Abstract
Background
Intramedullary nailing is a widely recognized technique for the fixation of proximal and diaphyseal humeral fractures. While implant removal is sometimes performed to alleviate symptoms such as impingement or pain, the procedure is not devoid of risks. The aim of this study was to systematically review removal rates after anterograde humeral intramedullary nailing and to assess how removal-specific morbidity is reported, including the frequency and type of explicitly reported adverse events.
Methods
This systematic review was conducted in accordance with the PRISMA guidelines. We included studies involving adult patients that reported data on implant removal rates, reasons for removal, and associated complications. The MINORS score was used to assess study quality.
Results
A total of 13 studies were included, comprising 545 humeral nailing procedures. Removal rates varied significantly between studies, ranging from 1.8% in modern straight nail series to 38.9% in older curved nail series. The most frequently cited reasons for removal were proximal screw back-out, subacromial impingement, and nonunion. Removal-specific adverse events were explicitly reported in 3/13 studies; within these studies, 3 major events occurred among 12 removals. Across all removals (n = 75), at least 3 major events were confirmed (minimum rate: 4%, 3/75); this figure represents a lower bound, not an estimate, because 10/13 studies did not report removal-specific morbidity. The true incidence of removal-specific morbidity remains unknown, as only three of the thirteen included studies explicitly reported removal-related complications as a predefined study endpoint.
Conclusion
Evidence is limited and heterogeneous across implant generations and fracture patterns; estimates should be interpreted cautiously. The removal of humeral intramedullary nails is associated with iatrogenic risks, difficult extraction, and retained hardware. Routine removal is not supported by the current evidence base; decisions should be individualized to clear indications.
PROSPERO registration
CRD420251265725.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12893-026-03857-5.
Keywords: Humeral shaft fracture, Intramedullary nail, Implant removal, Iatrogenic complications, Systematic review
Introduction
Intramedullary nailing is widely recognized as an effective technique for the fixation of proximal and diaphyseal humeral fractures [1]. It offers several advantages, including a minimally invasive percutaneous technique, preservation of the fracture hematoma, and improved biomechanical fixation [2]. The management of retained hardware remains a controversial topic in orthopedic trauma. In the context of proximal humeral fractures, internal fixation with locking plates is frequently associated with complications such as stiffness and impingement, often necessitating reoperation for implant removal and arthrolysis to restore functional range of motion [3]. This necessity for removal is echoed in lower limb trauma, where the extraction of femoral or tibial intramedullary nails is common but technically demanding; surgeons frequently encounter challenges such as osseous overgrowth at the end-cap or deep implant incarceration, which can lead to extended operative times and iatrogenic fractures during extraction [4, 5].
However, the removal of humeral intramedullary nails presents a unique anatomical challenge compared to these other implants. To prevent subacromial impingement, the proximal end of the nail is often intentionally buried deep beneath the humeral head cartilage or rotator cuff footprint [6, 7]. Consequently, retrieval is not a benign procedure; it often requires re-violating the rotator cuff tendon to access the deep-seated implant, thereby risking iatrogenic cuff injury and compromising shoulder function solely for the purpose of hardware removal [8]. Contemporary data indicate that with modern techniques, the prevalence of iatrogenic supraspinatus lesions ranges from 6% to 12.5%, with the majority remaining asymptomatic [9, 22, 23].
Despite these established risks, the literature lacks specific reports regarding the complications of humeral nail removal. This creates a reporting gap because removal-specific morbidity was often not reported as a study endpoint, limiting estimation of the frequency of complications, leaving surgeons without a clear risk-benefit analysis to guide clinical decision-making.
The aim of this study was to systematically review removal rates after anterograde humeral intramedullary nailing and to assess how removal-specific morbidity is reported, including the frequency and type of explicitly reported adverse events. The hypothesis was that implant removal after humeral intramedullary nailing is associated with underreported procedure-specific morbidity, including iatrogenic soft-tissue injury and technical failure.
Materials and methods
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the protocol was registered in PROSPERO (Number CRD420251265725).
Search strategy
The literature search was conducted in three databases: MEDLINE, EMBASE, and the Cochrane Library. The search strategy included terms related to the anatomical location (“humerus”, “humeral”), the device (“intramedullary nail”, “interlocking nail”). Procedure-specific terms (“removal”, “extraction”, “ablation”, “implant removal”) were not included in the search query because implant removal is typically reported in the results or discussion sections of nailing studies rather than in the title or abstract; including these terms would have substantially narrowed the results, risking omission of relevant studies (Supplementary A). The reference lists of identified articles and relevant systematic reviews were manually screened to identify additional studies. The search was completed on September 1, 2025.
