Internal fixation with plates, screws, intramedullary nails, Kirschner wires and cerclage constructs is integral to contemporary fracture care. Once fracture union has been achieved, however, the implant may either be retained or removed. Implant removal remains one of the commonest secondary procedures in orthopaedic practice, yet the indication for routine removal of an asymptomatic device is disputed and uniform evidence-based policies remain limited.[1-6]

The clearest indications for removal are implant-related infection, exposed or prominent material threatening skin or tendons, intra-articular penetration, implant failure, mechanical conflict, and selected growth-related circumstances. In contrast, pain of uncertain origin, patient preference, anxiety regarding retained metal and prophylactic removal after union are relative indications that require individualised assessment. Removal is not a trivial reversal of fixation: difficult surgical exposure, cold welding or damaged screw heads, neurovascular injury, wound complications, bleeding, incomplete removal and refracture can occur.[2,6,13]

The professional literature demonstrates considerable variation in practice. Hanson and colleagues found that approximately 58% of surveyed surgeons rejected routine removal in younger asymptomatic patients, while many did not believe retained implants conferred excess fracture or systemic risk.[3] A United Kingdom survey similarly reported that 92% of surgeons did not routinely remove metalwork in asymptomatic skeletally mature patients.[4] In the Netherlands, most surgeons supported removal for pain or functional impairment but not as a universal policy.[5] These studies establish professional uncertainty and variability, but they do not explain what patients understand when they request or decline a second operation.

Patients often make decisions using beliefs acquired from family, community networks, prior surgical experiences and informal media. The physical presence of “metal in the body” may be interpreted as temporary, toxic, corrosive or incompatible with long-term health. In settings where squatting, kneeling, cross-legged sitting and floor-level activities are important for daily living or religious practice, retained lower-limb implants may also be perceived as barriers to normal function even in the absence of objective restriction. Such beliefs can coexist with genuine concerns about another anaesthetic, surgical cost, recovery time and complications.

Outcome studies show why balanced counselling is necessary. Pain and function may improve after removal in appropriately selected symptomatic patients,[7-9] yet symptom resolution is not guaranteed and complications are well documented.[9,12,13] Conversely, patient-driven removal can consume substantial healthcare resources and time away from work.[1,10] The quality of the decision therefore depends not only on clinical indication but also on whether the patient understands the purpose of the implant, the uncertainty of benefit, the risks of removal, and the fact that routine removal after union is not universally required.

Published research has predominantly focused on surgeons' opinions, indications for removal or post-removal outcomes. There is comparatively little systematic information on awareness and misconceptions among patients who still have implants in situ, particularly in Indian tertiary-care settings. Identifying these gaps is necessary for designing culturally appropriate counselling and supporting shared decision-making. The present study therefore evaluated awareness and perceptions regarding orthopaedic implant removal among post-operative patients attending the Orthopaedics outpatient department of Mandya Institute of Medical Sciences (MIMS), Mandya.

The primary objective was to assess the level of awareness regarding orthopaedic implant removal among post-operative patients attending the Orthopaedics outpatient department at MIMS, Mandya.

The secondary objective was to describe patient perceptions and misconceptions regarding retained orthopaedic implants and the indications, benefits and risks of removal.

Study design: Hospital-based descriptive cross-sectional study.

Study period: Conducted during the approved study period in 2026. The manuscript was prepared in accordance with the principles of the STROBE reporting statement for cross-sectional studies.[16]

Sampling technique: Consecutive sampling of eligible patients presenting to the outpatient department, using convenience sampling until the required sample was achieved.

Sample size: The minimum sample size was calculated for estimation of a single proportion using n = Z²pq/d², with a 95% confidence level, an anticipated proportion of 61% as specified in the approved protocol, q = 39%, and relative precision of 20% of the anticipated proportion. The calculated value was 61.5 and was rounded to 62 participants.

Study set-up: Department of Orthopaedics (outpatient department), Mandya Institute of Medical Sciences (MIMS), Mandya — a tertiary care hospital.

Selection criteria:

Inclusion criteria - 1) Male and female post-operative patients aged 18 years or older who had undergone orthopaedic surgery involving internal fixation with a metallic implant, including plates, screws, intramedullary nails, Kirschner wires or combinations of these devices. 2) Completed at least three months from the index fixation procedure. 3) Willing to give written informed consent to participate in the study.

