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Journal of Children's Orthopaedics
Published in: Journal of Children's Orthopaedics 6/2016

Open Access 01-12-2016 | Current Concept Review

From prevention of pin-tract infection to treatment of osteomyelitis during paediatric external fixation

Authors: Dimitri Ceroni, Catherine Grumetz, Odile Desvachez, Sophie Pusateri, Pierre Dunand, Eleftheria Samara

Published in: Journal of Children's Orthopaedics | Issue 6/2016

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Abstract

Pin-tract infection (PTI) is the most commonly expected problem, or even an almost inevitable complication, when using external fixation. Left unteated, PTI will progress unavoidably, lead to mechanical pin loosening, and ultimately cause instability of the external fixator pin–bone construct. Thus, PTI remains a clinical challenge, specifically in cases of limb lengthening or deformity correction. Standardised pin site protocols which encompass an understanding of external fixator biomechanics and meticulous surgical technique during pin and wire insertion, postoperative pin site care and pin removal could limit the incidence of major infections and treatment failures. Here we discuss concepts regarding the epidemiology, physiopathology and microbiology of PTI in paediatric populations, as well as the clinical presentations, diagnosis, classification and treatment of these infections.
Literature
1.
Ilizarov GA (1989) The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Related Res (238):249–281
2.
Ilizarov GA (1989) The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction. Clin Orthop Related Res (239):263–285
3.
Paley D (1990) Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res (250):81–104. PubMed PMID: 2403498
4.
Antoci V, Ono CM, Antoci V, Jr., Raney EM (2008) Pin-tract infection during limb lengthening using external fixation. Am J Orthop (Belle Mead NJ) 37(9):E150–E1544. PubMed PMID: 18982187
5.
Battle J, Carmichael KD (2007) Incidence of pin track infections in children’s fractures treated with Kirschner wire fixation. J Pediatr Orthop 27(2):154–157. PubMed PMID: 17314639CrossRefPubMed
6.
Blum AL, BongioVanni JC, Morgan SJ, Flierl MA, dos Reis FB (2010) Complications associated with distraction osteogenesis for infected nonunion of the femoral shaft in the presence of a bone defect: a retrospective series. J Bone Joint Surg Br 92(4):565–570. PubMed PMID: 20357336CrossRefPubMed
7.
Egol KA, Paksima N, Puopolo S, Klugman J, Hiebert R, Koval KJ (2006) Treatment of external fixation pins about the wrist: a prospective, randomized trial. J Bone Joint Surg Am 88(2):349–354. PubMed PMID: 16452747
8.
Green SA (1983) Complications of external skeletal fixation. Clin Orthop Relat Res 180:109–116. PubMed PMID: 6627782
9.
Hosny GA (2005) Unilateral humeral lengthening in children and adolescents. J Pediatr Orthop B 14(6):439–443. PubMed PMID: 16200022CrossRefPubMed
10.
Jennison T, McNally M, Pandit H (2014) Prevention of infection in external fixator pin sites. Acta Biomater 10(2):595–603. PubMed PMID: 24076071
11.
Koseki H, Asahara T, Shida T, Yoda I, Horiuchi H, Baba K et al (2013) Clinical and histomorphometrical study on titanium dioxide-coated external fixation pins. Int J Nanomed 8:593–599. PubMed PMID: 23429667. Pubmed Central PMCID: 3575175
12.
Mahan J, Seligson D, Henry SL, Hynes P, Dobbins J (1991) Factors in pin tract infections. Orthopedics 14(3):305–308. PubMed PMID: 2020629
13.
Marsh JL, Bonar S, Nepola JV, Decoster TA, Hurwitz SR (1995) Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 77(10):1498–1509. PubMed PMID: 7593058
14.
Parameswaran AD, Roberts CS, Seligson D, Voor M (2003) Pin tract infection with contemporary external fixation: how much of a problem? J Orthop Trauma 17(7):503–507. PubMed PMID: 12902788
15.
Respet PJ, Kleinman PG, Meinhard BP (1987) Pin tract infections: a canine model. J Orthop Res Off Publ Orthop Res Soc 5(4):600–603. PubMed PMID: 3681533CrossRef
16.
