Orthopedic Hardware Problems

Orthopedic Hardware Problems

Todd R. Wilcox, MD, MBA, CCHP-A

Medical DirectorSalt Lake County Jail System

trwilcox@wellcon.net

801-990-3440

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Educational GoalsEducational Goals

Understand types of orthopedic hardware

Understand typical post-op management based on type

Understand hardware complications

Medical necessity of hardware complications

Brief HistoryBrief History

Earliest fracture management dates to 300 BC

Osteosynthesis did not start until 1900

AO group in Brussels

Various TechniquesVarious Techniques

Case 1Case 1

Presents to Sick Call

Injury 9 months ago

Having pain

Wants bottom bunk, special shoes, extra blanket

Basic Bone PhysiologyBasic Bone Physiology

Bone has 2 functions

Structural support

Metabolic

Bone FormationBone Formation

Occurs in 2 stages

Osteoblasts deposit osteoid

Osteoid is mineralized

Fracture RepairFracture Repair

Internal FixationInternal Fixation

Plate FixationPlate Fixation

External FixationExternal Fixation

Basic Fracture ManagementBasic Fracture Management

Soft Tissue Compression

Reduces Deformity

Load BearingLoad Bearing

Load SharingLoad Sharing

External FixationExternal Fixation

Wire / pin loosening is most common complication

pin care--normal saline and NO bacitracin

Elective HardwareElective Hardware

Dislocated HardwareDislocated Hardware

3% of primary THA’s

15% of revision THA’s

Require ER visit for anesthesia / sometimes need OR

Elective HardwareElective Hardware

Harrington Rods are common

Need to evaluate the fusion mass

Broken rods happen a lot, often not clinically significant

Broken HardwareBroken HardwareCommon source of patient complaint

Need to figure out underlying reason

infection

instability of fracture

insufficient hardware strength

Does it compromise the fracture mechanically?

Most broken hardware is not medically necessary to remove!!

Broken HardwareBroken Hardware

Syndesmosis

Screw often left in

Common to see these broken

Always have to be alert for this

Source of a lot of litigation

Need to do the complete workup and clinical evaluation

Need to handle the situation in accordance with accepted standards

Infected HardwareInfected Hardware

Infected Hardware WorkupInfected Hardware Workup

Xrays

Evaluate for loosening or breakage

Tests include CBC, Sed rate, C-reactive protein

If infected, all hardware must come out in infection zone in order to treat infection

Some infections are tolerated as chronic

Infected Elective HardwareInfected Elective Hardware

Xrays

CBC, Sed Rate, C-reactive protein, blood cultures

Radioisotope scans (Indium-111 leukocyte, tecnetium-99)

Arthrocentesis

Incidental HardwareIncidental Hardware

Incidental HardwareIncidental Hardware

Common to have shrapnel left in

Removing shrapnel usually does more damage than leaving it

Pain often not resolved by removing shrapnel because of blast injury

Only reason to consider removal is infection or obvious dysfunction

Painful HardwarePainful Hardware

Most orthopedic hardware is painful

Pain typically relieved with NSAIDS

Occasionally narcotics are indicated

Significant increase in pain needs workup to evaluate for infection

Removal of hardware frequently helps but is not medically necessary

Special Shoes ForSpecial Shoes For

Fixed deformities

Amputations

Significant tissue loss / grafting

Leg length discrepancy > 1.5 inches

Bottom BunkBottom Bunk

Only if fracture has not healed and is not infected

Historical fractures or retained hardware is not a legitimate justification

SummarySummary

Get Xrays

Understand the type of device in use

Know the biomechanics of fractures

Assess for infection

Assess for healing

Determine need for special requests / workup

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