Diluted povidone-iodine versus saline for dressing metal-skin interfaces in external fixation

"No Care Pin Care" Following Charcot Reconstruction With Static External Fixation

Charcot reconstruction with static external fixation provides stability in deformity correction. Concern for pin site health remains forefront to prevent premature fixator removal should infection develop. While previous investigations examined a spectrum of pin care protocol with a similar variation in outcomes, this study assesses results following a "no care pin care" routine. A retrospective analysis of patients with Charcot neuroarthropathy treated with static external fixation was performed where all pin sites were dressed using a chlorhexidine-soaked sponge without postoperative maintenance. Demographics, reconstruction-specific, and postoperative variables including pin site irritation, pin site infection, and pin tract infection were collected through frame removal. A comparison between uncomplicated and complicated pin sites was made. Statistical significance was set as p ≤ .05. Among 85 patients and their respective pin holes that posed potential spots of infection, 6 (7%) experienced pin site irritation and 5 (6%) experienced pin site infection. Moreover, 2 (2%) experienced a pin tract infection requiring removal. Out of the 768 wires/half-pins 2 (0.3%) were removed. There existed no statistically significant predictors of pin site irritation/infection other than age (p = .03). "No care pin care" proves an effective means at pin site care following static external fixation in Charcot reconstruction. Limited maintenance reduces the postoperative burden on providers and patients.

An assessment of the inter-rater and intra-rater reliability of the modified Gordon pin infection classification system

Objectives

A grading system deployed for continuous at-home monitoring of pin sites would potentially increase the chances of early detection of pin-site infections and the commencement of early treatment. The first five grades of the Modified Gordon Pin Site Classification Scheme (MGS) meet the criteria for a visual-only, digital assessment-based grading system. The aim of this study was to assess the inter- and intra-rater reliability of the first five grades of the MGS from digital images.

Methods

We graded 1082 pin sites from 572 digital photographs of patients who underwent external fixator treatment for various conditions using the first five grades of the MGS classification scheme. Percent agreement and kappa values were calculated to determine the inter- and intra-rater agreement. Results were also grouped into two categories: "good" consisting of MGS grades 0-2 and "bad" made up of grades 3 and 4 for sensitivity analysis. We also analyzed reliability based on color only using MGS grades 0 and 2.

Results

A total of 843 of the 1082 pin sites were scored by all raters. There was moderate reliability between raters with a Fleiss kappa value of 0.48 [CI 0.45, 0.51]. The reliability remained moderate based on grouping into "good' versus "bad" and based on color with Fleiss kappa values of 0.48 [CI 0.45, 0.52] and 0.45 [CI 0.42, 0.49], respectively. Intra-rater reliability demonstrated substantial agreement with kappa values of 0.63.

Conclusion

Scoring pin sites from digital images with the MGS demonstrated only moderate inter-rater reliability. Modifying the use of digital photos is needed for at-home monitoring of pin sites.

Pin-site Infection: A Systematic Review of Prevention Strategies

Introduction

Circular frame fixation remains a key tool in the armamentarium of the limb reconstruction surgeon. One of the key drawbacks is the onset of pin-site infection (PSI). As a result of limited evidence and consensus of PSI prevention, a wide variation in practice remains.

Aim

The principal aim of this review is to synthesise primary research concerning all aspects of treatment regarded as relevant to PSI in frame constructs.

Materials and methods

Comparative studies until week 26, 2021, were included in the trial. Studies were included that concerned patients undergoing management of a musculoskeletal condition in which pin-site care is necessary for over 4 weeks.

Results

Eighteen studies over a 13-year period were captured using the search strategy. Sulphadiazine and hydrogen peroxide cleansing was found to reduce PSI, with the use of low-energy fine wires and hydroxyapatite (HA)-coated pins also associated with lower infection rate. The remainder of studies found no significant improvement across interventions.

Conclusion

There is no superiority between weekly and daily care. Low-energy pin-insertion technique had lower rates of infection. Sulphadiazine has positive results as a pin-care solution, but more research is necessary to determine the most effective care regime. Current literature is limited by absence of established definitions and by a lack of studies addressing all aspects of care relevant to PSI.

How to cite this article

Shields DW, Iliadis AD, Kelly E, et al. Pin-site Infection: A Systematic Review of Prevention Strategies. Strategies Trauma Limb Reconstr 2022;17(2):93–104.

