What Do We Know About Pin Site Care For External Fixation?

Foot and ankle surgeons who utilize external fixator devices often face the challenge of reducing postoperative infections. Anecdotally, if I asked foot and ankle surgeons about their postoperative care instructions for external fixation, I would get various answers without much evidence-based medicine to support them. Some surgeons prefer soaking, some betadine, some chlorhexidine, some saline and some do not use any dressings at all. There are a lot of variables that play a part in postoperative infections. The evidence seems to suggest that the pin site care plays little role in who develops pin site infections.^1-4 However, let us review what we do know regarding pin site care.  

Normal saline, chlorhexidine, povidine-iodine and half-strength hydrogen peroxide are common cleansing solutions clinicians employ for pin site care. Does it really matter? Earlier this year, Saenz-Jaion and colleagues published a randomized clinical trial on pin site care.¹ They looked at chlorhexidine-alcohol versus povidone-iodine solution in 568 pin sites and found no significant difference between the antiseptic techniques. It appears the solution plays little role in infection control but more studies are necessary in order to look at whether cleansing pin sites play a part versus doing nothing.

In 2015, Ogbemudia and coworkers assessed the use of a 1% silver sulfadiazine cream-impregnated dressing and found a significant reduction in pin tract infections.⁵ However, this study was unblinded and not randomized.5 Other researchers have suggested that a dressing is not necessary at all.^2,3 If one uses a dressing protocol, it is important to remember that these patients will likely require home care to provide such a service. This may result in added patient burden and cost. It is also important to realize we are discussing pin site care independent of incision or ulcer care. Often, these patients will also have a wound that requires additional care and treatment considerations.

Whether one is performing dressing changes daily, weekly, sterilely, or non-sterilely, there is not a significant demonstrated difference between these options to reduce pin tract infections.^4,6,7 Again, this is independent of any wounds the patient may have. I personally find that the frequency of pin site care is completely dependent on patient activity. Often, patients who are in rehabilitation facilities, where activity is supervised, tend to soil their bandages less. Patients who are more active (with or against medical advice) tend to wear through their bandages more and require more frequent care.

Cavusoglu and team found that showering does not increase pin tract infection.⁶ Overall, there is little evidence towards whether these patients should shower and bathe. There is little evidence to no evidence demonstrating that showering and bathing will increase pin site infections.⁶  These same authors recommend avoiding baths due to increased bacteria potential.⁶ After showering, one should dry the external fixator and pin sites, and perform pin care per foot and ankle surgeon preference. 

Lethaby and colleagues in 2013 performed a Cochrane database review regarding the prevention of pin tract infections with external fixators.² They found three trials comparing cleansing regimens versus no cleansing, three trials comparing different cleansing agents, three trials looking at the frequency of cleansing, and one trial looking at different dressings. While the authors determined there was little trial evidence to draw conclusions, they did note that one study (with a high risk of bias) demonstrated significantly reduced risk of infection with the use of polyhexamethlyene.² No other studies demonstrated statistically significant differences.² 

Although we like to think that our pin care makes a difference with regard to infection, it is likely that other factors contribute to reduced complication rates. 

Dr. Pirozzi is a Fellow of the American College of Foot and Ankle Surgeons (ACFAS) and serves as Vice President for ACFAS Region 2. She is currently in private practice in Phoenix, AZ. 

References

1. Sáenz-Jalón M, Sarabia-Cobo CM, Roscales Bartolome E, et al. A randomized clinical trial on the use of antiseptic solutions for the pin-site care of external fixators: clorhexidine-alcohol versus povidone-iodine. J Trauma Nurs. 2020;27(3):146-150.

2. Lethaby A, Temple J, Santy-Tomlinson J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Rev. 2013;(12):CD004551.

3. Campbell F, Watt E. An exploration of nursing practices related to care of orthopaedic external fixators (pin/wire sites) in the Australian context. Int J Orthop Trauma Nurs. 2020;36:100711. 

4. Camathias C, Valderrabano V, Oberli H. Routine pin tract care in external fixation is unnecessary: a randomized, prospective, blinded controlled study. Injury. 2012;43(11):1969-1973. 

5. Ogbemudia AO, Bafor A, Ogbemudia EJ, Edomwonyi E. Efficacy of 1% silver sulphadiazine dressings in preventing infection of external fixation pin-tracks: a randomized study. Strategies Trauma Limb Reconstr. 2015;10(2):95-99.

6. Cavusoglu AT, Er MS, Inal S, Ozsoy MH, Dincel VE, Sakaogullari A. Pin site care during circular external fixation using two different protocols. J Orthop Trauma. 2009;23(10):724-730. 

7. Lee CK, Chua YP, Saw A. Antimicrobial gauze as a dressing reduces pin site infection: a randomized controlled trial. Clin Orthop Relat Res. 2012;470(2):610-615.