Pin Track Research Articles

Complications encountered while using thin-wire-hybrid-external fixation modular frames for fracture fixation: A retrospective clinical analysis and possible support for “Damage Control Orthopaedic Surgery”

One hundred ninety eight adult patients who had sustained long bone fractures were treated by external fixation from admission to bone healing and consolidation. Of these, 135 had sustained high-energy injuries, 39 of them had suffered multi-system injuries. Superficial pin track infection was the most common complication, occurring predominantly in pins located in the femur, upper tibia and upper humerus. There were no cases of deep infection or osteomyelitis. One patient with a femoral shaft fracture developed a DVT although he was on preventive low molecular weight heparin, i.e. sc Clexane 40 mg daily. There were no cases of PE or ARDS. External fixation systems are a minimal invasive surgical modality, which allow three-dimensional fracture fixation after closed or minimal open reduction. They require a good command of surgical anatomy, but provide an optimal preservation of the fracture's soft tissue envelope, the critical biological factor for new bone formation and fracture healing. Recent publications have suggested that in the critically ill patient, minimally invasive fracture fixation surgery may prevent the perpetuation of a reactive, life threatening inflammatory reaction (the "second hit") which may induce the development of multiple organ dysfunction (MODS).

Dynamic intradigital external fixation for proximal interphalangeal joint fracture dislocations

Many skeletal traction devices have been described to treat fracture dislocations of the proximal interphalangeal (PIP) joint. Most of these techniques are technically challenging or involve cumbersome frames. We present a design modification that enhances the stability of a simple dynamic fixation system described previously and report our results with this technique. A previously described simple dynamic fixator with no rubber bands was applied to 6 patients who sustained fracture dislocations of the PIP joint. The middle finger was involved in 3 patients, the ring finger in 1 patient, and the small finger in 2 patients. The average age of the patients was 27 years (range, 21-42 y). The average involvement of the base of the middle phalanx was 48% (range, 35% to 60%). The average time from the injury to the surgery was 6 days (range, 1-14 d). The average follow-up period was 24 months (range, 7-43 mo). Immediate active flexion extension was allowed and the fixator was removed after 3 to 4 weeks. The average range of motion of the PIP joint at the final follow-up evaluation was 5 degrees to 89 degrees (range, 0 degrees to 100 degrees ). Two patients developed pin track infection that resolved with oral antibiotics. Only one patient complained of mild pain with extreme flexion. Proper reduction and congruency of the joint was noted on final anteroposterior and lateral radiographs. A simple dynamic fixator for the treatment of unstable PIP joint fracture dislocations was used successfully in 6 digits to maintain reduction and restore digital range of motion. The addition of modifications to the original technique not only improves the solidity of the construct but also provides satisfactory functional results. Based on our experience we recommend this easy technique to treat fracture dislocations of the PIP joint.

Management and follow up of tibial plateau fractures by ′T′ clamp external fixator and limited internal fixation

Background: Tibial plateau fractures are difficult to treat especially when soft tissue is compromised by open reduction and internal fixation. Many methods have be1en tried in the past to manage these cases of which external fixation were shown to be effective as they limit the soft tissue and wound complications. Methods: Complex tibial plateau fractures of sixteen patients were treated by closed reduction, fixation of articular fragments by screws and application of unilateral external fixator. The external fixator was kept in place till fracture united clinically and radiologically. The patients were followed up for at least one year to assess the function of the knee joint Results: The average duration of external fixation was 13 weeks. All the fractures healed. Pin track infection (five patients) and instability (six patients) of the knee were encountered with this procedure. The average duration of follow up was 62 weeks. The mean range of motion was 1250 arc. The IOWA knee score averaged 90.3 points. Conclusions: External fixation with limited internal fixation may be effective in the management of complex tibial plateau fractures which requires further support from studies with large sample size. 'T' clamp external fixation with limited Internal fixation is the procedure of choice when alignment, stability, early mobilisation is required in a soft tissue compromised tibial plateau fractures.