Exclusion criteria - 1) Already undergone implant removal before enrolment. 2) Joint arthroplasty implant. 3) Active implant-related infection at assessment. 4) Cognitive impairment or a communication barrier that prevented a meaningful questionnaire response.

Institutional scientific and ethics review was obtained at Mandya Institute of Medical Sciences, Mandya, before starting the research project, and written informed consent was obtained from every participant. Participation was voluntary, refusal did not affect treatment, and confidentiality of personal information was maintained.

After written informed consent, participants were interviewed by the investigator using a pre-tested, semi-structured questionnaire administered in the participant's preferred language (Kannada or English). The instrument was organised into four domains: socio-demographic information; post-operative and clinical history; an implant-removal awareness questionnaire; and a perception assessment. Socio-demographic variables included age, sex, education, occupation and rural or urban residence. Clinical information included the type and site of fixation, duration since surgery, presenting complaints and current symptoms. A local examination of the operated site was performed for clinical documentation.

The awareness component contained eight dichotomous items addressing knowledge of implant material and purpose, awareness that removal requires a second surgery, belief that removal is mandatory, awareness of risks of removal and possible complications of retention, exposure to formal surgeon counselling, and influence of family or community opinion. Responses were coded using the pre-specified study scoring key to generate a total score from 0 to 8. A total score of at least 6 of 8 (at least 70%) was classified as adequate awareness; scores below 6 were classified as inadequate awareness.

The perception component contained seven agree/disagree statements relating to arthritis or joint damage, corrosion, cancer, cultural or religious acceptability, expected improvement in squatting or kneeling, perceived risk of a second operation, and preference for removal despite contrary surgical advice. The patient's primary information source was also recorded. No intervention or change in treatment was made on the basis of participation.

The primary outcome was the proportion of participants with adequate implant-removal awareness. Secondary outcomes included the mean awareness score, item-wise awareness responses, the distribution of perceptions and misconceptions, and associations between adequate awareness and selected socio-demographic or clinical variables.

After collection, data were entered in Microsoft Excel and analysed using IBM SPSS Statistics version 30.0. Continuous variables were summarised using mean and standard deviation. Categorical variables were presented as frequencies and percentages. The association between adequate awareness and sex, age group, educational status, residence and duration since surgery was examined using the chi-square test or Fisher exact test where appropriate. Available-case analysis was used for variables with missing observations, and the denominator is stated where it differed from 62. All tests were two-sided and a p-value below 0.05 was considered statistically significant.

A total of 62 post-operative patients with metallic internal fixation implants were included. Their mean age was 43.0 ± 18.7 years. The 40-59-year age group was the largest (43.5%, n=27), followed by 18-39 years (40.3%, n=25); 16.1% (n=10) were aged 60 years or older. Men constituted 79.0% (n=49) of the sample, and 74.2% (n=46) were rural residents. Educational status was available for 61 participants, of whom 20 (32.3% of the full sample) had no formal education. The most frequently represented occupations were farming (29.0%, n=18), housework (19.4%, n=12) and student status (19.4%, n=12). The mean duration since index surgery was 8.5 ± 12.1 months. Socio-demographic and clinical characteristics of the study population are summarised in Table 1.

Table 1: Socio-demographic and Clinical Profile of Study Participants (N = 62)

One participant had missing residence and educational-status data. Percentages are calculated using the full sample unless otherwise indicated. SD, standard deviation.

The mean total awareness score was 5.19 ± 2.32 of 8, equivalent to 64.9% of the maximum score. Thirty-two participants (51.6%) met the pre-defined threshold for adequate awareness, while 30 (48.4%) had inadequate awareness.

Knowledge was highest for the purpose of the implant (82.3%, n=51), followed by the implant material (74.2%, n=46) and awareness that removal requires a second surgical procedure (71.0%, n=44). However, 56.5% (n=35) believed implant removal was mandatory after fracture healing. Only 56.5% (n=35) reported awareness of removal-related risks, and 51.6% (n=32) were aware of possible long-term complications associated with implant retention. Formal counselling by the surgeon was reported by 61.3% (n=38), whereas 66.1% (n=41) stated that their decision was influenced by family or community opinion.

