Superficial Pin Tract Infection Research Articles

Ilizarov Frame Fixation Without Bone Graft for Atrophic Humeral Shaft Nonunion: 28 Patients With a Minimum 2-Year Follow-Up

To evaluate the outcomes of patients with atrophic humeral shaft nonunion (HSNU) treated by Ilizarov frame fixation without the use of bone graft. A retrospective review of 28 consecutive patients treated in 1 center between 1996 and 2002. Tertiary referral center. We studied 28 consecutive patients: 12 male and 16 female. Of the patients, 21 had been previously operated (15 by internal fixation using compression plates, 3 by intramedullary nailing, and 3 by external fixation), and 9 of those 21 patients also had failed revision procedures; 7 patients had been treated nonoperatively from the time of injury to the time of the index procedure for HSNU. Mean age at the time of the index operation was 44 years (16-73 years). Removal of the previous fixation device, excision of fibrous tissue at the HSNU site, opening of the intramedullary canal, excision of avascular bony ends, and stabilization fixation and compression of the humerus with an Ilizarov circular frame (proximal semicircular ring) using smooth 1.8-mm K-wires. No bone graft was used. The mean postoperative follow-up was 76 months (24-174 months). Radiologic union using plain radiographs. Clinical and functional outcome using the Lammens system, which evaluates pain, range of shoulder and elbow movements (and their limitations), and humeral alignment and union. Patient subjective outcomes were assessed using a 4-point patient satisfaction questionnaire. Bony union was achieved in all 28 cases after a mean of 4.1 months (3.4-5.7 months). There were 6 superficial pin tract infections (which resolved with antibiotics) and 1 transient radial nerve palsy (which resolved at 2.5 months). One patient refractured his humeral shaft following a fall, but the fracture successfully united 5.7 months later after a further Ilizarov frame application. All patients had good or excellent functional outcomes and range of shoulder and elbow movements as rated by the Lammens scoring system. Ilizarov circular frame fixation without bone graft is a reliable method for the treatment of atrophic nonunion of the humerus, even after failed previous surgery.

Correction of deformities in children using the Taylor spatial frame

The Taylor spatial frame is a unique external fixator. Despite its growing popularity, few reports on its use have been published. We evaluated the effectiveness of the Taylor spatial frame in the treatment of various deformities in 31 children and adolescents. All but one patient were anatomically corrected. Complications included superficial pin tract infection (45%), three fractures of the femoral regenerate, transient peroneal palsy, and injury to the genicular artery. Despite many challenging problems, our results compared favorably with the results achieved by others. We believe that the Taylor spatial frame is a very capable and accurate fixator for the precise correction of complex deformities.

Role of Ilizarov External Fixator in the Management of Proximal/Distal Metadiaphyseal Pediatric Femur Fractures

Given the constraints of a short metaphyseal fragment and adjacent growth plates, there are limited options for operative fixation of metadiaphyseal fractures of the femur in children. This article outlines the surgical technique and reports early results of metadiaphyseal pediatric femur fractures treated with an Ilizarov external fixator by a single surgeon. Ten skeletally immature males with 5 proximal and 5 distal metadiaphyseal femur fractures underwent closed reduction and application of an Ilizarov external fixator. Time in the fixator averaged 138 (range, 104-180) days. At a mean follow-up of 26 months, there were no cases of loss of reduction, refracture, malalignment, leg length inequality, or loss of knee and hip mobility. Although superficial pin tract infections were common, no patient developed deep infection or required premature pin removal. One patient developed a transient foot drop after external fixation for a distal metadiaphyseal fracture, which recovered after revision of the pin construct. A low profile Ilizarov fixator can be effective in the management of certain metadiaphyseal pediatric femur fractures that may be difficult to manage by traditional methods.

