Pin Site Infection Research Articles

Circular external fixation for knee fusion in complex indications.

Reconstructive surgery for complex knee problems is limited and challenging. The aim of this study is to report the technique, outcomes and complications of circular external fixation for knee fusion in complex indications. Retrospective review of a prospectively collected database of a complex limb reconstruction unit was done during December 2022. Patients with complex knee problems who underwent knee fusion with circular external fixator were included. Fourteen patients met the inclusion criteria. The mean age of the patients was 63 ± 16.8years. Deep infection was the indication for surgery in 11 patients (78.5%), of which 10 cases were related to previously failed revision arthroplasty. The mean duration of treatment in frame was 13 ± 4.1months, while the mean follow-up duration following frame removal was 7.1 ± 4.2years. Fusion was achieved in 13 patients (92.9%). The most common complication was pin site infection (6; 42.9%), of which three (21.4%) required pin/wire revision. One (7.1%) patient had fracture at the fusion site following frame removal that was treated with reapplication of the frame. Knee fusion using circular external fixation is a reliable surgical option for complex knee problems especially in infected failed revision total knee replacements.

Hydrotherapy for Patients With External Fixation: Effect on Infectious Events

Surgery to achieve long bone lengthening and deformity correction in skeletally immature patients is traditionally performed through external fixators. The incidence of infection during treatment is high. Hydrotherapy is highly beneficial during external fixation management, but the infection rates may impact its utilization. The objective of this paper is to document the incidence and duration of infection in patients who participated in a full hydrotherapy program when performed under medical supervision and in accordance with strict follow-up protocols. In this retrospective study, we documented the key characteristics of patients who participated in hydrotherapy after lower limb external fixation surgery including age, sex, diagnosis and surgery site, the incidence and duration of pin site infections, and the percentage of cases, which were able to comply with a full hydrotherapy protocol. The hydrotherapy pool met all daily water quality metrics. Thirty-four children (19 males and 15 females) had a mean±SD age of 10.9±4.6 years. Of the cases, 80% were unilateral and 20% were bilateral. Diagnoses included congenital hereditary (eg, achondroplasia), congenital nonhereditary conditions (eg, fibular hemimelia), and acquired conditions (eg, traumatic). The location of osteotomy site was quite evenly spread between the femur and the tibia/fibula. Three out of the 34 patients were unable to receive hydrotherapy due to continuous secretions; 2 patients did not miss any sessions. The mean number of treatments was 3 per week. During the entire period, a total of 1200 treatments were performed for these patients with only 32 cancellations (about 3%) due to secretions or other signs of infection. Spearman correlation coefficients showed significantly high correlations between the duration of external fixation and the duration of hydrotherapy. There are no significant correlations between infections and other factors (sex, age segment, whether the problem is unilateral or /bilateral, diagnosis, and duration of treatment). This is the first report, to our knowledge, that documents the low prevalence of infectious events during hydrotherapy treatment and demonstrates its feasibility. Level III; retrospective, comparative study.

Clinical outcomes of bone transport using rail fixator in the treatment of femoral nonunion or bone defect caused by infection.

The rail fixator can improve the treatment outcome and provide good stability in patients with femoral bone transport. The purpose of this study is to investigate the clinical outcomes of bone transport using the Ilizarov technique by rail fixator in the treatment of femoral nonunion or bone defects caused by infection. Clinical feature and treatment outcomes of 32 consecutive adult patients with femoral nonunion or bone defect caused by infection from January 2012 to January 2019 at a minimum of 2 years of follow-ups were retrospectively analyzed. Data were collected on participants' demographic details. All difficulties related to bone transport were documented according to Paley's classification. The clinical outcomes were evaluated using ASAMI criteria at the last clinical visit. All 32 patients with an average follow-up of 33.5 months. There were 17 problems, 21 obstacles, and 8 complications, and the complication rate per patient was 1.4. The main complications were pin-site infection (53.1%), axial deviation (21.9%), joint stiffness (18.8%), the delayed union of the docking site (18.8%), soft tissue incarceration(15.6%), delayed consolidation(6.3%), malunion(6.3%), and refracture (3.1%). All the patients achieved bone union, and no recurrence of infection was observed. The excellent and good rates of ASAMI bone and functional results were 87.5% and 81.3%, respectively. Bone transport using the Ilizarov technique is an effective method for the treatment of femoral nonunion or bone defect caused by infection, and rail fixators have obtained satisfactory results in terms of bone and functional results.

