Can pin-site infection be prevented? The literature provides no clear guidance on how best to prevent pin-site infection following orthopaedic surgery.
Skeletal external fixation involves the application of metal devices connected to pins or wires that pierce the soft tissues and bone of any limbs and attach to an outside metal frame. (2) There are different types of external fixator systems. They may be unilateral, bilateral, or circular, depending on the location of the fracture or the deformities being treated. (5) External fixator systems provide skeletal stability, allowing early ambulation and weight-bearing on the affected extremity, thus enhancing optimal bone healing. (6) In contrast with open reduction internal fixation, this less invasive technique is used by orthopaedic surgeons to change bone position incrementally to correct bone and cartilage deformities.,
Despite advances in external fixation in orthopaedics, complications still occur. The term "pin sites" describes the entry or exit points in the skin where the pins are inserted. (4) These sites frequently become infected, with the reported incidence of infection ranging from one to 80 per cent. (1)
Pin-site infection is the most commonly reported problem associated with the application of external fixators, (7) due to the disruption of the skin barrier. (8) If not prevented, infection can lead to severe complications, such as chronic osteomyelitis, pin loosening, delayed bone healing, non-union, loss of fracture alignment and systemic infection. (9) These could result in failure of the orthopaedic management of the fracture, due to early removal of the devices, and long-term pain for the patients. These complications could also cause financial burdens due to expensive treatment of infection and prolonged hospital stays. (10)
The prevention of pin-site infection is the primary responsibility of nurses caring for patients with external fixation. However, there are no uniform definitions of pin-site infection in the literature. (1,11) Different studies have attempted to define and classify pin-site infections, but large discrepancies have been reported. (8) This can make it difficult to distinguish between a normal tissue response that occurs 72 hours following the application of pins, and the development of infection. (12)
A tool has been developed as a classification system to define infection and is widely used. (13) Opinions are divided on the value of such an infection grading system, due to concerns about its validity and reliability. (5) Despite this, the tool still helps health professionals assess and monitor pin sites. (5) Nurses need to educate their patients to distinguish between typical local reactions and signs of infection. This helps ensure appropriate treatment is initiated promptly.
A recent systematic review of pin-site care reported there were no effective methods to recommend, because the management of pin sites remains controversial in clinical practice.. This article explores the different methods of pin-site care, eg cleaning, dressing and removing crusts from external fixators and pins. It aims to enhance nurses' knowledge and provide standardised assessment and a uniform approach to managing pin sites.
Cleaning vs no cleaning
Clinicians have different views on cleaning pin sites. Three randomised control trials were conducted to compare the results of cleaning and no cleaning of pin-site wounds. These trials found lower infection rates were associated with no active pin-site care, and suggested cleaning only when the patient's dressing became soiled with blood or serous fluid. (14,15,16)
However, a Cochrane review stated these trials had significant methodological flaws, including the small number of participants and the heterogeneity of pin-site protocols studied. (17) Most of the participants were children and adolescents, which could also have influenced the results, as children and adolescents have fewer co-morbidities.
One of the randomised control trials found an older population was significantly correlated with a higher risk of pin-site complications. (14)
Patient risk factors such as older patients and the presence of co-morbidities are of paramount importance when considering the prevalence of infection from external fixation. (18) Therefore, the less intensive approach to preventing pin-site infection might be appropriate for younger people without chronic conditions, while the more intensive approach may be more important for elderly populations.
The frequency and timing of cleaning pin-site wounds are also controversial issues in clinical practice. There are conflicting views on the best time to start the first postoperative pin-site cares. The first dressing is mostly saturated with blood 48 hours following the application of skeletal fixators or pins. (19) But another researcher has stated that serous or haemoserous drainage occurs 72 hours after the application of external fixation. (16)
The National Association of Orthopaedic Nurses (NAON) in the United States advises starting the care after first the first 48 to 72 hours, otherwise when heavy drainage is evident. (5) Nurses should, therefore, use their clinical judgement and reasoning to consider which approach is most appropriate for their patients.