No role for antiseptics in routine pin site care in Ilizarov fixators: A randomised prospective single blinded control study

INTRODUCTION

Pin site infection is the commonest complication of Ilizarov external fixation. The aim of the study was to examine if use of antiseptics was superior over control and further if daily dressing was superior to weekly dressing in regular pin site care in reducing the burden of pin site infection in Ilizarov fixators.

PATIENTS AND METHODS

A total of 114 patients (2363 pin sites) were randomised to receive regular pin site care alone (30 patients, 638 pin sites) or with additional application of povidone iodine (27 patients, 561 pin sites), silver sulfadiazine (27 patients, 570 pin sites) and chlorhexidine (30 patients, 594 pin sites). The pin tracts were sub-randomised to receive daily (1212 pin sites) or weekly (1151 pin sites) dressings. The primary outcome was pin site infection days rate across all four groups. The secondary outcomes were - mean duration to first episode of infection, differences between daily and weekly dressing groups, mean duration of antibiotic therapy and incidence of re-interventions and sequelae. We also recorded frequency of bacterial pathogens in all microbiological samples submitted. Block randomization using computer-generated random numbers was used. The assessor of outcome was blinded.

RESULTS

All patients completed the study. Pin site infection rate days per 1000 pin site days observed was marginally less in chlorhexidine group, but was not statistically significant compared to other antiseptics and control group (Absolute value in control, povidone iodine, silver sulphadiazine and chlorhexidine groups were respectively 2.04 ± 4.27, 2.04 ± 3.65, 1.85 ± 3.37, 1.37 ± 2.35, p value 0.92). Daily dressing category showed slightly less pin site infection days rate within each group and overall, but this was also not statistically significant (1.56 ± 3.99 versus 2.10 ± 5.1, p value 0.35). There was no statistically significant difference among the groups with regard to other secondary outcomes. Methicillin Sensitive Staphylococcus aureus was the most common bacterial pathogen isolated.

CONCLUSION

Use of antiseptics does not offer any advantage in regular pin site care in Ilizarov external fixation and daily pin site care is not superior to weekly pin site care. Empirical therapy in early and low grade pin site infections must be targeted against Staphylococcus.

A web-based survey to identify current practice in skeletal pin site management

Infections associated with percutaneous pins and wires are common complications which can have a significant impact on patient outcomes. A survey was undertaken to identify current practice and gain insight into variations of clinical practice. Invitations were sent by email to complete an electronic questionnaire using SurveyMonkey. The survey was left open for 100 days. The single largest group of respondents (37.4%, n = 120) cleansed pin sites daily, with significant differences identified between medical and nursing professions (P = 0.02), and country of practice (P < 0.001). Significant differences were also identified in the use of different cleansing solutions between medical and nursing professions (P < 0.001) and country (P < 0.001). The majority group preferences were saline 30% (n = 96) and alcoholic chlorhexidine 29.6% (n = 95). Pin site crusts were routinely removed by 57.9% (n = 186). Pin sites were left exposed by 50.3% (n = 160). Dry gauze was identified as the most common dressing used to dress pin sites, however, substantial variation was identified in the types of dressings used. Compression was not routinely applied to pin sites by 51.6% (n = 165). There remains considerable diversity of practice when caring for pin sites. Further research is required to identify the most effective methods in preventing pin site infection.

From prevention of pin-tract infection to treatment of osteomyelitis during paediatric external fixation

Pin-tract infection (PTI) is the most commonly expected problem, or even an almost inevitable complication, when using external fixation. Left unteated, PTI will progress unavoidably, lead to mechanical pin loosening, and ultimately cause instability of the external fixator pin-bone construct. Thus, PTI remains a clinical challenge, specifically in cases of limb lengthening or deformity correction. Standardised pin site protocols which encompass an understanding of external fixator biomechanics and meticulous surgical technique during pin and wire insertion, postoperative pin site care and pin removal could limit the incidence of major infections and treatment failures. Here we discuss concepts regarding the epidemiology, physiopathology and microbiology of PTI in paediatric populations, as well as the clinical presentations, diagnosis, classification and treatment of these infections.

Reference positions for transosseous elements in femur: A cadaveric study

INTRODUCTION

During external fixator treatment, displacement of soft tissue at pin sites may cause infection and contracture. Due to surrounding soft tissue thickness, the femur is especially susceptible to severe complications. However, standard textbooks demonstrate only how major neurovascular bundles should be avoided. This study is the first cadaver study investigating which pin sites within safe zones exhibit minimal soft tissue displacement.

