From prevention of pin-tract infection to treatment of osteomyelitis during paediatric external fixation
- 1.2k Downloads
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.
KeywordsPin Half-pin Wire Tract Infection Instability
External fixation has become a key tool in the orthopaedic surgeon’s modern armamentarium, being used both in traumatology and reconstructive surgery. The key advantage of this method is that the implant assembly—called the external fixator device—is located outside the body and is connected to the bone via transcutaneous pins or wires. External fixators were first applied to treat comminuted fractures, open fractures and bone loss, but its applications broadened in subsequent years, notably after Ilizarov’s development of distraction osteogenesis [1, 2], and external fixation is currently also used to correct congenital and acquired deformities, mobilise stiff joints and heal infected nonunions. However, external fixation is associated with high rates of morbidity, especially when a prolonged application is necessary , with inflammation and subsequent infection at the metal–skin interface—more commonly known as pin-tract infection (PTI)—being one of the most common problems encountered, with reported rates ranging from 1 to 100% [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15]. This great discrepancy in reported incidences of PTI is partly due to the lack of a uniform definition and classification system for the determination and quantification of this type of infection. At the present time, PTI infection is broadly defined as the signs and symptoms of infection around pins or wires that require the administration of an antibiotic, pin or wire removal, or even surgical debridement. In this current opinion review, we discuss the concepts regarding the epidemiology, physiopathology and microbiology of PTI in paediatric populations, as well as the clinical presentations, diagnosis, classification and treatment of this type of infection.
There is currently a lack of clear evidence and consensus on the pathogenesis of PTI, and many apparently contradictory hypotheses have been described. Numerous authors [3, 4, 16, 17] have reported that pin tract problems always develop from the outside to the inside, a hypothesis based on the belief that such problems start with a soft tissue inflammation that leads to soft tissue infection and finally to bone infection. According to this hypothesis, PTI can then spread through the continuity of the bone—despite the absence of any mechanical pin loosening—and result in colonisation of the medullary canal. In this case, the stability of the internal fixator is impaired, and infection may persist even after the removal of the wire or pin. This theory associates PTI with pin–skin motion, the amount of soft tissue between skin and bone and the diameter of the pin used . Clasper et al.  also incriminated fluid accumulation around the pin–bone interface as a cause of PTI.
This description of the development of PTI has been disputed by other authors [14, 18] who believe that it is a pathophysiological misconception to consider that pin loosening results from PTI. According to their theory, it is the instability of the external fixator pin–bone construct that leads to pin loosening and infection and, consequently, it is pin loosening that is the initiating event which ultimately leads to pin tract sepsis. In this hypothesis, the external fixator construct appears to be vital to the prevention of pin site complications since excessive movement at the fixator pin–bone interface leads to pin site irritation and infection. There is probably an ongoing race between the gradually increasing load capacity of the healing bone and the potential for failure at the bone–pin interface. An unstable fixator will create a mechanically unfavourable environment for optimal bone healing and lead to deleterious instability at the fixator pin–bone interface, thereby producing pin tract irritation and then infection [14, 18].
Bacterial colonisation of pin and biofilm production
Pin or wire colonisation by bacteria starts during surgery or in the early postoperative period and has been described as occurring in steps [19, 20]. Immediately after insertion of the wire or pin, plasma proteins rapidly coat the surface of the fixation pin implant . The current belief is that the initial interaction between bacteria and the adsorbed proteins is probably non-specific, occurring through a combination of Van der Waals, gravitational and Coulombic forces . Membrane proteins and polysaccharides subsequently allow the bacteria to bind firmly to the proteins on the device surfaces. Finally, certain bacterial species secrete a protective exopolysaccharide layer—the biofilm—which renders them resistant to antibiotics [23, 24]. Biofilm-related bacterial infections are recognised as being exceedingly difficult to treat with conventional systemic antibiotic therapies , thus validating the promising strategy of seeking to inhibit bacterial adhesion prior to biofilm formation.
