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Pin tract infection with external fixation of pediatric fractures
Journal of Pediatric Surgery (2007) 42, 1584–1587
www.elsevier.com/locate/jpedsurg
Pin tract infection with external fixation of pediatric fractures Johannes Schalamon a,* , Thomas Petnehazy a , Herwig Ainoedhofer a , Ernst B. Zwick b , Georg Singer a , Michael E. Hoellwarth a a b
Department of Pediatric Surgery, Medical University of Graz, Graz 8036, Austria Department of Pediatric Orthopedics, Medical University of Graz, Graz 8036, Austria
Index words: Pin infection; Pin site care; External fixation
Abstract Background: This study aimed to evaluate the incidence and severity of pin tract infections in a series of pediatric trauma patients. Methods: All pediatric trauma patients with external fixation who were treated at our institution between 1998 and 2003 were included. The charts of 30 children (20 males; 10 females; mean age, 13.2 years; range, 7-19 years) with 37 episodes of external fixation were reviewed. The average duration of external fixation was 17.5 weeks (range, 1-94 weeks). Pin tract infections were graded using the Dahl classification. Bacterial cultures were obtained in case of drainage from the pin site. Results: In 18 (48%) of 37 external fixations, no signs of infection occurred during the treatment period. In the remaining 19 (52%) external fixations, 35 episodes of infection were documented. Most infections were mild or moderate, whereas only 3 (9%) severe deep infections were noted (grade 5). Six (17%) infections healed with local application of rifamycin, whereas 27 (77%) of 35 infections were successfully treated with systemic antibiotics (cefuroxime, clindamycin). The remaining 2 infections (6%) required removal of a pin. Conclusions: Pin tract infection occurred in half of the patients who were treated with external fixations. Most of the pin site infections in the present series were mild and could be managed by local or systemic application of antibiotics. The occurrence of pin tract infections did not require a change of the method of stabilization. © 2007 Elsevier Inc. All rights reserved.
External fixation is a method of bone stabilization, where pins or wires are inserted into the bone through small skin incisions and are held together with an externally applied metal or carbon fiber frame. External fixators are commonly used for fracture stabilization in trauma patients as well as in orthopedic interventions for
* Corresponding author. E-mail address: [email protected] (J. Schalamon). 0022-3468/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.04.022
limb lengthening and reconstructive surgery. Although intramedullary nails gained increased acceptance for fracture treatment in diaphyseal fractures, stabilization with external fixators is widely used in patients with comminuted fractures, open fractures, and metaphyseal fractures [1]. Pin tract infection is a well-recognized problem in patients with external fixation. Infection rates of up to 100% were reported [2,3]. The aim of the present study was to analyze the incidence of pin tract infections in a series of pediatric trauma patients.
Pin tract infection with external fixation
1. Patients and methods We included all pediatric trauma patients younger than 19 years who were treated in a 6-year period from 1998 to 2003 with external fixation. Patients' charts were reviewed to gain information about the personal history, circumstances of the accident, clinical course, and complications related to the external fixation. Radiographic analysis was performed to identify possible malalignment and radiologic signs of bone infection. Pin tract infections were graded using the Dahl classification [2]. Bacterial cultures were obtained in case of drainage from the pin site.
1.1. Treatment strategy After initial inpatient treatment for fracture stabilization or correction of posttraumatic deformities, the children and adolescents were followed up weekly until removal of the external fixator. Pin site care was performed daily by patients or parents and at weekly follow-up by the medical staff. Pins were cleansed with saline, hydrogen peroxide, povidone iodine, or octenidine dihydrochloride depending on the surgeon's preferences. Crusts formed at the pin entry point were removed, even if there was no local sign of infection. Six months after pin removal, the patients were revisited to assess possible problems with a late onset.
