This retrospective observational study was conducted in the Department of Orthopaedics at Sree Mookambika Institute of Medical Sciences from February 2024 to January 2025 after obtaining approval from the Institutional Ethics Committee. Adult patients aged 18 years and above who underwent plate osteosynthesis for diaphyseal fractures of the radius, ulna, or both forearm bones during the study period were included. Patients with pathological fractures, infected implants, nonunion requiring revision surgery, incomplete medical records, or unavailable radiographs were excluded from the study.

The study population was derived from all eligible patients who underwent plate osteosynthesis for diaphyseal forearm fractures at the study centre between February 2024 and January 2025. Patient selection was performed retrospectively using hospital records, operative notes, and radiographic databases. The estimated sample adequacy was guided by the refracture rate reported by Navapong Anantavorasakul et al. (2022), in which refracture following implant removal was observed in 6.3% of cases [10]. After applying the inclusion and exclusion criteria, a total of 660 patients with 940 fractures were included in the final analysis.

Patient records, operative details, and serial radiographs were reviewed retrospectively to collect demographic information, fracture characteristics, implant-related details, and postoperative outcomes. Fractures were classified according to the AO/OTA classification system. Data regarding age, sex, fracture type, implant type, plate retention or removal, and occurrence of refracture were recorded. Refracture was defined as a fracture occurring at the previous fracture site, adjacent screw hole, or near the plate following fixation or implant removal. Details regarding the indication and timing of implant removal were also documented.

The study procedure involved assessment of follow-up radiographs and clinical records to evaluate fracture union, implant retention, implant removal, and refracture patterns. The association between implant removal and refracture was analysed, along with factors influencing plate removal and refracture risk.

Statistical analysis was performed using SPSS software version 25.0 (IBM Corp., Armonk, NY, USA). Categorical variables were expressed as frequency and percentage, while continuous variables were represented as median with interquartile range (IQR). Fisher’s exact test and Mann–Whitney U test were used where appropriate. Variables with p < 0.1 on bivariate analysis were included in multivariable logistic regression analysis to identify factors independently associated with refracture and plate removal. A p-value < 0.05 was considered statistically significant.

A total of 660 patients with 940 forearm fractures were included in the study. The median age of the patients was 42.5 years (IQR: 25.2–56.5), with males accounting for 63.0% of the study population. Unilateral forearm fractures were more common than bilateral fractures (97.4% vs. 2.6%). Among the fractures analysed, ulnar fractures (53.8%) were slightly more common than radial fractures (46.2%). Fractures involving both bones of the forearm constituted the majority of cases (55.6%), followed by isolated ulnar fractures (26.6%) and isolated radial fractures (17.8%). Closed injuries accounted for 66.7% of fractures, while 33.3% were open injuries. According to the AO/OTA classification, Type A fractures were the most common (48.2%), followed by Type B (30.7%) and Type C fractures (15.4%). Initial radiographs were unavailable in 5.7% of cases. Compression plates were the most frequently used implants (73.2%), followed by locking plates (25.9%) (Table 1).

 Table 1: Study Population Characteristics

Refracture was observed in 22 of the 940 fractures analysed. The rate of refracture was higher following plate removal (8.8%) compared to retained implants (1.8%). Most refractures involved the radius (68.2%) and occurred in closed fractures (68.2%). AO/OTA Type A fractures accounted for the highest proportion of refractures (50.0%). No significant differences in refracture patterns were observed with respect to sex or implant type. On bivariate analysis, none of the studied variables showed a statistically significant association with refracture (Table 2).

Table 2: Factors Associated with Refracture

Multivariable logistic regression analysis (Table 3) showed that plate removal was independently associated with a 3.72-fold increased risk of refracture (95% CI: 1.20–11.66; p=0.023). Radius fractures demonstrated 2.25-fold higher odds of refracture compared to ulnar fractures; however, the association did not reach statistical significance (p=0.06).

 Table 3: Multivariable Logistic Regression for Refracture

Plate removal was performed in 65 fractures and was more common in ulnar fractures (70.8%) than in radial fractures (29.2%) (p=0.003). AO/OTA Type A fractures constituted the largest proportion of implant removals (60.0%) and showed a significant association with plate removal (p=0.033). No significant association was observed between plate removal and fracture type, gender, or age (Table 4).

Table 4: Factors Associated with Plate Removal

Multivariable logistic regression analysis (Table 5) identified ulnar fractures as an independent predictor of plate removal, with 2.57-fold higher odds of implant removal compared to radial fractures (95% CI: 1.42–4.65; p=0.002). AO/OTA Type A fractures were also significantly associated with plate removal, demonstrating 3.19-fold increased odds (95% CI: 1.10–9.17; p=0.032). Although implant removal was less common in open fractures, the association did not reach statistical significance (p=0.06).