Staphylococcus epidermidis, S. aureus and Escherichia coli are the three most common infective agents of external fixation constructs . Staphylococci are recognised as the most frequent causes of biofilm-associated infections. Their exceptional status among biofilm-associated pathogens is due to the fact that staphylococci are frequent commensal bacteria on human skin and mucus. They are thus among the most likely germs to infect any medical device that penetrates these surfaces, such as those being inserted during surgery . Recent advances in our knowledge of staphylococcal molecular biology have provided a more detailed insight into biofilm formation by these opportunistic pathogens. A series of surface proteins mediate the initial attachment to host matrix proteins, and then the expression of a cationic glucosamine-based exopolysaccharide aggregates the bacterial cells. Similarly, and like many other Gram-negative microorganisms, E. coli also has the capacity to form biofilm structures in vivo and in vitro [27, 28].
Troublingly, classification of PTI varies throughout the literature, with some studies considering such subjective symptoms as pain, whereas others use clinical judgments of infection, radiological signs or microbiological diagnosis of infection. Unfortunately, any classifications are closely correlated to responses to treatment, indicating the retrospective nature of their usage. Thus, a clear systemic methodology for describing PTI is still lacking and, above all, there exists no validated grading system to evaluate the severity of this problem. Many PTI classifications are overly subjective, with varying inter-rater reliability when grading pain, the extent of erythema, tenderness and swelling at a pin site suspected of an infection. Additionally, a grading system which includes pain as a criterion may vary significantly based on cultural or social backgrounds .
Checketts–Otterburn grading system for level of pin site infection
Slight redness, little discharge
Improved pin site care
Redness of skin, discharge, pain and tenderness in the soft tissue
Improved pin site care, oral antibiotics
Grade 2 but not improved with antibiotics
Affected pin or pins resited and external fixation continued
Severe soft tissue infection involving several pins, sometimes with associated loosening of the pin
External fixation must be abandoned
Grade 4 but also involvement of the bone; also visible in radiographs
External fixation must be abandoned
The infection occurs after fixation removal. The pin track heals initially but will break down and discharge at intervals
Radiograph shows new bone formation and sometimes Sequestrum
Curettage of the pin track
How to prevent PTI?
It is widely agreed that any strategy for reducing PTI begins in the operating theatre , but it could be legitimately suggested that PTI prevention should start even earlier, i.e. during the surgical planning step. Choosing the correct external fixator is probably a crucial issue, especially for limb lengthening or deformity correction. Indeed, incidences of PTI during limb lengthening and lower-limb reconstruction are elevated [4, 18]. The high incidence of PTI reported in limb reconstruction surgery may be related to the long periods of time spent in the external fixator and high demands placed on the bone–pin interface during either bone transport or deformity correction . The primary goal of planning should be to ensure a stable bone–pin interface that will withstand the stresses transferred during the reconstructive period [14, 36] and, therefore, this criterion should determine the choice of the appropriate fixator for the planned surgery. Parameswaran et al.  demonstrated that the type of fixator had an effect on the incidence of PTI, with monolateral and hybrid fixators having a much higher incidence of PTI than ring fixators. In addition, Antoci et al. [14.] demonstrated that the incidence of PTI was higher with half-pin external fixators than with hybrid fixators using fine wires in addition to half-pins . As a general rule, it seems that a half-pin site is more prone to PTI than a fine-wire site . Interestingly, the Russian school demonstrated that elastic stable intramedullary nailing could stimulate new endosteal and periosteal bone formation and thus decrease the high incidence of PTI reported in limb reconstruction surgery due to the long periods spent in the external fixator .
