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Hardware: femur re-fracture after hardware removal?

You would think that there would be a lot of information about re-fracture of the femur for two reasons. The first is that fracture of the hip and subsequent treatment with a plate on the femur is very common in the elderly. And the second is that you would expect the elderly population to have a high incidence of repeat falls and therefore a risk of re-injury. But my personal experience has been that re-fracture of the hip is very rare. I must do about 50 hip fracture operations a year and after 20 years I cannot remember seeing a re-fracture. This is born out by searching the literature. A search for "refracture and femur" and "refracture and hip" yielded the following papers.

  • Stocker R, Heinz T, Vecsei V. Results of surgical management of distal femur fractures with joint involvement reported one refracture in 60 cases of distal femur fracture
  • Chen CM, Chiu FY, Lo WH, Chuang TY. Ipsilateral hip and distal femoral fractures 1 refracture in 15 cases where the orginal fracture affected the femur in two places.
  • Kahle WK. The case against routine metal removal. (1.4% refracture rate in children)
  • Meeder PJ, Haase T, Wagner K. Subsequent fractures of the femur shaft. Classification, etiology and treatment--a retrospective study 0.9% refracture in 2073 fractures
  • Cheng JC, Tse PY, Chow YY. The place of the dynamic compression plate in femoral shaft fractures. 3% refracture
  • Babst R, Renner N, Biedermann M, Rosso R, Heberer M, Harder F, Regazzoni P. Clinical results using the trochanter stabilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal fixation of selected unstable intertrochanteric fractures. One refracture out of 32 hip fractures "after premature implant removal".
  • Wand JS. Risk of refracture after removing hip fixation. No abstract available
  • Finsen V, Benum P. Refracture of the hip rare after removal of fixation device These authors studied refracture after removal of implants like the Richards nail. After 630 patient years in 99 patients they found 15 fractures in the other hip and 2 in the operated one.

It is even more difficult to compare the risk of refracture with the plate removed to the risk of refracture with the plate retained. However, it is probablbly true to say the both these risks are about the same and are low - about 1:50 or less. This is the same size of risk as the risk of a fracture on the other side. My own approach to this situation is to go by the patient's symptoms; if there are very few symptoms I advise against plate removal. If the pain is disabling I believe the risk of trouble of some sort (ulcers, overdosing from medications, falling, depression etc) to be greater if the plate is left in.

Recuperation involves recovery from the operation (usually one or two days in hospital for pain relief); healing of the skin and msucle where the operation took place (4 weeks); and recovery of full strength of the bone by filling in of the screw holes and restoration of normal bone anatomy (3 months. During this time there is probably an increased risk of refracture. In one of the papers cited they note that all "refractures" occured within 90 days of removal of the plate.

Myles Clough MD OS Jan 15 2002

From: Joan

What are the chances of refracturing the femur after the hardware is removed? Would this be easily re-fractured?
How long must one re-cuperate?

From: megan

is the possibility of femur fracture after removing an im nail higher if you have poor bone regeneration?

From: Phil

my femur broke again after 15 years.it had fractured before now and just had to go onto crutches for a few weeks.but 13th march this year it broke and it had to be fixed again with a rod and three screws.I had the old rod removed after two years

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