Effectiveness of transverse tibial bone transport in treatment of diabetic foot ulcer: A systematic review and meta-analysis.

Diabetic foot ulcerations (DFUs) are a common but highly morbid complication of long-standing diabetes, carrying high rates of associated major amputation and mortality. Transverse tibial bone transport (TTT) has recently been applied for treatment of DFUs with the aim of accelerating wound healing. This study was performed to evaluate the effectiveness and safety of TTT in patients with DFUs. Two authors independently retrieved the platforms of PubMed, Embase and CENTRAL, to identify studies associated with treatment of DFUs with TTT. Quantitative meta-analyses were performed to pool all available outcomes about the effectiveness and complications of TTT operation, with fixed- (I2<50%) or random-effect (I2>50%) model according to I2. A total of 7 studies, involving 818 participants, were included, with 661 participants treated with TTT operation. The pooled healing rate and limb salvage rate were 0.96 (95%CI: 0.93~0.98) and 0.98 (95%CI: 0.95~1.00) respectively after treatment with TTT. The pooled mean healing time was 15.03 (95%CI: 9.05~21.00) months. When compared with the pre-operative baseline values, the ankle-brachial index (ABI, MD: 0.23; 95%CI: 0.03~0.44; p<0.001), skin temperature (MD: 1.56; 95%CI: 0.30~2.81; p<0.001), and visual analogue scale (VAS, MD: 3.70; 95%CI: 1.97~5.44; p<0.001) were significantly improved at the final follow-up. When compared with non-TTT group, the TTT group was associated with higher healing rate (OR: 10.43; 95%CI: 3.96~27.43; p<0.001) and limb salvage rate (OR: 9.65; 95%CI: 3.30~28.20; p<0.001). Concerning the complications of the TTT process, the pooled risks of fracture at transportation site and pin-site infection were 0.02 (95%CI: 0.00~0.04) and 0.08 (95%CI: 0.00~0.22), respectively; and the DFU recurrence rate in TTT group was significantly lowered comparing to that of the non-TTT group (RR: 0.18; 95%CI: 0.06~0.49; p=0.001). TTT operation was associated with high healing rate and limb salvage rate, and could significantly improve the ABI, skin temperature, and VAS after operation. When compared with the control group, TTT group provided significantly higher healing rate and limb salvage rate. However, TTT operation should be conducted with caution concerning the incidences of fracture at tibia, infection at pin channels and necrosis of skin overlying the anterior tibia.

Early results of intramedullary nail fixation in distal tibia oblique osteotomy for the reduction of soft tissue complications.

During distal tibial oblique osteotomy, external fixators can increase pin site infection risk, whereas plates can cause wound necrosis, necessitating a compromise between soft-tissue position and length. We provide the first report of the early results of intramedullary nail fixation in these osteotomies for avoiding soft tissue complications. Ten ankles, classed as Takakura-Tanaka stages 3a to 4 and unclassified and treated via distal tibial oblique osteotomy for ankle osteoarthritis between 2017 and 2021, were included. Osteotomy was performed obliquely from the distal medial tibia to the tibiofibular joint. The distal tibial fragment was rotated distally in the coronal plane for realignment. An intramedullary nail fixation was applied for stabilization. The resulting gap was filled with iliac bone graft. Ankles were evaluated on the Japanese Society for Surgery of the Foot ankle-Hindfoot Scale and Self-Administered Foot Evaluation Questionnaire before surgery and at final follow-up. Radiographic assessments were performed. Bone union was achieved within 3 months in all patients. There were no cases of wound necrosis or correction loss postsurgery. Japanese Society scale scores significantly improved from 40.3 ± 15.9 to 87.5 ± 12.6 (P < 0.01). Mean self-evaluation scale scores (pain and pain-related, physical functioning and daily living, social functioning, general health and well-being) improved significantly. shoe-related scores did not change significantly but improved. There was no correction loss after surgery, with an average widening of 24.2 mm and opening angle of 22.6° at the osteotomy site. Our study showed that intramedullary nail for fixation of the osteotomy site in distal tibial oblique osteotomy effectively prevents soft tissues complications even in osteotomy sites with large openings.