Compass elbow hinge: short-term results in five adolescents

The Compass Elbow Hinge (Smith and Nephew, Memphis, Tennessee, USA) was developed in the late 1990s as a mean of treating elbow contractures, utilizing Ilizarov's principles of distraction histeogenesis and a circular frame external fixator. Subsequent reports were published on its use for treating elbow ankylosis and instability in adults. Since 1999 five paediatric patients (aged from 12 to 15 years) have been treated by this device in our institute. The indications were post-traumatic elbow stiffness in four patients and elbow ankylosis following septic arthritis in one patient. Application of the elbow hinge was accompanied by open soft tissue contracture release, both anteriorly and posteriorly. Elbow mobilization and physiotherapy were commenced immediately postoperatively. The hinge was removed after 6-8 weeks. Follow-up ranged from 5 to 36 months. Complications were limited to simple pin track infection in three patients, and transient ulnar neuropraxia in one. The Compass Elbow Hinge (Smith & Nephew) application was successful in improving the arc of motion in three patients out of five.

Local antibiotics: panacea for long term skeletal traction

Long periods of skeletal traction are frequently needed in busy tertiary centres due to long waiting lists for surgery. A frequent complication is pin track infection, which leads to revision of pin insertion or switching over to skin traction. A prospective study was conducted on sixty patients with upper tibial pin insertion for various causes. Antibiotic (injection Cephazolin 0.5 g after sensitivity testing—250 mg on each side) was injected on thirty patients at the site of pin insertion and no antibiotic was injected in 30 controls. Only one stage one pin track infection was seen in the study group (3% cases), where as six cases had stage 1 infection, one case had stage 2 infection and two cases had stage 3 infections in the control group (30% cases). This study showed the usefulness of this modification in preventing morbidity in patients who are planned for long-term skeletal traction by temporarily suppressing the local flora.

Extracapsular placement of distal tibial transfixation wires.

Treatment of tibial plafond fractures with external fixation may involve use of transfixation wires within the periarticular region. Pin track infections that develop along wires placed intracapsularly may lead to joint infection. To our knowledge, there have been no previous investigations assessing the circumferential reflection of the ankle capsule or the potential for communication between the distal tibiofibular joint and the tibiotalar joint. The purpose of this study was to define these anatomic entities to provide guidelines for safe extracapsular placement of distal tibial wires. Twelve fresh-frozen cadaveric ankles and three ankles of living human volunteers were utilized for this study. High-resolution magnetic resonance imaging was performed on each ankle after pressurized distention of the joint capsule with gadolinium solution. The perpendicular distance from the subchondral bone at the joint line to the capsular synovial reflection was measured with use of a verified technique. The cadaveric ankles were sectioned, the capsular synovial reflections were measured by investigators who were blinded to the imaging results, and the corresponding measurements were compared. The anterolateral capsular synovial region displayed the most proximal reflection in all specimens (mean, 9.3 mm; maximum, 12.2 mm). The anteromedial region displayed less reflection (mean, 3.3 mm; maximum, 5.5 mm). All posteromedial and posterolateral synovial reflections were <or=2 mm. Capsular synovial reflections proximal to the medial and lateral malleoli were negligible. In all ankles, the distal tibiofibular joint communicated with the tibiotalar joint and had a maximum proximal extension of 20.6 mm. Placement of distal tibial transfixation wires >12.2 mm from the subchondral surface of the plafond avoids penetration of the capsule. The distal tibiofibular joint communicates with the tibiotalar joint and thus should not be penetrated, to ensure extracapsular placement of the wires.

Antimicrobial Effect of Silver-Coated External Fixator Pins

One major complication of external fixation is pin track infection that may result in devastating osteomyelitis for the patient. The broad antimicrobial effect of silver is well known and this study was conducted to investigate the antibacterial activity of pins coated with colloidal silver. A total of 96 pins were inserted into one tibia of 24 sheep. Four pins of either stainless steel, titanium, silver-coated, or stainless steel pins coated with a polyurethane-argentum sleeve were inserted in six sheep, respectively. After pin insertion S. aureus was inoculated into the insertion channel between skin and bone and the animals were sacrificed after four weeks. Clinical assessment, radiological evaluation, microbiological and biomechanical testing, and histological methods were used. All animals developed clinical signs of infection after three to six days. The inoculated S. aureus was identified in all animals as an infection-causing strain by the DNA-fingerprinting technique. None of the different pin types, including silver-coated pins, showed a significant reduction of infection rates. Significant differences between the groups were rare and limited to few specific tests. Colloidal silver showed no significant reduction of pin track infections. Nanoparticulate silver with a higher active surface and a more homogenous distribution within biomaterials might be able to exhibit a better antimicrobial activity in coated pins.

