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More on Plates, Pins, Rods and Screws

*** One the commonest searches to this site asks about removal of implanted plates, rods and screws.

There is no single answer, and I have therefore mixed fragments of letters received with responses.

 

I have had a steel plate inserted on my radius and my NHS consultant insists that this plate is permanent.

He became angry with me when I asked him questions, and refused to discuss it further.

 

***It is not for him to get angry if you ask an entirely reasonable (and common) question. There are a number of parameters people could use in deciding which surgeon should be entrusted with their treatment, and this approach (in my book) would be exclusionary.

 

Based on a week of internet research it seems many athletes or people simply uncomfortable with permanent implants, have the plate and screws removed after a year or two.

My consultant insisted that this was not orthodox practise and that if I could find a UK surgeon willing to do this it would be a “WALLET BIOPSY”

 

***It is possible that in some countries the load on the hospital resources precludes relatively non-urgent surgery. Britain is not one.

My experience is the main reason why many salaried surgeons are disinclined to remove plates is lethargy: Another form of income abuse.

 

My surgeon told me that there was too great a risk of infection or of nerve damage by operating later to remove the plate,

 

***This response reflects an unacceptably high infection rate in the milieu in which he works, and lack of technical competence. Risks exist, but this generalisation is simply not true: He is trying to intimidate you with a variation of “techno talk”.

 

My surgeon said that he had just been to a seminar by Swedish experts and that leaving metal plates in is the world standard orthodox method.

 

***This is also not true. It is correct that at times it is appropriate to leave plates in for a large variety of reasons, but I have given some reasons which make it appropriate to have plates removed on another page. In many situations the presence of implants causes significant morbidity (particularly when they are not optimally inserted) and removal becomes imperative. In the last week I have seen a patient with a tibial nail which protruded from below the knee cap, preventing kneeling when working as a tiler. Another had a femoral intermedullary nail catching his gluteal muscles, forcing him to use crutches. Once the bone has healed both implants need removal.

 

***The desirability of not leaving foreign material implanted is demonstrated by the large industry which manufactures “bio-absorbable” implants.

 

Can you comment on this? http://www.ejbjs.org/cgi/reprint/70/9/1372.pdf

 

*** This incidence is significantly higher than in my experience with far larger numbers than the documented groups. It seems clear that many of these breaks were not united to the point of structural certainty. The post-operative instructions to protect the limb (i.e. no contact sport) for at least a year following removal may not have been clear. In http://www.ejbjs.org/cgi/reprint/70/9/1372.pd   figure 2 demonstrates a failure to rotationally correct both breaks, predictive of delayed union and permanent alteration of the design structural strength. Figure 3 demonstrates a “cross-over” fracture which requires meticulous realignment and compression.

 

 

 

Can you confirm that removal of my recently inserted plate is not one that I need to decide upon for some years?

 

*** The plates in your arm have a temporary role – purely to hold the bones in place whilst they heal. Once the bone is healed they are redundant. There are no “fixed dates”, and once bone is healed removal is often determined primarily by convenience.

 

The late sequelae of temporary implants divide into two –

  1. Symptomatic (perceptible discomfort, including aesthetic discomfort)
  2. Hidden hazard.

 

A guideline in elective orthopaedic surgery is that the patient seldom needs to consider whether to have or not have the surgery for symptomatic implants as a cognitive exercise. I suggest to my patients that they initially ignore the condition because the answer will usually arrive subliminally. One day the decision  “this is enough – I want it fixed” occurs spontaneously.

The degree of “hidden hazard” which a retained implant carries must be the assessment of a skilled and experienced orthopaedic surgeon.

 

It is disappointing when some surgeons retain “absolute rules”. Nothing is absolute in medicine, and the superior surgeon is constantly looking sideways, anticipating, benefitting from or guarding against the exceptions. By far the majority of medical errors result from unfounded assumptions. Tragically many unfounded assumptions are held in place by that ilk of person who has delusions of supremacy (arrogance if you like) or inferior perspectives resulting from poor training, incompetence, and defensiveness.

 

It would have been expected (at least by some of us) that your surgeon would have voluntary discussed, from the outset and without prompting, the sequelae of having foreign material implanted into your body. It is your body that he transgressed into, and it is you who carry potential sequelae.

 

Incidentally, to say that you will “recover fully” is not correct. Where forces are great enough to break bone the more vulnerable overlying or adjacent soft tissues will be injured. Damage to muscle heals by scar, an inadequate substitute tor the original tissue. Scar cannot contract voluntarily, and instead shortens progressively, inhibiting some functions. Structures which formerly slid or moved one over the other in a fluent and rapid motion often become bound to adjacent structures as a result of the injuries. Scar often gives the “cold syndrome”. Small nerves and blood vessels might be irreparably damaged. Even bruising is not without (perhaps minor) long term sequelae.

Similarly, the surgical injury will produce the same effects – more so if the surgeon is rough and crude in handling tissues, or is inept in designing and effecting the optimal surgical approach to the target. This is reflected in post-operative pain, indicative that damage of some significance has occurred, eventually causing the above sequelae. You might like to see the page on “painless surgery” on my web.

 

The surgeon who objects to internet enquiry by his patients is demonstrating poor self esteem wrapped in stupidity.

 

I read that nerve damage happened most often when junior doctors or locum surgeons removed plates.

My consultant denied this and said that even the most experienced surgeon could not operate safely and avoid damaging a nerve encased in scar tissue from the first operation.

 

***Scar does make the anatomy less obvious. However it is not difficult to visualise the nerve in normal tissue adjacent the scar, and dissect it out. Optical magnification, to my mind is mandatory (but not customary in the NHS)

Incidentally the locum surgeon could well, at times,  be better than the tenured consultant

 

 

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5 Responses

  1. hello should i be made to work i have perminent pins and plates in my right knee joint i have had them there for 18years my sergion warned me not to break it again as it will be nothing he can do he said the break is one of the worst breaks you can have as it was the bottom part of my knee jiont

  2. I have 3 metal plates in my legs with many screws, and one rod down my femur wrapped with Kirschner wires to prevent the femur from splitting more due to the rod being pounded through the center of the bone. It has been over 5 years since they were placed in my body and weather does affect my pain level, moist foggy mornings make me feel more achy, when it is cold outside my body gets cold and due to circulation I have to use a heating pad or take a hot shower to warm my body up expecially my feet. I feel pinching in my upper thigh from the wires at different times making climbing stairs torcher and so I have to use my other leg to go up each stair and just drag the other behind. I am unable to kneel with plates and screws just under skin and I can not squat down because of impaired range of motion and one leg is now shorter and a little bowed out causing my hips and lower back discomfort having to compensate. I get radiating pain up my arms and down my legs and at times I feel as if I want to chop my legs off because my body responds to all of the metal as something foreign and wants to reject them and this is at night, drives me crazy, it is like restless leg syndrome but medications for that do not work for me nor does meds for nerve damage the only thing that does seem to help is pain medications they help me sleep and make getting up and walking around tolerable, I at times use topical creams and sprays that help with pain and movement but they smell very strong and hard to wash off hands.

    • Nicole, it is sad that you have had this long residue from your accident. What you say serves to answer the letter from davisspine on this site (2010/10/03 at 11:35 pm).
      It is likely that your bone has healed by now, which should be checked radiologically. If so, there are good reasons for removing some or all of the implanted metal, which might help you considerably.

  3. I have had 2 plates and 15 screws implanted in my knee. My Dr. says I will have to keep them in for life is that necessary? Also will weather affect the metal in my leg? What can I expect 5-10 years down the road in regard to pain and function?

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