Daily or weekly cleaning?
Currently, there is only one randomised control trial comparing the effectiveness of daily and weekly cleaning of pin sites, using a normal saline solution. (20) This trial found no significant difference in infection rates between the two protocols.
Numerous studies have investigated daily cleaning protocols, using different cleaning solutions. Their findings revealed infection rates varying from 22.5 to 66.7 per cent. (14,15,21,22)
Cleaning the pin site twice a day is the common clinical practice in the ward I work on. Only a few studies have examined the effectiveness of twice daily pin-site cares. One study revealed higher infection rates, ranging from 33 to 46 per cent. (16) This practice is widely recommended in websites about external fixators. (5)
Based on the results of these trials, it seems the frequency of pin-site cares could potentially increase the incidence of pin-site infection. Despite the evidence, studies comparing the frequency of cleaning the sites were questionable, due to risk of bias. (1)
The lack of well-designed randomised control trials has driven a group of experts to recommend a weekly pin-site care protocol. (23) However, they recommend pin-site cares should be more frequent if signs of infection were evident or dressings became saturated. (23)
Efficacy of different solutions
Many clinicians have explored the efficacy of various cleaning solutions. These solutions included normal saline, chlorhexidine, hydrogen peroxide, diluted povidone-iodine, 70 per cent alcohol and even water and soap.
Three randomised control trials assessed the affects of different cleaning solutions in preventing pin-site infection. One study evaluated the effectiveness of daily cleaning, using normal saline or 70 per cent alcohol. (15) Both protocols revealed no significant differences in preventing infection of pin sites, with 25 per cent and 17.5 per cent infection rates respectively.
Another study reported no significant differences in reducing infection rates when assessing the efficacy of cleaning pin sites with normal saline, half-strength hydrogen peroxide or soap and water. (16)
The third study reported almost equal results when comparing povidone-iodine and normal saline, with 19 per cent and (17) per cent infection rates respectively. (24) Because of these results, the researchers advocated normal saline because it is cheaper, readily available and has a low risk of hypersensitivity. (24)
While the randomised control trials failed to determine a solution of choice for pin-site cleaning, comparative studies revealed possible promising outcomes. One found that chlorhexidine solution could decrease the development of pin-site infection compared to normal saline. (20)
Similarly, a recent comparative study suggested that chlorhexidine appeared superior to povidone-iodine, as the latter tripled the infection rate. (25) However, the results of both comparative studies were not statistically significant. Despite this, the NAON considered chlorhexidine solution as the most efficient in cleaning pin sites, due to its antimicrobial properties. (5) This recommendation is not supported by a consensus in the United Kingdom. Instead, a combination of alcohol and chlorhexidine is the solution of choice because of its drying effect and antimicrobial activity; but the concentration needs further clarification. (23) However, normal saline could be used in the presence of skin sensitivity or allergy. (23) As yet, there is not sufficient evidence to determine which solution is most efficient in preventing pin-site infections.