下腿開放骨折に対するＩｌｉｚａｒｏｖ創外固定器による治療

Ten open tibial fractures were treated with the Ilizarov external fixator. According to the Gustilo classification, two were Grade II, four Grade III a, three Grade III b, and one Grade III c. Bone union was achieved in all the cases without malalignment and deep infection. The external fixation time was 118 days on average. Four cases had pin track infection, and two required debridement with removal of the pins. Three cases were delayed union, and bone chipping was performed. The Ilizarov external fixator is a useful device for the management of open tibial fractures.

Unilateral hinged external fixator of the elbow in complex elbow injuries

We present the outcome of treating complex injuries of the elbow with the “Orthofix” external fixator in patients where the condition of the soft tissues did not permit extensile surgical approach or where the internal fixation would not be stable enough to permit safe early joint mobilization postoperatively. Eight patients were treated, three with supra-intercondylar fracture in the presence of marked osteoporosis and five with fracture–dislocation of the elbow and excessive soft tissue impairment. The fixator was applied for a mean of 8.5 weeks (5–13 weeks). Great care was taken to use the appropriate technique in applying the fixator, especially to define the correct centre of rotation. All the fractures were united, and no instability of the joint was noted. All the patients maintained a functional range of motion, with lack of extension less than 30° and flexion more than 120°. One patient who developed transient palsy of the radial nerve and two patients who developed pin track infection were treated with oral antibiotics. Despite the technical difficulties, external fixation of the elbow could be a salvage procedure in difficult cases of elbow trauma, where open procedures are not indicated.

Correction of Malunion after Pediatric Supracondylar Elbow Fractures

Malunion is the most common complication after pediatric supracondylar fractures. Cubitus varus may be cosmetically disturbing, consolidation in hyperextension restricts flexion. There is a considerable rate of complications for corrective osteotomies reported in the literature (incomplete correction, loss of correction, and unsightly scars). 13 patients (six boys and seven girls), average age 11 years (5–23 years), underwent supracondylar closing wedge osteotomies and lateral external fixation. Cubitus varus deformity averaged 23° (15–50°). Four patients were treated by flexion osteotomies, six by valgus osteotomies, and three by combined flexion-valgus osteotomies. Nine patients showed symmetric carrying angles, three had 5° more valgus on the operated arm. One patient had 10° more varus which still resulted in a physiologic valgus. One patient had slight lateral bony prominence despite symmetric carrying angles. Three patients complaint about unsightly scars. All three had previous open reduction of their fractures with keloids. All patients had already reached a range of motion at the time of metal removal which was within 15° of the values at the time of the latest follow-up. Seven patients with significantly decreased elbow flexion regained an average of 28° of flexion (20–35°). Two superficial pin track infections healed under oral antibiotics. External fixation facilitates correction by empirically searching for the desired carrying angle, cosmetic appearance, and function of the elbow. Functional aftertreatment shortens the recovery period. Metal removal is easy. Our experience confirms the excellent results in previous series on external fixators.

Limited open reduction and Ilizarov external fixation in the treatment of distal tibial fractures

The authors reviewed 31 distal tibial fractures (16 involving the tibial plafond) treated with Ilizarov external fixation. The study population was composed of 19 males and 12 females, with an average age of 54. The fractures were classified according to the AO classification: A1 (3), A2 (6), A3 (6), C1 (2), C2 (8), C3 (6). There were six open injuries. In 14 pilon cases, open reduction of the intra-articular fragments and bone grafting via a limited incision was performed. Clinical follow-up averaged 28 months (range 18–42). All but one fracture united with an average healing time of 13.9 weeks. Nearly all patients with AO type A fracture had excellent or good functional scores. The 14 cases of AO C2 and C3 group had five (38%) good results, five (38%) fair results and three (24%) poor results. This method yielded results comparable with previous studies using open reduction and internal fixation. Twenty-nine percent of the patients had pin track infection, which remained the most important complication of this method.

Long-term bactericidal properties of a gentamicin-coated antimicrobial external fixation pin sleeve.