Hexapod Circular Frame Fixation for Tibial Non-union: A Systematic Review of Clinical and Radiological Outcomes.

Tibial non-unions present with complex deformities, bone loss, infection, leg length discrepancy (LLD), and other features which influence function. Circular frame-based treatment is popular with the hexapod system used increasingly. This systematic review aims to determine the clinical and radiological outcomes of hexapod fixation when used for tibial non-unions. The review was performed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The search strategy was applied to MEDLINE and Embase databases on 15 December 2021. Studies reporting either clinical or radiological outcomes following hexapod fixation on tibial non-unions were included. Primary outcomes were radiological union and patient-reported outcome measures (PROMs). Secondary outcomes included LLD, tibial alignment deformity (TAD), return to pre-injury activity and post-operative complications. After the abstract and full-text screening, 9 studies were included; there were 283 hexapod frame fixations for tibial non-unions. Infection (46.6%) and stiff hypertrophic non-union (39.2%) accounted for most non-unions treated. The average age and mean follow-up were 42.2 years and 33.1 months, respectively. The average time to union was 8.7 months with a union rate of 84.8%. A total of 90.3% of patients had TAD below 5° in all planes, with an LLD ≤1.5 cm of the contralateral leg in 90.5%. Bony and functional results were at least good in over 90% of patients when using the Association for the Study of the Method of Ilizarov (ASAMI) criteria. A total of 84% of patients returned to pre-injury activities. There were complications as follows: a total of 34% developed pin-site infection, almost 9% experienced half-pin breakage and 14% developed an equinus ankle contracture. Hexapod frames for the treatment of tibial non-unions produce favourable functional outcomes. Complication rates are present and need to be discussed when this modality of treatment is proposed. Further comparative studies will allow for this option to be evaluated against that of the traditional Ilizarov frame and other methods of non-union surgery. Boksh K, Kanthasamy S, Divall P, et al. Hexapod Circular Frame Fixation for Tibial Non-union: A Systematic Review of Clinical and Radiological Outcomes. Strategies Trauma Limb Reconstr 2022;17(3):172-183.

Anterior superior iliac spine distraction for severe and recalcitrant diabetic foot ulcers

PurposeThe study aimed to introduce anterior superior iliac spine distraction to treat severe and recalcitrant diabetic foot ulcers. For comparison, we also included another group of diabetic foot ulcers treated with proximal tibial cortex transverse distraction. MethodsFrom February 1998 to February 2020, 87 patients (87 feet) with severe and recalcitrant diabetic foot ulcers were treated. The mean age of patients at surgery was 64 years (range, 47 to 87 years). The severity of the narrowed artery was assessed using the ankle-brachial index test. For comparison, another group of 91 patients (91 diabetic foot ulcers) treated with proximal tibial cortex transverse distraction was included. ResultsThe mean preoperative ankle-brachial indexes of the two groups were 0.41±0.07 and 0.39±0.05 (OR 0.65 [95% CI -0.77 to 1.58]; P=0.62), respectively. The mean preoperative limb pain was 3.42±2.84 cm and 3.52±3.11 cm (OR 1.54 [95% CI -077 to 1.35]; P=0.083), respectively. At the 2-year follow-up visit, ulcers healed in 72 (83%) and 74 (81%) patients, respectively (P=0.188). The mean postoperative limb pain was 0.52±0.23 cm and 0.49±0.41 cm (OR 2.32 [95% CI -0.27 to 1.66]; P=0.078), respectively. Pin-site infection occurred in 2 patients and 8 patients (P=0.09), respectively. Ulcer recurrence occurred in 13 (15%) patients and 15 (16%) patients (P=0.205), respectively. ConclusionsAnterior superior iliac spine transverse distraction may be an effective alternative treatment for severe and recalcitrant diabetic foot ulcers. It may be associated with fewer distraction-site complications than proximal tibial cortex transverse distraction. Level of evidenceTherapeutic study, Level IIa.