Clasper JC, Cannon LB, Stapley SA, Taylor VM, Watkins PE (2001) Fluid accumulation and the rapid spread of bacteria in the pathogenesis of external fixator pin track infection. Injury 32(5):377–381. PubMed PMID: 11382422
17.
Davies R, Holt N, Nayagam S (2005) The care of pin sites with external fixation. J Bone Joint Surg Br 87(5):716–719. PubMed PMID: 15855378
18.
Ferreira N, Marais LC (2012) Prevention and management of external fixator pin track sepsis. Strateg Trauma Limb Reconstr 7(2):67–72. PubMed PMID: 22729940. Pubmed Central PMCID: 3535127
19.
Ariza J, Euba G, Murillo O (2008) Orthopedic device-related infections. Enferm Infecc Microbiol Clin 26(6):380–390. PubMed PMID: 18588820
20.
Pascual A (2002) Pathogenesis of catheter-related infections: lessons for new designs. Clin Microbiol Infect 8(5):256–264. PubMed PMID: 12047402
21.
Holt J, Hertzberg B, Weinhold P, Storm W, Schoenfisch M, Dahners L (2011) Decreasing bacterial colonization of external fixation pins through nitric oxide release coatings. J Orthop Trauma 25(7):432–437. PubMed PMID: 21637124. Pubmed Central PMCID: 3117952
22.
Katsikogianni M, Missirlis YF (2004) Concise review of mechanisms of bacterial adhesion to biomaterials and of techniques used in estimating bacteria–material interactions. Euro Cells Mater 8:37–57. PubMed PMID: 15593018
23.
Donlan RM, Costerton JW (2002) Biofilms: survival mechanisms of clinically relevant microorganisms. Clin Microbiol Rev 15(2):167–193. PubMed PMID: 11932229. Pubmed Central PMCID: 118068
24.
Hoyle BD, Costerton JW (1991) Bacterial resistance to antibiotics: the role of biofilms. Progr Drug Res 37:91–105. PubMed PMID: 1763187
25.
Charville GW, Hetrick EM, Geer CB, Schoenfisch MH (2008) Reduced bacterial adhesion to fibrinogen-coated substrates via nitric oxide release. Biomaterials 29(30):4039–4044. PubMed PMID: 18657857. Pubmed Central PMCID: 2582185
26.
Vuong C, Otto M (2002) Staphylococcus epidermidis infections. Microb Infect Institut Pasteur 4(4):481–489. PubMed PMID: 11932199
27.
Costerton JW (1995) Overview of microbial biofilms. J Indust Microbiol 15(3):137–140. PubMed PMID: 8519468
28.
Probert HM, Gibson GR (2002) Bacterial biofilms in the human gastrointestinal tract. Curr Issues Intest Microbiol 3(2):23–27. PubMed PMID: 12400635
29.
Lee WS, Cheung WH, Qin L, Tang N, Leung KS (2006) Age-associated decrease of type IIA/B human skeletal muscle fibers. Clin Orthop Relat Res 450:231–237. PubMed PMID: 16691139
30.
Clint SA, Eastwood DM, Chasseaud M, Calder PR, Marsh DR (2010) The “Good, Bad and Ugly” pin site grading system: A reliable and memorable method for documenting and monitoring ring fixator pin sites. Injury 41(2):147–150. PubMed PMID: 19647820CrossRefPubMed
31.
Santy J, Vincent M, Duffield B (2009) The principles of caring for patients with Ilizarov external fixation. Nursing standard 23(26):50–55. Quiz 6. PubMed PMID: 19323111
32.
Ward P (1998) Care of skeletal pins: a literature review. Nursing Stand 12(39):34–38. PubMed PMID: 9776884
33.
Chan CK, Saw A, Kwan MK, Karina R (2009) Diluted povidone-iodine versus saline for dressing metal–skin interfaces in external fixation. J Orthop Surg (Hong Kong) 17(1):19–22. PubMed PMID: 19398787
34.
Checketts RGMA, Otterburn M (2000) Pin track infection and the principles of pin site care. In: DeBastiani AGAA, Goldberg DE (eds) Orthofix external fixation in trauma and orthopedics. Springer, Berlin Heidelberg New York, pp 97–103CrossRef
35.
