Hardware Removal in Craniomaxillofacial Trauma: A Systematic Review of the Literature and Management Algorithm.



Craniomaxillofacial (CMF) fractures are typically treated with open reduction and internal fixation. Open reduction and internal fixation can be complicated by hardware exposure or infection. The literature often does not differentiate between these 2 entities; so for this study, we have considered all hardware exposures as hardware infections. Approximately 5% of adults with CMF trauma are thought to develop hardware infections. Management consists of either removing the hardware versus leaving it in situ. The optimal approach has not been investigated. Thus, a systematic review of the literature was undertaken and a resultant evidence-based approach to the treatment and management of CMF hardware infections was devised.

Materials and methods

A comprehensive search of journal articles was performed in parallel using MEDLINE, Web of Science, and ScienceDirect electronic databases. Keywords and phrases used were maxillofacial injuries; facial bones; wounds and injuries; fracture fixation, internal; wound infection; and infection. Our search yielded 529 articles. To focus on CMF fractures with hardware infections, the full text of English-language articles was reviewed to identify articles focusing on the evaluation and management of infected hardware in CMF trauma. Each article's reference list was manually reviewed and citation analysis performed to identify articles missed by the search strategy. There were 259 articles that met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There were 81 grade II articles included in the meta-analysis.


Our meta-analysis revealed that 7503 patients were treated with hardware for CMF fractures in the 81 grade II articles. Hardware infection occurred in 510 (6.8%) of these patients. Of those infections, hardware removal occurred in 264 (51.8%) patients; hardware was left in place in 166 (32.6%) patients; and in 80 (15.6%) cases, there was no report as to hardware management. Finally, our review revealed that there were no reported differences in outcomes between groups.


Management of CMF hardware infections should be performed in a sequential and consistent manner to optimize outcome. An evidence-based algorithm for management of CMF hardware infections based on this critical review of the literature is presented and discussed.





Published Version (Please cite this version)


Publication Info

Cahill, Thomas J, Rikesh Gandhi, Alexander C Allori, Jeffrey R Marcus, David Powers, Detlev Erdmann, Scott T Hollenbeck, Howard Levinson, et al. (2015). Hardware Removal in Craniomaxillofacial Trauma: A Systematic Review of the Literature and Management Algorithm. Annals of plastic surgery, 75(5). pp. 572–578. 10.1097/sap.0000000000000194 Retrieved from https://hdl.handle.net/10161/25662.

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Alexander C Allori

Associate Professor of Surgery

Pediatric plastic and craniofacial surgeon, taking care of children with cleft lip/palate and other facial differences.

Dedicated to the improvement of multidisciplinary team-based care, especially by way of standardized, prospective outcomes measurement ("If you don't measure it, you can't improve it.")

Passionate about using causal inference methods to improve observational studies.


Jeffrey Robert Marcus

Professor of Surgery

My research parallels our specialized clinical programs at Duke. I am involved in clinical research looking comprehensively at outcomes of cleft care to develop standards for evaluating a team’s overall success. Based on a recent grant from the Centers for Disease Control (CDC), we are also participating with several centers to look specifically at academic, psychosocial, and surgical outcomes for all children with clefts born in North Carolina. We are committed to the technique of nasoalveolar molding for children with clefts and are engaged in analyzing its benefits. In rhinoplasty, we have developed a model for nasal respiratory physiology, and we are looking at the effects of specific surgical procedures on nasal airflow and resistance. Our Craniofacial imaging lab has developed sophisticated software to analyze cranial shape, and we use these techniques to define abnormal conditions and their treatment relative to normal. Lastly, our craniomaxillofacial trauma team continues to look at factors associated with facial trauma in North Carolina in order to implement techniques and processes to deliver optimal care and results.


David Bryan Powers

Professor of Surgery

Dr. Powers currently serves as a Professor of Surgery, and Director of the Craniomaxillofacial Trauma Program, at Duke University Medical Center.  Additionally, he is the Fellowship Director for the Craniomaxillofacial Trauma and Reconstructive Surgery fellowship within the Department of Surgery. His surgical experience in facial trauma was attained during a military career highlighted by the acute management of ballistic and other injuries of warfare, as well as performing secondary and tertiary facial reconstructive surgery during various staff assignments at Wilford Hall USAF Medical Center, the Walter Reed National Military Medical Center – Bethesda and the R Adams Cowley Shock Trauma Center in Baltimore, Maryland.  He lectures and has published extensively on the management of ballistic and high-energy transfer injuries to the craniomaxillofacial skeleton, comprehensive reconstruction techniques for facial trauma, and the use of computer-aided surgical planning and patient-specific implants for anatomic rehabilitation after catastrophic craniomaxillofacial injuries.

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