Table 5: Multivariable Logistic Regression for Plate Removal

This retrospective study consisted of 660 patients with 940 forearm fractures surgically treated with plate osteosynthesis, with an investigation of the clinical outcome of implant retention versus removal. The results are in agreement with and supplement data from several recently reported studies.

The median age of the study population was 42.5 years, with a male predominance of 63.0%, significantly following the demographic patterns established in similar cohort studies. Similarly, Köse et al. (2019) identified a male predominance for adult diaphyseal forearm fractures, which was related to higher rates of occupational and high-energy trauma in males [3]. Ulnar fractures (53.8%) appeared to be slightly more frequent than radial fractures (46.2%), and fractures that involved both bones were predominant (55.6%), in agreement with the outcomes of Vasara et al. (2024), who reported both-bone involvement to be the most common fracture pattern in adults who received treatment with compression plate fixation [5]. Our series had a relatively higher rate of open fractures (33.3%) when compared to other series. Saini et al. (2023) identified open injuries in around 20-25% of cases, and this may be a reflection of the variances in the mechanism of injury and trauma referral practices at the typical hospital [2]. The most frequent fracture type consisted of AO/OTA type A (48.2%), followed by type B (30.7%), and type C (15.4%). This distribution is in agreement with the outcomes presented by Factor et al. (2023), who identified simple fracture patterns as the most common in adult forearm fractures [7]. Compression plates were employed in 73.2%, while locking plates were implemented in 25.9% of cases. This is in accordance with the general surgical practice established by Justice et al. (2024), who showed that both types of plates provide similar levels of union and functional outcomes [8].

Refracture was identified in 22 of 940 fractures (2.3 % overall). Refracture rate was significantly higher in the plate removal group (8.8%) than in the implant retention group (1.8%). Multivariable logistic regression established that removal of the plate independently heightened the risk of refracture by 3.72-fold (95% CI: 1.20–11.66, p=0.023). The figures lend strong confirmation to the meta-analytic data of Cao et al. (2025), who demonstrated significantly elevated refracture risk after a plate removal compared to retaining implants, with pooled odds ratios higher than 3.0 across numerous subgroup analyses [9]. Yao et al. (2014) also identified a high risk of refracture after plate removal, most notably in the early postoperative period, and suggested long-term protective periods preceding elective removal [15]. This observation was further strengthened by Anantavorasakul et al. (2022), who demonstrated that retained forearm plates were correlated with significantly lower rates of mechanical failure [10]. The odds of refracture were 2.25 times more pronounced for the radius versus the ulna, but this was not statistically significant (p=0.06), perhaps attributed to a lack of statistical power from the relatively small number of refracture events.

Plate removal was performed in 65 (6.9%) of the 940 fractures analysed. Ulnar fractures showed significantly higher odds of implant removal (OR: 2.57; 95% CI: 1.42–4.65; p=0.002), which may be attributed to implant prominence and soft tissue irritation along the subcutaneous border of the ulna. Similar findings were reported by Chhawra et al., who identified implant prominence and local discomfort as common indications for elective hardware removal [11]. AO/OTA Type A fractures were also independently associated with plate removal (OR: 3.19; 95% CI: 1.10–9.17; p=0.032), possibly because uncomplicated fracture healing in these cases increases the likelihood of elective implant removal after union. Although plate removal was less common in open fractures, the association did not reach statistical significance (p=0.06). These findings are consistent with previous studies reporting that symptomatic hardware and patient preference are among the most frequent reasons for elective implant removal, particularly in younger and active individuals [14].

Present findings conform to the current consensus that routine elective plate removal in asymptomatic patients is not advisable. As previously mentioned by Cao et al. (2025) and Anantavorasakul et al. (2022), the hazards of refracture associated with plate extraction are a significant clinical risk that needs to be carefully weighed against any predicted benefit [9, 10]. It still is considered appropriate to proceed with symptomatic patients, especially those with ulnar hardware prominent features or AO/OTA Type A, in a tailored fashion. Future investigation with standardized follow-up protocols and patient-reported outcome evaluations is necessary to guide the development of more definitive guidelines for elective plate excision after consolidation of forearm fractures.

The present study has certain limitations, including its retrospective single-centre design and dependence on medical records and radiographic documentation. Variability in follow-up duration and implant removal indications may also have influenced outcomes. Further prospective multicentre studies are required to validate these findings.

The findings of the present study suggest that elective removal of forearm fixation plates is associated with an increased risk of refracture and may not be routinely indicated in asymptomatic patients following fracture union. Plate retention appears to be a safer approach after successful fracture consolidation. Ulnar fractures and AO/OTA Type A fractures were identified as important factors associated with implant removal. These findings are consistent with recent literature supporting a selective, symptom-based approach rather than routine implant removal. Clinical decision-making should therefore be individualised based on patient symptoms, fracture characteristics, and overall functional outcome.

Conflicts of Interest: The authors declare no conflicts of interest.

Funding: Nil.

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