2. Results Thirty children and adolescents (20 males; 10 females; mean age, 13.2 years; range, 7-19 years) with 37 episodes of external fixation were included. Twenty-three episodes of external fixation were caused by acute trauma. The children were mainly victims of traffic accidents (n = 11) or winter sport accidents (n = 9); less frequent were falls from a height of more than 1 m (n = 3). In 14 children, the external fixator was used for correction of a posttraumatic deformity. Overall, there were 28 lower extremity fixators (11 femur, 17 tibia), 5 devices to stabilize upper extremity fractures (humerus), and 4 fixators to treat pelvic ring injuries. More than 1 episode of external fixation were documented in 5 patients (3 patients with 2 episodes, 2 patients with 3 episodes). Thirty-four fixators were unilateral, whereas 3 children underwent a correction of a posttraumatic malunion using an Ilizarov ring fixator. The average duration of external fixation was 17.5 weeks (range, 1-94 weeks). In 18 of 37 external fixations (48%), no signs of infection occurred during the treatment period. In the remaining 19 (52%) external fixations, 35 episodes of infection were documented. These infections occurred after a 12-week period on average (range, 2-52 weeks). A total of 14 (40%) infections were classified as mild (grade 2), 12 (34%) as grade 3, and 6 as grade 4 (17%); only 3 (9%) severe deep infections were noted (grade 5). A total of 12 infections
1585 (34%) were related to the proximal pins, whereas in 23 cases (66%) a distal pin was affected. There was no difference in the frequency of pin infection between fixators used in acute trauma and those used for correction of a posttraumatic deformity. In all children with infections of grades 3 to 5, a bacterial culture was obtained. In 14 (78%) of 18 samples, a distinct bacterial species could be cultured. Staphylococcus aureus was found in most of the pin tract infections (Table 1). From 35 infections, 6 (17%) healed with local application of rifamycin, whereas 27 (77%) of 35 infections were successfully treated with systemic antibiotics (cefuroxime, clindamycin). The remaining 2 infections (6%) required removal and repositioning of a pin. Thus, none of the pin tract infections required a change in the method of stabilization.
3. Discussion A pin tract infection is generally diagnosed when local signs of infection occur. For this series, the incidence of pin infections is approximately 50% (Table 2) and represents the most frequent complication related to external fixation. Classifications of pin infections are commonly based on the degree of infection [2,12]. In contrast, Saleh and Scott [13] based their classification on the response to treatment. Ward [14] simplified the classification by categorizing pin tract infections in minor (“antibiotics can easily treat these”) and major types (“necessitate removal of one or more of the pins or the entire fixator before any infection may be resolved”). A standardized classification system is not established yet, but it would facilitate the comparison of study data. Thus, it is difficult to distinguish between the physiologic reactions of the surrounding skin in a normal healing process when compared to the signs of an initial pin site infection as a consequence of colonization. Several factors may influence the occurrence of a pin tract infection. Skin tension around the pins should be avoided to prevent necrosis of the surrounding tissue; furthermore, a correlation between loose pins and infection has been described [15,16]. Mahan et al [4] showed that most pins possess bacterial colonization, but loose pins correlated for infection with virulent species of bacteria at a highly significant level. Other authors have reported that pincoating materials such as silver or hydroxyapatite/ Table 1
Cultured bacteria from pin site (n = 18)
Bacteria
n (%)
S aureus Staphylococcus epidermidis Streptococcus viridans Nocardia No culture
6 (33) 4 (22) 3 (17) 1 (1) 4 (22)
1586 Table 2
J. Schalamon et al. Infection rates: overview of the literature
Author
Publication Patients (n) Infection date rate (%)
Mahan et al [4] Dahl et al [2] Gregory et al [5] Ahlborg and Josefsson [6] Parameswaran et al [7] Hedin et al [8] Hosny [9] Patterson [10] Mason et al [11] Schalamon et al
1991 1994 1996 1999 2003 2003 2005 2005 2005 2006
42 110 27 314 285 98 18 92 52 30
42 100 56 21 11 37 100 34 50 52
chlorhexidine enhance pin fixation, minimize bacterial colonization, and result in decreased pin infections [15,17,18]. High dynamic stress may also contribute to pin loosening by local bone yielding as a consequence of micromotion [19]. This is a preventable problem; the load of a single pin should be minimized by appropriate frame fixation and a sufficient number of pins proximal and distal to the fracture site. We could not identify loose pins in our study population except in 2 of those 3 patients with severe deep infections. The insufficient stability of the affected pin was the indication for pin removal in the 2 patients. We assume that loose pins are secondary to infections rather than their primary cause. Another factor that is supposed to influence the occurrence of infections is the pin site care. Several authors discussed different strategies. Whereas Dahl et al [20] found no difference between daily and weekly pin site care, Davies et al [21] had a favorable outcome in a group of patients with weekly pin site care and the local