The use of dressings on pin sites varies in clinical practice, and insufficient evidence is available on whether it is best to dress the sites or not. Surgeons usually apply dressing intraoperatively to absorb serous and haemoserous fluids, which occurs in the first 48-72 hours following external fixator application. While opinions vary on whether to cover with a dressing or to expose the pin sites when oozing stops, there are also different views on what types of dressing should be applied. (10)
Only one trial compared dressing with no dressing in the management of pin sites. This trial concluded routine pin-site care was pointless because similar outcomes were reported from both protocols. (26) However, possible confounding factors such as age, sex, pin locations and fixator duration could affect the result of this study. (1)
On the other hand, most literature supported covering the pin sites with dressing to protect from contamination by dust particles (6) and to absorb exudate from the sites. (2)
The type of dressings to reduce the incidence of pin-site infection is another area of discussion. One trial found that weekly dry dressing changes had an infection rate of 2.5 per cent compared to an infection rate of five per cent with weekly dressing changes using Biopatch dressings. (14)
Another study reported significant reduction in the incidence of infection with a daily application of one per cent polyhexamethylene biguanide (PHMB) and plain gauze (4.5 per cent). This trial concluded that PHMB is superior compared to plain gauze. (27)
In contrast, two trials reported higher infection rates, varying from 40 to 66.7 per cent, when comparing different types of dressings. One investigated daily application of dry gauze and gauze soaked with povidone-iodine, (21) and the other examined silver sulphadiazine and dry gauze dressing. (28) However, the results of these four trials were not statistically significant and had methodological limitations. (1)
While no effective dressing is proven to decrease the prevalence of pin-site infection, Biopatch and PHMB dressings could be used because, aside from their antiseptic characteristics, both have shown superiority compared to other dressings. Conversely, plain gauze could also be advocated because of its availability and inexpensiveness.
Pin-site crusting is another controversial issue, with no specific empirical research on whether removing or leaving the crust where the pin pierces the skin reduces infection rates. (10) Some protocols suggested removing the crust to allow wound assessment and exudate drainage. (15) However, another study opposed this and suggested retaining the crust unless signs of infection were evident. (20) This was supported by a study, which compared the effect of retention and removal of crust to reduce infection rates. (29) This reported a (36) per cent infection rate when leaving the crust in place, and a 61 per cent infection rate when removing the crust. (29) Although retaining the crust provided significant protection against infection, researchers discovered that infected pin sites were more resistant to antibiotic treatment than pin sites where the crust had been removed during cleaning. (29)
Management of crust
Based on this evidence, crust retention could serve as a natural barrier to pin sites; however, it could predispose to abscess formation, leading to infection. The importance of assessing pin sites for signs of infection and crust formation is essential, because both removal and retention of crust have arguments in their favour. However, there are no recommendations in the management of pin-site crusts from the NAON and the current British consensus group. (5,6)
Other aspects of cleaning pin sites could affect infection rates. There were only two controlled trials comparing sterile and non-sterile approaches in administering pin-site care. (16,22) One multi centre study compared two sterile cleaning solutions with non-sterile soap and water. (16) The results revealed that the sterile technique was superior to the non-sterile technique, with infection rates of 29 per cent and 45 per cent respectively. (16) However, the result of the study was not tested statistically on publication, so the validity of the research is questionable. (1)
The other study examined the efficacy of cleaning the pin sites using sterile gauze soaked with povidone iodine and using a soft toothbrush with soap after daily showering. (22) The trial reported no evidence of superiority between the protocols. (22)
Pin-site infection remains a dilemma for nurses caring for patients with external fixation because of the lack of available evidence on which to base practice. Clinicians should use their clinical judgment and reasoning in assessing and managing pin sites to prevent infection. It is important different clinicians caring for the same patient use the same pin-site care protocol to avoid inconsistencies of care and confusion for the patient. Further research on the best cleaning solutions, the timing and frequency of care, the types of dressing and crust management is needed to find the best way to prevent pin-site infection.
This article has been reviewed by nurse practitioner Kirstie Cooke, who works at Grace Hospital in Tauranga, the charge nurse of the orthopaedic ward at Tauranga Hospital Ross Turner and the co-editors of Kai Tiaki Nursing New Zealand.
* References for this article are on p48
Mark Abbariao, RN, PGDip, is a staff nurse on an orthopaedic ward at Christchurch Hospital. This article was developed from an assignment he wrote towards his masters of nursing.
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Caption: 'Despite advances in external fixation in orthopaedics, complications still occur.'
Caption: The importance of assessing pin sites for signs of infection and crust formation is essential, because both removal and retention of crust have arguments in their favour.'
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|Publication:||Kai Tiaki: Nursing New Zealand|
|Date:||Oct 1, 2018|
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