External fixation is a versatile method of fracture treatment. However, pin-track infections remain a major complication. Despite the routine use of antibiotics, pin-track infections occur in 57% to 75% of cases1,2. One factor contributing to the high prevalence of infection is the access that the pin track provides to bacteria and the ability of bacteria to colonize the metal surface of the pin or wire. The OrthoGuard AB antimicrobial sleeve (Smith and Nephew, Memphis, Tennessee) inhibits bacterial colonization on external fixation pins and wires by providing sustained local delivery of gentamicin to the pin or wire site. In order for local antibiotic delivery to be bactericidal, (1) the antibiotic must be effective against pathogens common to pin-track infections and (2) the sleeve must deliver an effective dose into the pin track in a sustained manner. The purpose of the present study was to evaluate the results of in vitro testing in order to establish the long-term bactericidal properties of the OrthoGuard AB antimicrobial sleeve. The OrthoGuard AB sleeve consists of polyurethane tubing that has a thin gentamicin-loaded coating on its inner and outer surfaces. After insertion of the fixation pin or wire, the sleeve is placed over the pin or wire and is manually pushed through the subcutaneous tissue up to the point of contact with the bone (Fig. 1). The sleeve is measured and cut before placement so that at least 1 cm of the sleeve is protruding from the skin surface in order to allow for …

Pin Track Infection and Pin Loosening in Dynamic Axial External Fixation: Preliminary Results of Hydroxyapatite Coating

One of the most frequent and troublesome complications in the treatment using external fixation is the occurrence of pin track infections [1] [2] [7] [8]. There are experimental and clinical observations suggesting a superior bone-pin interface and a lower rate of pin track related infections using hydroxyapatite (HA) coated pins [3] [4] [5]. Since HA-coated pins are considerably more expensive in manufacture compared to steel pins, we look critically for clinical advantages to justify a general recommendation for their use. The goal of this study was to evaluate the severity and frequency of pin-related infections and the bonding of the bone pin interface using dynamic axial external fixation in the lower limb.

The use of trans-articular and extra-articular external fixation for management of distal tibial intra-articular fractures

Twenty-nine consecutive cases of distal tibial intra-articular fractures treated by trans-articular or extra-articular external fixation techniques have been reviewed. Eleven cases were treated initially with a trans-articular dynamic axial fixator. Of these seven were converted to an extra-articular SHF, for a combination of poor ankle motion and delayed healing of the metaphyseo-diaphyseal dissociation (MDD). Three of these cases (two patients) required bone grafting for delayed healing of the diaphyseal component of the fracture. Apart from one refracture through the MDD, no major complications were seen. No deep infections and no angular malalignments were noted. There were 11 pin track infections. Subjective assessment using short form-36 (SF-36) questionnaires, however, revealed significant differences compared to a normal population particularly in physical function and pain at a mean follow-up of 21 months. Using Bone’s criteria for assessment of range of motion there were 62% excellent and good results, which dropped to 53% when fractures with a metaphyseo-diaphyseal extension were included. The use of minimally invasive techniques of internal fixation and stabilisation with a Sheffield hybrid frame in the management of distal tibial intra-articular fractures has minimal complications. Trans-articular external fixation is a good primary treatment for badly comminuted articular fractures with poor soft tissue condition. Conversion to extra-articular external fixation is recommended for slower healing fractures allowing ankle movement and early weight-bearing. The presence of a MDD dissociation lengthens the treatment time significantly, adds to the morbidity and affects final outcome.

Treatment of non-union of the humerus using the Orthofix ® external fixator

An Orthofix ® monolateral axial external fixator was used to treat 31 patients with non-union of the humeral shaft, 30 of whom had been previously treated surgically. In seven cases the non-union was hypertrophic and one of these cases had been treated by simple fixation anol compression, the others by fixation, bone grafting and decortication; in 20 cases the non-union was hypotrophic and had been treated by fixation and decortication with bone grafting. The remaining four cases had septic non-union, treated by debridement of the focus of infection and fixation, followed in three cases by a bone graft and osteomuscular decortication once the infection had been eradicated. The fracture site consolidated in all patients in a mean time of 4.9 months. Five patients required further surgery: three in the group with infected non-union and two who had had a new bone graft and application of the external fixator, one because of a refracture (the patient was receiving chronic treatment with antimitotic agents) and one because of persistent non-union. There were no major complications (e.g. radial nerve palsy, joint stiffness, deep infection), and only six cases of pin track infection (5% of the screws implanted). The authors believe that this method is reliable, effective and low risk provided that the patient is cooperative; furthermore, the monolateral axial external fixator is tolerated well and allows movement of the shoulder and elbow throughout the period of treatment.

