Orthopedic Hardware Problems

Todd R. Wilcox, MD, MBA, CCHP-A Medical Director Salt Lake County Jail System

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Educational Goals Understand types of orthopedic hardware Understand typical post-op management based on type Understand hardware complications Medical necessity of hardware complications

Brief History Earliest fracture management dates to 300 BC Osteosynthesis did not start until 1900 AO group in Brussels

Various Techniques

Case 1 Presents to Sick Call Injury 9 months ago Having pain Wants bottom bunk, special shoes, extra blanket

Basic Bone Physiology Bone has 2 functions Structural support Metabolic

Bone Formation Occurs in 2 stages Osteoblasts deposit osteoid Osteoid is mineralized

Fracture Repair

Internal Fixation

Plate Fixation

External Fixation

Basic Fracture Management Soft Tissue Compression Reduces Deformity

Load Bearing

Load Sharing

External Fixation Wire / pin loosening is most common complication pin care--normal saline and NO bacitracin

Elective Hardware

Dislocated Hardware 3% of primary THA’s 15% of revision THA’s Require ER visit for anesthesia / sometimes need OR

Elective Hardware Harrington Rods are common Need to evaluate the fusion mass Broken rods happen a lot, often not clinically significant

Broken Hardware Common 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 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 Hardware

Infected 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 Hardware Xrays CBC, Sed Rate, C-reactive protein, blood cultures Radioisotope scans (Indium-111 leukocyte, tecnetium-99) Arthrocentesis

Incidental 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 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 For Fixed deformities Amputations Significant tissue loss / grafting Leg length discrepancy > 1.5 inches

Bottom Bunk Only if fracture has not healed and is not infected Historical fractures or retained hardware is not a legitimate justification

Summary 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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