Study selection
We included randomized clinical trials, cohort studies, case-control studies, and observational case series involving adult patients (≥ 18 years) treated with anterograde humeral intramedullary nailing and reporting implant removal data. We excluded pediatric populations, constitutional bone diseases, severe systemic diseases, and studies without removal-related data. Title/abstract screening (n = 1,932 records), full-text eligibility assessment (n = 217 reports), and structured data extraction were supported by an AI-assisted workflow (DeepDocs) applying the predefined inclusion/exclusion criteria. Given the limited number of included studies (n = 13), all extracted data were independently verified and validated by two human reviewers.
Evaluation of selection
To assess the reliability of AI-assisted screening, fixed a priori manual validation samples were defined for each stage. Sixty records were randomly selected at each stage (title/abstract, n = 1,932; full-text, n = 217). One reviewer manually reassessed eligibility and compared decisions with the AI output; a discrepancy was defined as a discordant include/exclude decision. The sample size (n = 60 per stage) was chosen to ensure that, if zero discrepancies were observed, residual misclassification could be bounded below a predefined acceptability threshold of 10% (see Supplementary C for statistical methodology). In both validation samples, no eligible records were missed (0 false negatives), although additional records were flagged for full-text review (overselection).
Summary measures
The risk of bias was independently assessed by two reviewers using the Methodological Index for Non-Randomized Studies (MINORS) score. Binary outcomes are reported as number and percentage. Continuous outcomes are presented with mean ± SD or median (IQR). Analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria). Meta-analysis was not performed because removal-specific adverse events were inconsistently defined and largely unreported across studies, which would have produced a spuriously low pooled estimate. We assumed that, given the significant heterogeneity in study designs, implant generations, and the lack of standardized safety reporting in the included studies, a meta-analysis could not be performed. Data were summarized using a narrative synthesis approach. Studies were grouped thematically according to implant generation (curved vs. straight nails), type of reported complication, and availability of functional outcome data. Heterogeneity was addressed descriptively by comparing removal rates and complication patterns across these subgroups rather than through statistical pooling.
Results
Study characteristics
A total of 13 studies were included in the final review (Fig. 1, Table 1), involving a total of 545 humeral nailing procedures. The studies ranged from 2001 to 2025, reflecting the evolution of nailing systems from early designs (e.g., Seidel, Russell-Taylor) to modern straight nails (e.g., MultiLoc, Tornier). The majority of studies were retrospective comparative studies (46.2%) or case series (46.2%), with one prospective controlled trial included.
Fig. 1.
PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only
Table 1.
Characteristics of included studies (N=545 procedures)
| Characteristic | Value n (%) |
|---|---|
| No. of studies | 13 |
| No. of included patients | 545 |
| Mean age of patients (years) | 51.9 |
| Gender (n = 536) | |
| Male | 259 (48.4%) |
| Female | 277 (51.6%) |
| Type of study | |
| Retrospective comparative study | 6 (46.2%) |
| Retrospective case series | 6 (46.2%) |
| Prospective controlled trial | 1 (7.7%) |
| Fracture indication | |
| Humeral shaft fracture | 9 (69.2%) |
| Proximal humerus fracture | 4 (30.8%) |
| Nail material | |
| Titanium (Polarus, MultiLoc, AO-UHN, Expert) | 6 (46.2%) |
| Stainless Steel (Russell-Taylor) | 2 (15.4%) |
| Mixed/Not Specified | 5 (38.5%) |
| Number of reasons for nail removal (n = 82) | |
| Pain / Impingement / Protrusion | 37 (45.1%) |
| Routine (young age) | 13 (15.9%) |
| Non-union (exchange nailing/plating) | 13 (15.9%) |
| Revision to Arthroplasty (AVN/Cut-out) | 10 (12.2%) |
| Implant Failure (Breakage) | 3 (3.7%) |
| Infection | 2 (2.4%) |
| Unspecified | 4 (4.9%) |
Quality assessment
There was a significant reporting gap in the literature. Only 3 studies (n = 55 patients) defined ‘complications of removal’ as a study endpoint. The remaining 10 studies mentioned removal incidentally without defining safety outcomes. Based on the MINORS score, the methodological quality varied across included studies. Among comparative studies (n = 7), one study was classified as high quality (score ≥ 19), six were moderate quality (scores 13–18), and none were low quality (scores 7–12). Among non-comparative case series (n = 6), none reached high quality (score ≥ 13), four were moderate quality (scores 9–12), and two were low quality (scores 5–8). The mean MINORS score was 16.9 for comparative studies and 9.3 for non-comparative studies (both classified as moderate quality) (Supplementary B).