Table 2: Item-wise Implant-Removal Awareness Responses (N = 62)

Table 3: Overall Implant-Removal Awareness Score (N = 62)

Misconceptions about the biological effects of retained implants were common. Fifty participants (80.6%) agreed that a retained implant causes arthritis or joint damage, and 48 (77.4%) believed metal implants can rust or corrode inside the body. A smaller but clinically relevant proportion, 17.7% (n=11), believed retained implants can cause cancer. Cultural and functional considerations were also prominent: 61.3% (n=38) regarded retention as culturally or religiously unacceptable and 62.9% (n=39) believed removal would improve squatting or kneeling. Twenty-six participants (41.9%) viewed the second operation as too risky. Twenty-nine (46.8%) stated that they would prefer removal even if their surgeon advised against it.

Table 4: Perceptions and Beliefs Regarding Retained Implants and Implant Removal (N = 62)

Row totals may be less than 62 because a small number of responses were not recorded. Percentages use N=62 as reported in the final results dataset.

No statistically significant association was observed between adequate awareness and sex, age group, education, residence or duration since surgery. Age group showed the strongest trend but did not reach statistical significance (χ²=4.83, p=0.090). Mean awareness scores were 5.24 in participants aged 18-39 years, 5.30 in those aged 40-59 years and 3.80 in those aged 60 years or older. Participants with formal education had a higher mean score than those with no formal education (5.35 versus 4.71), and urban residents had a higher mean score than rural residents (5.73 versus 5.00); these differences were not statistically significant.

Table 5: Association Between Adequate Awareness and Selected Variables

Chi-square or Fisher exact test as appropriate. A two-sided p-value <0.05 was considered statistically significant.

This study provides a patient-centred assessment of knowledge and beliefs concerning orthopaedic implant removal in a tertiary-care population. The principal finding was a marked gap between partial factual awareness and persistent misconceptions. Although approximately three-quarters understood the implant material or the need for another operation and more than four-fifths understood its original purpose, only 51.6% achieved the threshold for adequate overall awareness. Simultaneously, most participants believed that retained metal causes arthritis or joint damage, more than three-quarters believed it can rust or corrode, and nearly half would prefer removal even against surgical advice. These findings indicate that knowing why an implant was inserted does not necessarily translate into an evidence-aligned understanding of whether it should later be removed.

The belief that removal is mandatory after fracture healing was reported by 56.5% of participants. This contrasts sharply with surveys of orthopaedic surgeons. Hanson et al. reported that 57.8% of surgeons disagreed with routine removal in younger asymptomatic patients, while only 37.1% agreed.[3] Jamil et al. found that 92% of practising United Kingdom surgeons did not routinely remove metalwork in asymptomatic skeletally mature patients.[4] Similarly, the Dutch survey by Vos et al. showed broad support for removal when pain or functional deficit was present but no universal practice of routine removal.[5] The respondent populations and health systems differ, so direct numerical comparison is inappropriate; nevertheless, the direction of the contrast is important. Professional practice increasingly favours selective removal, whereas a substantial proportion of patients in the present study perceived removal as an expected final stage of fracture treatment.

Misconceptions regarding biological harm were especially prominent. In the present study, 80.6% believed retained implants cause arthritis or joint damage, 77.4% believed they rust or corrode, and 17.7% believed they cause cancer. In Hanson et al., 58.1% of surgeons disagreed that retained implants caused allergy or malignancy and only 18.8% agreed.[3] More than half of Dutch surgeons also rejected the proposition that retained implants increase fracture, infection, allergy or malignancy risk.[5] Available reviews acknowledge concerns such as corrosion, metal sensitivity and local tissue reactions but conclude that these do not justify universal removal of stable, asymptomatic fracture implants; current recommendations generally favour symptom- and indication-based decisions with proper informed consent.[2,6,12] The extremely high prevalence of arthritis and corrosion beliefs in this cohort therefore represents an important educational target.

The present findings also demonstrate the social context in which implant-removal decisions are made. Two-thirds of participants reported family or community influence, 61.3% considered retained material culturally or religiously unacceptable, and 62.9% expected removal to improve squatting or kneeling. These beliefs are clinically relevant in Mandya, where occupational work, household activity and customary floor-level postures may shape the perceived meaning of an implant. A purely technical explanation of union and implant stability may not address these concerns. Counselling should specifically discuss expected range of motion, clarify whether symptoms are actually attributable to the hardware, and invite influential family members when the patient agrees.

