Evidence Based Analysis of Removal of Orthopaedic Implants in the Pediatric Population

Author(s): Raney EM, Freccero DM, Dolan LA, Lighter DE, Fillman RR and Chambers HG

Source: J Pediatr Orthop 28:701-704, 2008.

Summary:

There remains considerable controversy regarding the routine removal of Orthopaedic implants in the pediatric population.  In an attempt to obtain evidence, the Pediatric Orthopaedics Society of North America (POSNSA) requested the evidence based medicine committee to review the available literature. 

The committee searched the English literature for articles discussing Orthopaedic implant removal.  Implant retention was also searched.  The search engines reviewed articles back to 1950.  A total of 110 articles were found and 28 were deemed pertinent for this review.  There was not a single article with evidence level 1, 2, or 3.  Therefore, a true meta-analysis could not be performed. 

The results’ summary showed that there is no high level evidence to promote or refute routine implant removal.  The overall complication rate for implant removal is 10%, but the majority involved slipped capital femoral epiphysis screw removal.  When this is excluded the overall complication rate drops to 6%. 

There was a variety complications associated with routine implant removal.  These include fracture, infection, hematoma, wound dehiscence and/or failure to remove the entire implant.  As stated previously, this was most common in removal of screws for slipped capital femoral epiphysis.  There were no prospective studies regarding the long term retention of implants in the pediatric Orthopaedic literature. 

There were some observations gleaned from the literature review.  Malignancies related to Orthopaedic implants are infrequently reported and impossible to confirm causation.  Late infections have been infrequently reported primarily after spine fusion.  Lastly, retention of forearm plates reduces fracture risk in adults, but this observation has not been replicated in children.

There has also been the question regarding systematic spread of ions and allergies.  The literature shows some increased levels of variety of metals following spinal surgery.  However, there is no method to prove that these ions lead to future problems.  There is also a question regarding sensitivity to nickel and chromium, which has been estimated at 1 and 15 percent.  However, these studies have been done on skin, which may or may not be equivalent to generalized sensitivity. 

In summary, this study reviewed the entire literature and showed no high level evidence to support or refute routine implant removal.  The major and minor complication rate for all reported pediatric Orthopaedic implant removal, excluding that from slipped capital femoral epiphysis, was 6%.  The authors encourage better systematic review of patients to allow for higher level of evidence regarding routine implant removal.