application of alcoholic antiseptic and occlusive pressure dressings compared with a group with daily pin site care. Gordon et al [22] presented a successful “nihilistic approach” with daily showers without physical pin cleansing. Nigam et al [23] performed a prospective survey comparing a group of patients with antibiotic injections at the site of pin insertion with a group of control subjects and found a significant decrease in pin tract infections (3% vs 30%). This seems to be a promising approach; although standard pin site care is limited to cleaning of the pins at skin level and above, Nigam et al showed the benefit of clean pins at tissue level. Still it remains to be clarified whether the effect of the local injection of an antibiotic solution is superior to the injection of antiseptics such as hydrogen peroxide, povidone iodine, or octenidine dihydrochloride. We assume that the benefit is mainly based on the way of application, not on the antibiotic agent itself. Finally, dressings are supposed to reduce movement around the pins and may thereby help in preventing infections by increasing stability [14]. Nevertheless, a systematic review by Temple and Santy [24] indicated a complete lack of evidence for any particular strategy of pin site care. This fact was further underlined by Holmes,
Brown, and the Pin Site Care Expert Panel [25], who stated: “Whether pin site care reduces infections is unknown.” We assume that regular follow-ups of the pin site will probably not prevent infection from spreading; however, it helps in the early recognition of this entity. In our study, the pin tract infections occurred in a mean of 12 weeks after beginning of treatment with external fixation despite continuous pin site care and weekly follow-up in an outpatient department. Pins may get loose and patients may neglect pin site care with time. After a skin tract infection has been diagnosed, the treatment options are local application of antibiotics, the use of oral antibiotics, treatment with intravenous antibiotics, and the removal of the infected pin. Although these are the general recommendations, Gregory et al [5] were successful in treating pin infections with oral antibiotics, and only 1 patient required frame removal because of persistence of the infection. In view of the fact that infections may be controlled by oral antibiotics and infection is the most frequent complication of external fixation, an oral antibiotic prophylaxis should be considered. However, the effect of prophylactic administration of oral antibiotics has not been evaluated yet. We presume that a conclusive prospective study should be performed to evaluate the efficacy of oral prophylactic antibiotics in prevention of pin site infections.
4. Conclusion Pin tract infection occurred in half of the patients who were treated with external fixation devices. Most of the pin site infections in the present series were mild and could be managed by local or systemic application of antibiotics. The occurrence of pin tract infections did not require a change of the method of stabilization. Nevertheless, the significant rate of pin site infections, the successful antibiotic treatment, and the limited period of external fixation may justify the administration of oral prophylactic antibiotics while carrying a device for external bone fixation.
References [1] Beaty JH. Operative treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 2005;434:114-22. [2] Dahl MT, Gulli B, Berg T. Complications of limb lengthening. A learning curve. Clin Orthop Relat Res 1994;301:10-8. [3] Green SA. Complications of external skeletal fixation. Clin Orthop Relat Res 1983;180:109-16. [4] Mahan J, Seligson D, Henry SL, et al. Factors in pin tract infections. Orthopedics 1991;14:305-8. [5] Gregory P, Pevny T, Teague D. Early complications with external fixation of pediatric femoral shaft fractures. J Orthop Trauma 1996;10: 191-8. [6] Ahlborg HG, Josefsson PO. Pin-tract complications in external fixation of fractures of the distal radius. Acta Orthop Scand 1999;70: 116-8.
Pin tract infection with external fixation [7] Parameswaran AD, Roberts CS, Seligson D, et al. Pin tract infection with contemporary external fixation: how much of a problem? J Orthop Trauma 2003;17:503-7. [8] Hedin H, Hjorth K, Rehnberg L, et al. External fixation of displaced femoral shaft fractures in children: a consecutive study of 98 fractures. J Orthop Trauma 2003;17:250-6. [9] Hosny GA. Unilateral humeral lengthening in children and adolescents. J Pediatr Orthop B 2005;14:439-43. [10] Patterson MM. Multicenter pin care study. Orthop Nurs 2005;24: 349-60. [11] Mason WT, Khan SN, James CL, et al. Complications of temporary and definitive external fixation of pelvic ring injuries. Injury 2005;36:599-604. [12] Checketts RG. Pin tract infection and the principles of pin site care. In: DeBastiani A, GrahamApley A, Goldberg DE, editors. Orthofix external fixation in trauma and orthopaedics. Berlin: Springer; 2000. p. 97-103. [13] Saleh M, Scott BW. Pitfalls and complications in leg lengthening: the Sheffield experience. Sem Orthop 1992;7:207-22. [14] Ward P. Care of skeletal pins: a literature review. Nurs Stand 1998;12: 34-8. [15] Collinge CA, Goll G, Seligson D, et al. Pin tract infections: silver vs uncoated pins. Orthopedics 1994;17:445-8. [16] Mason WT, Khan SN, James CL, et al. Complications of temporary and definitive external fixation of pelvic ring injuries. Injury 2005; 36:599-604.
