Orthopedic hardware, including implants like screws, plates, rods, and pins, is commonly used in surgery to stabilize broken bones or correct skeletal deformities. These devices function as an internal scaffold, holding the bone fragments in correct alignment while the body’s natural healing process takes place. Once a fracture is fully healed, the question of whether to remove this fixation hardware often arises, leading to a procedure known as hardware removal (HWR). This secondary surgery is a frequent occurrence in orthopedic practice. The decision to proceed with hardware removal is typically based on specific clinical indications rather than being a routine requirement for all patients.
Reasons for Removing Orthopedic Hardware
Localized pain or discomfort is one of the most frequent reasons for hardware removal. This discomfort often occurs when the hardware, such as a plate or the head of a screw, is prominent or lies close to the skin’s surface, causing irritation or rubbing against overlying soft tissues. Patients often report mechanical symptoms, especially in areas with thin tissue coverage like the ankle, foot, or collarbone.
Another significant indication for hardware removal is infection, where the implant itself can provide a surface for bacteria to colonize, making the infection difficult to clear with antibiotics alone. In these cases, removing the hardware is often a necessary step to resolve the infection completely. Less commonly, mechanical issues, such as the hardware loosening, migrating, or fracturing, may necessitate a second surgery to prevent instability or further injury. Finally, the hardware may be removed simply because its function is complete, and the patient requests the elective procedure once the bone has achieved full structural healing.
Bone Remodeling After Screw Removal
When a screw is removed from a bone, it leaves behind a physical void, which is essentially a small, cylindrical hole running through the bone cortex. This empty hole creates a localized area of mechanical weakness known as a “stress riser.” A stress riser concentrates mechanical forces around its edges, significantly lowering the amount of energy required to cause a re-fracture compared to intact bone.
The body immediately initiates a natural healing process to address this structural defect through bone remodeling. This continuous cycle involves two specialized cell types: osteoclasts, which break down old bone tissue, and osteoblasts, which form new bone matrix. This coordinated activity is directed toward filling the empty space with new, healthy bone tissue.
The process begins as blood vessels grow into the site, delivering the necessary nutrients and precursor cells to the defect. Osteoblasts then start to deposit a new bone matrix within the screw hole, gradually filling it from the outside edges inward. While the hole itself can take six weeks or longer to visibly fill with new bone, the full restoration of structural strength is a protracted process. The area’s strength increases as the new bone matures and mineralizes, reducing the stress riser effect. Although the risk of a re-fracture is highest in the weeks immediately following removal, permanent structural weakness is rare once the remodeling process is completed, which typically takes several months.
Post-Operative Recovery and Activity Restrictions
The hardware removal procedure is generally less involved than the initial surgery and is often performed on an outpatient basis, allowing the patient to return home the same day. Post-operative pain is managed with medication, which is typically needed for only a few days to a week. Wound care involves keeping the incision clean and dry, with the soft tissues usually healing within one to two weeks, at which point sutures are often removed.
Activity restrictions are the most important part of the recovery, as they protect the bone while the screw holes are filling and the stress risers are being mitigated. Patients must avoid high-impact activities, heavy lifting, and any activity that places excessive rotational or bending stress on the affected limb. The specific restrictions, such as the duration of non-weight-bearing or limited weight-bearing, depend heavily on the bone involved and the number and size of the holes.
This period of protection is necessary because the bone is temporarily at a higher risk of re-fracture, with some recommendations suggesting avoiding aggressive athletic activity for up to four months. Crutches or a walker may be used for comfort and support during the first week or two, gradually transitioning back to full weight-bearing as advised by the surgeon. Adhering to these temporary restrictions is crucial to allow the bone’s natural remodeling process to fully restore its mechanical integrity.