A novel technique for pediatric femoral locked submuscular plate removal: the ‘push-pull’ technique
Journal of Orthopaedic Surgery and Research
A novel technique for pediatric femoral locked submuscular plate removal: the 'push-pull' technique
Martin F Hoffmann 0
John Gburek 2
Clifford B Jones 1
0 Grand Rapids Medical Education Partners , 1000 Monroe Ave NW, Grand Rapids, MI 49503 , USA
1 Orthopaedic Associates of Michigan , 230 Michigan Street NE, Grand Rapids, MI 49503 , USA
2 College of Human Medicine, Michigan State University , 15 Michigan Street NE, Grand Rapids, MI 49503 , USA
Submuscular and minimally invasive plate insertion is gaining popularity reducing the need for large open approaches and resulting in a smaller operative 'footprint.' With pediatric fractures and titanium implants, fibrous and osseous ingrowth to the implant and osseous implant integration may interfere with implant removal. Therefore, the small minimally invasive implant insertion procedure may require a large maximally invasive exposure for implant removal after fracture healing. To reduce soft tissue damage, bleeding, scarring, and pain associated with implant removal, a minimally invasive procedure utilizing the pre-existing incisions while controlling the implant is efficient and beneficial. The surgical technique is described, and a case series of 21 treated pediatric femoral fractures illustrates the successful performance of the procedure and its limitations.
Locked plating is very popular with increasing locked
plating indications . The main indications of locked
plating are poor bone quality, fracture comminution
and/or bone loss, and short segment fixation [2,3].
Additionally, submuscular and minimally invasive plate
insertion is gaining popularity reducing the need for
large open approaches, interfragmentary fixation, and
bone grafting [4-8], and resulting in smaller, more
cosmetically appearing scars . Bridge plating with or without
locked screws utilizes balanced fixation relying on longer
plates and selective screw insertion leaving many screw
hole sites empty. With plate irritation, patient preference,
or surgeon preference, removal of submuscular plates may
become necessary [10-15].
A controversy exists regarding routine implant removal
in children . Routine removal in children was justified
based on potential future risks, and many institutions offer
routine removal of implants to skeletally immature
patients [17-19]. Resulting thereof, 60% to 90% of all implant
removals in children are performed electively [17,20,21].
Implant removal is not without complications or
consequences [14,22-25]. The problem with submuscular
insertion especially with titanium implants and pediatric
patients is that fibrous and osseous ingrowth to the
implant interferes with implant removal  (Figure 1).
This may lead surgeons to use more extensive approaches
for implant removal. Noticeably wider and cosmetically
disadvantageous scars after implant removal compared to
the initial approach have been reported (Figure 2). In one
study, 3.6% of the patients had asked to see a plastic
surgeon . Some innovative techniques have been
described to remove pelvic and spinal implants via
minimally invasive techniques [28,29]. To our knowledge, no
technique for minimally invasive implant removal on long
bones has been described. Routine hardware removal is
offered most often to pediatric patients . Therefore,
we have chosen purposefully a pediatric study population.
Final radiographs are preoperatively evaluated and
confirmed for fracture healing, manufacturer type, and
screw (standard versus locked) position. Appropriate
screwdrivers are confirmed. The lower extremity is
placed on a radiolucent table. The fluoroscopic imaging
unit is brought in from the contralateral side of the table
from the implant. Therefore, laterally applied femoral or
tibial implants have the fluoroscope imaging coming
Figure 1 Bone beginning to grow over distal end of plate after
osteosynthesis for pediatric femoral fracture.
from the contralateral side while medially applied tibial
plates have the fluoroscopic unit on the ipsilateral side.
Screw positions with the incisions and the fluoroscopic
unit were confirmed. With reduced fractures and
swelling after healing, the incisions may not line up perfectly
with the screw sites. Small incisions corresponding to
the screw sites were made. The limb was rotated so that
the screw heads and implant are perpendicular to the
imaging unit to improve visualization and triangulation
of the screwdriver head. Once the screwdriver head is
adjacent to the screw head, the anterior and posterior
aspect of the plate was palpated with the screwdriver
head to insure positioning in the sagittal plane. When
the screwdriver is positioned appropriately in all planes
(axial, coronal, and sagittal), the screwdriver head was
tapped gently with a mallet while carefully reversing the
screwdriver head (similar to a jeweler). Once initially
seeded into the screw head, the screwdriver was further
tapped until placed deep into the concavity of the screw
head. Utilizing the fluoroscopic magnification will
improve visualization and confirm positioning. The screw
was reversed from the plate while applying pressure on
the screwdriver head to avoid losing contact. Once the
screw tip is within the near cortex, the screw head was
grasped with a hemostat or needle driver. The screw was
fully removed with a coordinated effort of gentle
pressure from the screwdriver and axial removal from
the hemostat or needle driver.