Removal and complications
Reported indications were non-standardized, variably defined, and often selective rather than systematic. The rates of removal varied widely, from 1.8% in recent series using straight nails [9] to 38.9% in older series using curved nails [10]. Among the studies with granular safety data, three major intraoperative complications were described over 55 patients (three studies): one case of iatrogenic fracture due to osseous overgrowth, and two cases of retained hardware due to instrument failure or impossibility of extraction (Table 2) [11–13].
Table 2.
Intramedullary nail removal and complications
| Study (Year) | Pop. (N) | Removed n (%) | Complication rate n (%) | Specific complications |
|---|---|---|---|---|
| Lakhani et al. (2022) [14] | 30 | 2 (6.7%) | NR | NR |
| Ajmal et al. (2001) [15] | 33 | 11 (33.3%) | NR | NR |
| Adedapo & Ikpeme (2001) [11] | 23 | 1 (4.3%) | 1 (100%) | Traumatic: Screw heads overgrown, difficult to locate. |
| Nolan et al. (2011) [10] | 18 | 7 (38.9%) | NR | NR |
| Scheerlinck et al. (2002) [12] | 22 | 8 (36.6%) | 1 (12.5%) | 1 case of impossibility to remove the nail. |
| Pogliacomi et al. (2008) [16] | 40 | 11 (27.5%) | NR | NR |
| Lopiz et al. (2014) [17] | 52 | 6 (11.5%) | NR | NR |
| Lopiz et al. (2023) [9] | 110 | 2 (1.8%) | NR | NR |
| Angachekar et al. (2024) [13] | 10 | 3 (30.0%) | 1 (33.3%) | Retained: Distal part of broken nail left in canal. |
| Ninković et al. (2024) [18] | 20 | 2 (10.0%) | NR | NR |
| Barret et al. (2024) [6] | 72 | 8 (11.1%) | NR | NR |
| Griswold et al. (2024) [19] | 78 | 9 (11.5%) | NR | NR |
| Rasbi et al. (2025) [20] | 37 | 5 (13.5%) | NR | NR |
NR removals reported, but removal-specific complications were not reported
Specific complications
Removal-specific adverse events were explicitly reported in 3/13 studies. In these studies, 3 major events occurred among 12 removals [11–13]. Across all removals (n = 75), at least 3 major events were confirmed (minimum rate: 4%, 3/75); this figure represents a lower bound, not an estimate, because 10/13 studies did not report removal-specific morbidity. Failed removal resulting in retained hardware was the most frequently described complication. Angachekar et al. reported a case where a broken nail could not be fully retrieved, leaving the distal segment in the canal [13]. Similarly, Scheerlinck et al. noted cases where removal was impossible [12]. Adedapo and Ikpeme described a removal as “extremely traumatic” due to bone overgrowth covering the locking screws [11].
In the remaining 10 studies, no data regarding intraoperative complications or the specific morbidity of the removal event were provided. These studies did not explicitly state that no complications occurred; rather, they did not include removal safety as a study endpoint. Therefore, no inference can be made regarding the presence, absence, or frequency of removal-specific complications in those series. This highlights a gap in reporting standards, as many of these studies focused on union rates rather than removal morbidity [6, 9, 10, 14–20].
These data do not allow estimation of the true incidence of removal morbidity because removal-specific complications were not systematically reported in most studies.
Functional outcomes
When reported, implant removal generally improved subjective pain symptoms but did not consistently restore objective shoulder function. Pogliacomi et al. evaluated 40 patients treated with Seidel antegrade nailing at a mean follow-up of 62 months (range 24–126); 11 patients (27.5%) underwent nail removal at a mean of 12 months (range 8–22), of whom 9 were elective removals in young asymptomatic patients and 2 were performed for symptomatic subacromial nail protrusion (4 mm and 3 mm, respectively). In these two patients, removal reduced subjective pain; however, their final Constant Score was rated ‘acceptable’, the lowest category in that cohort (overall mean Constant Score: 92.02, range 62–98), indicating that the structural damage caused by initial nail malpositioning was not reversed by hardware removal [16]. Ajmal et al. reported that among 33 patients treated with Russell-Taylor nails, 5 (15%) underwent removal for proximal nail protrusion or shoulder pain; at a mean follow-up of 17.6 months (range 3–36), 18 patients (56%) experienced persistent shoulder or fracture-site pain and only 17 (51%) were satisfied; the authors noted that ‘impingement symptoms persisted in some cases even after the removal of the metalwork’ [15]. Conversely, Ninkovic et al. reported complete pain relief in 2 of 20 patients after removal of migrated osteosynthetic material following fracture union [18] (Table 3).
