OT notes · Orthopaedics

Implant removal

Usual anaesthesia
Regional block for the upper limb; spinal for the lower limb; general when needed
Position
Supine; arm on a hand table for upper limb
Setting
elective

Operative note template for removal of orthopaedic implants (plates, screws, nails, wires) after fracture healing, with a filled example for removal of a distal radius bridge plate under brachial plexus block.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • refracture through the old fracture or screw holes
  • a broken or stripped screw may have to be left in the bone
  • nerve or tendon injury near the implant
  • wound infection
  • pain may not improve after removal
  • need for a bigger incision or bone window to get the implant out
  • stiffness needing therapy

Pre-operative details for this operation

  1. Original operationdate, procedure, hospital; implant type, make and number of screws from old op note or discharge card if available
  2. Indication for removalPlanned removal (bridge plate, syndesmotic screw)Prominent or painful implantImplant failure / breakageInfectionNonunionJoint penetrationPatient request
  3. Time since fixationmonths; compare with the usual time for that bone
  4. Union on X-rayAP and lateral: fracture lines obliterated, canal restored; implant count on X-ray (screws, bolts, end cap, wires, broken pieces)
  5. Extraction instruments availablematching screwdrivers, extraction set for the implant system, broken-screw removal set
  6. Neurovascular status before surgery

Anaesthesia and position

  1. AnaesthesiaBrachial plexus blockSpinalGeneralLocal
  2. Positionsupine, arm on hand table / lateral / prone
  3. Tourniquetsite, pressure in mmHg, inflation and deflation times
  4. C-armUsedNot usedfor locating screws and confirming complete removal

Operative findings

  1. Implant found as expectedYesNo (what differed)
  2. Bone over or around implantovergrowth over plate / screw heads, callus
  3. Screw headsIntactStripped (number)Broken (number, level)
  4. Signs of infectionNonePus / sinus / loose implant: cultures sent
  5. Fracture site after removalunited / gap / mobile

Procedure (steps)

  1. Incisionthrough old scar or separate stab incisions; length
  2. Exposure of implantstructures protected (tendons, nerves); bone cleared from screw heads
  3. Locking screws or bolts removednumber removed of number present
  4. Plate / nail extractionplate freed and lifted out; for a nail, extraction jig or bolt attached and nail pulled out
  5. Stripped or broken screw handlingNot neededRemoved with extraction setLeft in situ (which, where, why)
  6. Complete removal confirmedall pieces counted against the pre-op X-ray; C-arm image if used
  7. Wound wash and haemostasistourniquet released before closure

Closure, drains and dressing

  1. Deep layersuture
  2. Skinsuture and technique
  3. DrainNoneSuction drain
  4. Dressing and splinttype of splint and for how long
  5. Distal neurovascular status at end

Specimens and implants

  1. Implants removedlist each item: plate (holes, size), number of screws, nail and bolts, end cap, wires; make if known
  2. Disposal of removed implantsBlue container (metallic body implants) per BMW rulesHanded to patient on written request
  3. Cultures / tissueNoneSent (reason)

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Distal neurovascular chartingevery 2 hours for 12 hours
  2. Limb elevation
  3. Splint or protectiontype and duration; protected loading of the bone
  4. Movement and therapyfinger / joint exercises from day 1
  5. Analgesiadrug, dose, frequency
  6. Avoid heavy loading or contact sportperiod advised because of refracture risk
  7. Check X-rayif not done on C-arm
  8. Stitch removal and follow-update

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. P.D., 46 years, 14 weeks after a comminuted distal radius fracture of the left wrist fixed with a dorsal distal radius bridge plate, now united on X-ray.

Case details

Date: 21/09/2026. Elective. OT 4.

In OT 10:00. Block given 10:05. Tourniquet up 10:35. Tourniquet down 11:05. End 11:15.

Surgeon: Dr A. (2nd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Planned removal of dorsal distal radius bridge plate after union. Original surgery 15/06/2026 in this unit: 2.4 mm stainless steel bridge plate from radius to second metacarpal, 3 screws in radius, 3 screws in second metacarpal (old op note seen).

X-ray left wrist AP and lateral 18/09/2026: fracture united, radial length maintained. Six screws and one plate seen. No broken screw.

Pre-op: radial pulse felt, sensation normal in all fingers.

Consent: general, procedure-specific (including refracture, broken screw left in situ) and anaesthesia consent taken in Marathi from patient; husband as witness.

WHO checklist sign in and time out done. Left side marked. Inj cefazolin 2 g IV at 10:25 as per unit protocol.

