A high incidence of associated infection with the use of transcutaneous metal devices has been widely reported. The aims of this study were: (1) to record the incidence of pin site infection in a Plastic Surgery department, (2) to compare the infection rate in our department with published literature and (3) to identify factors that contribute to infection. A prospective cohort study was performed including all patients presenting to the plastic surgery unit with any type of transcutaneous metal in situ over a 3-month period. Patients and staff were questioned on wound hygiene and whether they had been provided with specific protocols. Our study revealed an infection rate of 24%. Patients and staff were not aware of preventive protocols. From this study, the following conclusions are made: (1) pin site infection is a major problem, and no consensus has been reached on the best way to manage pin sites, (2) there is variable knowledge of pin-site care, (3) there is a need for a clearer definition of pin-site infection and a standardised system of assessment, classification and treatment and (4) there is a need for more innovative technology in pin-site manufacture as studies reveal that the type of material used in the pins does affect infection rates.
The utilisation of transcutaneous metal devices is common practice in orthopaedic practice, and with increasing involvement of plastic surgeons in hand trauma and combined management of lower limb injuries, many of these patients are managed for variable periods by plastic surgeons. Transcutaneous devices of various types are used on a short- or longer-term basis to stabilise fractures or to correct deformity. Kirschner wires, known as K-wires, are most commonly used on a short-term basis as a simple and cost-effective way to provide stability to small bone fractures [1]. The Hoffman external fixator or the Ilizarov circular frame, used for long bone fractures, may be applied for periods extending to several months with an increasing incidence with time. Essentially, a pin tract is a chronic wound containing a foreign body providing an ideal focus for bacterial colonisation. Although pin-tract infection is often not considered to be a serious complication in the short term, it has the potential to decrease the stability of the bone–pin interface, which can cause pin loosening, osteomyelitis and poor functional outcome [2, 3]. The problem has heretofore been widely reported in orthopaedic literature, but as pin-site infection impacts the care of plastic surgery patients also, it is important for plastic surgeons to understand the scale of the problem and strategies for prevention.
The aims of this study were:
1.
To record the incidence of pin-site infection in a Plastic Surgery department in comparison with published reports;
2.
To review literature on comparative trials of pin site management to determine from the literature what method of wound care best prevents pin-site infection;
3.
To establish current nursing practices in pin-site care and patient-initiated practices;
4.
To determine the need for more innovative technology in prevention.
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Methods
A prospective, cohort study was conducted on patients presenting to the Plastic Surgery ward or clinic with any type of transcutaneous metal device. Patients presenting between November 1, 2010 and February 1, 2011 were included. Episodes of subjective or objective complications were recorded. Objective data comprised of demographic information, the reason for the transcutaneous metal insertion, details of the type of fixator used, any reported complication, the results of microbiology swabs sent to the laboratory, antibiotic use and relevant radiological findings. Infection was defined by clinical symptoms such as redness, pain, prolonged discharge and functional loss. Subjective data were obtained by interviewing the patient, asking about skin problems, discharge, functional loss associated with the metal device and any discomfort (Figs. 1, 2, 3, 4, 5).
Fig. 1
K-wiring of the little finger
Fig. 2
Hoffman external fixator
Fig. 3
Insertion of external fixator pins
Fig. 4
Pennig orthofix
Fig. 5
Infected threaded pin
×
×
×
×
×
Results
Thirty-five consecutive patients with transcutaneous metal devices were seen in our specialised outpatient clinic from November 1, 2010 to February 1, 2011. Of these, 25 individuals were suitable for inclusion in the study. Seven patients were excluded as their K-wires were buried, and three were not compliant with follow-up. Of the 25 cases, 9 patients had an external fixator (51 pin sites) and 16 had K-wires (27 pin sites) in situ. In Table 1, you find the patients’ characteristics and recorded complications. The duration of treatment varied between 14 and 78 days for K-wires and between 21 and 78 days for external fixators. The duration of follow-up varied between 7 and 89 days.