Table 3.
Functional outcomes and subjective results after humeral intramedullary nail removal
| Study (Year) | Nail Type | Pop. (N) | Removed n (%) | Functional Score | Subjective Outcome After Removal |
|---|---|---|---|---|---|
| Adedapo & Ikpeme (2001) [11] | Polarus (curved) | 23 | 4 (17.4%) | Neer: median 89 (3-part), 60 (4-part); Constant: mean 88.4 (3-part), 67 (4-part) | 50% complete pain relief at 1 year; 13% incapacitated by pain |
| Ajmal et al. (2001) [15] | Russell-Taylor (straight) | 33 | 5 (15.2%) | VAS pain and satisfaction only; no formal shoulder score | 56% persistent pain; 51% satisfied; impingement persisted after removal in some cases |
| Scheerlinck & Handelberg (2002) [12] | AO-Unreamed humeral nail (curved) | 52 | 15 (28.8%) | Constant: median diff. 8 pts (MVN) vs. 17 pts (AO-UHN), p = 0.007 | 13/17 AO-UHN pain-free at final review |
| Pogliacomi et al. (2008) [16] | Seidel (curved) | 40 | 11 (27.5%) | Constant: mean 92.02 (range 62–98) affected; 95.73 (85–100) healthy | Pain reduced in 2 symptomatic patients; Constant Score rated “acceptable” (lower) despite pain improvement |
| Nolan et al. (2011) [10] | Polaris (short, curved) | 18 | 7 (38.9%) | Constant: mean 61 (20–100); ASES: mean 67 (10–100) | NR separately after removal |
| Lopiz et al. (2023) [9] | MultiLoc (straight) | 110 | 5 (4.5%) | Constant: 82 ± 19; rotator cuff symptoms: 6.4% | NR separately after removal |
| Ninković et al. (2024) [18] | IM locking nail (unspecified) | 20 | 2 (10.0%) | Constant: 67.55 (nail) vs. 78.05 (plate), NS; DASH: 45% minimal disability | Complete pain relief after removal |
NR Not reported separately after removal
Discussion
Across the 13 included studies, 75 removals were reported among 545 nailings; removal rates varied widely between studies. The available reports suggest technical difficulties during extraction, but the frequency of such events cannot be estimated reliably from the current literature. This estimate is based on only three studies reporting removal morbidity and should be interpreted as descriptive only.
A key finding of this review is the discrepancy in reporting standards between older and newer studies, which constitutes a significant “reporting gap.” Older studies, such as those by Scheerlinck et al. (2002) and Adedapo & Ikpeme (2001), provided detailed accounts of removal morbidity, reporting removal complication rates as high as 26.7% (4 complications among 15 removals) in specific nail types [11, 12]. In contrast, modern series using third-generation straight nails report lower removal rates and few explicit complications [6, 9, 20]. In the majority of these modern studies (10/13), successful removal was noted without detailing the presence or absence of specific technical difficulties. This pattern should be interpreted with caution. In most modern series, removal morbidity was not reported as a specific endpoint; therefore, absence of reported events cannot be interpreted either as evidence of absence or as evidence of underreporting. Because removal-specific complications were explicitly reported in only 3/13 studies, the available data do not allow estimation of the true event rate.
This review therefore highlights inconsistency in outcome reporting rather than a demonstrable difference in safety across implant generations. Future studies must include ‘removal morbidity’ as a specific safety endpoint.
Several factors may explain the underreporting of removal-specific morbidity in modern studies. Most contemporary series were designed to evaluate fracture union and overall shoulder function rather than removal safety; removal was mentioned incidentally without being predefined as a study endpoint. Shorter follow-up periods may have precluded the detection of late complications. Additionally, publication bias may favor the reporting of positive union outcomes over adverse events occurring during secondary procedures.