Technical notes for surgery
Many authors advocate that great efforts should be made to ensure that not only pin and wire insertion is as atraumatic as possible for the skin, but also for soft tissue and bone, thereby minimising iatrogenic damage to these structures. Thus, the location or placement of the pin must be considered carefully. Skin incisions should only be as large as the diameter of the pin , and these incisions should be made with care in order to avoid tension on the skin. Immediate subcutaneous bone surfaces are preferable, since pins located in areas with considerable soft tissue, tendons and tendon sheaths are at the greatest risk of infection [38, 39]. Wires should not be drilled through to soft tissue, but rather pushed into the near cortex, then drilled through the bone and finally advanced through the opposite soft tissue by tapping with a mallet . Any muscle compartment traversed during the placement pins or wires should be placed under stretch [38, 39] in order to prevent transfixing muscles in a shortened position [38, 39]. Heat generation must be avoided during pin or wire insertion, as this could lead to thermal necrosis of the surrounding bone, ring sequestra and pin loosening. Thus, the anterior tibial crest should be avoided at all cost, as drilling through the thick cortical bone can generate excessive heat [18, 38]. It is thus advisable to drill using continuous cold saline irrigation to ensure proper pin cooling . For half-pin placement, pre-drilling should always be performed, even when using self-drilling pins . After drilling, the pilot hole must be irrigated to remove any bone swarf that might act as sequestra and prevent optimal bone–pin fixation [17, 18]. Finally, many authors follow Davies’ recommendations and, as far as possible, use a no-touch technique when inserting half-pins [17, 18]. To ensure a no-touch technique for inserting wires, chlorhexidine or alcoholic iodine-soaked swabs are used to handle and manipulate wire placement. The immediate use of pressure dressings and the removal of any blood from the skin, especially around the pin site, also lessen the proliferation of bacteria within a haematoma and minimise pin–skin motion.
New pins with bactericidal effects
A number of technical advances have been made to reduce the risk of PTI while maintaining pin stability. Clinicians have attempted numerous methods to solve the problem of PTI , including applying external electromagnetic fields, using alloys to manufacture pins or coating the pin with antibiotics or chemical substances such as hydroxyapatite [36, 42, 43, 44, 45, 46, 47, 48, 49], hydroxyapatite with chlorhexidine [47, 50], silver nanoparticles [51, 52, 53, 54, 55, 56], chlorhexidine, zinc or titanium oxide  and micron-thin sol–gel films .
Hydroxyapatite-coated pins show improved fixation strength, with extraction torque forces that are higher than the initial torque forces and 90-fold higher than those of standard uncoated pins . This improved fixation translates into lower rates of osteolysis and subsequently to lower incidences of pin loosening and lower pin site infection than uncoated pins [36, 42, 43, 44, 46, 49]. Hydroxyapatite–chlorhexidine-coated pins exhibit the dual benefits of enhanced bone stability through bonding to the pin (due to hydroxyapatite) and localised release of chlorhexidine. Silver-coated pins decrease bacterial colonisation  and result in fewer infections and PTI . Unfortunately, silver-coated pins may induce cytotoxicity [61, 62, 63] as some authors have found significant amounts of silver in blood serum . Diffused silver in the blood serum may act as a Trojan horse by entering cells and then releasing silver ions that damage intracellular function . The bactericidal effect induced by nano-titanium dioxide (TiO2) exposed to ultraviolet radiation has been used successfully in many areas, such as the disinfection of water and textiles and in other cleaning processes [64, 65, 66]. When irradiated by near-ultraviolet light, nano-TiO2 shows strong bactericidal activity [65, 67]. One new, attractive perspective for combating PTI is the covalent bonding of antibiotics onto the surface of a titanium pin . Other clinicians, such as Forster et al.  have assessed the potential of antibiotic polyurethane sleeves to inhibit bacterial colonisation on pins; based on their results, they concluded that the use of such sleeves should reduce the incidence of PTI.
Care at the pin site
There is currently no universally accepted protocol for the optimal care of pin sites . A myriad of protocols for pin site care has been described, with significant variations in nearly all aspects of care in terms of types of disinfection solutions, cleansing methods, dressing materials and, above all, the frequency of dressing changes . Thus, pin site care protocols range from a nihilistic approach advocating no active pin care  to aggressive regimens involving twice-daily cleaning, dressing and oral antibiotics for the entire length of the treatment with an external fixator .