Table 1
Characteristics and recorded complications of patients with transcutaneous metal devices seen between November 1, 2010 and February 1, 2011
Injury
Fracture
Device
Type and size
Duration (days)
Complications
Infection
Swabs
Antibiotics
Duration
1
Dupuytren
No
External fixator
Pennig Orthofix (Mini) 4 × wires, hand
28
None
None
NA
Co-amoxiclav
2× tabs for 7 days
2
Dupuytren
No
External fixator
Pennig Orthofix (Mini) 8× wires, hand.
21
Infection
Yes
NA
Co-amoxiclav
1× IV for 1 day
3
Traumatic
Yes
External fixator
Hoffman external frame 3 × 4 mm Pins 1 × 5 mm Pins, leg.
22
None
No
NBG
None
None
4
Degloving
No
K-wire
1 × 0.9 mm, hand.
16
None
None
NA
Co-amoxiclav
1× IV for 3 days, 1× tabs for 5 days
5
Traumatic
No
External fixator
Mini Hoffman II 3 and 2 mm pinsa, hand.
74
Infection technical errora
Twice, two admissions
S. aureus +++
Co-amoxiclav and flucoxacillin
4× IV for 1 day, 1× IV for 7 days, 1× tabs for 7 days
6
Blunt
Yes
K-wire
1 × 0.9 mm K-wire, hand
28
None
None
NA
None
NA
7
Traction
No
K-wire
1× K-wire, hand
14
None
None
NA
Co-amoxiclav
1× IV, 1× tabs for 5 days
8
Mallet
Yes
K-wire
1 × 0.9/1 × 1.1 mm, hand.
30
Migration K-wire
None
NA
None
NA
9
Occupational
No
K-wire
1 × 0.9 mm K-wire, hand
31
None
None
NA
Co-amoxiclav
1× IV 1.2 g
10
Industrial
Yes
External fixator
Pennig Orthofix, hand.
28
None yet
None
NA
None
Not applicable
11
Crush
Yes
K-wire
6 × 0.9 mm, hand
21
Infection
Twice
S. aureus +
Co-amoxiclav
IV 7, tab 10
12
Enchondroma
No
K-wire
2 × 0.7 mm, hand
30
None
None
NA
None
NA
13
Unstable
Yes
K-wire
2 × 1.1 mm, hand
30
Slight migration
None
NA
Co-amoxiclav
1× 7 days
14
Crush
Yes
K-wire
2 × 1.1 mm Orthofix mini, hand
28
None
None
NA
Co-amoxiclav
IV, 3 days; Tab, 5 days
15
Traumatic
Yes
K-wire
2 × 1.1 mm, hand
78
None
None
NA
Co-amoxiclav
1 × IV 1.2 g
16
Dog bite
Yes
K-wire
1 × 0.9 mm, hand
27
None
Yes
MCS
Co-amoxiclav
IV, 3 days; tabs, 7 days
17
Dupuytren
No
Ext. fixation
Pennig Orthofix, hand
26
Technical error
Yes
NA
Flucloxacilline Co-amoxiclav
Tabs 7 days
18
Traumatic
Yes
Circular frame
7× wires, 3× pins, lower leg
60
Infection and nerve injury
Many
S. aureus +++
None
NA
19
Traumatic
Yes
K-wire
2 × 1.1 mm, hand
33
Infection
Once
NA
Co-amoxiclav
1 × IV 1.2 g
20
Traumatic
Yes
K-wire
1 × 1.2 mm, hand
35
None
None
NA
None
None
21
Circular saw
Yes
K-wire
1 × 1.1 mm, hand
44
None
None
NA
Co-amoxiclav
IV, 3 days; Tabs, 7 days
22
Sports injury
Yes
Needle
Hollow needle, hand
14
Slight migration
None
NA
Co-amoxiclav
Tabs, 5 days
23
Deglovement
Yes
External fixator
Hoffman II 2 × 4 mm 2 × 5 mm pins, hand
27
None
None
NA
Co-amoxiclav Gentamicin
IV, 3 days
24
Assault Axe injury
Yes
K-wire
1 × 0.9 mm, hand
21
None
None
NA
Co-amoxiclav
IV 6 days; Tabs, 7 days
25
Occupational
Yes
External fixator
Pennig Orthofix, hand
27
None
None
NA
None
NA
NBG no bacterial growth, NA not applicable
aPins were changed due to insertion of wrong-sized pins
Of the 25 patients with transcutaneous metal devices, nine developed complications (36%). In three cases, slight migration of K-wires occurred (12%). Six patients suffered from pin-tract infection (24%, with a 95% confidence interval (CI) of 12% to 43%). In three patients, the swab taken from the pin site was positive for Staphylococcus aureus. The external fixator had to be prematurely removed from one patient due to an infection. This patient developed recurrent infections at the site of his previous pin tracts even after pin removal. Of the patients surveyed, 80% had not been provided with instructions on wound management. Only one of the patients had the benefit of a district nurse assessment with pin-site care. The patients did not receive instructions on either washing the pin sites or on cleaning them.