Once all the screws are removed, the incision that was
initially created was opened to insert the plate. The soft
tissue attachments from the end of the plate were
cleared off. The plate was gently elevated off the bone
with a Cobb elevator. The shoulder hook (Zimmer Inc.,
Warsaw, IN, USA) (Figure 3 (a)) was slipped under the
plate and through a screw hole. Through a screw hole
site and incision along the other end of the plate, the
curved bone tamp (Synthes, Paoli, PA, USA) was
percutaneously inserted (Figure 3 (b)). With a coordinated
effort, the implant was gently pulled with the shoulder
hook and pushed with the bone tamp (Figure 4). Hitting
the angled tamp with a mallet is usually required for
release of the fibrous and osseous ingrowths. The plate
will usually have an initial release, which is related to
the plastic deformation of the fibrous tissue. Once the
plate escapes the release from the tissues, it will move
quickly and with ease. To avoid the plate from
Figure 2 Cosmetically disadvantageous keloid formation after
open approach to the femur.
Figure 3 Shoulder hook (a) and bone tamp (b) for
percutaneous implant removal.
Figure 4 Pushing and pulling in a combined effort removes the
implant with minimal soft tissue damage.
scratching the skin upon removal, the shoulder hook
was kept angled slightly upward. If a deep incision is
present from obesity or muscularity, the Cobb elevator
was kept under the plate to protect the skin and direct
the plate removal. To avoid the plate to quickly escape
the control of the shoulder hook upon removal, the
shoulder hook was gently but not aggressively pulled on.
Once the plate is removed and bleeding assessed, the
larger incision fascia was closed with absorbable sutures.
The skin was closed with nylon or Vicryl sutures
(Figure 5). The incisions were infiltrated with 0.25%
Marcaine based upon body weight limitations. A
minimally compressive dressing was applied. Although possibly
controversial, the patient was allowed weight bearing as
tolerated [30-32]. Once able, the patient was allowed to
return to normal activities.
A retrospective evaluation of plate removal after
submuscular plate insertion in pediatric patients was performed
in one level I trauma center. All patients were initially
treated, and implant removal was performed by the senior
author (CBJ). Submuscular insertion techniques and
patients were identified from a registry using CPT codes
27506, 27507, 27511, 27513, and 27514 of plated pediatric
femoral fractures between 2005 and 2010. Patients were
followed up in a single private practice.
We recorded the age at injury, the length of the plate
used, and the numbers of screws placed. We recorded
the time from plate insertion to plate removal. Charts
were reviewed to determine the stated reason for
removal. Radiographs were reviewed to determine any
bony overgrowth. Operative records and office notes were
reviewed to determine any noted complications during
removal and postoperatively. Ethical standards were
followed in the conduct and dissemination of the study.
We identified 26 patients at our institution that
underwent submuscular plating for femoral fractures during
the study period. Thereof, 21 (81%) implants were
removed using the described submuscular technique in
all cases. Four patients were followed up in their home
towns, and one patient with paraplegia did not undergo
The average age at the time of surgery was 8 years
(range, 3 to 12 years). The documented reason for plate
removal was the surgeons recommendation ,
beginning bone overgrowth , and pain or irritation . The
median plate length was 14 holes (range, 8 to 18 holes).
The mean number of proximal as well as distal screws was
2 (2 to 3). Plates were twenty 3.5-mm locking compression
plates (Synthes) and one 3.5-mm compression plate
(Zimmer Inc.). The mean time from plate insertion to
plate removal was 8.0 months (range, 4.0 to 26.6 months).
Because of implant removal difficulties, one patient
(4.8%) required a change of the procedure to an open
approach. The complication was caused by a cold
welded screw head. Another patient had an anticipated
broken screw, which could be retrieved completely
through one of the incisions. All implants were removed
completely. No postoperative complications regarding
hematoma formation, wound healing problems,
infections, or nerve injuries were recorded.
