Journal of Pediatric Orthopaedics - 2026-08-01 - Journal Article
Routine Removal of Orthopaedic Implants in Pediatric Trauma Patients With Fracture Union: Who, When, and Why.
Ihnow S, Raymond B, Horodyski M, Baez C, McQuerry J, Wallace AW
Topics
Key Takeaway
Flexible forearm nails are routinely removed by 90.8% of POSNA members, while clavicle plates are removed by only 31.6%, with 43% of surgeons citing 'routine practice' rather than evidence as the primary justification.
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Summary
This IRB-approved online survey queried POSNA members on practice patterns for routine implant removal after pediatric fracture union across implant type, anatomic location, patient age, and timing. Flexible nails were most commonly removed (84.6–90.8% by location), while rigid femoral nails and clavicle plates were least commonly removed (32.6% and 31.6%, respectively). The dominant justification for removal was 'routine practice' (mean 43%), with evidence-based rationale cited by only 10% of respondents.
Key Limitation
The response rate is not reported, making it impossible to assess nonresponse bias or determine whether the 285 respondents represent the practice patterns of the broader POSNA membership.
Original Abstract
PURPOSE
While the indications and options expand for treatment of pediatric fractures with metallic implants, routine removal of implants remains controversial. There is a paucity of randomized prospective trials to determine the risk of retention versus removal. Prior studies provided insight into the preferences of POSNA members versus their nonpediatric counterparts; however, they did not capture specifics regarding timing, anatomic location, implant type, or patient age. This study aims to report POSNA members' practice habits regarding the routine removal of orthopaedic implants after fracture union.
METHODS
This is an IRB-approved online survey of POSNA members regarding the routine removal of orthopaedic trauma implants after fracture union. The questionnaire consisted of 6 parts: demographics, implant removal with consideration of patient age and time since implantation, the most common reason for removal, the most common complications of removal, and a comment section.
RESULTS
Two hundred eighty-five POSNA members responded to at least 1 implant-related question. Flexible nails were the most commonly removed implants (90.8% for the forearm, 87.3% for the femur, 86.3% for the tibia, and 84.6% for the humerus), followed by femur plates and screws (79.9%). The least likely implants to be routinely removed were clavicle plates and screws (31.6%), femur rigid nails (32.6%), and tibial tubercle screws (37.1%). There was a lower likelihood of implant removal in patients older than nine. Upper extremity implants tended to be removed earlier than lower extremity implants (between 7 and 9 mo vs. 10 and 12 mo postimplantation). The most cited reasons for removal included routine practice (mean 43%) and symptomatic hardware (mean 32%), while the least selected reason was evidence-based research (mean 10%).
CONCLUSIONS
Rates of routine implant removal in pediatric trauma patients after fracture union range from 90.8% for flexible forearm nails to 31.6% for clavicle plates and screws. Removal typically occurs between 7 and 12 months postimplantation. As patients age, surgeons are less inclined to remove implants. There was minimal consensus on the rationale for routine removal.
LEVEL OF EVIDENCE
Level V.