1587 [17] Campbell AA, Song L, Li XS, et al. Development, characterization, and anti-microbial efficacy of hydroxyapatite-chlorhexidine coatings produced by surface-induced mineralization. J Biomed Mater Res 2000;53:400-7. [18] Moroni A, Pegreffi F, Cadossi M, et al. Hydroxyapatite-coated external fixation pins. Expert Rev Med Devices 2005;2:465-71. [19] Aro HT, Markel MD, Chao EY. Cortical bone reactions at the interface of external fixation half-pins under different loading conditions. J Trauma 1993;35:776-85. [20] Dahl W-A, Toksvig-Larsen S, Lindstrand A. No difference between daily and weekly pin site care: a randomized study of 50 patients with external fixation. Acta Orthop Scand 2003;74:704-8. [21] Davies R, Holt N, Nayagam S. The care of pin sites with external fixation. J Bone Joint Surg Br 2005;87:716-9. [22] Gordon JE, Kelly-Hahn J, Carpenter CJ, et al. Pin site care during external fixation in children: results of a nihilistic approach. J Pediatr Orthop 2000;20:163-5. [23] Nigam V, Jaiswal A, Dhaon BK. Local antibiotics: panacea for long term skeletal traction. Injury 2005;36:199-202. [24] Temple J, Santy J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Rev 2004;1:CD004551. [25] Holmes SB, Brown SJ. Pin Site Care Expert Panel. Skeletal pin site care: National Association of Orthopaedic Nurses guidelines for orthopaedic nursing. Orthop Nurs 2005;24:99-107.
www.elsevier.com/locate/jpedsurg
Pin tract infection with external fixation of pediatric fractures Johannes Schalamon a,* , Thomas Petnehazy a , Herwig Ainoedhofer a , Ernst B. Zwick b , Georg Singer a , Michael E. Hoellwarth a a b
Department of Pediatric Surgery, Medical University of Graz, Graz 8036, Austria Department of Pediatric Orthopedics, Medical University of Graz, Graz 8036, Austria
Index words: Pin infection; Pin site care; External fixation
Abstract Background: This study aimed to evaluate the incidence and severity of pin tract infections in a series of pediatric trauma patients. Methods: All pediatric trauma patients with external fixation who were treated at our institution between 1998 and 2003 were included. The charts of 30 children (20 males; 10 females; mean age, 13.2 years; range, 7-19 years) with 37 episodes of external fixation were reviewed. The average duration of external fixation was 17.5 weeks (range, 1-94 weeks). Pin tract infections were graded using the Dahl classification. Bacterial cultures were obtained in case of drainage from the pin site. Results: In 18 (48%) of 37 external fixations, no signs of infection occurred during the treatment period. In the remaining 19 (52%) external fixations, 35 episodes of infection were documented. Most infections were mild or moderate, whereas only 3 (9%) severe deep infections were noted (grade 5). Six (17%) infections healed with local application of rifamycin, whereas 27 (77%) of 35 infections were successfully treated with systemic antibiotics (cefuroxime, clindamycin). The remaining 2 infections (6%) required removal of a pin. Conclusions: Pin tract infection occurred in half of the patients who were treated with external fixations. Most of the pin site infections in the present series were mild and could be managed by local or systemic application of antibiotics. The occurrence of pin tract infections did not require a change of the method of stabilization. © 2007 Elsevier Inc. All rights reserved.
