1 Introduction 759
1.1 Indications and contraindications for implant removal 759
1.2 Influencing factors on implant removal 760
1.3 Timing of implant removal 761
1.4 What the surgeon needs to know before implant removal 761
1.5 What the patient needs to know before implant removal 762
1.6 Should the implant be removed using a minimally invasive or a conventional open technique? 762
2 Preoperative assessments 762
2.1 General patient information 762
2.2 Analysis of x-rays 762
2.3 Instruments for implant removal 762
3 Operative procedure 764
3.1 Intraoperative complications and how to overcome them 764
3.2 Aspects of minimally invasive implant removal 764
3.3 Pitfalls and pearls 764
4 Complications 766
5 Postoperative management 766
6 References 767
Implant removal represents one of the most common operations in bone and joint surgery accounting for up to 30% of all elective orthopaedic procedures [ 1]. It is a procedure that results in an increase in various known morbidities, such as refracture rate, hematoma, operative time, and implant failure [ 2]. Previously listed criteria for implant removal include implant migration or movement, infection, or simply at the patient‘s request. Prophylaxis should also be considered with an aging population with possible future complications, such as removal of intramedullary nails in case of future joint replacement, or removal of fracture fixation implants to allow future insertion of dental stents in craniomaxillofacial surgery [ 3– 5]. While implant removal procedures are frequently considered simple, they can also be challenging [5, 6]. Therefore, implant removal should be a decision made only after careful examination of the medical and economic implications. Many surgeons see patients with inexplicable local symptoms and complaints which can be resolved after implant removal. However, implant removal requires a second surgical procedure in scarred tissue, with all the risks of an operation. Thus, when driven by pain alone, the procedure can sometimes have disappointing results, and patients’ expectations should be consequently moderated. Protection against toxicity, allergy, carcinogenesis, or possible implant failure should not prompt systematic removal. Implant removal in children should be considered separately, since metal implants can sometimes interfere with normal growth patterns. Overall, implant removal should not be considered a routine procedure and indications for surgery should reflect a thorough examination of the risks and benefits.
Indications and contraindications for implant removal
There is still no controlled trial that would justify a valid trade-off between the benefits and detriments of implant removal and scientifically grounded counseling of patients. Indications for implant removal will differ with respect to the age and general condition of the patient, as well as to the location of the implant. For example, an implant left in the lower, weight-bearing extremities leads to different bone metabolism caused by the implant, and depending on changes of the biomechanical properties risks peri-implant failures [ 7], whereas the effects of an implant left in situ to the bone metabolism of the upper extremities may be insignificant. Current literature fails to offer systematic guidelines. The decision to remove an implant must be made after careful consideration of the risks and benefits of the procedure.
The following are considered straightforward absolute indications for implant removal:
Infection at implant site
Implant protrusion or intrusion into a joint
Nonstable fixations or loosening with build-up of fretting particles
Soft-tissue irritation, or prevention of free movement of gliding tissues, such as tendons
Allergic reaction to the implant
Nonunion with implant loosening or breakage
Malunion that requires removal for reconstruction
Obvious mechanical problems
Skin and soft-tissue irritation caused by a prominent implant
Exposure of the implant in the oral cavity
Perioperative implant failure
The uses of external fixator or K-wires are also absolute indications for removal because of the risk of pin-track infection or implant migration.
Relative indications for implant removal must be measured against the risks of leaving implants in place. These include:
Changes in the bone metabolism
Late infections by bacterial colonization
Skeletally immature patients
Prevention of postunion stress shielding
Prevention of bacterial colonization
Avoidance of difficult surgery owing to the potential for refracture or implant failure
Potential functional improvement with implant removal
Artifacts with later MRI and CT imaging
At the patient‘s request: for cosmetic reasons, pain, discomfort, protrusion under skin, (even visually), cold intolerance, patient‘s fear of carcinogenesis
An indication for implant removal is in most cases not obligatory and must be made on an individual basis with respect to and in consultation with the patient. The listed risks of leaving implants in place are relative indications and should not lead directly to a surgical procedure. One contraindication for implant removal is if the extent of the surgical procedure is extensive and the risk of complications are disproportionate to the benefits of the operation (eg, pelvis surgery). The decision to remove implants in elderly patients with comorbidities and the high risk of anesthetic complications, must be balanced with the severity of symptoms caused by the implant and the risk of removal.