Results of Tibial Rotational Osteotomy Without Concomitant Fibular Osteotomy in Children With Cerebral Palsy

A retrospective review was performed of 46 consecutive ambulatory children with cerebral palsy and tibial torsion who underwent 72 distal tibial derotational osteotomies without concomitant fibular osteotomy. The average amount of derotation measured at surgery was 21 +/- 5 degrees. The average change in thigh-foot angle at follow-up was 21 +/- 9 degrees. There were eight perioperative complications (11%): three delayed unions, three superficial wound dehiscences, one case of osteomyelitis, and one superficial pin tract infection. There were no incidences of malunion or nonunion. Preoperative and postoperative three-dimensional gait analysis data were used to determine the effect of distal tibial osteotomy on foot progression angle in seven subjects (11 limbs). Foot progression improved significantly. This study shows that distal tibial osteotomy alone (without concomitant fibular osteotomy) is an effective and safe procedure for correcting and maintaining correction of tibial torsion in patients with cerebral palsy.

The Incidence of Infection in Interlocking Intramedullary Nailing after Skeletal Traction of Distal Femur

Purpose: The insertion site of K-wire for skeletal traction is proximal part of tibia or distal part of femur. However, people prefer proximal tibia over distal femur due to lower risk of infection rate when change to interlocking IM nailing is needed. We evaluated the infection rate of interlocking IM nailing. Materials and Methods: Fourty-seven patients were included in this study who underwent interlocking IM nailing due to femur shaft fracture. Traction was applied at the distal femur in 19 cases and proximal tibia in 10 cases before interlocking IM nailing. No skeletal traction was applied to the remaining 18 cases. Thirty-eight patients were male and 9 were female. The average age at the time of surgery was 36.7 years old (range, 15~17 years). The average traction period was 9.5 days (range, 3~33 days) and the average followed-up period was 17.2 months. Results: In the distal femoral traction group, 8 cases of superficial pin tract infection developed, but no case of deep infection such as osteomyelitis occurred. In the proximal tibia traction group, 2 cases of superficial pin tract infection developed, but no case of deep infection occurred. In the group that received no skeletal traction before interlocking IM nailing, no case of infection developed. Conclusion: In femur shaft fracture, the distal femoral skeletal traction followed by interlocking IM nailing of femur, compared to proximal tibia skeletal traction, did not increase the risk of deep infection such as osteomyelitis.

Tibial lengthening over nails in children using modified Ender nails: preliminary results of a new treatment

Tibial lengthening over nails, using modified Ender nails, was performed in nine children whose mean age at surgery was 12.8 years. The prerequisite for using this technique was the absence of axial malalignment and an indication for tibial lengthening only. Lengthening was not performed in one case due to the development of a compartment syndrome after the tibial osteotomy. Breakage of one interlocking screw without loss of alignment or length was observed in one case. Superficial pin tract infections were observed in two cases. An average of 4.1 cm (range 3-4.5 cm) lengthening of the tibia was achieved in eight of the nine cases. The modified Ender nails used permitted locking at both ends after achieving the desired distraction and permitted early removal of the external fixator. The advantage of this technique is that it permits early removal of the fixator and thus decreases the incidence of fixator related problems and facilitates early rehabilitation.

Triple arthrodesis with an external rail fixator: A review of 8 cases

The results of 8 patients who underwent triple arthrodesis with a rail external fixator were reviewed retrospectively. The frame construct allowed immediate axial loading and unrestricted ankle joint mobilization. Assistive ambulatory equipment was not required postoperatively. Periodic adjustment to compression was performed weekly until evidence of radiographic consolidation. The mean duration of frame application was 11.5 weeks. Follow-up averaged 15.9 months. Fusion occurred in all joints. One superficial pin-tract infection developed that resolved with oral antibiotics. The results of this study indicate that the rail frame system provides a viable fixation alternative for triple arthrodesis and warrants further investigation.

The role of AO external fixation in proximal femoral osteotomies in the pediatric neuromuscular population

Internal fixation in proximal femoral osteotomies using traditional devices may be sub-optimal in children with neuromuscular disorders who have small or osteopenic bone. In this population, between 1988 and 2000, we performed 36 proximal femoral varus osteotomies in 28 patients. These were controlled by the AO external fixator. The average age at surgery was 7 years (range, 2-13 years). A mean varus correction of 34 degrees (range, 15-90 degrees) was obtained. Complications consisted of one superficial pin tract infection, one skin breakdown, and one non-union. Other than the non-union, all osteotomies were stable at the time of the fixator removal. The AO external fixator is an effective alternative in maintaining corrective proximal femoral osteotomies in children with fragile bones.