External fixation is a method of bone stabilization, where pins or wires are inserted into the bone through small skin incisions and are held together with an externally applied metal or carbon fiber frame. External fixators are commonly used for fracture stabilization in trauma patients as well as in orthopedic interventions for
* Corresponding author. E-mail address: [email protected] (J. Schalamon). 0022-3468/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.04.022
limb lengthening and reconstructive surgery. Although intramedullary nails gained increased acceptance for fracture treatment in diaphyseal fractures, stabilization with external fixators is widely used in patients with comminuted fractures, open fractures, and metaphyseal fractures [1]. Pin tract infection is a well-recognized problem in patients with external fixation. Infection rates of up to 100% were reported [2,3]. The aim of the present study was to analyze the incidence of pin tract infections in a series of pediatric trauma patients.
Pin tract infection with external fixation
1. Patients and methods We included all pediatric trauma patients younger than 19 years who were treated in a 6-year period from 1998 to 2003 with external fixation. Patients' charts were reviewed to gain information about the personal history, circumstances of the accident, clinical course, and complications related to the external fixation. Radiographic analysis was performed to identify possible malalignment and radiologic signs of bone infection. Pin tract infections were graded using the Dahl classification [2]. Bacterial cultures were obtained in case of drainage from the pin site.
1.1. Treatment strategy After initial inpatient treatment for fracture stabilization or correction of posttraumatic deformities, the children and adolescents were followed up weekly until removal of the external fixator. Pin site care was performed daily by patients or parents and at weekly follow-up by the medical staff. Pins were cleansed with saline, hydrogen peroxide, povidone iodine, or octenidine dihydrochloride depending on the surgeon's preferences. Crusts formed at the pin entry point were removed, even if there was no local sign of infection. Six months after pin removal, the patients were revisited to assess possible problems with a late onset.
2. Results Thirty children and adolescents (20 males; 10 females; mean age, 13.2 years; range, 7-19 years) with 37 episodes of external fixation were included. Twenty-three episodes of external fixation were caused by acute trauma. The children were mainly victims of traffic accidents (n = 11) or winter sport accidents (n = 9); less frequent were falls from a height of more than 1 m (n = 3). In 14 children, the external fixator was used for correction of a posttraumatic deformity. Overall, there were 28 lower extremity fixators (11 femur, 17 tibia), 5 devices to stabilize upper extremity fractures (humerus), and 4 fixators to treat pelvic ring injuries. More than 1 episode of external fixation were documented in 5 patients (3 patients with 2 episodes, 2 patients with 3 episodes). Thirty-four fixators were unilateral, whereas 3 children underwent a correction of a posttraumatic malunion using an Ilizarov ring fixator. The average duration of external fixation was 17.5 weeks (range, 1-94 weeks). In 18 of 37 external fixations (48%), no signs of infection occurred during the treatment period. In the remaining 19 (52%) external fixations, 35 episodes of infection were documented. These infections occurred after a 12-week period on average (range, 2-52 weeks). A total of 14 (40%) infections were classified as mild (grade 2), 12 (34%) as grade 3, and 6 as grade 4 (17%); only 3 (9%) severe deep infections were noted (grade 5). A total of 12 infections
1585 (34%) were related to the proximal pins, whereas in 23 cases (66%) a distal pin was affected. There was no difference in the frequency of pin infection between fixators used in acute trauma and those used for correction of a posttraumatic deformity. In all children with infections of grades 3 to 5, a bacterial culture was obtained. In 14 (78%) of 18 samples, a distinct bacterial species could be cultured. Staphylococcus aureus was found in most of the pin tract infections (Table 1). From 35 infections, 6 (17%) healed with local application of rifamycin, whereas 27 (77%) of 35 infections were successfully treated with systemic antibiotics (cefuroxime, clindamycin). The remaining 2 infections (6%) required removal and repositioning of a pin. Thus, none of the pin tract infections required a change in the method of stabilization.
