Nearly 68% of patients improve after hardware removal, but surgery is costly

Outpatient vs. in-hospital removal cost about $4,500 compared to $7,500, but patients paid much more.

Surgeons should be selective about removing orthopedic hardware in the presence of a healed fracture, even if it is painful and patients are symptomatic. Investigators who studied this area said the benefits of such procedures remain unclear and costs can be substantial.

Investigators found reliable results after hardware removal in certain cases, such as explanting locking screws for intramedullary (IM) nails, but they were not as predictable following other types of hardware removal, such as plates and screws.

"There were also certain anatomic locations where the patient's had a higher rate of improvement," Brian A. Fissel, MD, told Orthopedics Today.

Fissel presented results of a chart review and costs analysis at the American Academy of Orthopaedic Surgeons 74th Annual Meeting on 236 patients who had hardware removed July 2002 to March 2005. Overall, he and a colleague included 102 patients in the final analysis who underwent removal of symptomatic, painful hardware. They factored in all surgical costs and surgeons' fees plus added expenses, such as anesthesia time, supplies and medicine.

Average time to hardware removal was 16.8 months. Lower extremity hardware removal was generally more prevalent in the retrospective study with 47 cases involving the femur and tibia.

Frequently the added costs considerably ran up the overall surgical price tag. "The cost of hardware removal is not insignificant, with the procedure averaging about $14,000, plus the indirect cost of time off work," Fissel said at the meeting. "It is less expensive to perform the operation at an outpatient surgery center."

Basic surgical costs for outpatient hardware removal at an ambulatory surgical center (ASC) were significantly less (P<.001), about $4,500 vs. $7,500 when the removal was performed in the hospital. "The overall mean costs for all hardware removals were approximately $6,800," Fissel said.

Looking at postoperative pain relief, 68% of patients reported symptom relief compared to 18% with no relief at 3.7 months post-removal, average. Equivalent information was unavailable for the other 14%.

Four patients developed infections postoperatively and six required another surgery.

Hospital-based surgeries were most common and 19 patients had i-patient procedures with an average 1.4 night length of stay.

Surgical times were approximately the same for both surgical locations, but hospital anesthesia time was significantly longer, 83.2 minutes vs. 61.8 minutes at ASCs (P=.002).

Fissel told Orthopedics Today he counsels patients preoperatively according to the part of their anatomy from where he plans to remove the hardware and the expected results. He is more optimistic with someone needing a distal locking screw for a femoral

IM nail removed, since his study showed they are more likely to improve. But he clearly explains to a patient with mid-foot or Lisfranc hardware their odds of getting better are only about 50%.

Though usually done by junior surgeons, hardware is often harder to take out than put in, Fissel said. "It is usually an outpatient procedure and intuitively you would think patients would benefit from it, but oftentimes they do not improve. That's been shown not just in our study, but in many studies."

The researchers based dollar amounts on 2006 charges.

For more information:
Brian A. Fissel, MD, can be reached at St. Louis University Hospital, 3635 Vista at Grand, St., Louis, MO 63110; 314-577-8850; fisselb@gmail.com. He has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies.
Fissel BA, Watson JT. Cost effectiveness of symptomatic hardware removal. #149. Presented at the American Academy of Orthopaedic Surgeons 74th Annual Meeting. Feb. 14-18, 2007. San Diego.