Saleh MSB, PacilltSe SO (1992) Pitfalls and complications in leg lengthening: the Sheffield experience. Semin Orthop 7:207–222
36.
Moroni A, Toksvig-Larsen S, Maltarello MC, Orienti L, Stea S, Giannini S (1998) A comparison of hydroxyapatite-coated, titanium-coated, and uncoated tapered external-fixation pins. An in vivo study in sheep. J Bone Joint Surg Am 80(4):547–554. PubMed PMID: 9563384
37.
Shevtsov VI, Popkov AV, Popkov DA, Yerofeev SA, Prevot J, Lascombes P (2004) Elastic stable intramedullary nailing in Ilizarov bone lengthening. Rev Chir Orthop Reparatrice Appar Mot 90(5):399–410. PubMed PMID: 15502762
38.
Bibbo C, Brueggeman J (2010) Prevention and management of complications arising from external fixation pin sites. J Foot Ankle Surg 49(1):87–92. PubMed PMID: 20123298
39.
Holmes SB, Brown SJ (2005) Skeletal pin site care: National Association of Orthopaedic Nurses guidelines for orthopaedic nursing. Orthop Nurs 24(2):99–107. PubMed PMID: 15902006
40.
Rose R (2009) Pin site care with the Ilizarov circular fixator. Internet J Orthop Surg 16(1):1–4
41.
Bajpai I, Balani K, Basu B (2014) Synergistic effect of static magnetic field and HA-Fe3O4 magnetic composites on viability of S. aureus and E. coli bacteria. J Biomed Mater Res B Appl Biomater 102(3):524–532. PubMed PMID: 24142888CrossRefPubMed
42.
DeJong ES, DeBerardino TM, Brooks DE, Nelson BJ, Campbell AA, Bottoni CR et al (2001) Antimicrobial efficacy of external fixator pins coated with a lipid stabilized hydroxyapatite/chlorhexidine complex to prevent pin tract infection in a goat model. J Trauma 50(6):1008–1014. PubMed PMID: 11426113
43.
Harding IS, Rashid N, Hing KA (2005) Surface charge and the effect of excess calcium ions on the hydroxyapatite surface. Biomaterials 26(34):6818–6826. PubMed PMID: 15955555
44.
Moroni A, Aspenberg P, Toksvig-Larsen S, Falzarano G, Giannini S (1998) Enhanced fixation with hydroxyapatite coated pins. Clin Orthop Relat Res (346):171–177. PubMed PMID: 9577425
45.
Moroni A, Cadossi M, Romagnoli M, Faldini C, Giannini S (2008) A biomechanical and histological analysis of standard versus hydroxyapatite-coated pins for external fixation. J Biomed Mater Res Part B Appl Biomater 86(2):417–421. PubMed PMID: 18286593
46.
Moroni A, Caja VL, Maltarello MC, Savarino L, Marinelli F, Stea S et al (1997) Biomechanical, scanning electron microscopy, and microhardness analyses of the bone-pin interface in hydroxyapatite coated versus uncoated pins. J Orthop Trauma (1997) 11(3):154–161. PubMed PMID: 9181496
47.
Moroni A, Faldini C, Rocca M, Stea S, Giannini S (2002) Improvement of the bone-screw interface strength with hydroxyapatite-coated and titanium-coated AO/ASIF cortical screws. J Orthop Trauma 16(4):257–263. PubMed PMID: 11927807
48.
Moroni A, Heikkila J, Magyar G, Toksvig-Larsen S, Giannini S (2001) Fixation strength and pin tract infection of hydroxyapatite-coated tapered pins. Clin Orthop Relat Res 388:209–217. PubMed PMID: 11451122CrossRef
49.
Moroni A, Orienti L, Stea S, Visentin M (1996) Improvement of the bone-pin interface with hydroxyapatite coating: an in vivo long-term experimental study. J Orthop Trauma 10(4):236–242. PubMed PMID: 8723401
50.
Campbell AA, Song L, Li XS, Nelson BJ, Bottoni C, Brooks DE et al (2000) Development, characterization, and anti-microbial efficacy of hydroxyapatite-chlorhexidine coatings produced by surface-induced mineralization. J Biomed Mater Res 53(4):400–407. PubMed PMID: 10898881
51.
