# Systematic Review of Incidence of Cold-Welding Phenomenon in Use of Implants for Fracture Fixation and Collation of Removal Techniques

## TL;DR

This paper reviews how often cold welding happens with fracture implants and summarizes techniques used to remove them.

## Contribution

This is the first systematic review compiling removal techniques for cold-welded implants in fracture fixation.

## Key findings

- Cold welding commonly occurs at the screw–plate interface in implants.
- Bolt cutters or burrs are the most frequently used tools for removing cold-welded implants.
- Only 3.5% of screws (58 out of 1654) were found to be cold welded across the studies reviewed.

## Abstract

Introduction: Cold welding is an anecdotally well-known complication of removal of metalwork, most commonly at the screw–plate interface, and can often complicate extraction of implants after fracture fixation. Even though this phenomenon is familiar amongst the orthopedic community, there is relatively little formalized discussion or literature pertaining to its identification and management clinically. In addition, as far as we can establish, there does not seem to be a paper that discusses the various techniques described in the literature that are employed to combat cold welding. Methods: A systematic review was carried out in accordance with the PRISMA guidance, with two independent reviewers and a third person to arbitrate for any discrepancies. Manuscripts were identified using a search of PubMed/MEDLINE and Google Scholar. Studies eligible for inclusion were tabulated and the results categorized qualitatively with respect to the technique described for removal of the implants. Results: A total of 272 manuscripts were identified using a search of PubMed/MEDLINE and Google Scholar, and of these 14 were ruled to be eligible for inclusion reporting on 292 patients. Common locations of the cold-welded screws included femur, tibia, distal radius and clavicle. The most common technique for metalwork removal was using either bolt cutters or burrs to cut the plates between the screws and mobilize the screw and plate as one unit. Other techniques included using specialized removal tools and cutting between the screw head and body. There was no appreciable correlation between the specific anatomic location of the welded implant and the technique used in its removal. From the studies, it was found that, of the total number of screws (n = 1654), 58 (3.5%) were cold welded. The mean time to metalwork removal was 1104 days (36.8 months). Conclusions: As far as we can tell, this is the first systematic review pertaining to the phenomenon of cold welding specifically, and with this project we have collated the techniques used to remove implants affected by cold welding from a variety of different articles. Our work aims to highlight the relative paucity of literature in this area and provide a number of accessible and safe techniques to facilitate the removal of cold-welded implants in fracture fixation.