Impacts of Circular Frame Fixator (Ilizarov) on Management of Compound fractures of proximal tibia

Aim: To determine the outcome of patients diagnosed with complex fractures of tibial plateau with associated soft tissue compromise treated by using Ilizarov fixator. Study design: Prospective observational study. Place and period of study: Orthopaedic unit, Chandka Medical College SMBBMU Larkana from January 2021 to December 2021 Methods: Patients diagnosed with complex tibial plateau fracture with associated soft tissue compromise fulfilling inclusion criteria were enrolled in study. All participants were managed with Ilizarov fixator and it was removed when fracture was united clinically and radiologically. Outcome of patients was evaluated on the basis aggregate score of knee society score and knee functional score at 6month follow up. Results: Twenty seven consecutive patients met the inclusion criteria, of which 19(70.37%) were male and 8(29.7%) were female. Average age of patients was 32.37 years. All fractures healed by the end of the 4th month. Ring fixator was removed routinely at 16th weeks after initial surgery in all patients. Transient peroneal nerve injury was found in 2 patients; no patients developed deep vein thrombosis, whereas pin site infection was most common complication and occurred in 5 patients (18.5%). According to knee society score results were excellent in 15(55.55%) patients, good in 08(29.62%) patients, fair in 03(11.11%) in patients and poor in 01(3.70%) patient. Practical implication most of proximal tibial plateau fractures with soft tissue compromise are kept under observation till the soft tissue status become favorable for open reduction and internal fixation, while fixing these type of fracture with Ilizarov fixator one can provide early relief to patients and results of this study will be help for operating surgeons while managing complex proximal tibia fractures. Conclusion: complex tibial plateau fracture can be effectively treated with Ilizarov fixation method without any complication, when exposed reduction and interior fixation with plate is contraindicated due to compromised soft tissue. Keywords: Tibial plateau, fractures, Ilizarov, fixation method, outcome, soft tissue compromise,

Resorbable magnesium screws for fixation of medial epicondyle avulsion fractures in skeletally immature patients: A comparison with Kirschner wires.

Displaced medial epicondyle fractures are treated with open reduction and internal fixation with K-wires or screws. Rates of implant prominence, failure, or non-union reported are considerable. Magnesium screws have demonstrated biocompatibility, osteoconductivity, and high pull-out strength. The aim of this study was to compare surgical fixation of medial epicondyle fracture using resorbable magnesium Herbert screws to K-wires, in skeletally immature patients. A retrospective analysis was performed from January 2015 to April 2020. Inclusion criteria were as follows displaced medial epicondyle fracture, <15 years, and absence of concomitant ipsilateral upper limb fractures. Two consecutive cohorts based on fixation device were made: Group A (wires) and Group B (magnesium screws). Alignment, pain, range of motion, Mayo Elbow Performance Score, and radiological healing were assessed. A total of 27 patients were included: 15 in Group A and 12 in Group B. Groups were comparable for age and sex. Mean follow-up was higher in Group A (38.73 ± 3.15 vs 26.18 ± 4.85 months; p < 0.001). No significant differences were observed regarding range of motion, alignment, pain, and Mayo Elbow Performance Score, with excellent results in both groups. Two patients in Group A developed a deep wound pin site infection requiring antibiotics. X-rays revealed three cases of non-union in Group A and one in Group B, all of them asymptomatic. No patient required a second surgical procedure. Open reduction and internal fixation of medial epicondyle fractures with magnesium screws showed comparable results to a widely accepted procedure such as the use of K-wires, potentially with a lower incidence of non-union and infection. No adverse reactions were recorded. level III.

