Session III - Upper Extremity
Fri., 10/8/04 Upper Extremity, Paper #22, 3:57 pm
Pin Care following External Fixation of the Wrist: A Prospective Randomized Trial of Three Techniques
Purpose: The purpose of this IRB approved prospective randomized trial was to evaluate 2 commonly utilized methods of external fixation pin care and compare them to a newer method.
Methods and Materials: 120 patients were randomized into 1/3 treatment groups following placement of an external fixation device for the treatment of a displaced, unstable distal radius fracture. All fixators were placed under a standardized protocol and all patients were placed in a sterile dry dressing immediately. At 1 week after surgery patients were randomized into one of three pin care treatment regimens: 1) weekly dry dressing changes without pin care. 2) Daily pin care with a solution of 1/2 normal saline and 1/2 hydrogen peroxide. 3) Chlorhexadine impregnated discs (Biopatch, Johnson and Johnson) placed around the pins and changed weekly by the treating surgeon. In all cases the pin sites were wrapped in a Kling dressing. The patients were followed at weekly intervals until the fixator was removed. Radiographs were obtained biweekly.
Patients were evaluated for: 1) erythema, 2) cellulitis, 3) drainage, 4) clinical or radiographic evidence of pin loosening, 5) need for antibiotics 6) return to the operating room for infection or implant failure and 7) need for pin removal before fracture healing due to infection. Multivariate Poisson regression was used to evaluate differences in complication rate among the three post operative dressing groups adjusting for age, gender, and ORIF.
Results: The study group consisted of 120 patients, 75 female and 45 male. There were 54 left wrists, 62 right wrists, and 2 bilateral. The average age of the patients was 54 years (min 18, max 91, std 19.4). 47 had an open procedure (ORIF) in addition to the external fixator, either bone grafting or open reduction and internal fixation. The fixators remained on an average of 5.9 weeks.
There was a greater proportion of men randomized to the Biopatch group and fewer to the DSD and peroxide groups than women (p=0.001). However, the groups were equivalent in terms of average age (p=0.44), and circumstances of injury (p=0.12). Proportionately, those getting additional ORIF were more likely to have gotten Biopatch or peroxide and less likely to have gotten DSD than those not getting additional ORIF (p=0.02).
Twenty-three patients had a pin tract related complication for a rate of 28%. Twelve patients (10%) required antibiotics. There was one patient with a deep infection that required surgical debridement and long term antibiotics. 117 patients (98%) healed their fracture in the fixator, and 3 patients (2%) had the fixator removed prior to fracture healing due to pin infection. There was one case of pin loosening which was evident both clinically and radiographically.
The Biopatch group had a 19% complication rate, the hydrogen peroxide group 33% and the dry dressing group 18% (_2=3.2, p=0.20). Nine of the 12 patients requiring antibiotics, all 3 patients with early fixator removal, and the only patient requiring return to the operating room was in the hydrogen peroxide group.
Only age was statistically significantly associated with increased risk of post operative complication. The average age of patients developing a complication was 64 years versus 51 years for those without complications (p=0.04).
Conclusion: There is a significant incidence of local wound complications around external fixation pin sites, however, most are minor and can be observed or treated with oral antibiotics. The incidence of these complications was not decreased by the use of hydrogen peroxide wound care or chlorhexidine impregnated dressings. Based on these results, we do not recommend additional wound care expense beyond dry, sterile dressings for pin tract care after external fixation for distal radius fracture.