In our study, we found that pin-site care was not consistent. Mostly, the pins were cleaned daily with normal saline and a new dressing was applied. The pin sites were not washed. In some cases, betadine or chloramphenicol 1% ointment was applied to the pin sites.
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In our study, there was no standard protocol on the prescription of antibiotics in patients with transcutaneous metal. Fifty percent received a preoperative antibiotic dose. Others received a single dose or multiple postoperative doses of co-amoxiclav or flucloxacillin.
Discussion
Our data show six infections from 25 patients, which is 24%, with a 95% CI of 12% to 43%. Thus, the true infection rate in the whole patient population is between 12% and 43%.
Our key limitation is the small number of patients. We calculated that if we would have entered more patients, or if we would repeat the study, we could expect an infection rate in the same range (for 95 out of 100 projects). Assuming the same infection rate of 24%, with 12 infections from 50 patients, the 95% CI is 14% to 37%, and with 24 infections from 100 patients, the 95% CI is 17% to 33%. As these numbers would not have made a great difference, we decided to keep our number of patients to 25.
The reported rate of pin-tract infection in the literature is high, ranging from 4.5% to 71%. Although diagnostic criteria vary (Santy [20]), and this may be a factor in the wide range of these quoted figures, certain factors however seem to be important. In Table 2, you find the reported infection rates in the literature, with the prevention and management measures listed. Table 3 explains the several classification systems which are used to diagnose a pin-tract infection.
Table 2
Reported infection rates in the literature; diagnosis, prevention and management of pin-tract infection
Pre- and postop IV cephazolin open # IV gentamicin and ornidazole TBS
Daily showering and - group 1: brushing the pin sites with soap and a soft toothbrush; group 2: cleaning the crusts using sterile gauze impregnated with 10% polyvinylpyrrolidone iodine (Polyod)
Unstable or displace fractures of the distal radius
Average 41.3
>6 months
Prospective, randomized
19%
10.1%
Requiring oral antibiotics
Three doses of IV cephalosporin
(1) Weekly dry dressing changes without pin-site care, (2) daily pin-site care with a solution of 1/2 normal saline and 1/2 hydrogen peroxide, (3) placement of a weekly changed chlorhexidine-impregnated disc (Biopatch) around the pins
A. 1/2 strength peroxide + gauze, B. 1/2 strength peroxide + Xenoform dressing, C. saline + gauze, D. saline + Xenoform dressing, E. antibacterial soap and water + gauze, F. antibacterial soap and water + Xeroform dressing, G. no cleansing + gauze
Sterile compresses moistened by chlorhexidine in alcohol + dressed, left for 1 week. After that, cleaned with chlorhexidine alcohol + sterile compress.