The generation and design of the implant may influence the technical challenges encountered during removal, although through different mechanisms. Curved nails, such as the Polarus nail, use a lateral entry point within the greater tuberosity footprint area; their removal may require bone removal around the entry site to access the buried implant. Adedapo and Ikpeme described full device extraction as ‘extremely traumatic’ because cancellous screw heads were overgrown with bone and difficult to locate [11]. Straight nails use a more proximal entry point through or near the articular cartilage, requiring dissection through the rotator interval or the supraspinatus tendon to identify the entry point during removal, which carries a risk of iatrogenic rotator cuff injury. In the included studies, third-generation straight nails (e.g., MultiLoc) were associated with implant removal rates of 4.5% [9] to 11.5% [17], compared with 27.5% [16] to 38.9% [10] for older curvilinear designs, although no controlled comparison across implant generations exists in the current literature. The observed differences in removal rates between curved and straight nails may reflect confounding by era, surgical technique, patient selection, and reporting practices rather than a true difference attributable to implant design alone.
Unlike femoral or tibial nail removal, where the primary concerns relate to cortical weakening and refracture risk [4, 5], humeral nail removal presents unique challenges due to the proximity of the rotator cuff, the supraspinatus tendon, and the axillary nerve. The antegrade entry point through or near the articular surface requires re-dissection of these structures during removal, creating a risk of iatrogenic soft-tissue injury that has no direct equivalent in lower limb implant removal.
As the main causes of nail removal are impingement and pain, we underline the importance of guiding the extremity of the nail to be under the cartilage [21]. While removal is often requested for pain relief, functional recovery is not guaranteed [16]. These findings suggest that subjective pain relief following implant removal may not reliably translate into measurable functional recovery, and that the benefit of removal likely depends on the underlying mechanism of symptoms (Table 3). The issue of “impossible removal” or retained hardware is a significant morbidity that forces surgeons to abandon the procedure or resort to more invasive exposures [4]. This is often caused by bone overgrowth over cancellous locking screws, as noted by Adedapo and Ikpeme [11], or implant breakage, as noted by Angachekar et al. [13].
The interaction between humeral nailing and the rotator cuff remains a critical consideration, primarily due to the necessity of a proximal entry point near the supraspinatus tendon. While iatrogenic tendon injury and postoperative functional impairment are recognized risks, the magnitude of these complications appears strictly dependent on surgical technique and implant design [9, 22, 23]. The introduction of third-generation straight nails and the adoption of rotator interval approaches have notably mitigated these issues. Contemporary data indicate that with modern techniques, the prevalence of supraspinatus lesions is low (approximately 6-12.5%), with the majority remaining asymptomatic and showing no significant impact on functional scores [9, 22, 23]. However, technical errors such as prominent or excessively lateral nail placement remain significant risk factors for symptomatic pathology [24]. Although microcirculatory studies suggest that tendon splitting causes transient hypoperfusion, this effect appears reversible with meticulous soft tissue handling [25]. Furthermore, techniques avoiding direct tendinous violation, such as the mini-deltopectoral or rotator interval approaches, have been shown to minimize structural compromise [26–28]. Consequently, clinically significant rotator cuff dysfunction is uncommon with appropriate technique, suggesting that persistent shoulder pain should not be automatically attributed to the implant without excluding other pathologies [9, 22–24]. While the primary concern during the exposure phase is the preservation of the rotator cuff, the extraction phase presents distinct mechanical challenges that can lead to intraoperative failure. The available literature does not allow attribution of postoperative cuff symptoms to nail insertion versus the removal procedure itself, as pre-removal cuff status and removal-specific functional follow-up were rarely assessed.
One notable technical complication identified in this review was the phenomenon of “impossible removal” or retained hardware. This morbidity frequently necessitates the abandonment of the procedure or the conversion to more invasive exposures [4]. The primary etiologies include osseous overgrowth obscuring cancellous locking screws, as described by Adedapo and Ikpeme [11], and instrument failure leading to retained broken implants, as reported by Angachekar et al. [13].
It is crucial to consider the evolution of implant technology when interpreting these risks. Historically, difficult extraction was associated with second-generation curved stainless steel nails, which were prone to incarceration and deeper insertion depths [11, 12]. However, the available data do not allow a controlled comparison across implant generations, so no conclusion can be drawn regarding the effect of technological evolution on removal risk. Our review identified retained hardware due to instrument failure in a 2024 series using modern implants [13], indicating that technical difficulty may still occur in contemporary practice.