Submuscular plating of pediatric femoral fractures has
become a useful treatment option [33,34]. Multiple
reasons, fears, and complaints of both patients and
orthopedic surgeons result in the removal of previously
implanted fixation devices. To avoid complete osseous
integration of the implant, surgeons recommend removal
of all pediatric implants used for fixation of long bone
fractures . Concern has been voiced regarding a more
invasive and open approach for implant removal than for
fracture fixation affecting pain, bleeding, healing,
cosmesis, and patient satisfaction .
In our attempt to avoid extensive approaches for
implant removal procedures after initially submuscularly
inserted plates, we found this novel push-pull technique
an extremely useful tool. Open approaches with a
second hit on soft tissues and additional scarring were
avoided in 92% of our patient population. Additionally, no
complications regarding hematoma formation, wound
healing problems, infections, or nerve injuries were noted.
In performing the procedure correctly, careful tapping of
the bone tamp with a mallet and coordinated pulling of
the shoulder hook to guide plate removal avoid forceful
removal with a clamp or hook. Therefore, we consider the
procedure as safe and effective when performed for the
Indications for submuscular plate removal are
wellhealed fractures without complete osseous overgrowth
of the implant void of overlying neurovascular
structures. Therefore, lateral femoral, lateral proximal tibial,
and medial tibial areas are well suited for this technique.
The distal lateral tibial pilon could be removed with this
technique but with caution to avoid injury to the
overlying anterior tibial artery and nerve upon removal. The
humerus and forearm have many crossing neurovascular
structures; therefore, percutaneous plate removal should
be discouraged. Even though not personally experienced,
percutaneous plate removal in settings of osseous
overgrowth should not be attempted . Even with open
techniques, plate removal can be problematic with
laborious removal of all osseous ingrowth and
overgrowth. Screw-related complications are uncommon and
not predictable. With previously diagnosed broken
screws, stripped screw heads, or cross-threaded locked
screw heads, wider incisions or open techniques of
successful plate removal should be encouraged. If the
screwdriver will not seat in the screw head, an incision
will be made to expose the screw head, the debris will be
removed within the screw head, and the osseous
material around the screw head and within the screw hole
will be removed to avoid screw head stripping, which
necessitates a larger approach and possibly inability to
remove the plate without more invasive and aggressive
methods. If the screw head is cross-threaded and
cold worked into the threaded screw hole, the head may
need to be drilled out, the plate cut with a
diamondtipped wheel leaving metal debris in the soft tissues, or
the plate pulled off the osteopenic bone . With
friable skin or skin conditions, expanding the incisional
length will avoid ripping the skin edges upon plate
removal or bone tamp manipulation.
Although not as efficient, the surgeon can successfully
remove the plate with alternative devices. Although not
small and as easily inserted, a bone hook can be
substituted for a shoulder hook. Since the shoulder hook
has a T-shaped end, any substitution should allow for
rotational control of the device. Also, a traditional bone
tamp may be utilized but must be able to fit within the
screw hole shape and have an incision large enough for
angled insertion. To diminish the risk of bleeding or
creating injury to the bone or soft tissue, sharp instruments
for pushing such as a periosteal elevator or osteotome were
avoided. The smaller sharp instrument may inadvertently
slip through the screw hole creating a fracture in the bone
or past point distally outside the screw hole injuring the
muscle or possibly a vessel.
We acknowledge the limitations of our study. The major
limitation of this study was its retrospective design and
the small number of patients. Additionally, patient
satisfaction was not addressed utilizing standardized
questionnaires. The surgical outcome or complications were not
compared to a contemporaneous control group.
This study is a structured description of a technical
trick in combination with a single-center case series.
Therefore, this study has the potential to reflect technical
difficulties and complication incidence.
Minimally invasive removal of long bone plating in
pediatric patients can be successfully performed utilizing
the described push-pull technique. Indications should
exclude anatomic sites endangering neurovascular
structures and local difficulties including bone overgrowth
and broken or striped screws.
MFH participated in the conception and design of the study, performed the
data acquisition, participated in the statistical analysis, and drafted the
manuscript. CBJ participated in the conception and design of the study,
provided administrative support, carried out the critical revision of the
manuscript, and supervised the study. JG participated in the data acquisition.
All authors read and approved the final manuscript.
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