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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41 Responses to “More on Plates, Pins, Rods and Screws”

  • I forgot to mentioned to you about my age. I'm now 66 yrs. old and very active in working and excercise. I have a 17 yrs foot surgery that they plant the 2 screw or plates in my left foot ankle and according to my doctor who moved already in United States my surgery was successful and said that's for a lifetime. But other people told me to removed the screw so it become normal. I'm only wondering despite the plates on my foot takes how many years still it was great but sometimes it's sore specially if the climate changes or if I hit my foot on walking that's the time it will be sore. Do I have to ask other doctor to removed the screw or plates in my foot? Actually, the doctor who put the screw told me my foot was a bad break its in the curve of my left ankle. So, up to know I don't know what to do? Hope I can get your advice.Thanks a lot.

    • jp:

      It seems that your problems are relatively infrequent, and intrude into your function minimally. There is no absolute reason to remove the implants. I suggest that you "live with" the very occasional discomfort (as I understand it). If matters worsen then removal should be relatively simple, with little convalescent down-time.

  • I have 2 plates or screw in my left ankle. I go the surgery in 1997 December 25.I fall in our basement in our lather where I hit my left foot that caused the fracture and broked my left foot ankle bone. During winter my left foot sometimes its sore but occasionally its only normal like other foot. Up to know I'm still working during night shift and when I use my left foot to press the machine it become sore but if I'm not working that machine it will go back into normal. I really want my plates or screw in my left foot since 1999 but i got second thought it might affect my walking if it will not successfully in removing the screw and build up some infections etc.So it means my foot is already 17 years but my walking still good and normal only once in a while there's a sore during the change of weather or climate and sometimes if it hits on walking around. What would you advice to me?

    • jp:

      You will have seen my reasoning in another letter. In your case the metal seems to be more intrusive, and justifies removal. The chance of infection are small, and full rapid recovery would be usual.

  • Denise:

    I had a PAO, periacetabular oseotomy, Jan. 29th of this year, 2014. I have noticed that on the cold days and the days with stormy/rainy weather I have increased pain. I also feel pain in the buttocks arrea that goes up into the hip. They put 4 screws in and I had x-rays done Monday and he bone is still healing. My surgeon said that a year after surgery, when the bone is completely healed, they broke the bone in 3 places, that he would be able to take the screws out. My question is, can the colder weather and rain is it common for people to have pain where they have screws? Thanks.

    • jp:

      Both implants and any injury to bone and connective tissue can react to weather changes (in some or many people) by unpleasant sensations - at times this is pain, more often an ache and on occasion feelings of warmth or cold. There are those who can predict a fall in barometric pressure by these sensations!

  • Emily:

    Hi my name is Emily. And back in august 2013 I fell onto some rocks 20-30 feet , I broke my pelvis in three spots , they put rods and screws where the fractures were. After that I healed great. Then I started getting this rash on my stomach , I went to the clinic and they said I could be allergic to nickel and to stop wearing my belt , and gave me cream to put on it daily , twice a day. But now a couple months later I still have the rash and it has gone from my stomach to my arms and legs. Also started getting the rash on my lower back on my scar , from when I had the surgery. I just recently found out that nickel is in some foods , so im trying to stay away from those foods. But I was curious if the rods and screws was made of nickel ?

    • jp:

      Nickel is a constituent of many types of steel. Because of that a reaction known as “nickel itch” can occur following metal implants in sensitised individuals. It is suggested that you ask the implanting surgeon to ask the manufacturers of the implanted metal whether there is nickel in the implants. Read more: http://www.lenntech.com/periodic/elements/ni.htm#ixzz2z9QSxxP6

  • Jakub:

    Hi I am 19 years old and I had a compound fracture in my humerus on Jan 20 2013. I had a plate put in my arm along with 18 screws. Now I am fully healed but whenever I put weight on my arm I feel pain. I tried to get the plate removed but anytime I asked my doctor he was hesitant to do so. He kept on telling me that the risks are high and that I may get radial nerve palsy. He told me that the risks are much higher to take the plate out because the scar tissue makes it harder to dissect out the nerve and because he would have to "peel the nerve off of the plate". He also told me that the the plate is slim and the same density as the bone so it shouldn't cause any problems and that surgery could make the pain worse. Along with the pain that came after the surgery my ulnar nerve subluxation got worse. At first my doctor agreed to do both the plate removal and the ulnar nerve transposition, but a week before the surgery he told me to come in for an appointment and he told me that he was not going to do the surgery. He said that he talked to 5 surgeons and they all said that it is too risky. Is it really as risky as he says it is? I have a feeling that he is making it seem much more risky then it is. He even got me to get a second opinion from a doctor that he works with, which I feel is completely biased. I also feel like it would be best to get the doctor who put the plate in to remove it since he already operated on me before hand and knows my situation best. The doctor however told me that he will not do the operation and I would have to go to a different doctor if I still wanted to remove the plate. Should I be worried about this?

    • jp:

      Surgeons do worry about these types of complications, perhaps excessively. The reason is the litigation climate, which has succeeded in driving out obstetricians and neurosurgeons from many States. Having said that you need to know why you have the pain, and whether it is in fact being caused by the plate. That is the question your surgeon must be asked, and ask himself. There are many clinical ways of making this diagnosis, which include selective local anaesthetization.

  • Daniela:

    Hi my son sustained the injury 7 months ago and they have booked him in to have the screw remove at 9 months. Thank you for your response

  • Daniela:

    Hello, my 13year old son had a Salter-Harris type 3 fixed with a screw, he is extremely athletic and is serious about training with the goal of one day playing soccer professionally. The surgeon said that at 13 they don't routinely remove screws but if I really want it they will. I don't want him to be at risk with the surgery but I feel that if they take it out now then he can recover and strengthen properly before starting contact sports ( currently training technique and athletics only). I'm scared that if he returns to playing serious soccer in the future he will be tackled and cause the screw to shatter the bone around it, rather than a clean break. Is this enough to justify the surgery or is there no concern about serious fractures with the screw still in the bone?

    • jp:

      You do not say how old was your son when he received the injury (or said another way how long has the screw been in place?). If it is a single screw then it can be removed with a tiny incision under local anaesthetic. That information might help you to balance the relevant merits. I presume that the screw went through the growth plate. There is a danger, since he is still growing, that such a screw will hold the bone on both side of the growth plate, effectively arresting epiphysis growth. I would have such a screw removed if it was my son, and the screw had been in for less than two years. Longer than two years, in a now 13 year old, the growth has probably already been arrested.

  • Sharon Stinson:

    I went to my family doctor. He is Internal Medicine. I explained I was hurting in my hip, I had a plate and srew in 2010. And I also could feel like when I turn that I could feel the plate move. His office called and said it looks like the screw and plate are working loose. And made an apointment with my surgent. Will they need to do a hip replacement? I am 58yrs old and I had a bone Dencidie test and if I fall I could break a bone

    • jp:

      It may not necessary to do a hip "replacement". I prefer the term hip substitution, since no implant can fully replace the normal, natural hip. It seems that you have been frightened by a bone densitometry test for osteoporosis. The osteoporosis may not be nearly as severe as you seem to believe. You need guidance from an objective, experienced (and kindly) source.

  • Margaret:

    I recently had a screw removed from my hip/pelvis and unfortunately developed an abscess on the bone where the screw was removed. I was admitted to hospital and had the abscess aspirated and was on a 5 day course of iv antibiotics followed by a 5 day course of oral antibiotics. My concern is that the infection may affect the bone and the chance of recurrence of the abscess developing again. I would appreciate your advise. I have several pieces of metal left in my hip and have no arthritis.

    • jp:

      There is not much which you can do to prevent these possible consequences. I suggest that you try to ensure that you are not a MRSA carrier (with a nasal swab) and perhaps have a single prophylactic antibiotic if you have dental work.

  • I had back surgery a number of years ago and they put metal plates and screws pain has been getting so bad that just can not tolerate any longer what would be the best thing to do, in starting checking a few weeks ago the metal plates and screws not approved and had coused a lot of the same problems please any advice ot information ass I do not know how to go on much longer

    • jp:

      Clearly something must be done. Step one is to determine whether the plates are the cause of your pain (Other entities could produce pain at the same site). You need expert appraisal by a spinal surgeon. Feel free to write if I can help your more.