Comparison of Pin Site Infection Rate between Schanz Screws and K-Wires in Ilizarov Fixator for Tibial Fracture

Objective: Comparison of pin site infection rate between schanz screws and k-wires in ilizarov fixator for tibial fracture Methodology: It was a randomized control trial, conducted at department of Orthopedics, Khyber Teaching Hospital, MTI, and Peshawar from July 2021 to June 2022. Sampling Technique was Non-probability consecutive sampling. Patients were divided into two groups using computer generated random sequence number. Patients in group A were stabilized using K-wires and patients in group B were stabilized using k-wire and schanz screws. Data were entered in specially designed proforma. Result: Mean age in group A patients was 35±2.77 years, while in group B it was 38±3.12 years. Gender distribution between two groups was analyzed. In Group A 72.3% were males and 27.7 % females while in Group B patients, 70% were males and 30% were females. Mean duration from injury to surgery was 5 days with SD±2.12 in group A, while 5.5±2.37 days in Group B. Analysis of PSI among both groups shows that Group B, in whom Schanz pins technique was used, had significantly high rates of pin site infection (24.1%) compared to group A (9.6%) in whom K-wires technique was used (p 0.012). Conclusion: Our study concludes that the frequency of pin site infection is significantly less in Ilizarov fixator using K-wires (9.6%) as compared to Ilizarov fixator using Schanz pins(24.1%).

Functional And Radiological Outcome of Schatzker Type V and VI Tibial Plateau Fracture Treated with Closed Reduction and Ilizarov Fixation with or without Minimally Invasive Screw Supplementation

Introduction: Controversy exists as to the best treatment approach for high-velocity tibial plateau fractures. This study was done to assess the functional and radiological outcome of Schatzker type V and VI tibial plateau fractures treated with closed reduction and Ilizarov ring fixation with or without cancellous screw supplementation. Methods: An analytical cross sectional study was conducted among 25 cases of both closed and open Schatzker type V and VI tibial plateau fractures treated with closed reduction and Ilizarov ring fixation with or without minimally invasive cannulated cancellous screw supplementation. The outcome variables analyzed were union time, knee range of motion, American Knee Society Score (AKSS), Rasmussen’s Radiological Score (RRS), and complications. Data analysis was done using SPSS-20. P-value &lt;0.05 was considered as statistically significant. Results: There were 15 type V fractures, 10 type VI fractures, 21 closed fractures, and 4 open fractures. All the fractures united with a mean union time of 15.88 weeks (range 12-24). The mean American Knee Society score was 77.8 (range 68-95), Rasmussen’s radiological Score (RRS) 15.12 (range 10-18), and mean range of motion was 112.40 (range 90-135). Superficial pin site infection was present in 7 (28%) of the cases. There was no case of nonunion, deep infection, repeat surgery other than implant removal, or nerve palsy. Conclusions: Closed reduction and Ilizarov ring fixation with or without minimally invasive screw supplementation give rise to good to excellent functional and radiological outcomes in most of the cases in the treatment of Schatzker type V and VI tibial plateau fractures with minimal bone or soft tissue related complications.

Distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children.

The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children. In this study, there were 59 consecutive tibial lengthening and deformity corrections in 57 children using a circular frame. All were performed or supervised by the senior author between January 2013 and June 2019. A total of 25 who underwent a distal tibial osteotomy were analyzed and compared to a group of 34 who had a standard proximal tibial osteotomy. For each patient, the primary diagnosis, time in frame, complications, and lengthening achieved were recorded. From these data, the frame index was calculated (days/cm) and analyzed. All patients ended their treatment with successful lengthening and deformity correction. The frame index for proximal versus distal osteotomies showed no significant difference, with a mean 48.5 days/cm (30 to 85) and 48.9 days/cm (28 to 81), respectively (p = 0.896). In the proximal osteotomy group, two patients suffered complications (one refracture after frame removal and one failure of regenerate maturation with subsequent valgus deformity) compared to zero in the distal osteotomy group. Two patients in each group sustained obstacles that required intervention (one necessitated guided growth, one fibula lengthening, and two required change of wires). There was a similar number of problems (pin-site infections) in each group. Our data show that distal tibial osteotomies can be safely employed in limb lengthening for children using a circular frame, which has implications in planning a surgical strategy; for example, when treating a tibia with shortening and distal deformity, a second osteotomy for proximal lengthening is not required.Cite this article: Bone Joint J2022;104-B(11):1273-1278.