METHODS

To identify the clear direction of any pin, the femoral shaft was divided into eight levels, from I to VIII. The transverse sections at each level were further divided into 12 radial positions analogous to a clock face, where the anterior direction was assigned twelve o'clock, the medial three, etc. Fifteen adult cadavers were used. Twelve wires were aligned radially on the examined ring, and were dyed at each point toward the soft tissue. Each soft tissue displacement was measured by marking the surface before and after three particular joint motions, namely hip flexion (0-90°), abduction (0-45), and knee flexion (0-90). The same procedures were performed in three layers of soft tissue: skin, fascia, and muscle.

RESULTS

The average displacement was determined in 89 directions excluding the groin part, upon three joint motions. The three layers of skin, fascia, and muscle showed similar data curves. Greater displacements were seen at juxta-articular areas than at the mid-diaphyseal. The data curve exhibited a bimodal characteristic, with larger displacements at the extension and flexion directions. The amount of displacement at 6 o'clock was large at the levels near the hip joint, whereas at 12 o'clock, it was large near the knee joint.

DISCUSSION

"Reference positions" for transosseous elements were defined within zones absent neurovascular bundles, indicating 30 sites with minimal tissue displacement. Three or four directions at each level were chosen: I.9-11, II.9-11, III.8-11, IV.8-11, V.7-10, VI.3, 7-9, VII.3, 4, 8, 9, and VIII.3, 4, 8, 9. The anterolateral aspect near the hip joint and the posterolateral aspect near the knee tended to be chosen. They may prove useful in perioperative practice.

Assessment of an implant-skin interface scoring system for external skeletal fixation of dogs

OBJECTIVE To assess intraobserver repeatability and interobserver and in vivo versus photographic agreement of a scoring system for the implant-skin interface (ISI) of external skeletal fixation (ESF). SAMPLE 42 photographs of ISIs from 18 dogs for interobserver agreement and intraobserver repeatability and 27 photographs of ISIs from 6 dogs for in vivo versus photograph agreement. PROCEDURES An ISI inflammation scoring system was developed. It included scales for 6 metrics (erythema, drainage amount, drainage type, swelling, hair loss or lack of hair regrowth, and granulation tissue). Photographs of the ISI of ESF were obtained by use of a standard protocol and evaluated to determine intraobserver repeatability and interobserver agreement (Cronbach α; 4 raters) of the ISI score. Agreement between in vivo and photographic ISI scores (2 raters) and correlation between median scores across metrics were evaluated. RESULTS 42 photographs met the inclusion criteria. Overall intraclass correlation coefficients ranged from 0.922 to 0.975. Interobserver overall Cronbach α ranged from 0.835 to 0.943. For in vivo versus photographic assessment, 27 ISIs in 6 dogs and their photographs were evaluated. The Cronbach α for both raters ranged from 0.614 to 0.938. Overall, the Cronbach α ranged from 0.725 to 0.932. Mean photographic scores were greater than mean in vivo scores for each metric. Pearson correlation coefficients ranged from 0.221 to 0.923. Erythema, swelling, and granulation were correlated with all other metrics. CONCLUSIONS AND CLINICAL RELEVANCE In this study, an ISI scoring system used in this study had high repeatability and agreement and may therefore be considered for use in clinical situations. Photographic scores were not equivalent to in vivo scores and should not be used interchangeably.

Pin-site care: can we reduce the incidence of infections?

BACKGROUND

This study was conducted to determine the pin-site care protocols currently in use and to analyse their effectiveness and outcomes.

METHODS

PubMed, the Cochrane Library and Embase databases were screened for manuscripts that described comparative studies of different methods of pin-site care and referred to complications related to any kind of external fixator application.

RESULTS

A total of 369 manuscripts were screened and only 13 of these met the inclusion criteria evaluating different protocols of pin-site care. This review is based on a total of 574 patients. Infection rates were very variable depending on the type of implant used and the protocol of pin-site care applied.

CONCLUSIONS

None of the different protocols of pin-site care that were evaluated in this study were associated with a 0% infection rate. There is currently no consensus in the international literature about which protocol should be applied universally. Meticulous surgical technique during pin insertion and implementation of one of the existing protocols of pin-site care are the mainstay of prevention and/or reduction of the incidence of pin-site infections.

