Indications and Challenges of Implant Removal Following Long Bone Osteosynthesis in Four Urban Hospitals in Kenya

Abstract

Introduction In orthopedic trauma, surgical stabilization is key and majorly involved. Fracture stabilization by the use of metals has been widely used since the Second World War. It is a widely accepted method, with almost all fractures managed with metallic implants in recent times. Osteosynthesis is the treatment of fractures in which bone fragments are joined with screws, plates, or nails. Following fracture healing, the question arises whether to remove the implant or leave it in situ. While a great deal of research has been conducted in the area of osteosynthesis, scholars have not addressed the question on if and when the implant should be removed. This study aims to fill a knowledge gap by examining the various indications used in implant removal surgery as well as the challenges encountered during the actual implant removal surgery. This knowledge will guide surgeons when approaching the decision of removing or leaving the implant in situ and the challenges that can be encountered during the removal. Study Objective To determine the indications and challenges of implant removal following long bone osteosynthesis in four urban hospitals in Kenya. Study Setting This study was conducted in four urban hospitals in Kenya; Kenyatta National Hospital, Nairobi Hospital, Aga Khan Hospital and PCEA Kikuyu Hospital. Study Design This is a quantitative research involving use of cross-sectional descriptive design. The use of this design is justified because it helps in estimating a population parameter, such as the prevalence of indications and challenges of implant removal after long-bone osteosynthesis, or 13 determining the average value of a quantitative variable in the study population. Convenience sampling was used to recruit participants. Study Population All patients presenting at Kenyatta National Hospital, Nairobi Hospital, Aga Khan Hospital and PCEA Kikuyu Hospital for removal of implants following long-bone osteosynthesis. Methodology The main method of data collection was researcher-administered questionnaires and examination of medical records. Data collected through questionnaires from patients presenting for implant removal after long bone osteosynthesis, data on the challenges encountered during the surgical removal of implants and physical characteristics of broken implants was retrieved from the patient's medical records. Data Analysis Data collected through questionnaires and medical records was analysed through descriptive and inferential statistics with the help of Statistical Package for Social Sciences (SPSS) software, version 25. Where significant associations were established multivariate logistic regression was computed between the variables. Results Data was collected using questionnaires from 204 patients at Kenyatta National Hospital, Nairobi Hospital, Aga Khan Hospital and PCEA Kikuyu Hospital. Pain in the implant area was the most common reason for implant removal at the four hospitals. 46.1% of patients reported implant-related pain, and that the doctor was the one who suggested the implant be removed (43.6%). Furthermore, 36.3 % of patients reported that they had an infection in the implant area, 32.4% said they had a swelling in the implant area while 21.6% said they commonly had irritation/implant prominence. 14 The study found out that broken implants (19.6%), bone overgrowth (10.8%), and locked screws on plates (11.8%) were the main challenging aspects of implants encountered during surgical implant removal. On the category of broken implants removed 21.1% of the patients had mechanical failure and implants of 14.2% of the patients were damaged and broken while implants removed from 5.9% of the patients had brittle failure. Discussion The study found that in the four urban hospitals, pain in the implant area, doctor's request, swelling in the implant area, and irritation/implant prominence were the most common indications for implant removal which is consistent with findings of other similar studies. Broken implants, bone overgrowth and locked screws were major challenges encountered during implant removal among respondents in this study. In addition, bone growth over the implant, rounded screw head core, cold fusion, difficulty finding the implant, and inability to remove part of the implant were other notable challenges affecting implant removal. Mechanical failure and breakage were common characteristics of broken implants removed from patients. Conclusion The most common indication for implant removal in this study was implant related pain. The study concludes that there is a significant relationship between indications of implant removal, challenges of implant removal and characteristics of broken implants and the decision for implant removal at the four urban hospitals in Kenya. This finding is supported by multinomial regression analysis which determined that there was a significant relationship between independent and dependent variables (p-value, 0.000). Presence of indications of implant removal would hence result in consideration of removal of the said implant.