The appropriate time to start pin site care varies greatly in the literature, ranging from 24 h to 10 days after surgery [14, 17, 18, 38, 39, 40, 66, 70, 71]. Most of the time, the first fresh dressing is applied within 2 days of surgery, since gauzes are usually blood-soaked and occlusive crusts can appear around the pins. The frequency of pin site cleaning also differs, with authors suggesting cleaning twice daily [14, 72], once daily [39, 73], weekly  and, more rationally, “when required” . In fact, the frequency of pin site cleaning should be correlated with the local status around the pin–tract site. If swelling, crusts or signs of an exudate are observed, then the frequency of pin site cleaning should be more regular (once every day or second day). Once the pin sites have healed and are clean and dry, the frequency of pin site cleaning can decrease, and it is recommended that dressings be replaced weekly.
Various cleaning solutions have been advocated in the literature, including soap and water, sterile water, normal saline, peroxide, polyvinylpyrrolidone-iodine, isopropyl alcohol, polyhexamethylene biguanide and chorhexidine aqueous or alcoholic solutions [14, 17, 18, 38, 39, 40, 70, 71, 72, 73, 75]. It should be remembered that prolonged skin contact with strong antiseptic solutions may lead to dry skin, skin irritation or even a hypersensitive reaction . Fortunately, such adverse effects can usually be resolved by substituting a strong antiseptic solution with a mild antiseptic soap and water. Once pin sites have healed and are clean, patients are allowed to shower, provided that the limb and its external fixator are carefully tested thereafter . In accordance with the recommendations of most authors, we do not advise swimming, but swimming in a chlorinated pool may be permitted in specific cases if beneficial to bone healing.
There is also controversy over which kind of dressing to use after pin tract cleaning. Regardless of the dressings chosen, their main purpose is to keep pin sites clean and dry and to absorb any blood and exudates . Many authors consider that pins should be dressed with sterile gauze in the presence of exudates, but left uncovered in their absence [4, 40]. Others advocate impregnating gauzes with antiseptic solutions in order to decrease the rates of PTI, such as benzalkonium chloride antiseptic solution , polyurethane , polyhexamethylene biguanide  or an alcoholic solution . Paley reported using antibiotic-soaked sponges over pin sites . We do not recommend the use of betadine-soaked gauzes as they induce crust formation and probably induce the skin to stick to the pins. New gauzes have been developed to promote skin healing and decrease PTI. In the presence of abundant exudates, hydrofibre dressings are useful due to their absorptive capacity. Antimicrobial silver dressings have also gained popularity due to the increase in antibiotic-resistant pathogens [76, 77, 78]. These are also interesting for their capacity to reduce the microbial contamination of wounds from environmental sources [79, 80] and, above all, because these dressings may be left in place for up to 7 days .
How the gauze should be fixed in place is yet another topic for discussion. The Russian protocol suggests the use of bulky pressure dressings to restrict movement between the skin and pins . Paley  also recommends minimising pin–skin motion by applying pressure to the skin, either by using gauze compressed by rubber or by using foam sponge cubes pushed down using plastic clips. In a similar approach, Hoffmann  recommended relieving the skin tension around pins in order to prevent infection.
Treatment of pin tract infection
When planning to use external fixation, orthopaedic surgeons should expect many of their patients to develop a PTI, particularly when lengthening limbs or correcting deformities. The most common bacterial etiology for PTI is cocci-shaped Gram-positive bacteria (methicillin-sensitive S. aureus, S. epidermidis and Streptococcus species) [4, 12, 53]. Rare cases of PTI involving methicillin-resistant S. aureus have been observed, especially when chronic osteomyelitis is present. Gram-negative bacteria may also be responsible for PTI, and pathogens such as E. coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterococcus faecalis, Serratia marcecens and Vibrio vulnificus may develop at the pin site. In rare cases, a mixed flora has even been identified . Thus, it would appear that pin site swabs are required before any antibiotic treatment is initiated.