Multifocal percutaneous pin fixation of talar neck fractures: An alternative to ORIF in the polytraumatized patient

PurposeUnique anatomy, precise articulations, fragile vascularity, and the demand for anatomic reduction make talar neck fractures challenging to treat, whether with screws and/or plates. Multifocal percutaneous pin fixation (MPPF) offers an alternative to ORIF, particularly in the polytraumatized patient. MethodsUnless an open lateral wound or medial malleolus fracture was present, a standard anteromedial approach was performed. K-wires placed within the talar head were used as joysticks to facilitate and finalize reduction. At least 3 wires were placed medially and 2 laterally across the talar neck. Incisions were closed in 2 layers, and either a well-padded short leg splint or adjunctive ankle-spanning external fixation was utilized. Patients remained non-weightbearing until K-wire removal in the office at approximately 6–8 weeks postoperatively. ResultsMPPF was performed in 7 patients, the majority of whom were female (6 of 7). The average patient age at the time of injury was 30.3 years (range 17–51 years). The median time of final follow up was 27 months. Comminution was present in all patients. Avascular necrosis (AVN) developed in 3 patients and non-union occurred in 2 patients. All patients developed subtalar posttraumatic arthritis, and 6 additionally developed tibiotalar arthritis. No patients underwent talectomy or osteotomy, and there were no superficial pin site infections or loosening of pins prior to scheduled removal. ConclusionsObtaining and maintaining an adequate reduction is possible with minimal soft tissue compromise through MPPF. Despite the complexity of the series, outcomes utilizing MPPF are comparable to those reported in the literature.

Current Classifications of Pin Site Infection and Quality of Reporting

Introduction: Pin site infection is a commonly encountered complication. There is no universally accepted definition or classification system which impairs data interpretation and the development of evidence-based practice. The aim of this systematic review is to investigate the existing classification systems and the quality of reporting pin site infections in the current literature. Materials and Methods: The systematic review protocol was prospectively registered (PROSPERO; National Institute for Health Research and University of York, 2015) and conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A comprehensive search strategy was executed. Data were extracted pertaining to clinical, radiological, microbiological, and mechanical elements alongside associated grading and demographics. The scope of the classification systems was considered. Results: Twelve reports of classifications were included in the synthesis. Four classifications provide information for guiding decision-making and management while the remainder are descriptive or informative in nature. There is no classification with prognostic inference. Four of the classifications can only be applied retrospectively as they are outcome derived. Staging relies on a single variable in six of the classifications. It relies on multiple variables (maximum of four) in the remainder. Conclusion: There is a lack of a clear definition of pin site infection and a lack of a universally accepted grading system. Existing classifications focus on different aspects and have a number of limitations. Establishing standard reporting guidelines will allow for future development of a meaningful and universally accepted definition and classification.

Future Directions in the Prevention of Pin-Site Infection

Context:Pin-site infections are a common complication associated with the use of external fixators. While many different pin-site care protocols have been described, there is no universally accepted and effective method to eliminate this issue. Further research in this area is necessary.Aims:This scoping review evaluates published research dedicated to investigating potential new methods of pin-site infection prevention.Settings and Design:A scoping review was performed with a structured search of MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (EBSCO platform), Scopus, Web of Science, and the Cochrane Library using a range of terms related to pin-site infection.Methods:A qualified librarian carried out the search between February 7, 2021, and September 7, 2021. Studies involving human and animal experiments as well asin vivoandin vitroexperiments that evaluated modifications to the pin–skin and bone–pin interface, as well as pin surface morphology, were included. Studies based on the type of intervention and the reported outcomes of infection prevention were evaluated.Results:Four thousand six hundred and twenty-two studies using this search strategy were identified. Following screening and full-text review, 33 studies fit the criteria and were included in this review. Thirty studies involved research that evaluated integration at the bone–pin interface and three studies assessed the pin–skin interface.Conclusions:The review identified a very diverse group of modalities. The majority of the research focused on coating with compounds that possess antibacterial properties or modifications to surface morphology to improve the integration of the pin or wire at the bone–pin interface. While most of the researches did not involve human trials, this review highlights the future directions of pin- and wire-site management in an effort to eliminate or minimize the risk of pin-site infections.

