High rate of hardware removal found after ORIF of metacarpal fractures

Syed S. Injury Extra. 2010. doi: 10.1016/injury.2010.07.482.

A study investigating open reduction and internal fixation for patients with metacarpal fractures shows a 20% reoperation rate for hardware removal and tenolysis.

Researchers from the United Kingdom studied the complication and revision rates of 49 patients with metacarpal fractures who underwent open reduction and internal fixation using AO/Synthes plates or lag screws at a single center between October 2007 and March 2008. The researchers had a final follow-up of at least 6 months for 41 patients.

Of the eight patients who were revised, the researchers found that hardware removal occurred between 4 and 6 months of fixation, according to the study abstract. The study revealed that three patients reported hypersensitivity at the scar site. In addition, complex regional pain syndrome was discovered in one patient, and another developed parasthesia of the dorsal branch of the ulnar nerve.

“This study identified high rates of tenolysis and removal of metalwork following open reduction and internal fixation of metacarpal fractures,” the researchers wrote. “Informed consent should highlight these high rates of re-operation when patients undergo internal fixation of functionally displaced metacarpal fractures.”

I am puzzled by the results of the study. Usually, this procedure has excellent results and good return of motion. In fact, patients who have ORIF often have regained their motion in 4 weeks about when nonoperative patients get out of a cast.

Factors that I think of that might alter the results are the amount of associated soft tissue injury and/or the number of metacarpals that are fractured. Maybe more important, is how secure were the authors with the stability of the fixation and were the patients started on an early rehab program, 10 days or less.

Removal of the hardware is not so surprising. It depends on the kind of hardware used and how bulky it was.

If the indication for surgery in these cases is stiffness then taking out the hardware is appropriate, but not the reason for surgery in the first place. In other words, one cannot attribute the hardware as the reason for the surgery unless it was painful; the stiffness is the reason for the surgery.

— Barry P. Simmons, MD
Brigham & Women’s Hospital
Boston

Barry P. Simmons, MD, has no direct financial interest in any products or companies mentioned in this article.

Subjective outcomes such as requests for removal of implants, tender scars, and disproportionate pain and disability are more difficult to interpret than objective outcomes such as broken plates or ruptured tendons. It is impossible to be sure why the implants were removed in these patients. Even when a “tenolysis” is performed, the indications and separate mention of this are also highly variable and influenced by factors other than stiffness such as billing.

It is possible that either the patients or the surgeons were inclined to remove them even when they were not problematic. I do however, consider internal fixation in the hand to be best reserved for complex injuries when possible and best considered temporary. On the other hand, if there is no tendon irritation it may be safest to leave them in.

— David C. Ring, MD
Massachusetts General Hospital
Orthopaedic Hand and Upper Extremity Service
Boston

David C. Ring, MD, receives royalties from DePuy and Wright Medical Technology; is a member of the speakers bureau for Acumed, DePuy and Synthes; is a paid consultant or employee of Acumed and Wright Medical Technology; has received research or institutional support from AcuMed, Biomet, SBI, Smith & Nephew, Tornier and Wright Medical Technology; and has stock options in Mimedex and Illuminoss.