Formal counselling had been received by 61.3% of participants, yet misconceptions remained frequent. This may reflect counselling that was brief, delivered during acute injury or perioperative stress, focused on the immediate fixation procedure, or not reinforced after union. It may also reflect language, health-literacy and recall barriers. The absence of a significant association between educational status and awareness should not be interpreted as evidence that communication needs are uniform. The mean score was numerically higher among participants with formal education, but the study had limited power. A standardised approach using plain-language Kannada and English materials, pictorial explanations, an implant card and teach-back may be more reliable than unstructured verbal counselling alone.

The clinical literature reinforces the need for balanced messaging rather than an absolute “retain” or “remove” recommendation. In symptomatic patients, removal can provide meaningful pain relief and functional improvement. Minkowitz et al. reported substantial reductions in pain after removal of painful implants, although complete pain resolution was not universal.[8] Reith et al. found that patients undergoing removal for pain or impaired function frequently reported improvement, but a 10% patient-reported complication rate was also observed.[7] Brown et al. reported persistent pain in nearly half of ankle-fracture patients who underwent hardware removal for lateral pain.[9] These data should be communicated in a way that neither dismisses symptoms nor creates unrealistic expectations.

Implant removal also has procedural and system-level consequences. Böstman and Pihlajamäki reported that routine removals accounted for 29% of elective operations and 15% of all operations in a large trauma unit.[1] In a Nigerian prospective study, patient request was the main indication in 72.3% of removals, and the authors highlighted both direct cost and time away from work.[10] An Indian series of 83 removals found pain or prominence to be the commonest indication, followed by infection, failure and patient insistence, while emphasising that removal can be technically difficult.[11] These observations are pertinent to public tertiary hospitals, where operating-room capacity and patient expenditure are limited. Improving awareness may reduce non-indicated requests, while also helping patients with true indications seek timely care.

No tested socio-demographic or clinical variable showed a statistically significant association with adequate awareness. The age-group comparison approached significance, and participants aged 60 years or older had a notably lower mean score. Urban residence and formal education were also associated with numerically higher scores. These patterns are clinically plausible but should be regarded as exploratory. With only 62 participants and several categorical comparisons, the study was underpowered to detect modest associations. Future multicentre studies should use validated instruments and multivariable analysis to distinguish the effects of age, literacy, counselling quality, implant site, symptom status and information source.

The study has practical implications. Counselling should begin at the index fixation procedure but be repeated after fracture union, when the removal decision becomes relevant. A minimum counselling set should explain that the implant supported healing; that routine removal is not always necessary; the specific absolute and relative indications; the possibility that removal may not relieve non-specific pain; and risks such as infection, nerve injury, difficult extraction and refracture. Because family influence was common, family-inclusive counselling should be offered. Documentation of counselling and provision of a bilingual implant-information card could improve continuity across facilities.

Strengths and limitations

The study directly assessed patients with retained fracture-fixation implants and incorporated beliefs that are relevant to local cultural and functional practices. The questionnaire was interviewer-administered in Kannada or English, reducing exclusion due to literacy, and the results provide an immediately actionable baseline for patient education at the institution.

Several limitations should be considered. First, the single-centre convenience sample was small and predominantly male and rural, which limits generalisability. Second, the questionnaire was locally developed and pre-tested but did not undergo formal psychometric validation. Its composite score includes factual knowledge, counselling exposure and social influence, and should therefore be interpreted as a broad awareness construct rather than a pure knowledge scale. Third, responses were self-reported and may be affected by recall or social-desirability bias. Fourth, a small number of residence, education and perception responses were missing. Fifth, the study did not stratify perceptions by implant site, material, symptom status or source of information in the final analysis. Finally, the cross-sectional design cannot determine whether counselling caused higher awareness or whether beliefs ultimately led to implant removal.

Only about half of post-operative patients in this tertiary-care sample demonstrated adequate overall awareness regarding orthopaedic implant removal. Misconceptions that retained implants cause arthritis, corrosion or functional restriction were widespread, and social or cultural influence was substantial. Nearly half of the participants would prefer removal despite contrary surgical advice. These findings support a structured, repeated, bilingual and family-inclusive counselling pathway that clearly distinguishes indications for removal from myths about retained metal, explains the uncertain benefit of elective removal, and communicates the risks of a second operation. Larger multicentre studies using a validated patient-awareness instrument are required to confirm the determinants of these beliefs and evaluate whether targeted education changes decision-making and unnecessary removal rates.

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