institutional review board (IRB)-approved study protocol. Data collected and analyzed included demographics, operative documentation, and postoperative follow-up. Multimedia material was collected intraoperatively and postoperatively. A total of 231 patients underwent 262 operations with a total of 1224 FFS procedures. The average follow-up time was 7.7 ± 11 months. Out of the 262 operations, 24 (9.2%) patients experienced minor complications, including 3 (1.1%) with wound dehiscence, 13 (5.0%) with hematomas, and 14 (5.3%) with postoperative infection requiring antibiotics. Of those, 3 (1.1%) required a return to the operating room for washout or removal of malar implants. Although there is a consensus on the fundamental surgical principles to achieve adequate feminization of the facial architecture, the specific techniques to do so differ according to individual practices. As techniques diverge, so do their risk profiles and outcomes; techniques must, thus, align with patients' interventional goals. The material presented here is one of many that can support trainees and junior surgeons as they build a gender-affirming practice.

Removal of uncemented components: hope for the best, prepare for the worst-technical tips and tricks.

Removing well-fixed uncemented components can be challenging. With thoughtful surgical planning, appropriate surgical instruments, and proper surgical techniques, most implants can be removed expeditiously with little bone loss and minimal impact on the subsequent reconstruction. Preoperative planning is one of the most essential steps to remove uncemented implants. Obtaining previous surgical records, although tedious, should always be attempted preoperatively to determine if specific instruments will be required and to help anticipate which steps may need special attention. These include the presence of ceramic or metal bearings and the presence of acetabular screws or stem collars. Without proper preparation and available tools, the removal of implants can negatively impact the subsequent reconstruction and patient outcomes. We will describe techniques and practical tips for removing uncemented stems from the top (intramedullary) or transfemoral using an extended trochanteric osteotomy. We will also describe techniques and tools to remove uncemented acetabular shells efficiently. Case examples will highlight these clinical situations where careful planning is necessary and potential problems that may be encountered with the recurring theme of preparing for the worst but hoping for the best. We have also included cases such as removing well-fixed cementless collared stems, broken stems, and fully coated stems.

Multicenter, Prospective, Observational Study of Nonoperative Versus Operative Treatment for High-Energy Midshaft Clavicle Fractures.

Evaluate if nonoperative or operative treatment of displaced clavicle fractures delivers reduced rates of nonunion and improved Disability of the Arm, Shoulder, and Hand (DASH) scores. Multicenter, prospective, observational. Seven Level 1 Trauma Centers in the United States. Adults with closed, displaced (100% displacement/shortened >1.5 cm) midshaft clavicle fractures (Orthopaedic Trauma Association 15.2) were treated nonoperatively, with plates and screw fixation, or with intramedullary fixation from 2003 to 2018. DASH scores (2, 6 weeks, 3, 6, 12, and 24 months), reoperation, and nonunion were compared between the nonoperative, plate fixation, and intramedullary fixation groups. Four hundred twelve patients were enrolled, with 203 undergoing plate fixation, 26 receiving intramedullary fixation, and 183 treated nonoperatively. The average age of the nonoperative group was 40.1 (range 18-79) years versus 35.8 (range 18-74) in the plate group and 39.3 (range 19-56) in the intramedullary fixation group (P = 0.06). One hundred forty (76.5%) patients in the nonoperative group were male compared with 154 (75.9%) in the plate group and 18 (69.2%) in the intramedullary fixation group (P = 0.69). All groups showed similar DASH scores at 2 weeks, 12 months, and 24 months (P > 0.05). Plate fixation demonstrated better DASH scores (median = 20.8) than nonoperative (median = 28.3) at 6 weeks (P = 0.04). Intramedullary fixation had poorer DASH scores at 6 weeks, 3 months, and 6 months than plate fixation and worse DASH scores than nonoperative at 6 months (P < 0.05). The nonunion rate for nonoperative treatment (14.6%) was significantly higher than the plate group (0%) (P < 0.001). Operative treatment of displaced clavicle fractures provided lower rates of nonunion than nonoperative treatment. Except at 6 weeks, no difference was observed in DASH scores between plate fixation and nonoperative treatment. Intramedullary fixation resulted in worse DASH scores than plate fixation at 6 weeks, 3 months, and 6 months and worse DASH scores than nonoperative at 6 months. Implant removal was the leading reason for reoperation in the plate and intramedullary fixation groups, whereas surgery for nonunion was the primary reason for surgery in the nonoperative group. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Intercondylar T-Type Distal Humerus Fracture in a 10-Year-Old: A Case Report.

A 10-year-old, postmenarchal girl presented to the emergency department with a closed, displaced, intercondylar T-type distal humerus fracture. Open reduction and internal fixation was performed 3 days following initial presentation. The patient healed but experienced elbow stiffness in the 7 months following the procedure. Implant removal and capsular release were performed at that time. At the 31-month follow-up, the patient reported satisfactory elbow functionality. There is limited literature available discussing optimal management and associated outcomes of intercondylar T-type distal humerus fractures in the young-adolescent population. This report presents a possible method for management of the initial injury and the most common associated complication.