Do you remove stainless steel implants after Open Reduction Internal Fixation (ORIF)?

Hardware Removal After ORIF: A Risk-Stratified Approach

Routine removal of stainless steel implants after ORIF is not recommended unless specific indications exist, including infection, symptomatic hardware, implant failure, or interference with growth in children. 1

Clear Indications for Removal

Absolute Indications

• Infected hardware must be removed regardless of fracture union status, as infection cannot be adequately treated with antibiotics alone when biofilm forms on metallic implants 2, 3
• Symptomatic implant failure including rod, hook, or screw migration, dislodgment, or breakage requires removal 4
• Non-union after surgery with hardware in place warrants removal and revision 1
• Obvious mechanical problems such as prominent hardware causing soft tissue irritation are straightforward indications 1, 5

Relative Indications

• Pain and discomfort are the most common reasons patients request removal (representing the majority of elective removals), though outcomes can be disappointing when pain is the sole indication 5
• Implant prominence causing mechanical symptoms, particularly common with distal tibial/ankle plates (14.45% of removals), olecranon hardware (12.04%), and patellar tension band wiring (9.53%) 5
• Pediatric patients should be considered separately, as metallic implants can interfere with normal growth patterns 1

When NOT to Remove Hardware

Do not remove hardware routinely for concerns about toxicity, allergy, carcinogenesis, or theoretical implant failure - these are not evidence-based indications 1

Material-Specific Considerations

• Stainless steel versus titanium: While some data suggest titanium may have slightly lower infection rates in contaminated cases, the difference is not statistically significant in most clinical scenarios 6
• Material type alone should not drive removal decisions in asymptomatic patients 6

High-Risk Populations Requiring Vigilance

Certain patient factors significantly increase infection risk and may lower the threshold for removal if any concerning symptoms develop:

• Diabetes mellitus with chronic complications (OR=1.69) 2
• Obesity (OR=1.85) 2
• Deficiency anemia (OR=1.59) 2
• Liver disease (OR=2.04) 3
• Rheumatoid arthritis (OR=2.06) 3
• Male gender (OR=1.67) 2

Anatomic Site-Specific Risk

Infection-related removal rates vary significantly by location:

• Highest risk sites: Phalanges/hand (5.61%), phalanges/foot (5.08%), tarsal/metatarsal fractures (OR=1.45), and tibial fractures (OR=1.82) 2, 3
• These high-risk anatomic locations warrant closer surveillance and lower threshold for removal if infection is suspected 2

Clinical Pitfalls to Avoid

• Do not promise pain relief from removal - when pain is the sole indication without mechanical symptoms or infection, results are often disappointing and patient expectations should be moderated 1
• Do not underestimate removal complexity - bone ingrowth, implant wear, and tissue scarring can make removal technically challenging and not a "routine" procedure 5
• Do not delay removal of infected hardware - the economic burden is substantial (mean charge $166,041 for infection-related removal vs $133,110 for elective removal) 2

Post-Removal Management for Infection

When hardware is removed for infection:

• Antimicrobial therapy duration: 10-14 days for isolated pocket infection, at least 14 days for bloodstream infection, and 4-6 weeks for complicated infections (endocarditis, osteomyelitis, persistent bacteremia) 7
• Blood cultures must be negative for at least 72 hours before considering reimplantation if needed 7

Practical Algorithm

1. Assess for absolute indications (infection, failure, non-union, mechanical problems) → Remove if present
2. Evaluate patient risk factors (diabetes, obesity, immunosuppression) → Lower threshold for removal if symptomatic
3. Consider anatomic location (hand, foot, tibia = higher risk) → Closer surveillance warranted
4. If pain alone: Thoroughly investigate mechanical causes and set realistic expectations before proceeding
5. If asymptomatic and united: Leave hardware in place regardless of material type