Management of shotgun-induced fractures of the humerus with Ilizarov external fixator

Our aim was to evaluate the clinical efficacy of Ilizarov external fixator used for the management of shotgun induced open humeral fractures with special emphasize on neurovascular sequelae. The authors retrospectively reviewed eleven shotgun induced open humeral fractures managed with emergent application of Ilizarov external fixator. No patient had associated neurovascular injury. All fractures were stabilized with Ilizarov external fixator immediately after meticulous debridement and irrigation under emergent conditions. With Ilizarov fixation technique complete bony union occurred in all patients within 14 to 44 weeks (average, 21 weeks) postoperatively. One patient required a second intervention in order to adjust the external fixator rings. Two patients required a rotational fasciocutaneous flap so as to handle the soft tissue coverage problem. Superficial pin tract infection was present in eight patients, however in none of the patients deep tissue infection or osteomyelitis has been observed. Good to excellent results were achieved in 10 patients with Ilizarov fixation technique according to the rating system proposed by Smith and Cooney. Emergent Ilizarov external fixation is a safe method of obtaining a functional limb in the management of shotgun induced open humeral fractures with severe soft tissue damage.

Derotational Osteotomy and External Fixation for Increased Femoral Anteversion

Purpose: To describe a method of femoral derotational osteotomy using an external fixator. Materials and Methods: A retrospective review was conducted of 6 patients with 12 femora treated by derotational osteotomy with a semicircular modified Ilizarov external fixator and Schanz screws. The mean follow-up period was 17 months (in the range 12-28 months). There were two boys and four girls of mean age 11 years (in the range 10 to 13 years). The deformities were all idiopathic and there was no combined disease. Mean preoperative femoral anteversion was 38 degrees (in the range 31-50 degrees) and mean internal and external hip rotation were 76 degrees (in the range 70-85 degrees) and 23 degrees (in the range 20-30 degrees), respectively. Results: After operation, the mean internal rotation at the hip diminished to 47 degrees (in the range 40-50 degrees) and the mean external rotation increased to 52 degrees (in the range 45-55 degrees). In all cases, the mean varus angle 6 degrees (3-9 degrees) was made with conical washers on the osteotomy site to correct combined genu valgum. Mean clutch ambulation was started at 5 days postoperatively. The Ilizarov external fixator was removed at a mean 9 weeks after the operation and there was no refracture. No significant complication occured in any cases excepting 3 cases of superficial pin tract infection. Conclusion: Femoral derotational osteotomy using a semicircular modified Ilizarov external fixator with Schanz screws has the advantages of simplicity, an exact correction of deformity, early ambulation, and the freedom to alter the alignment postoperatively.

Treatment of post-traumatic humeral diaphyseal nonunion with bone loss

Four patients with post-traumatic nonunion and shortening of the humeral diaphysis were treated with a hybrid advanced Ilizarov technique. The mean age of the patients was 32 years, and the mean total amount of humeral shortening was 6.63 cm. Three nonunions were atrophic and infected, and one was hypertrophic. All patients obtained union of the humeral fracture with resolution of infection at a mean external fixation time of 8 months. Restoration of normal humeral length was achieved in two patients, with a third having a residual discrepancy of 1 cm. The final patient, who had an infected nonunion with 11 cm of total humeral shortening, had a residual limb length discrepancy of 3 cm. All had improvement in shoulder and elbow motion after treatment. Superficial pin tract infections were seen in all patients, but all responded to pin-site care and oral antibiotics. Two patients had three refractures after removal of the fixator, two of which were treated by a second application of an Ilizarov frame and one by a cast. All patients had reduced pain and improved function at completion of the treatment. The Ilizarov method, though not a panacea for all humeral nonunions with extensive bone loss, does offer a viable salvage procedure in this unusual and often complex clinical problem.