The Checketts–Otterburn PTI classification is commonly used as a guide to decision-making because it provides valuable information regarding treatment . This classification distinguishes between two groups of PTI—minor (grades 1–3) and major (grades 4–6)—with the main difference being that the external fixation pin has to be removed in cases of major infection (see Table 1). Although PTI is common, very few cases lead to major complications, and most PTI are mild and may therefore respond to increased local pin site care. It is thus legitimate and safe to start treatment of a grade 1 PTI by increasing the frequency of local cleaning and dressing changes; it is also advisable to use more absorbent dressings in cases with excessive exudate. Hydrofibres can absorb large amounts of wound fluids, including exudate with bacteria. This is then transformed into a soft gel which creates a moist environment to support the body’s healing process. Furthermore, silver-releasing dressings have been proven to be as effective as oral antibiotics for controlling PTI; they could thus constitute the first-line therapy . For a grade 2 Checketts–Otterburn PTI, not only should pin site care be improved, but patients should be treated with a course of oral antibiotics. Swabbing of the infected pin site is advised before initiating 7–10 days of oral antibiotics aimed at S. aureus. If the PTI resolves within that 7- to 10-day course of antibiotic, the medication can be discontinued, and regular pin site care may be resumed. A patient with grade 3 Checketts–Otterburn PTI should be admitted to hospital for intravenous antibiotics, inpatient pin site care and limb elevation. If these grade 3 PTI do not respond adequately to treatment, the pins or wires involved should be removed and changed, but external fixation can continue.
Major PTI, i.e. grade 4–6 Checketts–Otterburn PTI, should be managed by removing the infected pins or wires and performing an adequate debridement of the pin tracts to remove all necrotic debris [18, 83]. In cases of osteomyelitic pin tracts with sizeable cavities following debridement, the cavities can either be treated by leaving antibiotic beads in the tracts  or by using absorbable calcium-sulphate pellets impregnated with antibiotic to back-fill those tracts . However, it is essential to remember that pin or wire removal must not destabilise the frame construction, as this will result in increased movement at the fixator pin–bone interfaces of the remaining pins and wires, with the potential for further infection . The generally acceptable, and most preferable strategy is to re-situate the septic pins and wires rather than simply removing and replacing them, noting that all of these actions should be done without the overall external fixation being abandoned .
Pin tract infection is an almost inevitable complication when using external fixation. It remains a clinically challenging problem, especially in treatments involving limb lengthening or deformity correction. Standardised pin site protocols that encompass an understanding of external fixator biomechanics and meticulous surgical technique during pin and wire insertion, postoperative pin site care and removal could limit the incidence of major infections and treatment failures.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 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):249–281Google Scholar
- 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):263–285Google Scholar
- 3.Paley D (1990) Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res (250):81–104. PubMed PMID: 2403498Google Scholar
- 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: 18982187Google Scholar
- 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: 20357336CrossRefPubMedGoogle Scholar
- 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: 16452747Google Scholar
- 8.Green SA (1983) Complications of external skeletal fixation. Clin Orthop Relat Res 180:109–116. PubMed PMID: 6627782Google Scholar
- 10.Jennison T, McNally M, Pandit H (2014) Prevention of infection in external fixator pin sites. Acta Biomater 10(2):595–603. PubMed PMID: 24076071Google Scholar
- 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: 3575175Google Scholar
- 12.Mahan J, Seligson D, Henry SL, Hynes P, Dobbins J (1991) Factors in pin tract infections. Orthopedics 14(3):305–308. PubMed PMID: 2020629Google Scholar
- 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: 7593058Google Scholar
- 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: 12902788Google Scholar
- 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: 11382422Google Scholar
- 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: 15855378Google Scholar
- 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: 3535127Google Scholar
- 19.Ariza J, Euba G, Murillo O (2008) Orthopedic device-related infections. Enferm Infecc Microbiol Clin 26(6):380–390. PubMed PMID: 18588820Google Scholar
- 20.Pascual A (2002) Pathogenesis of catheter-related infections: lessons for new designs. Clin Microbiol Infect 8(5):256–264. PubMed PMID: 12047402Google Scholar