Fluid accumulation and the rapid spread of bacteria in the pathogenesis of external fixator pin track infection

An animal model was used to study the pathogenesis of pin track infection. The roles of fluid accumulation around the pin/bone interface and mechanical loosening of the pin were specifically studied. In addition, the spread of bacteria in relation to the clinical appearance of the pin track was assessed. This study demonstrated that fluid accumulation around the interface is an important factor in the spread of infection from the superficial wound track to the medulla of the bone. Spread occurs despite the absence of mechanical pin loosening, and can occur before any clinical features of infection are apparent.

Spread of infection, in an animal model, after intramedullary nailing of an infected external fixator pin track

Implant sepsis, due to previous external fixator pin track infection, is the most common complication of secondary intramedullary (IM) nailing of the tibia. We have developed an animal model, which allows different treatment methods to be studied. Using an established ovine model of a pin track infection, Staphylococcus aureus was used to infect the external fixator pins, two weeks prior to reamed IM nailing. In the control group, the animals were killed at a mean of 10.5 days following nailing, when widespread infection was evident, with septic arthritis, abscess formation, and infection of the entire length of the tibia in all six animals. In the treatment group, before IM nailing, the pin sites were débrided, and both local and systemic antibiotics were administered. All surgical wounds healed without evidence of infection, 4 of the 6 animals survived for 28 days, and bacteria were only isolated from 1 of the 6 implants. Treatment was successful at reducing, but not eliminating, infection after secondary nailing.

Simple Anterior Pelvic External Fixation

Unstable pelvic ring disruptions are often associated with significant morbidity and mortality, especially in patients with multiple injuries. Early pelvic fixation provides stability and should diminish ongoing hemorrhage. A simple anterior single-pin pelvic external fixator can be applied rapidly and accurately to stabilize pelvic ring injuries as a part of the initial patient resuscitation of such patients. Simple anterior pelvic external fixation (SAPEF) frames can be used as either temporary, definitive, or supplementary fixation depending on the pelvic injury pattern. Over a 32-month period, 41 patients with unstable pelvic ring disruptions were stabilized using a simple anterior pelvic external fixator. Eight patients had open pelvic ring injuries and 13 others had genitourinary system disruptions. Fluoroscopic imaging was used to insert all of the fixation pins into the iliac crest between the iliac cortical tables to a depth of at least 5 cm. Each patient had closed manipulative reduction of the pelvic ring using external methods before SAPEF application. One patient died less than 24 hours after injury because of torrential hemorrhage. Clinical evaluations and serial radiographs, including postoperative computed tomographic scans, were available for the other 40 patients postoperatively. Seventy-five of the 80 (94%) pins were completely contained between the iliac cortical tables, according to the computed tomographic scans. The initial pelvic closed reductions were maintained until the fixators were removed in 37 of 40 patients (93%). Only one deep pin track infection developed, mandating early frame removal and intravenous antibiotic therapy. Simple anterior pelvic external fixation can be applied rapidly using fluoroscopic guidance to direct accurate pin insertion and closed manipulative reduction of the pelvis. Depending on the specific pelvic ring injury pattern and clinical scenario, SAPEF can serve as a resuscitative temporary fixation device, as definitive pelvic treatment, or as a supplement for pelvic internal fixation implants.

Ankle arthroscopy: the use of an Ilizarov Half-Frame Fixator to distract the ankle joint

Summary Invasive skeletal traction is useful in some arthroscopic ankle procedures. Current techniques use large skeletal pins (with risk of pin track complications) and may limit access to the joint. We describe the use of an Ilizarov frame with fine wires. We consider this method to have practical and theoretical advantages over those previously described.

INTERNAL SUTURE FOR MALLET FINGER FRACTURE

An internal suture technique has been used for mallet finger fractures involving at least 30% of the articular surface. It provides fixation without a button or transfixion of the fragment. An independent retrospective review was conducted of ten patients at a mean follow-up of 17 months. Mean visual analogue score (0 to 10) for pain was 2.4 and satisfaction 7.9. Mean active range of motion was 13 to 49°, passive motion was 2 to 56°, pinch strength of effected finger to thumb was 3.8 kgf (81% of the opposite finger), grip strength 37.9 kgf (95% of the opposite hand). All fractures united and there were no neuromas. Complications included two nail deformities, a superficial infection and a pin track infection. One patient with a crush injury continued to have pain despite an arthrodesis.