Removal of Forearm Plate Leads to a Higher Risk of Refracture—A Systematic Review and Meta-Analysis

Abstract

Objective: Plate fixation is the preferred method for treating forearm shaft fractures. However, it remains controversial regarding the necessity of implant removal after bone union. This review aims to assess refracture risk after plate removal.

Methods: We searched various data sources, including PubMed, Embase, Web of Science, and Cochrane Library. A total of 6749 papers were identified, of which 23 studies were eligible for final quantitative syntheses. Subgroup analyses and sensitivity analyses were conducted to reduce heterogeneity and make the results more reliable.

Results: The total risk difference (RD) was 0.06 (0.04–0.09), indicating that the difference was significant. In the “Reasons for Removal” subgroup analysis, the RD of the “No Symptom” subgroup was 0.07 (95% CI = 0.04–0.11), while the RD of the “Symptoms” subgroup was 0.04 (95% CI = –0.02 to 0.10). In the “Plate Type” subgroup analysis, the RD of the “LCP” subgroup was 0.07 (95% CI = 0.02–0.13), while the RD of the “DCP” subgroup was 0.07 (95% CI = 0.01–0.13). After omitting each study one by one, the RDs were all significant.

Conclusions: Plate retention is significantly associated with a lower rate of refracture than plate removal. Consequently, it is not recommended to remove implants, especially for patients without implant-related symptoms, but more reliable evidence is still needed.

Trial Registration: The review was registered on PROSPERO and the registration ID is CRD42023424743, and a protocol was not prepared

Keywords

forearm shaft fractures / meta-analysis / plate removal / refracture

References

[1] R. F. Small, M. Taqi, and A. M. Yaish, “Radius and Ulnar Shaft Fractures,” in StatPearls (Treasure Island, FL: StatPearls Publishing LLC, 2024).

[2] B. M. Rafi and V. Tiwari, “Forearm Fractures,” in StatPearls (Treasure Island, FL: StatPearls Publishing LLC, 2024).

[3] H. N. Burwell and A. D. Charnley, “Treatment of Forearm Fractures in Adults With Particular Reference to Plate Fixation,” Journal of Bone and Joint Surgery. British Volume (London) 46 (1964): 404–425.

[4] L. D. Anderson, D. Sisk, R. E. Tooms, and W. I. Park, 3rd, “Compression-Plate Fixation in Acute Diaphyseal Fractures of the Radius and Ulna,” Journal of Bone and Joint Surgery. American Volume 57, no. 3 (1975): 287–297.

[5] N. Anantavorasakul, J. Lans, N. H. A. Wolvetang, E. T. Walbeehm, and N. C. Chen, “Forearm Plate Fixation: Should Plates be Removed?,” Archives of Bone and Joint Surgery 10, no. 2 (2022): 153–159.

[6] N. M. Behnke, H. R. Redjal, V. T. Nguyen, and D. M. Zinar, “Internal Fixation of Diaphyseal Fractures of the Forearm: A Retrospective Comparison of Hybrid Fixation Versus Dual Plating,” Journal of Orthopaedic Trauma 26, no. 11 (2012): 611–616.

[7] N. Haas, C. Hauke, M. Schütz, M. Kääb, and S. M. Perren, “Treatment of Diaphyseal Fractures of the Forearm Using the Point Contact Fixator (PC-Fix): Results of 387 Fractures of a Prospective Multicentric Study (PC-Fix II),” Injury 32, no. Suppl 2 (2001): B51–B62.

[8] J. P. Wang, F. Y. Chiu, C. M. Chen, and T. H. Chen, “Surgical Treatment of Open Diaphyseal Fractures of Both the Radius and Ulna,” Journal of the Chinese Medical Association 68, no. 8 (2005): 379–382.

[9] I. Azboy, A. Demirtas, B. Y. Uçar, M. Bulut, C. Alemdar, and E. Ozkul, “Effectiveness of Locking Versus Dynamic Compression Plates for Diaphyseal Forearm Fractures,” Orthopedics 36, no. 7 (2013): e917–e922.

[10] P. A. Deluca, R. W. Lindsey, and P. A. Ruwe, “Refracture of Bones of the Forearm After the Removal of Compression Plates,” JBJS 70, no. 9 (1988): 1372–1376.

[11] J. P. T Higgins, J. Thomas, J. Chandler, et al., eds., “Cochrane Handbook for Systematic Reviews of Interventions version 6.4,” updated August 2023, Cochrane, 2023, www.training.cochrane.org/handbook.

[12] A. Liberati, D. G. Altman, J. Tetzlaff, et al., “The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Healthcare Interventions: Explanation and Elaboration,” BMJ 339 (2009): b2700.

[13] The Cochrane Collaboration, “Review Manager (RevMan),” Version 5.4, 2020, http://revman.cochrane.org/.

[14] A. S. Bi, N. D. Fisher, S. R. Konda, K. A. Egol, and A. Ganta, “Delayed Versus Primary Closure of Diaphyseal Forearm Fractures in Adults: Short-Term Soft Tissue Outcomes,” Indian Journal of Orthopaedics 56, no. 9 (2022): 1594–1600.

[15] A. G. Bot, J. N. Doornberg, A. L. Lindenhovius, D. Ring, J. C. Goslings, and C. van Dijk, “Long-Term Outcomes of Fractures of Both Bones of the Forearm,” Journal of Bone and Joint Surgery. American Volume 93, no. 6 (2011): 527–532.