Pin site care for preventing infections associated with external bone fixators and pins

BACKGROUND

Metal pins are used to apply skeletal traction or external fixation devices in the management of orthopaedic fractures. These percutaneous pins protrude through the skin, and the way in which they are treated after insertion may affect the incidence of pin site infection. This review set out to summarise the evidence of pin site care on infection rates.

OBJECTIVES

To assess the effect on infection rates of different methods of cleansing and dressing orthopaedic percutaneous pin sites.

SEARCH METHODS

In September 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL.

SELECTION CRITERIA

We evaluated all randomised controlled trials (RCTs) that compared the effect on infection and other complication rates of different methods of cleansing or dressing orthopaedic percutaneous pin sites.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the citations retrieved by the search strategies for reports of relevant RCTs, then independently selected trials that satisfied the inclusion criteria, extracted data and undertook quality assessment.

MAIN RESULTS

A total of eleven trials (572 participants) were eligible for inclusion in the review but not all participants contributed data to each comparison. Three trials compared a cleansing regimen (saline, alcohol, hydrogen peroxide or antibacterial soap) with no cleansing (application of a dry dressing), three trials compared alternative sterile cleansing solutions (saline, alcohol, peroxide, povidone iodine), three trials compared methods of cleansing (one trial compared identical pin site care performed daily or weekly and the two others compared sterile with non sterile techniques), one trial compared daily pin site care with no care and six trials compared different dressings (using different solutions/ointments and dry and impregnated gauze or sponges). One small blinded study of 38 patients found that the risk of pin site infection was significantly reduced with polyhexamethylene biguanide (PHMB) gauze when compared to plain gauze (RR 0.23, 95% CI 0.12 to 0.44) (infection rate of 1% in the PHMB group and 4.5% in the control group) but this study was at high risk of bias as the unit of analysis was observations rather than patients. There were no other statistically significant differences between groups in any of the other trials.

AUTHORS' CONCLUSIONS

The available trial evidence was not extensive, was very heterogeneous and generally of poor quality, so there was insufficient evidence to be able to identify a strategy of pin site care that minimises infection rates. Adequately-powered randomised trials are required to examine the effects of different pin care regimens, and co-interventions - such as antibiotic use - and other extraneous factors must be controlled in the study designs.

Rates of pin site infection during distraction osteogenesis based on monthly observations: a pilot study

PURPOSE

To assess the monthly rates of infection of individual pin sites in 7 patients during distraction osteogenesis.

METHODS

Five men and 2 women aged 15 to 35 (mean, 23) years underwent distraction osteogenesis for 8 tibias using the Ilizarov ring external fixator or Taylor Spatial Frame. Patients were taught to perform standard daily pin site care at home, and were evaluated monthly for pin site infection by a single observer using a standardised grading system.

RESULTS

Of 1334 observations made on 110 pin/wire sites, there were 83 (6%) pin site infections; 44 (3%) were grade 1 and 39 (3%) were grade 2. The risk of infection was higher at half pin than wire sites. The highest rates occurred in the distal segment.

CONCLUSION

Monthly evaluation of individual pin sites enables comparison between studies.

Antimicrobial gauze as a dressing reduces pin site infection: a randomized controlled trial

BACKGROUND

Pin site infection is a common problem in external fixation. Plain gauze wetted with normal saline is commonly used for a pin site dressing owing to the simplicity and low cost. Evidence to support adding an antimicrobial agent in the dressing material is lacking.

QUESTIONS/PURPOSES

We compared the rate of pin tract infection using plain gauze and gauze impregnated with polyhexamethylene biguanide in patients undergoing limb lengthening procedures.

PATIENTS AND METHODS

We included 38 patients (40 limbs) undergoing limb lengthening or deformity correction using an external fixator between July 2009 and June 2010. There were 23 male patients and 15 female patients, with a mean age of 26.3 years (range, 5-68 years). The patients were randomized into two groups: a polyhexamethylene biguanide group (22 limbs) and a control group (18 limbs). The metal-skin interfaces were assessed by a researcher blinded to the type of gauze at 2, 4, 8, and 12 weeks after surgery for the pin site infection based on a predetermined grading system. There were a total of 483 metal-skin interfaces, with 1932 total observations. Infection rates were compared using the chi square test and relative risk with 95% confidence interval.