3. Discussion A pin tract infection is generally diagnosed when local signs of infection occur. For this series, the incidence of pin infections is approximately 50% (Table 2) and represents the most frequent complication related to external fixation. Classifications of pin infections are commonly based on the degree of infection [2,12]. In contrast, Saleh and Scott [13] based their classification on the response to treatment. Ward [14] simplified the classification by categorizing pin tract infections in minor (“antibiotics can easily treat these”) and major types (“necessitate removal of one or more of the pins or the entire fixator before any infection may be resolved”). A standardized classification system is not established yet, but it would facilitate the comparison of study data. Thus, it is difficult to distinguish between the physiologic reactions of the surrounding skin in a normal healing process when compared to the signs of an initial pin site infection as a consequence of colonization. Several factors may influence the occurrence of a pin tract infection. Skin tension around the pins should be avoided to prevent necrosis of the surrounding tissue; furthermore, a correlation between loose pins and infection has been described [15,16]. Mahan et al [4] showed that most pins possess bacterial colonization, but loose pins correlated for infection with virulent species of bacteria at a highly significant level. Other authors have reported that pincoating materials such as silver or hydroxyapatite/ Table 1
Cultured bacteria from pin site (n = 18)
Bacteria
n (%)
S aureus Staphylococcus epidermidis Streptococcus viridans Nocardia No culture
6 (33) 4 (22) 3 (17) 1 (1) 4 (22)
1586 Table 2
J. Schalamon et al. Infection rates: overview of the literature
Author
Publication Patients (n) Infection date rate (%)
Mahan et al [4] Dahl et al [2] Gregory et al [5] Ahlborg and Josefsson [6] Parameswaran et al [7] Hedin et al [8] Hosny [9] Patterson [10] Mason et al [11] Schalamon et al
1991 1994 1996 1999 2003 2003 2005 2005 2005 2006
42 110 27 314 285 98 18 92 52 30
42 100 56 21 11 37 100 34 50 52
chlorhexidine enhance pin fixation, minimize bacterial colonization, and result in decreased pin infections [15,17,18]. High dynamic stress may also contribute to pin loosening by local bone yielding as a consequence of micromotion [19]. This is a preventable problem; the load of a single pin should be minimized by appropriate frame fixation and a sufficient number of pins proximal and distal to the fracture site. We could not identify loose pins in our study population except in 2 of those 3 patients with severe deep infections. The insufficient stability of the affected pin was the indication for pin removal in the 2 patients. We assume that loose pins are secondary to infections rather than their primary cause. Another factor that is supposed to influence the occurrence of infections is the pin site care. Several authors discussed different strategies. Whereas Dahl et al [20] found no difference between daily and weekly pin site care, Davies et al [21] had a favorable outcome in a group of patients with weekly pin site care and the local application of alcoholic antiseptic and occlusive pressure dressings compared with a group with daily pin site care. Gordon et al [22] presented a successful “nihilistic approach” with daily showers without physical pin cleansing. Nigam et al [23] performed a prospective survey comparing a group of patients with antibiotic injections at the site of pin insertion with a group of control subjects and found a significant decrease in pin tract infections (3% vs 30%). This seems to be a promising approach; although standard pin site care is limited to cleaning of the pins at skin level and above, Nigam et al showed the benefit of clean pins at tissue level. Still it remains to be clarified whether the effect of the local injection of an antibiotic solution is superior to the injection of antiseptics such as hydrogen peroxide, povidone iodine, or octenidine dihydrochloride. We assume that the benefit is mainly based on the way of application, not on the antibiotic agent itself. Finally, dressings are supposed to reduce movement around the pins and may thereby help in preventing infections by increasing stability [14]. Nevertheless, a systematic review by Temple and Santy [24] indicated a complete lack of evidence for any particular strategy of pin site care. This fact was further underlined by Holmes,
Brown, and the Pin Site Care Expert Panel [25], who stated: “Whether pin site care reduces infections is unknown.” We assume that regular follow-ups of the pin site will probably not prevent infection from spreading; however, it helps in the early recognition of this entity. In our study, the pin tract infections occurred in a mean of 12 weeks after beginning of treatment with external fixation despite continuous pin site care and weekly follow-up in an outpatient department. Pins may get loose and patients may neglect pin site care with time. After a skin tract infection has been diagnosed, the treatment options are local application of antibiotics, the use of oral antibiotics, treatment with intravenous antibiotics, and the removal of the infected pin. Although these are the general recommendations, Gregory et al [5] were successful in treating pin infections with oral antibiotics, and only 1 patient required frame removal because of persistence of the infection. In view of the fact that infections may be controlled by oral antibiotics and infection is the most frequent complication of external fixation, an oral antibiotic prophylaxis should be considered. However, the effect of prophylactic administration of oral antibiotics has not been evaluated yet. We presume that a conclusive prospective study should be performed to evaluate the efficacy of oral prophylactic antibiotics in prevention of pin site infections.
