The Impact of Psychological Factors on Device Removal Surgery

BACKGROUND: Implant removal is a common procedure in orthopedic surgery which can be associated with many complications such as scar formation, hematoma, nerve injury, infection, and refracture. Indications for orthopedic implant removal have declined in recent years. Most studies have considered orthopedic hardware removal as an unnecessary procedure in the absence of severe complications such as nonunion. Some studies have reported the complications of orthopedic hardware removal to be 24% to 50% dependent on their types and locations as well as on other factors such as patient’s condition and the orthopedist’s experience. OBJECTIVES: The present study surveyed possible mental and psychological causes among patients who asked for removal procedures in spite of orthopedic surgeons’ advice and being aware of complications. PATIENTS AND METHODS: Patients who had undergone plating for the treatment of radius and ulna fractures from 2011 to 2013, were told that it is not necessary to remove the plate and they were warned of all the risks of removal surgery, such as anesthesia, possible nerve or vascular damage, and the cost of surgery. Then, their tendency to remove the plate was examined based on evaluation criteria scores. Patients were divided into two groups: patients who insisted on surgery despite all the risks and patients who had little tendency or gave up after explanations. Both groups were given visual analog pain scale (VAS), symptom checklist-90 (SCL-90), and pain catastrophizing scale (PCS) questionnaires. The questions were explained for patients by an expert trained in the clinic and in case of ambiguity further explanations were given to the patients. The data were then entered into statistical package for the social science (SPSS) version 20 for analysis. RESULTS: A total of 29 patients with plates were enrolled. The first group consisted of 16 male and 13 female patients. In the control group (group II), there were 30 patients with no tendency for plate removal. In this group, 15 patients were male and 15 were female. The mean age of the first group was 38.25 ± 11.12 years and for the second group it was 36.82 ± 12.01 years. There was no significant difference between the two groups in terms of age and gender. Mean discomfort of patients was 7.75 ± 1.74 in the first and 3.96 ± 1.90 in the second group, indicating a statistically significant difference (P = 0.000). Mean VAS score was 3.96 ± 1.20 in the first group and 3.80 ± 1.15 in the second group, which was not statistically significant (P = 0.593). Mean daily pain and discomfort was 10.62 ± 3.09 hours in the first and 4.86 ± 2.23 hours in the control group, indicating a statistically significant difference (P = 0.000). Linear regression analysis results demonstrated a significant correlation between increased VAS scores in the first group (P = 0.000), but it was not significant in the second group (P = 0.083). The results also showed that increase in time of daily pain and discomfort had a linear relationship with increased discomfort score in both groups (P = 0.00). Mean pain catastrophizing scale (PCS) score was 10.13 ± 3.62 in the first and 9.56 ± 3.07 in the second group, which was not statistically significant. Mean somatization score was 52% ± 6.53% and 47.96% ± 7.17% in the first and second groups, respectively, which showed no significant differences (P = 0.013). Obsessive compulsive score was 54.63 ± 5.34 in the first and 46.63 ± 4.49 in the second group, which was statistically significant (P = 0.000). CONCLUSIONS: Mental and psychological backgrounds can affect the severity of discomfort of the implant. Given that so far the present study is the only study investigating the relationship between mental criteria and tendency of patients for implant removal, further studies with larger sample sizes seem warranted.