Influencing factors on implant removal
Removal of an internal fracture fixation (IFF) device can be problematic, despite being generally considered as a “routine” procedure. A major cause of complication is the amount of excessive bone ongrowth and ingrowth in and around a device. In children, about 13% of complications are encountered during scheduled IFF device removal, which is related to the occurrence of excessive bone overgrowth on the device [ 8, 9]. When bone grows into the “dead” empty spaces of a device, such as through empty holes in a plate, between a screw thread and a plate, into a screw head, or into the interlocking holes in a nail, the surgeon may subsequently face a variety of problems during removal, such as implant breakage, implant-debris tissue contamination, bone refracture, nerve damage, or excessive blood loss ( Fig 26-1 ). Surface microtopography of an implant is a major determinant of both osteoblast (bone forming) cells [ 10] and actual bone tissue [ 11– 13] interactions with the implant. The influence of surface microtopography persists from the moment of implantation until a final tissue response has been completed, be that integration or encapsulation. With metal plates and nails surface microtopography does not appear to have an influence on infection susceptibility (within the ranges and current metals used in clinics) [ 14, 15]. For details as to what happens to the device surface upon implantation within the body from protein to cell adhesion, from local factor production and control of terminal osteoblast cell differentiation and subsequent bone formation, the reader is referred elsewhere [5, 10].
For a surface-provoked cell response to arise it is essential that the actual cells perceive the surface‘s microroughness. Hence, the dimensions of the surface need to be within the dimensions of an actual cell. There is an optimal range for a substrate-mediated cell response, the “effective roughness spectrum” within which cells and tissues will optimally react to a surface . Within this range osseointegration (direct bone-implant integration) will occur, which can impede device removal; whereas outside this range bone may approach the device yet will not osseointegrate and will ease device removal. With long-term or permanent metal implant devices, such as prosthetics, osseointegration is vital to their success. Consequently, many studies have focused on increasing osseointegration. However, this is not generally desired for trauma, including pediatric IFF, since many of these implants may have to be removed (due to the reasons outlined in 1 Introduction).
Microrough surfaces have been extensively identified as the most important determinant for bone osseointegration to clinically produced and used metals. Reducing the microroughness of these devices has been shown in vitro  to delay osteoblast differentiation and in vivo to reduce extraosseous formation and osseointegration, and accordingly ease of implant removal of cortex screws , locking compression plates (LCP) and screws [ 12], and intramedullary nails . Histological observations from certain studies [11–13] challenge the overall assumption that osseointegration is essential for implant stability. The challenge of this general assumption is supported by the lack of published data describing direct osseointegration for stainless-steel implants (checked by the team of RG Richards at the AO Research Institute, Davos) at the macro level, but not at the micro level (where it needs to be evaluated). Osseointegration is not required for IFF stability when using locked implant systems, since the stability is inherent from the device itself (when correctly implanted) . Reducing the microroughness of fracture fixation devices does not negatively affect bone apposition whereas microrough surfaces, as used currently in clinics, accelerate bone apposition. Reducing the surface microroughness with, eg, polishing, prevents long-term strong bone adherence. Thus, the combination of the reduced strength of matrix adhesion to smooth/polished samples with the slower rate of remodeling/apposition relative to standard microrough devices would directly reduce the occurrence of bone overgrowth/integration.
Current fracture fixation implants (locked plates or nails) achieve immediate stability through their design and consequently direct osseointegration is not required for their stability. The implants only require stability for the period of the biological fracture healing. Surfaces that do not encourage direct osseointegration, or surfaces that discourage protein and cell attachment and direct osseointegration, are preferred for such devices. This would also aid implant removal and help allow gliding tissues to freely move (nerves, tendons, muscles) over the implant surface. Future developments for IFF trauma implants should produce surfaces which discourage protein and cell attachment and biofilm formation in osteosynthesis implants.