Pediatric fractures following implant removal: A systematic review

Abstract

Objectives: To evaluate the available literature for postoperative fracture rates following implant removal in the pediatric population.

Methods: A systematic review of articles in the PubMed and Embase computerized literature databases from January 2000 to June 2022 was performed using PRISMA guidelines. Randomized controlled trials, case-control studies, cohort studies (retrospective and prospective), and case series involving pediatric patients that included data on fracture rate following removal of orthopedic implants were eligible for review. Two authors independently extracted data from selected studies for predefined data fields for implant type, anatomic location of the implant, indication for implantation, fracture or refracture rate following implant removal, mean time to implant removal, and mean follow-up time.

Results: Fifteen studies were included for qualitative synthesis. Reported fracture rates following implant removal vary based on several factors, with an overall reported incidence of 0%-14.9%. The available literature did not offer sufficient data for conduction of a meta-analysis.

Conclusion: Our systematic review demonstrates that fracture following implant removal in pediatric patients is a relatively frequent complication. In children, the forearm and femur are the most commonly reported sites of fracture following removal of implants. Traumatic fractures treated definitively with external fixation have the highest reported aggregate rate of refracture. Knowledge of the incidence of this risk is important for orthopedic surgeons. There remains a need for well-designed studies and trials to further clarify the roles of the variables that contribute to this complication.

Keywords: Implant removal; fracture; refracture.

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart of studies.

Figure 2.

AP (a) and lateral (b) radiographs following initial closed reduction and casting of a 12-year-old female who suffered a left bone forearm fracture. (c) Radiograph of the forearm at the time of ulnar ESIN removal. (d) Lateral fluoroscopic radiograph demonstrating refracture of the ulnar shaft 12 weeks after ESIN removal.