External fixation in fractured patients aged more than 60 years

Fractures account for significant morbidity and mortality among the elderly. Commonly, surgical procedures like internal fixation are not exempt of complications (infection, soft-tissue problems). In this study, we examined the use of external fixation (EF) in 28 patients aged more than 60 years with a total of 30 fractures. There were 16 men and 12 women with a mean age of 72 (61–85) years. The upper limb was involved in four cases and the lower limb in 26. In half of the cases, open fractures were present, which were classified according to Gustilo: eight type I, six type II, and one type III. Fracture healing, angular deviation and bone aspect in the pin site were accessed radiologically. Clinical criteria included fracture healing, pain and articular function. The average time for fracture union was 7 (2–18) months. The overall rate of complications was high (66.6%). The most common complications were malunion (20%), non-union or delayed union (20%) and superficial pin-tract infection (10%). However, severe complications were rare. No deep infection or soft-tissue problems occurred. We consider that EF can be used not only for open and comminuted fractures but also in closed and minimally comminuted fractures with a high risk of soft-tissue problem where no other fixation is suitable.

Management of pertrochanteric fractures in high-risk patients with an external fixation.

In 44 surgical high-risk patients (ASA grade 3 or 4) pertrochanteric fractures were treated with a newly developed external fixator; all fractures healed within 14 weeks. Seven patients had a superficial pin tract infection and in 12 patients the fracture united with a shortening of 18 (5-30) mm. No implant failures or limitation of knee movements were recorded. Nine patients died during the first 6 months. The "pertrochanteric fixator" is a valuable alternative for treating high-risk, elderly patients.

Treatment of humeral shaft nonunion by external fixation: a valuable option

We report the treatment of six patients with nonunion of the humerus, using a unilateral fixator and bone grafting. Union was obtained in all patients, with an average time to union of 4.5 months. Superficial pin tract infection was seen in five patients, but resolved uneventfully. One patient had transient radial nerve palsy. The results, according to the Stewart and Hundley criteria, were excellent in one patient, good in three, fair in one, and poor in one. The main cause of the fair and poor results was marked limitation of shoulder and elbow motion. This method, however, seems to be therapeutically effective.

Medial Approach for Operative Treatment of the Widely Displaced Supracondylar Fractures of the Humerus in Children

Twenty-seven widely displaced supracondylar fractures of the humerus in children were treated by open reduction and cross K-wire fixation by the medial approach over a 30-month period. The mean follow-up was 14 months, average age 8 years and the mean delay in presentation 49 hours. Medial approach provided an excellent view of the medial bone pathology via an internervous plane and enabled an anatomical reduction in all cases. Cross K-wire fixation obviated the need to immobilize the elbow at 90 degrees or more flexion. No postoperative neurovascular complication was noted. Most patients regained full range of motion within 6 weeks of pin removal and no change in the carrying angle was noted. Delayed presentation, repeated manipulations and massage were responsible for loss of motion. Superficial pin tract infection was noted in 5 patients and resolved with dressings and antibiotics. No deep infection occurred. Medial approach for open reduction and internal fixation of the widely-displaced supracondylar fracture of the humerus is safe and straightforward, ensuring anatomical reduction and excellent function.

Treatment of Late-Onset Tibia Vara Using Afghan Percutaneous Osteotomy and Orthofix External Fixation

The Afghan osteotomy was combined with external fixation on 19 patients (23 extremities) with late-onset tibia vara. The average weight was 258 lb and all patients weighed >95th percentile. The average preoperative deformity was 28.2°. The average intraoperative correction was 27.6°. Average healing time was 141 days. The mean follow-up was 2.7 years. Based on radiographic correction, at long-term follow-up, there were 15 excellent, two fair, and six poor results. The quality of the initial correction was the only significant variable, and it was borderline (p = 0.0587). Complications included loss of alignment, peroneal nerve palsy, superficial pin tract infection, deep infection, and fracture. This method offers a technically simple procedure with a relatively low complication rate. It allows early mobilization and provides the ability to manipulate the correction postoperatively. An excellent long-term outcome is predicated on achieving an acceptable initial correction as determined by intraoperative mechanical axis radiographs.