  • My son is 12. He had 8 plates implanted on Dec. 14, 2012 to correct some bowing in his legs. He is already 5'8" so we knew we had a small window and needed to attempt to correct the bowing. His surgeon said he used to remove the 8 plates and screws once correction occurred (generally one year) but now he says it is standard practice to leave them in. My husband feels strongly that they should be removed. I am trying to weigh the risks and benefits of removing them when the correction period is over. Could you please give your opinion? Thanks.

    • jp:

      Can I assume that these are small plates inserted to prevent epiphyseal growth? Were the shin bones cut through and angled?

      • You are correct. These are small 8 plates inserted with two screws to attempt to correct bowing. The shin bones were not cut. My son also has a twist in his femurs and in his tibia. He had a 6 month appointment two days ago to see if any correction had occurred. Although he has grown 1 1/2 inches, no correction has taken place. We were told, for the first time, that on occasion the twisting in the long bones can actually get a little worse by having the 8 plates in. That was never spoken when deciding whether or not to do the surgery. Anyway, my husband (his Dad) has always believed the plates and screws should be removed when there is no more expected correction. His doctor says he will remove them if we are adamant about it but he discourages a second surgery. We certainly don't want to place any unneccesary risk to our son. So, I am looking for information to support taking them out or leaving them in-not just opinion but rather some sound evidence of either. I really appreciate your input. Thanks!

        • jp:

          You have time, and the opportunity to seek opinion and reflect over the next few years as your son continues growing and correcting the alignment. The answer might present itself if a screw begins to "back out". Removal will then be forced, and if one screw is to be removed under general anaesthetic, then all should be removed.

  • Grant:

    My wife has a Diabetic Foot and her Third Metatarsal joint broke and overlapped. There was nothing to screw to so the surgeon drilled a steel rod through the tip of her toe down through her joints and into her Cuniform, approximately 4 inches or 10 centameters. It started working it's way out about 3/4 of an inch. We met with the surgeon and he said that this happens when the swelling comes down and he did not want to remove the rod at this time in fear of the break happening again. Yesterday the rod slipped completely out to our shock! What kind of problems can this cause? Should we try and see the Dr. as soon as possible?

    • jp:

      Such an “internal fixation” by intra-medullary pin is not unconventional. Subsequent migration is common. You do not say whether the metatarsal shaft retained its position after the rod migrated. If the metatarsal remains adequately aligned, then leave alone, expecting further consolidating healing. What could concern me more is the reason the metatarsal broke. In a diabetic this is probably because of gradual deformity of the forefoot (expressed by claw toes and similar). Such deformities cause abnormal focal pressure on the sole (often reflected by a callus) If this is the case your wife requires super-specialist expertise to avoid potential ulcers of the sole in high-pressure areas. The danger of ulceration is far more serious than the metatarsal break.

  • Lori Parent:

    I had a bunionectomy that resulted in non-union. A different surgeon performed corrective surgery 7 months later (a bone graph was necessary to correct mistakes of first surgeon). Everything seemed to heal fine and I resumed normal activity with periodic swelling and discomfort. Just recently (21 months after corrective surgery), I noticed a protrusion on the side of my foot that became painful. The arch also has a burning sensation. I had an xray and went back to my surgeon. The xray shows the the painful bump on the in side of my foot is a bone shard. Also, one screw has come completely displaced and is trying to poke through the bottom of my foot. The surgeon said there may also be some degeneration around the joint and he's not sure how secure the second screw is. He said another surgery is necessary and wants to put a plate in this time. I am so devastated. My question is, is it possible that my body simply won't tolerate the screws or plate? Are there other options? Why would an otherwise healthy, strong woman not heal from a bunionectomy? I'm 50 years old. I have been hiking, biking, swimming and generally very active.

    • jp:

      This is the sad tale of many "bunion surgeries". I do not think the problem is a "rejection" or "allergy" to the metal. The material used is highly inert. I think the cause of the problem and the complications lies elsewhere.