Agarwal A, Weis TL, Schurr MJ, Faith NG, Czuprynski CJ, McAnulty JF et al (2010) Surfaces modified with nanometer-thick silver-impregnated polymeric films that kill bacteria but support growth of mammalian cells. Biomaterials 31(4):680–690. PubMed PMID: 19864019. Pubmed Central PMCID: 4824047
52.
Atiyeh BS, Costagliola M, Hayek SN, Dibo SA (2007) Effect of silver on burn wound infection control and healing: review of the literature. Burns J Int Soc Burn Injuries 33(2):139–148. PubMed PMID: 17137719
53.
Collinge CA, Goll G, Seligson D, Easley KJ (1994) Pin tract infections: silver vs uncoated pins. Orthopedics 17(5):445–448. PubMed PMID: 8036188
54.
Li B, Liu X, Cao C, Dong Y, Ding C (2009) Biological and antibacterial properties of plasma sprayed wollastonite/silver coatings. J Biomed Mater Res Part B Appl Biomater 91(2):596–603. PubMed PMID: 19496150
55.
Necula BS, Fratila-Apachitei LE, Zaat SA, Apachitei I, Duszczyk J (2009) In vitro antibacterial activity of porous TiO2-Ag composite layers against methicillin-resistant Staphylococcus aureus. Acta Biomater 5(9):3573–3580. PubMed PMID: 19454327
56.
Vasilev K, Sah V, Anselme K, Ndi C, Mateescu M, Dollmann B et al (2010) Tunable antibacterial coatings that support mammalian cell growth. Nano Lett 10(1):202–207. PubMed PMID: 19968257
57.
Matsunaga J, Watanabe I, Nakao N, Watanabe E, Elshahawy W, Yoshida N (2015) Joining characteristics of titanium-based orthodontic wires connected by laser and electrical welding methods. J Mater Sci Mater Med 26(1):5391. PubMed PMID: 25595723
58.
Qu H, Knabe C, Radin S, Garino J, Ducheyne P (2015) Percutaneous external fixator pins with bactericidal micron-thin sol-gel films for the prevention of pin tract infection. Biomaterials 62:95–105. PubMed PMID: 26036176
59.
Piza G, Caja VL, Gonzalez-Viejo MA, Navarro A (2004) Hydroxyapatite-coated external-fixation pins. The effect on pin loosening and pin-track infection in leg lengthening for short stature. J Bone Joint Surg Br 86(6):892–897. PubMed PMID: 15330032
60.
Masse A, Bruno A, Bosetti M, Biasibetti A, Cannas M, Gallinaro P (2000) Prevention of pin track infection in external fixation with silver coated pins: clinical and microbiological results. J Biomed Mater Res 53(5):600–604. PubMed PMID: 10984710
61.
Asharani PV, Lian Wu Y, Gong Z, Valiyaveettil S (2008) Toxicity of silver nanoparticles in zebrafish models. Nanotechnology 19(25):255102. PubMed PMID: 21828644
62.
Chen X, Schluesener HJ (2008) Nanosilver: a nanoproduct in medical application. Toxicol Lett 176(1):1–12. PubMed PMID: 18022772
63.
Park EJ, Yi J, Kim Y, Choi K, Park K (2010) Silver nanoparticles induce cytotoxicity by a Trojan-horse type mechanism. Toxicology in vitro: an international journal published in association with BIBRA 24(3):872–878. PubMed PMID: 19969064
64.
Fretwell R, Douglas P (2002) Nanocrystalline-TiO2-Pt photo-electrochemical cells–UV induced hydrogen evolution from aqueous solutions of alcohols. Photochem Photobiol Sci 1(10):793–798. PubMed PMID: 12656480CrossRefPubMed
65.
Fujishima A, Honda K (1972) Electrochemical photolysis of water at a semiconductor electrode. Nature 238(5358):37–38. PubMed PMID: 12635268
66.
Gordon JE, Kelly-Hahn J, Carpenter CJ, Schoenecker PL (2000) Pin site care during external fixation in children: results of a nihilistic approach. J Pediat Orthop 20(2):163–165. PubMed PMID: 10739275
67.