RESULTS

The infection rate was lower (χ(2) [1, n = 1932] = 23.00) and the risk for infection was lower (relative risk, 0.228; 95% confidence interval, 0.118, 0.443) for the polyhexamethylene biguanide group (n = 1068; 1.0%) than for the control group (n = 864; 4.5%).

CONCLUSIONS

Use of polyhexamethylene biguanide-impregnated gauze can reduce the risk of pin tract infection in external fixation.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The influence of perioperative risk factors and therapeutic interventions on infection rates after spine surgery: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

The objectives of this systematic review were to determine the patient and perioperative risk factors that contribute to infections after spine surgery and to examine the level of evidence to support the use of therapeutic interventions to reduce infection rates.

SUMMARY OF BACKGROUND DATA

Infection continues to be one of the most common and feared complications after spine surgery. As such, it is used as a sentinel event for quality assurance processes. It is clear that the causes of infections after spine surgery are multifactorial and numerous patient- and procedure-related factors have been proposed as contributory elements. In addition, numerous perioperative adjuncts have been suggested to reduce infection rates.

METHODS

A systematic review of the English-language literature (published between January 1990 and June 2009) was undertaken to identify articles examining risk factors associated with and adjunct treatment measures for preventing surgical-site infections. Two independent reviewers assessed the level of evidence quality using the Grading of Recommendations Assessment, Development, and Evaluation criteria, and disagreements were resolved by consensus.

RESULTS

Of the 127 articles identified, 32 met the criteria to undergo full-text review. Individual patient, operative, and perioperative variables have been identified that are associated with increased infection rates (i.e., older age, obesity, diabetes, malnutrition, higher American Society of Anesthesiologists score, posterior approaches, and blood transfusions) but these variables have not been combined to provide individual patient risks based on a composite of factors (e.g., risk stratification). Of the surgical adjuncts investigated, only irrigation with dilute betadine solution showed moderate support for reducing infection rates.

CONCLUSION

It is clear that the causes of postoperative spinal site infections are multifactorial and related to a complex interplay of patient and procedural influences. Because of these complexities, for any individual and surgical procedure, predictable infection rates likely exist that do not extrapolate to 0. Although we have identified factors associated with increased infection rates, further studies will be required to allow multifactorial risk stratification for individual patients and to further investigate the use of therapeutic adjuncts.

Pin site care for preventing infections associated with external bone fixators and pins

BACKGROUND

Metal pins are used to apply skeletal traction or external fixation devices in the management of orthopaedic fractures. These pins protrude through the skin (described as 'percutaneous') and the way in which they are treated after insertion may affect the incidence of pin site infection. This review set out to summarise the evidence on the effect of pin site care on infection rates.

OBJECTIVES

To assess the effect on infection rates of different methods of cleansing and dressing orthopaedic percutaneous pin sites.

SEARCH STRATEGY

For this first update the following electronic databases were searched: the Wounds Group Specialised Trials Register (searched June 2008); CENTRAL (2008, Issue 2); Ovid Medline (1950 to May 2008), Ovid EMBASE (1980 to May 2008) and Ovid CINAHL (1982 to May 2008). In addition, reference lists of review articles and relevant trials were also searched and some handsearching undertaken.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing the effect on infection and other complication rates of different methods of cleansing or dressing orthopaedic percutaneous pin sites were evaluated.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the citations retrieved by the search strategies for reports of relevant RCTs, independently selected trials that satisfied the inclusion criteria, extracted data and undertook quality assessment.

MAIN RESULTS

For this first update an additional five trials were identified, in total six trials (349 participants) were eligible for inclusion in the review. Three trials compared a cleansing regimen with no cleansing, 2 trials compared cleansing solutions, 1 trial compared identical pin site care performed daily or weekly and 4 trials compared dressings. One of these trials reported that infection rates were lower (9%) with a regimen that included cleansing with half strength hydrogen peroxide and application of Xeroform dressing when compared with other regimens with different cleansing and dressing regimens (rates >26%) but this may be a chance difference. There was no evidence of a difference between groups in any of the other trials. No trials were identified that compared any dressing versus no dressing or different massage regimens.

AUTHORS' CONCLUSIONS

There is insufficient evidence for a particular strategy of pin site care which minimises infection rates. Adequately powered randomised trials are required to examine the effects of different pin care regimens and co interventions such as antibiotic use and other extraneous factors must be controlled in the study designs.