Treatment of nonunion of the humerus using the Ilizarov external fixator.

Ilizarov's method of monofocal compression was used in 30 humeri with a diaphyseal pseudarthrosis. Twenty-one patients had previous surgery but had loosening of the osteosynthesis material. Nine patients initially were treated with a hanging cast, resulting in interfragmentary distraction. Fourteen nonunions were hypertrophic, and 16 were atrophic, of which six were infected. A complete circular frame was used only in the first nine patients, whereas the remaining 21 patients were treated with the modified semicircular fixator. Union was obtained in all but two patients, with an average consolidation time of 4.5 months (range, 2.5-10 months). No patient required additional bone grafting. Apart from superficial pin tract infection seen in most of the patients, three had a minor temporary sensory neurologic problem. Four patients experienced a second fracture after removal of the fixator that required a second application of an Ilizarov frame. Although similar results with regard to union are reported after plate osteosynthesis, there was no radial nerve palsy or deep infection in this series, indicating that the treatment by the Ilizarov technique is associated with less complications. The authors' findings suggest that the Ilizarov method is a reliable treatment for humeral nonunions, even after multiple previous operations or in the event of infection.

Home Traction of Femoral Shaft Fractures in Younger Children

The study describes a home traction program of femoral shaft fractures in preschool children using the 90-90 traction technique. A special bed stretcher was designed for the program and adapted for use in ordinary ambulances and in all types of homes. Twenty-four patients, 2.2-5.9 years of age, were followed. The average hospital stay was 7.0 days, and the average home traction period was 22.1 days. One patient had a superficial pin tract infection. The treatment was uneventful in all other cases. All fractures healed with a shortening of < or = 1 cm. The angulation was < or = 10 degrees in all cases but one, which healed with a valgus angulation of 15 degrees but without functional disability. Interviews showed that the parents were very satisfied with the treatment program. The cost savings are obvious compared to traction treatment in the hospital.

Hybrid external fixation in tibial plafond fractures.

Fourteen patients with Ruedi/Allgower types II and III distal tibia fractures received indirect reduction followed by application of a Monticelli-Spinelli hybrid external fixation system. All 14 patients were available for followup. A stability similar to that of an open reduction and internal Fixation was noted. The mean time to union was 13 weeks. There were no nonunions. One patient experienced malunion in 7 degrees varus. Superficial pin tract infections occurred in 8 pins (3 patients), and all resolved with aggressive pin care and a short course of orally administered antibiotics. Through postoperative tomography, 1 pin was found to be within the ankle joint and was removed. There were no deep infections. The subjective and objective results were classified according to Ovadia and Beals. On the basis of these early results, by limiting additional trauma to the soft and bony tissues and allowing early ankle range of motion, indirect reduction and application of a hybrid external fixator is useful, particularly if the fracture fragments are so comminuted that anatomic reduction cannot be expected despite surgical intervention.

Hybrid External Fixation of Comminuted Tibial Plateau Fractures

Comminuted tibial plateau fractures present a surgical challenge to the orthopaedic surgeon. Over the years, treatment has ranged from traction to cast immobilization to open reduction and internal fixation. More recently, indirect reduction techniques with external fixation have been used. At the authors' institution, from 1990 to 1992, 18 Schatzker Types V and VI tibial plateau fractures were treated in 18 patients with indirect reduction and application of a Monticelli-Spinelli hybrid external fixation system. Two patients had additional internal fixation and were excluded from this review. All 16 patients were available for followup evaluation. The mean time to union was 4.5 months. There were no nonunions. Three patients developed a varus deformity. Fifteen had radiographic evidence of early degenerative changes at 1 year followup. There were 11 superficial pin tract infections in 4 patients; all resolved with local pin care and a short course of oral antibiotics. There were no deep infections. With the added advantages of minimal to no soft tissue stripping and early knee range of motion, this technique is recommended for treatment of these difficult fractures.