Villatte G, Massard C, Descamps S, Sibaud Y, Forestier C, Awitor KO (2015) Photoactive TiO(2) antibacterial coating on surgical external fixation pins for clinical application. Int J Nanomed 10:3367–3375. PubMed PMID: 26005347. Pubmed Central PMCID: 4428362
68.
Forster H, Marotta JS, Heseltine K, Milner R, Jani S (2004) Bactericidal activity of antimicrobial coated polyurethane sleeves for external fixation pins. J Orthop Res 22(3):671–677CrossRefPubMed
69.
Lethaby A, Temple J, Santy J (2008) Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database System Rev (4):CD004551. PubMed PMID: 18843660
70.
Lee-Smith JSJ, Davis P, Jester R, Kneale J (2001) Pin site management: toward a consensus. J Orthop Nurs 5:37–42CrossRef
71.
A WD, Toksvig-Larsen S (2004) Pin site care in external fixation sodium chloride or chlorhexidine solution as a cleansing agent. Archiv Orthop Trauma Surg 124(8):555–558. PubMed PMID: 15338244
72.
Patterson MM (2005) Multicenter pin care study. Orthop Nurs 24(5):349–360. PubMed PMID: 16272914
73.
Cavusoglu AT, Er MS, Inal S, Ozsoy MH, Dincel VE, Sakaogullari A (2009) Pin site care during circular external fixation using two different protocols. J Orthop Trauma 23(10):724–730. PubMed PMID: 19858981
74.
Timms A, Pugh H (2012) Pin site care: guidance and key recommendations. Nurs Stand 27(1):50–55. Quiz 6. PubMed PMID: 23082364
75.
Lee CK, Chua YP, Saw A (2012) Antimicrobial gauze as a dressing reduces pin site infection: a randomized controlled trial. Clin Orthop Relat Res 470(2):610–615. PubMed PMID: 21842299. Pubmed Central PMCID: 3254747
76.
Driver VR (2004) Silver dressings in clinical practice. Ostomy/wound management. 50[9A Suppl]:11S–15S. PubMed PMID: 15499163PubMed
77.
Schaller M, Laude J, Bodewaldt H, Hamm G, Korting HC (2004) Toxicity and antimicrobial activity of a hydrocolloid dressing containing silver particles in an ex vivo model of cutaneous infection. Skin Pharmacol Physiol 17(1):31–36. PubMed PMID: 14755125
78.
Bhattacharyya MBH (2006) Antibiotics vs an antimicrobial dressing for pin-track infection. Wounds 2(2):26–33
79.
Edwards-Jones V, Buck R, Shawcross SG, Dawson MM, Dunn K (2004) The effect of essential oils on methicillin-resistant Staphylococcus aureus using a dressing model. Burns J Int Soc Burn Injur 30(8):772–777. PubMed PMID: 15555788CrossRef
80.
Dunn K, Edwards-Jones V (2004) The role of Acticoat with nanocrystalline silver in the management of burns. Burns J Int Soc Burn Injur 30[Suppl 1]:S1–S9. PubMed PMID: 15327800CrossRef
81.
Dowsett C (2003) An overview of Acticoat dressing in wound management. Br J Nurs 12[19 Suppl]:S44–S49. PubMed PMID: 14593271
82.
Hoffmann R (1961) Osteotaxis: fixation squelettique externe par fiches transcutanées et rotules, en traumatologie et en orthopédie. Guide technique et clinique. Published by Jaquet Frères (Nyon)
83.
Morgan HG, Ryder DA, Wheble VH (1976) Tungsten-fibre reinforced composite pin with potential applications in orthopaedic surgery. Med Biol Eng 14(5):528–531. PubMed PMID: 979376CrossRefPubMed
Metadata
Title
From prevention of pin-tract infection to treatment of osteomyelitis during paediatric external fixation
Authors
Dimitri Ceroni
Catherine Grumetz
Odile Desvachez
Sophie Pusateri
Pierre Dunand
Eleftheria Samara
Publication date
01-12-2016
Publisher
Springer Berlin Heidelberg
Published in
Journal of Children's Orthopaedics / Issue 6/2016
Print ISSN: 1863-2521
Electronic ISSN: 1863-2548
DOI
https://doi.org/10.1007/s11832-016-0787-8

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