In an elective implant removal cohort, postoperative wound infection occurred in 11.6% of procedures (10% superficial; 1.6% deep) [29]. In a large U.S. database of hardware-removal-only procedures, the overall complication rate was 9.6%, including 1.5% medical/anesthetic complications and 1.6% infection [30]. Similarly, in a large French single-center series of non-compulsory planned hardware removal after limb fracture (n = 1990), postoperative complications occurred in 4.1%, including 1.56% major complications; infections and wound-healing problems accounted for 69.6% of events [31]. Finally, implant removal may shift from straightforward to complex depending on implant characteristics and technical factors, and should not be framed as a trivial procedure delegated without appropriate expertise and supervision [32, 33].
Based on the available evidence, removal should be considered only for clear clinical indications such as symptomatic hardware prominence, mechanical impingement limiting range of motion, or nonunion requiring revision. Surgeons should anticipate potential difficulties including osseous overgrowth over locking screws and deep implant incarceration. Preoperative planning with computed tomography may help identify such obstacles. The procedure should be performed by experienced surgeons with appropriate instrumentation, and patients should be counseled that subjective pain relief does not guarantee restoration of objective shoulder function.
Limitations
The evidence base is limited and heterogeneous, spanning more than two decades of implant evolution and variable fracture patterns. This systematic review has limitations. (1) The primary limitation is the lack of high-quality evidence regarding the specific morbidity of humeral nail removal. The overwhelming majority of included studies were retrospective in design (12/13), with only one prospective controlled trial identified. This predominance of retrospective data increases the risk of selection bias, recall bias, and incomplete outcome reporting, and limits the strength of conclusions drawn from this review. (2) A major limitation is the inconsistency of removal-specific outcome reporting across studies. Only 3 out of 13 studies provided explicit, granular data on intraoperative adverse events. In the remaining studies, successful removal was often noted without detailing the presence or absence of specific technical difficulties. These data do not allow conclusions regarding the presence, absence, or frequency of specific complications in studies that did not report removal morbidity. No meta-analysis of removal-specific complications was performed because morbidity was not reported as an endpoint in most studies and event definitions were inconsistent; therefore, only descriptive summaries are possible. (3) We observed significant heterogeneity in the timeframe and implant technology. The included studies span over 30 years, covering the evolution from early curved nails to modern straight nails. This evolution adds heterogeneity to the evidence base, but the available data do not allow reliable comparison of removal morbidity across implant generations. Scope excluded arthroscopic removal approaches; therefore, the arthroscopic nail removal technical series by Kim et al. (n = 6), which reported no complications, was not included in the quantitative synthesis [8]. The exclusion of arthroscopic removal series limits the generalizability of our findings, as arthroscopic techniques may present a different risk profile compared to open removal. (4) Functional outcomes were inconsistently reported. Many studies focused on subjective relief (pain) rather than objective shoulder scores, limiting assessment of postoperative function after removal.
Conclusions
The removal of humeral intramedullary nails is associated with distinct iatrogenic risks, including difficult extraction, retained hardware, and potential soft-tissue injury. The true incidence of removal-specific morbidity remains unknown, as only 3/13 studies reported removal-related complications as a predefined endpoint. Routine removal is not supported by the current evidence base, and the decision should remain individualized according to clinical indication. Future studies should systematically report whether the implant was removed, the indication for removal, and any removal-specific complications encountered. Adoption of a standardized definition of removal-specific morbidity would enable future meta-analyses and meaningful comparison across studies.
Supplementary Information
Acknowledgements
We would like to thank the unconditional support of Mathilde Sennhauser (MD) and Raphaella Cohen (MD) and Mahaut Omnes and Danielle Ennesser (PhD).
Authors’ contributions
VH and JD conceived the study. VH, JD, and QB performed the literature search and study selection. Selection, data extraction and validation were performed by DQ. CB and GN and PB contributed to methodological oversight and critical revision of the manuscript. VH and JD drafted the initial manuscript. All authors critically revised the manuscript and approved the final version.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
All data analyzed in this study are derived from publicly available published articles. Extracted data supporting the findings of this review are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study is a systematic review of previously published literature. It did not involve the collection of new data from human participants or animals, nor the use of identifiable personal data. Therefore, ethical approval and informed consent were not required.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Victor Housset, Email: victor.housset@hotmail.fr.
Jules Descamps, Email: dr.jdescamps@gmail.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data analyzed in this study are derived from publicly available published articles. Extracted data supporting the findings of this review are available from the corresponding author upon reasonable request.