- 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: 3117952Google Scholar
- 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: 15593018Google Scholar
- 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: 118068Google Scholar
- 24.Hoyle BD, Costerton JW (1991) Bacterial resistance to antibiotics: the role of biofilms. Progr Drug Res 37:91–105. PubMed PMID: 1763187Google Scholar
- 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: 2582185Google Scholar
- 26.Vuong C, Otto M (2002) Staphylococcus epidermidis infections. Microb Infect Institut Pasteur 4(4):481–489. PubMed PMID: 11932199Google Scholar
- 27.Costerton JW (1995) Overview of microbial biofilms. J Indust Microbiol 15(3):137–140. PubMed PMID: 8519468Google Scholar
- 28.Probert HM, Gibson GR (2002) Bacterial biofilms in the human gastrointestinal tract. Curr Issues Intest Microbiol 3(2):23–27. PubMed PMID: 12400635Google Scholar
- 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: 16691139Google Scholar
- 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: 19323111Google Scholar
- 32.Ward P (1998) Care of skeletal pins: a literature review. Nursing Stand 12(39):34–38. PubMed PMID: 9776884Google Scholar
- 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: 19398787Google Scholar
- 35.Saleh MSB, PacilltSe SO (1992) Pitfalls and complications in leg lengthening: the Sheffield experience. Semin Orthop 7:207–222Google Scholar
- 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: 9563384Google Scholar
- 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: 15502762Google Scholar
- 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: 20123298Google Scholar
- 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: 15902006Google Scholar
- 40.Rose R (2009) Pin site care with the Ilizarov circular fixator. Internet J Orthop Surg 16(1):1–4Google Scholar
- 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: 11426113Google Scholar
- 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: 15955555Google Scholar
- 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: 9577425Google Scholar
- 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: 18286593Google Scholar
- 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: 9181496Google Scholar
- 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: 11927807Google Scholar
- 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: 8723401Google Scholar
- 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: 10898881Google Scholar
- 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: 4824047Google Scholar
- 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: 17137719Google Scholar
- 53.Collinge CA, Goll G, Seligson D, Easley KJ (1994) Pin tract infections: silver vs uncoated pins. Orthopedics 17(5):445–448. PubMed PMID: 8036188Google Scholar
- 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: 19496150Google Scholar
- 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: 19454327Google Scholar
- 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: 19968257Google Scholar
- 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: 25595723Google Scholar
- 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: 26036176Google Scholar
- 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: 15330032Google Scholar
- 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: 10984710Google Scholar
- 61.Asharani PV, Lian Wu Y, Gong Z, Valiyaveettil S (2008) Toxicity of silver nanoparticles in zebrafish models. Nanotechnology 19(25):255102. PubMed PMID: 21828644Google Scholar
- 62.Chen X, Schluesener HJ (2008) Nanosilver: a nanoproduct in medical application. Toxicol Lett 176(1):1–12. PubMed PMID: 18022772Google Scholar
- 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: 19969064Google Scholar
- 65.Fujishima A, Honda K (1972) Electrochemical photolysis of water at a semiconductor electrode. Nature 238(5358):37–38. PubMed PMID: 12635268Google Scholar
- 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: 10739275Google Scholar
- 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: 4428362Google Scholar
- 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: 18843660Google Scholar
- 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: 15338244Google Scholar
- 72.Patterson MM (2005) Multicenter pin care study. Orthop Nurs 24(5):349–360. PubMed PMID: 16272914Google Scholar
- 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: 19858981Google Scholar
- 74.Timms A, Pugh H (2012) Pin site care: guidance and key recommendations. Nurs Stand 27(1):50–55. Quiz 6. PubMed PMID: 23082364Google Scholar
- 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: 3254747Google Scholar
- 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: 14755125Google Scholar
- 78.Bhattacharyya MBH (2006) Antibiotics vs an antimicrobial dressing for pin-track infection. Wounds 2(2):26–33Google Scholar
- 81.Dowsett C (2003) An overview of Acticoat dressing in wound management. Br J Nurs 12[19 Suppl]:S44–S49. PubMed PMID: 14593271Google Scholar
- 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)Google Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.