[16] M. W. Chapman, J. E. Gordon, and A. G. Zissimos, “Compression-Plate Fixation of Acute Fractures of the Diaphyses of the Radius and Ulna,” JBJS 71, no. 2 (1989): 159–169.

[17] P. Henle, K. Ortlieb, K. Kuminack, C. A. Mueller, and N. P. Suedkamp, “Problems of Bridging Plate Fixation for the Treatment of Forearm Shaft Fractures With the Locking Compression Plate,” Archives of Orthopaedic and Trauma Surgery 131, no. 1 (2011): 85–91.

[18] R. Hertel, M. Pisan, S. Lambert, and F. T. Ballmer, “Plate Osteosynthesis of Diaphyseal Fractures of the Radius and Ulna,” Injury 27, no. 8 (1996): 545–548.

[19] A. Kose, A. Aydın, N. Ezirmik, and Ö. S. Yıldırım, “A Comparison of the Treatment Results of Dpen Reduction Internal Fixation and Intramedullary Nailing in Adult Forearm Diaphyseal Fractures,” Ulusal Travma ve Acil Cerrahi Dergisi 23, no. 3 (2017): 235–244.

[20] D. A. Labosky, M. B. Cermak, and C. A. Waggy, “Forearm Fracture Plates: To Remove or Not to Remove,” Journal of Hand Surgery 15, no. 2 (1990): 294–301.

[21] S. K. Lee, K. J. Kim, J. W. Lee, and W. S. Choy, “Plate Osteosynthesis Versus Intramedullary Nailing for Both Forearm Bones Fractures,” European Journal of Orthopaedic Surgery and Traumatology 24, no. 5 (2014): 769–776.

[22] F. Leung and S. P. Chow, “A Prospective, Randomized Trial Comparing the Limited Contact Dynamic Compression Plate With the Point Contact Fixator for Forearm Fractures,” Journal of Bone and Joint Surgery. American Volume 85, no. 12 (2003): 2343–2348.

[23] F. Leung and S. P. Chow, “Locking Compression Plate in the Treatment of Forearm Fractures: A Prospective Study,” Journal of Orthopaedic Surgery (Hong Kong) 14, no. 3 (2006): 291–294.

[24] A. D. Mih, W. P. Cooney, R. S. Idler, and D. G. Lewallen, “Long-Term Follow-Up of Forearm Bone Diaphyseal Plating,” Clinical Orthopaedics and Related Research 299, no. 2 (1994): 256–258.

[25] U. Ozkaya, A. Kiliç, U. Ozdoğan, K. Beng, and Y. Kabukçuoğlu, “Comparison Between Locked Intramedullary Nailing and Plate Osteosynthesis in the Management of Adult Forearm Fractures,” Acta Orthopaedica et Traumatologica Turcica 43, no. 1 (2009): 14–20.

[26] O. Polat and S. Toy, “Comparison of the Clinical and Radiographic Outcomes of Plate Fixation Versus New-Generation Locked Intramedullary Nail in the Management of Adult Forearm Diaphyseal Fractures,” Acta Orthopaedica et Traumatologica Turcica 56, no. 5 (2022): 321–326.

[27] J. W. Rosson, G. W. Petley, and J. R. Shearer, “Bone Structure After Removal of Internal Fixation Plates,” Journal of Bone and Joint Surgery. British Volume (London) 73, no. 1 (1991): 65–67.

[28] J. P. Sargent and W. A. Teipner, “Treatment of Forearm Shaft Fractures by Double-Plating: A Preliminary Report,” JBJS 47, no. 8 (1965): 1475–1490.

[29] E. H. Schemitsch and R. R. Richards, “The Effect of Malunion on Functional Outcome After Plate Fixation of Fractures of Both Bones of the Forearm in Adults,” JBJS 74, no. 7 (1992): 1068–1078.

[30] W. A. Teipner and J. W. Mast, “Internal Fixation of Forearm Diaphyseal Fractures: Double Plating Versus Single Compression (Tension Band) Plating—A Comparative Study,” Orthopedic Clinics of North America 11, no. 3 (1980): 381–391.

[31] C. K. Yao, K. C. Lin, Y. W. Tarng, W. N. Chang, and J. H. Renn, “Removal of Forearm Plate Leads to a High Risk of Refracture: Decision Regarding Implant Removal After Fixation of the Forearm and Analysis of Risk Factors of Refracture,” Archives of Orthopaedic and Trauma Surgery 134, no. 12 (2014): 1691–1697.

[32] G. S. Beaupre and J. J. Csongradi, “Refracture Risk After Plate Removal in the Forearm,” Journal of Orthopaedic Trauma 10, no. 2 (1996): 87–92.

[33] S. L. Woo, W. H. Akeson, R. D. Coutts, et al., “A Comparison of Cortical Bone Atrophy Secondary to Fixation With Plates With Large Differences in Bending Stiffness,” Journal of Bone and Joint Surgery. American Volume 58, no. 2 (1976): 190–195.

[34] M. J. Gardner, R. H. Brophy, D. Campbell, et al., “The Mechanical Behavior of Locking Compression Plates Compared With Dynamic Compression Plates in a Cadaver Radius Model,” Journal of Orthopaedic Trauma 19, no. 9 (2005): 597–603.

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2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.