4. Conclusion Pin tract infection occurred in half of the patients who were treated with external fixation devices. Most of the pin site infections in the present series were mild and could be managed by local or systemic application of antibiotics. The occurrence of pin tract infections did not require a change of the method of stabilization. Nevertheless, the significant rate of pin site infections, the successful antibiotic treatment, and the limited period of external fixation may justify the administration of oral prophylactic antibiotics while carrying a device for external bone fixation.
References [1] Beaty JH. Operative treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 2005;434:114-22. [2] Dahl MT, Gulli B, Berg T. Complications of limb lengthening. A learning curve. Clin Orthop Relat Res 1994;301:10-8. [3] Green SA. Complications of external skeletal fixation. Clin Orthop Relat Res 1983;180:109-16. [4] Mahan J, Seligson D, Henry SL, et al. Factors in pin tract infections. Orthopedics 1991;14:305-8. [5] Gregory P, Pevny T, Teague D. Early complications with external fixation of pediatric femoral shaft fractures. J Orthop Trauma 1996;10: 191-8. [6] Ahlborg HG, Josefsson PO. Pin-tract complications in external fixation of fractures of the distal radius. Acta Orthop Scand 1999;70: 116-8.
Pin tract infection with external fixation [7] Parameswaran AD, Roberts CS, Seligson D, et al. Pin tract infection with contemporary external fixation: how much of a problem? J Orthop Trauma 2003;17:503-7. [8] Hedin H, Hjorth K, Rehnberg L, et al. External fixation of displaced femoral shaft fractures in children: a consecutive study of 98 fractures. J Orthop Trauma 2003;17:250-6. [9] Hosny GA. Unilateral humeral lengthening in children and adolescents. J Pediatr Orthop B 2005;14:439-43. [10] Patterson MM. Multicenter pin care study. Orthop Nurs 2005;24: 349-60. [11] Mason WT, Khan SN, James CL, et al. Complications of temporary and definitive external fixation of pelvic ring injuries. Injury 2005;36:599-604. [12] Checketts RG. Pin tract infection and the principles of pin site care. In: DeBastiani A, GrahamApley A, Goldberg DE, editors. Orthofix external fixation in trauma and orthopaedics. Berlin: Springer; 2000. p. 97-103. [13] Saleh M, Scott BW. Pitfalls and complications in leg lengthening: the Sheffield experience. Sem Orthop 1992;7:207-22. [14] Ward P. Care of skeletal pins: a literature review. Nurs Stand 1998;12: 34-8. [15] Collinge CA, Goll G, Seligson D, et al. Pin tract infections: silver vs uncoated pins. Orthopedics 1994;17:445-8. [16] Mason WT, Khan SN, James CL, et al. Complications of temporary and definitive external fixation of pelvic ring injuries. Injury 2005; 36:599-604.
1587 [17] Campbell AA, Song L, Li XS, et al. Development, characterization, and anti-microbial efficacy of hydroxyapatite-chlorhexidine coatings produced by surface-induced mineralization. J Biomed Mater Res 2000;53:400-7. [18] Moroni A, Pegreffi F, Cadossi M, et al. Hydroxyapatite-coated external fixation pins. Expert Rev Med Devices 2005;2:465-71. [19] Aro HT, Markel MD, Chao EY. Cortical bone reactions at the interface of external fixation half-pins under different loading conditions. J Trauma 1993;35:776-85. [20] Dahl W-A, Toksvig-Larsen S, Lindstrand A. No difference between daily and weekly pin site care: a randomized study of 50 patients with external fixation. Acta Orthop Scand 2003;74:704-8. [21] Davies R, Holt N, Nayagam S. The care of pin sites with external fixation. J Bone Joint Surg Br 2005;87:716-9. [22] Gordon JE, Kelly-Hahn J, Carpenter CJ, et al. Pin site care during external fixation in children: results of a nihilistic approach. J Pediatr Orthop 2000;20:163-5. [23] Nigam V, Jaiswal A, Dhaon BK. Local antibiotics: panacea for long term skeletal traction. Injury 2005;36:199-202. [24] Temple J, Santy J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Rev 2004;1:CD004551. [25] Holmes SB, Brown SJ. Pin Site Care Expert Panel. Skeletal pin site care: National Association of Orthopaedic Nurses guidelines for orthopaedic nursing. Orthop Nurs 2005;24:99-107.