    • Lori:

      I've been reading about other cases where metal allergies led to non-unions. The nickel in the screws can cause problems. Mine are coming out and the surgeon will use an external fixator this time around. I will ask that the screws be titanium and hope that I will finally heal for good. I do think that people should think twice before bunion surgery - I was uncomfortable before but have had nothing but problems and interruptions to normal living since my first surgery.

      • jp:

        You do not give the sources of your internet search. There are many speculative, un-informed and plain erroneous commentaries on the internet. My strong advice (to all who search the internet for medical advice) is to be highly selective about the information extracted, and check the source assiduously. Even reputable sources such as the Mayo Clinic and Harvard have made comments which even at the first order of common sense are non-sensical (see earlier posts on this site). It is true that many metals cause sensitivity reaction on the skin. However if these metals are incorporated into alloys their qualities change, as will their potential for sensitivity. I suggest you write to the manufacturers of the implants which you have received, and request the scientific literature relating to their products. The large manufacturers, such as Johnson and Johnson (and their subsidiaries) will give objective comment. The vast majority of non unions (if not all) are caused by two factors - impaired blood supply and infection. Indeed infection is frequently associated with impaired blood supply as the primary factor. Impaired blood supply, in elective surgery (not trauma) is frequently attributable to the surgeon - either poor design of the surgery, poor technique, or failure to recognise the implications of an underlying disease process.

  • Lee:

    I have had metal plate and rod put in to replace part of my pelvis, when it's cold and raining I'm in excruciating pain and it feels like he screw hats in my back sticks out more than usual is this normal and will I always have pain as the years go on

    • jp:

      The object of the screws and plates was to re-position displaced bones, so that they would heal in a functional position. Once the bones have healed the metal has no function. If it is then troublesome it can be removed.

  • Ella:

    My foot turns in when I walk, and it affects me tripping over flat ground,will inflict knee pain, amd will affect my cross country. i saw an orthopedic surgeon with my mother, and we both agreed it would be a good idea. When my father caught wind of it, i thought he'd also agree. Instead, he said that no athlete was ever the same after the surgery, and that he never has even seen me trip, which isn't true. He said that the surgery was unnecessary, that it couldn't go on without his approval, and that I can't go tripping all over the place to convince him. Heis a doctor, so I trust his opinion, but then he went on to call me decietful. Is he right? That I won't ever be the same athletically?

    • jp:

      As always, a precise diagnosis is crucial to the result of surgery. I suggest that you obtain from that surgeon his notes as to exactly what he has found, and his intended surgical solution. Feel free to send me those notes which will put me in a position to comment.

  • Margaret:

    I was knocked down almost 15 years ago and broke both my knees broke my left shoulder broke my ulna in 3 parts smashed up my pelvis and broke both the ball joint and socket of my left hip into several pieces. I was very lucky to have been transferred to the care of a very gifted trauma surgeon who, with great difficulty, managed to put me back together again with 2 rods through my ulna, 3 screws through my pelvis and hip as well as several plates screwed into each other and then through the usable parts of my pelvis. after 1 year I had the rods removed from my ulna because they were poking through my skin. I then had to have 1 of the screws removed from my pelvis/hip because it had become 'loose' and was catching on muscle when I walked. both of these procedures were done without any difficulty. I now find myself in a lot of pain and difficulty walking and my surgeon believes the screws in my pelvis/hip have become loose and may possibly have infection around them, I have had several tests done and will be back to see the surgeon soon and he advised that he is preety sure that he will have to remove the remaining screws. my main concern is that after nearly 15 years the bone will have regenerated over the screws and the bone will need to be broken in order to remove the screws, does this not cause an irreversible weakness in my pelvis and hip? I am going to discuss these issues with my surgeon before the removal but would like your opinion if that is possible. Kind regards

    • jp:

      Margaret. The most likely cause of the pain is a degenerative arthritis of the left hip. One way to try and be certain about this is to have the left hip joint injected with local anaesthetic (and cortisone, since the needle is there anyway). If there is (temporary) relief from pain that will tend to prove the source of the pain. It is unusual for plates on the pelvis to become incarcerated in bone. The pelvis is sturdy, and removal of the plates is unlikely to weaken it.

  • 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

  • Nicole:

    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.

    • jp:

      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.

  • arya:

    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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