Anaesthesia and position

Supraclavicular brachial plexus block. Supine, left arm on hand table. Upper-arm tourniquet inflated to 250 mmHg after elevation. C-arm available.

Parts painted with povidone-iodine and draped.

Findings

Plate and all six screws found as expected. Screw heads intact. No pus, no loose screw. Thin fibrous tissue over plate. Wrist stable after removal.

Procedure

Distal incision of 4 cm through the old scar over the second metacarpal. ECRL insertion identified and protected. Three metacarpal screws removed.

Proximal incision of 4 cm through the old scar over the radial shaft, between ECRL and ECRB. Three radial screws removed.

Plate freed from soft tissue and drawn out through the distal incision. Stainless steel plate came out without twisting.

Six screws and one plate counted against the pre-op X-ray. C-arm AP and lateral: no implant left. Screw holes intact, no fracture.

Tourniquet released at 11:05. Haemostasis by bipolar cautery. Wounds washed with normal saline.

Closure

Subcutaneous tissue with interrupted polyglactin 910 (Vicryl) 3-0. Skin with interrupted polyamide (Ethilon) 3-0. No drain.

Sterile dressing. Removable short-arm splint applied.

Fingers warm and pink, capillary refill normal at end.

Specimens and implants

Removed: one 2.4 mm stainless steel distal radius bridge plate and six 2.4 mm cortical screws. Placed in blue container for metallic body implants. No specimen for HPE.

End of procedure

Estimated blood loss 20 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 76/min, BP 128/80 mmHg.

Post-op orders

Arm elevated on pillow. Finger circulation and sensation every 2 hours for 12 hours.

Finger movements from today. Removable short-arm splint for 2 to 3 weeks, then hand therapy for motion and strength.

No lifting of heavy weights with the left hand until review.

Oral analgesic as per ward protocol.

Discharge today if comfortable. Stitch removal at review in OPD.

Signature

Dr A., JR-2, Orthopaedics. Reg. no. ________. 21/09/2026, 11:30.

Must document for this operation

  • The indication for removal and the time since fixation. Removal before solid union risks refracture, so the note must show why it was done at that time.
  • Union seen on pre-operative X-ray. If the bone breaks again, the record must show that healing was checked first.
  • Each implant removed, counted against the pre-op X-ray. A missing screw or end cap found later is a medicolegal problem, and the count shows removal was complete.
  • Any broken or stripped screw left in the bone, with its site and the reason. The patient must be told, and the next surgeon or radiologist needs to know it is there on purpose.
  • Nerves and tendons seen and protected, and distal status at the end. A nerve or tendon problem found after removal must be dated correctly.
  • What happened to the removed implants. Patients sometimes ask for their implants, and disposal must follow bio-medical waste rules.

Common mistakes in these notes

  • Writing 'implant removed' without listing the plate, the number of screws and the end cap or bolts.
  • Not recording whether a broken screw was left behind.
  • No mention of fracture union before removal.
  • Missing tourniquet time.
  • No advice on protecting the bone after removal.

Indian practice and paperwork

  • Removed orthopaedic implants are 'metallic body implants' under Bio-Medical Waste rules and go in the puncture-proof blue container to the common treatment facility. (Bio-Medical Waste Management Rules 2016, CPCB guidelines, category Blue (b))
  • An audit of orthopaedic operation notes in a Mumbai tertiary centre found tourniquet time recorded in only 41.8% and closure details in 17% of notes. (Tuteja S et al., Indian J Orthop 2022;56(12):2223-2227, PMID 36507202)
  • A patient or legal authority can ask for copies of the medical record, including the operation notes; they are to be issued within 72 hours. (Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002, Reg. 1.3.2)

Sources

  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2027, Ch 58, General principles of fracture treatment: plate and screw fixation, plate removal, Table 58.12 (timing of implant removal), pp. 2546-2550.
  • Tornetta P III, ed; Wiesel SW, editor-in-chief. Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed., Ch 9, Bridge plating of distal radius fractures (Martineau, Malone, Hanel), incl. hardware removal pearls; also Ch 2 (refracture after forearm plate removal), Ch 17 (clavicle implant removal), Ch 43 (end cap and stripped screws), Ch 51 (tibial nail removal and knee pain), pp. 94-99; 20; 163-164; 447; 562.
  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 25, Intramedullary nailing of tibial shaft fractures: nail removal timing and countersinking, pp. 125-127.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Adult cefazolin dose 2 g IV (3 g if 120 kg or more) within 60 min before incision. The guideline does not list implant removal separately; give prophylaxis per unit protocol. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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