4× additional surgery
NA not applicable, NM not mentioned, PTI pin-tract infection
aIn Table 3 you find the different classification systems
Table 3
Different classification systems of pin-tract infection
Green classification 1983: A major pin-tract infection produces sufficient redness, pain or drainage to require hospital admission for either parenteral antibiotic therapy, pin removal or removal of the entire fixator. A chronic pin-tract infection or persistent drainage after pin removal is also considered a major infection. Any other pin reaction is defined as minor, even those with purulent discharge
Modified Moore and Dahl classification 2009
0
Normal appearance
1
Inflamed
2
Serous discharge
3
Purulent discharge
4
Osteolysis
5
Ring sequestrum
Sims and Saleh classification 1996
1
Copious serous drainage
2
Superficial cellulitis
3
Deep infection
4
Osteomyelitis
Saleh and Scott Classification 1992
0
No problems
1
Responds to local care, for example increased cleaning and massage
2
Responds to oral antibiotics
3
Responds to intravenous antibiotics or pin site releases
4
Responds to removal of the pin
5
Responds to local curettage
6
Chronic osteomyelitis
Checketts–Otterburn Classification (2000)
1
Slight redness, little discharge
2
Redness of skin, discharge, pain and tenderness in the soft tissue
3
Grade 2 but not improved with antibiotics
4
Severe soft tissue infection involving several pins, sometimes with associated loosening of the pin
5
Grade 4 but also involvement of the bone; also visible on radiographs
6
This infection occurs after fixator removal. The pin track heals initially but will break down and discharge at intervals. Radiograph shows new bone formation and sometimes sequestra
K-wires and external fixators in the hand and wrist
In a retrospective study by Stahl and Schwartz [1], which considers the use of K-wires in wrists, the authors reported an infection rate of 5.5%; 13 out of 236 patients developed infection around the pin. Margic [4] observed 100 patients in a prospective study of small external fixators used on metacarpal and phalangeal fractures, and found an infection rate of 7%. Studies on external fixator use for fractures of the distal radius report a higher recurrent infection rate of between 10.1% and 43% [5, 9, 10]. Egol et al. [6] performed a randomized controlled trial on such fixators and recorded an infection rate of 10.1%.
The role of skin movement
Hove et al. [7], who investigated the differences between static and dynamic fixation of the wrist, found that 15 of their patients (43%) in the dynamic fixator group and 4 (11%) of the static group had a superficial pin-tract infection (p < 0.01). They attributed this difference to the motion allowed by the dynamic fixator which seemed to increase skin irritation around the wrist.
Fixators applied to the elbow must also contend with motion. Cheung et al. [8] looked at the hinged external fixator .The pin-tract infection rate was found to be 25%.
External fixators in areas prone to infection
The pelvic external fixator is another device associated with a high rate of infection; Mason et al. [9] reported a complication rate of 62% for definitive pelvic fixators (mean duration of treatment is 60 days) and an infection rate of 21% for temporary fixators (mean duration of treatment is 8 days). This resulted in the premature removal of seven devices, the reinsertion of one pin and the drainage of two abscesses.
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Lower limb external fixator devices
The lower limb is an area where wound healing is notoriously difficult.
Blasier et al. [10] investigated 132 children with fractures of the femur who were treated with external fixators. They found an infection rate of 40.5%; a rate of superficial infection of 36% and a rate of 4.5% for cases requiring intravenous antibiotics. Sims and Saleh [11] reported a higher pin-tract infection rate of 86% associated with external fixation of the femur. These authors related the high infection rate to the bulk of tissue in the upper leg and its associated movement.
External fixation devices for tibial shaft fractures have been widely investigated. The Ilizarov circular, external frame is one of the transcutaneous devices often used to treat tibial fractures. The pin-tract infection rate varies from 36% to 54.2% [12, 13]
Pin-site wound care
Lethaby et al. showed in 2008, in a systemic review, that there is insufficient evidence available on any one best way to care for pin sites [14]. Recently, the Russian Protocol of pin-site care has become more popular. This Russian Protocol was developed by the “Ilizarov Scientific Centre” for Restorative Orthopaedics in Russia. The system advises non-touch techniques when using the wires and pins, the utilisation of pulsed drilling, the removal of bone swarf and immediate coverage of the pin-site with dressings soaked in Chlorhexidine 1% ointment. The pins should be cleaned daily for 3 days with 70% alcohol, after which an occlusive dressing should be applied. This ritual is repeated every 7 days while the transcutaneous metal device is in place. Davies et al. [15] showed that infection rates are higher by 37% in cases where the Russian Protocol is not utilised (p < 0.001). The Cochrane review dismissed the findings of Davies et al. as it questioned their methods of randomizing their sample, even though, Timms and Pugh [16] advocate the following of this prescription.