The Influence of Pin Material and Coatings on the Incidence of Pin Site Infection after External Fixation

Introduction: External fixation is used for a wide variety of surgical treatments. The transcutaneous pins used in external fixation, however, provide a route for bacterial migration from the external to subcutaneous space, and high rates of pin site infection have been reported. The material of which the pin is composed, or any surface coating that is applied, may significantly influence tissue integration and pin site infection. However, clinical data are scarce. The aim of this systematic review and meta-analysis was to summarize the clinical evidence for the role of pin material, and surface coatings, on the incidence of infection at external fixator pin sites. Materials and Methods: A systematic review was performed following registration with PROSPERO. A search was performed using Medline, Embase, and Cochrane. Inclusion criteria were (1) recorded diagnosis of infection, (2) involved external fixation, (3) any bone, (4) English language, (5) human subjects, (5) pin material known, and (6) all levels of evidence. All stages of the review process were performed by two independent reviewers. A meta-analysis was performed using a random effects model meta-analysis to produce odds ratios. Study bias was assessed using the Cochrane risk of bias tool Rob II. Strength of evidence was based on the American Academy of Orthopaedic Surgeons methodology for defining the strength of recommendation. Results: After exclusion, 8 studies were further analyzed. One study compared stainless steel and titanium with an odds ratio of 1.00 (95% confidence interval [CI]: −0.70–2.70). Three studies compared stainless steel to hydroxyapatite (HA)-coated pins with an odds ratio of 0.25 (95% CI: −0.52–1.02). Two studies analyzed titanium compared to HA-coated pins with an odds ratio of 1.12 (95% CI: −4.25–6.48). Two studies analyzed silver compared to stainless steel with an odds ratio of 0.12 (95% CI: −0.89–1.12). However, the strength of evidence was limited for all studies. Overall, 0 studies had a low risk of bias, 4 studies had an unknown risk of bias, and 4 studies had a high risk of bias. Conclusion: There is currently limited evidence of the effect of different pin material or coatings on the incidence of pin site infection, with the available studies showing contrasting results. Further high-quality and adequately powered studies are required to provide definitive guidance.

Effect of Frame and Fixation Factors on the Incidence of Pin Site Infections in Circular External Fixation of the Tibia

Introduction: Pin site infections (PSIs) are frequent complications encountered with the use of circular external fixators. PSIs range in severity, and the numerous factors have been suggested to affect the incidence. We aim to perform a systematic review of all comparative studies including circular external fixation applied to the tibia diaphysis in adult patients and to explore frame and fixation factors that may be associated with the development of PSI. Materials and Methods: We conduct a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess the available data with the specific focus on frame factors that might contribute to the development of PSI. A literature search of major electronic databases was conducted to identify journal articles. A scoping review process was adopted due to the expected broad variation of studies in our research topic using the PRISMA for Scoping Reviews guidelines. Results: The initial electronic database search produced 360 publications. After a review process, only four publications were retained for final analysis. Type of fixation pins and wires, frame fixation configurations, and reconstructive methods were compared in these studies. There are very few clinical studies comparing the different frame and fixation factors that can influence PSI rates in circular external fixation. The available studies reflect a significant degree of bias and confounding, representing a low level of evidence. Conclusion: Further research is needed, and with the present paucity of data, it is not possible to make any firm recommendations. Within the same frame construct, it appears that tensioned wires may carry a lower risk of PSI than half-pins.

Orthopedic complications after osteotomy in patients with classic bladder exstrophy and cloacal exstrophy: a comparative study

