How difficult is titanium plate and screw implant removal? A retrospective case series.

Introduction: Titanium implants are commonly used for surgical fixation in orthopedic trauma, and have many benefits compared to stainless steel implants. Despite these benefits, some orthopedic surgeons remain hesitant to use titanium implants due to concerns of difficulty with future implant removal, given concerns with cold-welding and screw strippage. The objective of this study was to assess difficulties associated with titanium plate and screw implant removal.

Methods: This is a retrospective case series from a large hospital system. Patients were identified using Current Procedural Terminology (CPT) code 20,680 from 2017 to 2020. Patients were included if they had removal of titanium plate and screws from the upper or lower extremity, were at least18 years of age, and considered skeletally mature. The ease of titanium plate/screw removal was determined by assessing for implant cold-welding, broken screws, stripped screws, and the need for advanced tools (screw removal set, trephine, burr).

Results: 157 patients were identified, with a mean age of 54 years and 59 % female. In total 1274 screws were removed: 14 (1.1 %) were stripped, 8 (0.6 %) were cold-welded, 42 (3.3 %) were loose, and 13 (1.0 %) were broken. 183 plates were removed in total, and 15 (8.2 %) had bone overgrowth that required removal. 12 (7.6 %) procedures were complicated and required the use of advanced tools. Complicated implant removal operations occurred after significantly longer in vivo implant time (mean of 3.7 vs. 1.1 years, p = 0.036), were associated with a younger age, were more likely to occur in lower extremity procedures (p = 0.034), and took significantly longer time for removal (95 vs. 42 min, p < 0.001).

Conclusions: Despite concerns with titanium implants, we found a low rate of screw strippage, breakage, and cold welding during the removal process. However, 7.6 % of the 157 surgeries required additional tools other than just a screwdriver, and needed additional operative time. This information allows treating surgeons to plan for implant removal when titanium implants have been used for fixation.

Level Of Evidence: IV.