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Grant et al. [17] concluded that there is a role for the application of a bactericidal solution, such as 10% povidone–iodone solution, to the skin surrounding the pin sites. The problematic aspect of this treatment is the difficulty in securing an occlusive dressing.
The pin insertion technique
When inserting Ilizarov or K-wires, it has been shown that several important issues should be addressed to keep the infection rate down; adequate cooling during drilling is vital to prevent thermal damage, and (as recommended in the Russian Protocol) drilling should be conducted using the pulsed technique. The ends of transcutaneous wires should be bent to avoid migration [18] (in our study, three wires migrated; one of which had not been bent).
Pre-drilling was thought to be necessary for certain pins in certain bones, and unnecessary for other situations. If the pins have sharp-cutting trocar points, pre-drilling may be unnecessary. In a study by Hutchinson et al. [19], soft tissue inflammation around the pins was almost twice as common in pre-drilled pin sites, which could be attributable to the increased soft tissue trauma associated with two passages of the wire across the tract. It has been suggested that with the use of sharp trocar points, the skin does not need pre-incision, but the skin should be incised if tenting appears at the pin site, as otherwise a fluid reservoir could develop and attract bacteria [20].
Antibiotics
There is evidence that the presence of transcutaneous metal leads to the development of a biofilm between the skin and metal which allows bacterial growth. As transcutaneous metal is a foreign material, prophylactic antibiotics may be considered. Yet, according to W-Dahl and Toksvig-Larsen [21], antibiotics should be used as little as possible, and only those with a specific spectrum should be employed. These authors showed that prolonged antibiotic use has no benefit in eradicating infection. As you see in Table 2, good wound management and optimal insertion techniques do not eradicate this problem. The quickest answer to pin-site infection is often pin removal.
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Technological solutions
Various technological solutions have been tried in the hope of preventing pin-tract infection. Coated pins create an extra defence barrier between the pin and bacteria. In a recent systematic review of the influence of hydroxyapatite coating on pin loosening and pin-tract infection by Saithna [22], he concluded that there was less loosening with coated pins, but unfortunately not less infection.
Titanium is frequently used in Dentistry and in Orthopaedics for intraoral or intraosseous prostheses. [23]. This material produces a reduced susceptibility to bacterial adhesion. In a study by Pieske et al. [24], titanium alloy pins were compared with stainless pins in 80 patients. There was no difference in the incidence of pin-tract infection. Masse et al. [25] found, in a randomized study, that silver pins resulted in a lower rate (30%) of positive microbiology cultures than uncoated pins (42%), but this difference was not statistically significant, and there was a raised serum silver in the patients with silver-coated pins. Much money is spent each year on improving technology, yet such attractive possibilities should not distract staff from executing the simple, basic but effective methods of wound and pin-site care.
Implications for practice
1.
Our study found an infection rate of 24% associated with transcutaneous metal.
2.
Plastic surgery departments need to develop clear protocols for prevention of pin-site infection, and randomized controlled trials are necessary to establish the best practice.
3.
Patients need clearer instructions on how best to care for their pin sites.
4.
There is a need to consider new technological solutions for this problem. Long-term implantation in dental practice has been established, but it is less successful in skin than oral mucosa.
Acknowledgements
The authors wish to thank Sigrid Whiteside, Medical Statistician and Honorary Research Assistant at the University Hospital of South Manchester for her statistical assistance.
Conflict of interest
None
Open Access
This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
Open AccessThis is an open access article distributed under the terms of the Creative Commons Attribution Noncommercial License (https://creativecommons.org/licenses/by-nc/2.0), which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
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