The addition of pelvic osteotomy to the armamentarium of tools for correction of classic bladder exstrophy (CBE) and cloacal exstrophy (CE) has undeniably served as one of the most effective advancements in improving the likelihood of successful primary bladder closure. Osteotomy-related complications have been studied and documented extensively in patients with CBE, yet evaluation remains limited in CE concordant with its relative rarity. To compare orthopedic complications in patients with CBE and CE who underwent primary bladder closure with osteotomy. A prospectively maintained, IRB-approved database of 1401 exstrophy-epispadias patients was reviewed for patients with CBE or CE after primary closure and pelvic osteotomy performed at a single institution from 1975 to 2021. Failed closure was defined as dehiscence, bladder prolapse, or vesicocutaneous fistula at any point. Surgery or anesthesia-related complications were captured within 6 weeks of osteotomy or closure. A total of 146 patients were included in the analysis with 109 and 37 patients with CBE and CE, respectively. Between the CBE and CE cohorts, there were significant differences in median age at primary closure (68 days [IQR 10-260] vs 597 [448-734]; p<0.001), diastasis width (4cm IQR [3.8-4.6] vs 6.1 [5.0-7.2]; p<0.001), osteotomy at time of closure (99.1% vs 75.7%; p<0.001), and utilization of external hip fixation (67.9% vs 89.2%; p=0.011). There was no significant difference by gender, osteotomy technique, or hip immobilization technique. Regarding exstrophy closure outcomes, there were 5 failures in the CBE group and 1 in the CE group (p=1.000). Complications were experienced in 38.5% and 56.8% of CBE and CE patients (p=0.054) with a significant difference in orthopedic complications (primarily consisting of superficial pin-site infections) between the cohorts (4.6% vs 16.2%, p=0.031). There was no significant difference in grade 3 or higher complications between cohorts (5.5% vs 13.5%, p=0.147). This was the first study comparing orthopedic complications after osteotomy between CBE and CE, providing valuable insight into which factors vary among cohorts and which are associated with increased complication rates. Despite availability of high case numbers for these rare disorders, the analysis continued to be limited sample size and missing data for retrospective analysis. While exstrophy closure success and overall complications rates are similar in patients with CBE and CE, patients with CE experience more superficial pin-site infections after pelvic osteotomy. External hip fixation may be associated with the increase in orthopedic complications, though further research is required to elucidate the underlying cause of these complications.

The outcome of displaced pediatric supracondylar fractures of the elbow treated with lateral three divergent K wires

Introduction: Supracondylar fracture of the humerus is the commonest elbow injury in children, treated with closed reduction and percutaneous fixation. Crossed K-wires fixation is more biomechanically stable than lateral K – wires only. Recent biomechanical studies have shown that 3 lateral divergent K—wire fixation is as stable as cross K-wire fixation. Furthermore, lateral divergent fixation is associated with a good clinical outcome. Methods: A descriptive cross-sectional study was conducted in the department of orthopedics at People’s General Hospital, Kathmandu between the period of January 2018 to December 2020. Medical records of 76 supracondylar fractures of humerus Gartland type III and IV were reviewed out of which 46 patients were included in the study after meeting the inclusion criteria. Radiological assessment was done to assess fracture union and stability. Flynn's grading system was used for functional outcomes. Results: The mean age was 7.3 years (range 4 – 13 years). The boys were 32 (70%) and girls were 14 (30%). The follow-up was 9.2 months (range 3 – 12 months). At the final follow-up, the mean range of elbow motion at final follow up was 0.86 ± 4.58° - 135.86 ± 4.078°, the mean arc of motion was 139.9 ± 6.2°, and the mean carrying angle was 13.63± 32.15°. No iatrogenic ulnar nerve injury was noted. Five patients (10.8%) had superficial pin site infection, managed with local dressings after pin removal. According to Flynn’s grading system, 41 patients (89.1%) achieved excellent results, and one patient had poor results. None of them had chronic discharge after the wire removal. Conclusion: Closed reduction and percutaneous 3 lateral divergent K – wire fixation for type III and IV supracondylar fracture of humerus in children provides a stable configuration with good functional outcomes and avoids iatrogenic ulnar nerve injury.

Distraction osteogenesis for treatment of iatrogenic shortening of the first ray

The purpose of this study is to present a surgical treatment option following iatrogenic shortened first ray pathology and report the postoperative outcomes. Retrospective analysis of two surgeon’s patients (N=5) who underwent gradual distraction osteogenesis following previously failed first ray surgery was conducted. Surgical outcomes were measured including time in the external fixator and amount of distraction achieved. Complications measured included neurovascular complications, non-union, mal-union, infections, mal-alignment, pain, wound dehiscence, stiffness and transfer metatarsalgia. The average time spent in an external fixator was 78.8 (34-108) days. Average distraction achieved was 12.2 (2-22) mm. Four of the 5 patients experienced at least one of the following postoperative complications: pin site infections, wound dehiscence, non-union and postoperative pain. This study suggests that distraction osteogenesis may be a feasible surgical treatment option for iatrogenic shortened first ray with the right patient selection, but needs further evaluation.