Risk of cold welding in titanium plates and screws should be low if the screws have been inserted in an orthogonal fashion to the plate with a torque-limiting screw driver. We did not microscopically examine the screw holes after removal, but gross visual examination did not reveal any metal transfer. Even if a cold weld spot was present, our technique is less destructive when compared with cutting the whole plate or screw and overdrilling the screws. A locking screw that cannot be removed with a torque-limiting screw is technically jammed whether it is attributable to cold welding or cross-threading or just over-tightened. Bony overgrowth is a substantial problem in titanium implants [4, 7]. As the screws were so tightly jammed that the conical extraction screw failed to remove the screw, the technique of using a foil  in the stripped screw head recess before the conical extraction screw would have failed. If only the central screw is jammed, then our technique of making a radial cut all the way to the central screw hole will still work, as would destroying the screw head with carbide drills and burrs and removing the plate followed by removing the screw shank with a conical extraction screw. However, we still think our technique is less destructive.
There is always the danger of thermal bone necrosis or iatrogenic bony injury when using high speed burrs and discs. We have no experimental data regarding whether heat generated by cutting the plate is lesser or greater than heat generated in burring out the screw heads and removing the plate. The principle we follow when we have used high-speed instruments has been to have adequate flow of normal saline to absorb the heat generated and remove debris. As mentioned earlier, several possible factors alone or in combination can make screw removal difficult or impossible. Bony overgrowth around orthopaedic implants is well known in pediatric patients. However, bony overgrowth can occur even in adults and could add to the difficulty in removing titanium screws.
It is essential to have all the appropriate implant removal instruments, including carbide drill bits and high-speed burrs and discs, and prepare for a long procedure . A conical extraction screw is not always successful in removing the jammed screw . The risks of high-speed burrs and discs are high local temperature and metal debris. This technique requires running normal saline solution (to keep the temperature low) and continuous suction to remove all the metal debris.
As with any problem, prevention is the best treatment. All precautions should be taken to ensure the locking screws are inserted perpendicular to the plate without cross-threading using a torque-limiting screw driver. The problem of screw head jamming is not seen with stainless steel screws . The technique described here would be a good addition to the armamentarium of a trauma surgeon for removing jammed screws from locking plates.
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