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A Technical Note on Submuscular Plate Removal for Symptomatic Children and Youth

To the Editor: In the recent series (J Pediatr Orthop 2009;29:709–712) regarding removal of submuscular plates that were applied for stabilizing length unstable femur fractures in children and youth, the authors addressed a common critique of this treatment option, in which hardware removal can be more invasive than plate fixation itself as far as muscle damage and cosmetically appearing scars are concerned. The authors stated that removing hardware for this population makes clinical sense and that a predictive factor for requiring a larger incision for removing the plate is bone overgrowth over the leading edge of the plate, which usually occurs distally for proximally inserted plates and proximally for distally inserted plates. The need for removing plates in children and youth remains questionable. Operating and giving general anesthesia for preventing hypothetically more challenging operations that a patient may possibly require in the future go against the principle of “first doing no harm.” From a population health perspective, removing hardware of asymptomatic patients consume health resources [ie, operating room, human resources, time, equipment, etc] that are required for treating symptomatic patients, and therefore do not make clinical sense until evidence of medical need can be demonstrated. The operative technique that was used for hardware removal is not described in the study, which is claimed to be the first series concerning removal of submuscular plates in children. For this reason, a technical note would complement this study. For symptomatic patients who require hardware removal to relieving their symptoms, given the screw head next to the leading edge of the plate is not covered with bone, and therefore can be removed through a stab wound developed over the scar caused for screw insertion, and if all remaining screws are removed with the same process, the plate can be removed through a surgical wound developed over the scar caused for plate insertion (usually of approximately 5 to 10 cm), precluding the need for additional surgical scars and muscle damage. After removal of screws and of overgrown bone over the exposed edge of the plate, a nail extractor (or a similar tool) can engage one of the plate holes after gently lifting, and “in situ” bending this part of the plate toward the outside of the wound. Thus, similarly to what is done for removing intramedullary nails, the plate can be gradually pulled toward the opposite direction in which the plate was inserted, fracturing overgrown bone that is predictably present over the leading edge of the plate.