Journal of Limb Lengthening & Reconstruction

: 2022  |  Volume : 8  |  Issue : 3  |  Page : 1--2

International pin site consensus: Time to develop common grounds and collaborate?

Hemant K Sharma1, Nando Ferreira2, Catriona McDaid3, Martin McNally4,  
1 Hull Limb Reconstruction and Bone Infection Unit, Hull University Teaching Hospitals, Hull York Medical School, University of Hull, Hull, UK
2 Head Clinical Unit: Tumour, Sepsis and Limb Reconstruction, Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
3 Department of Health Sciences, University of York, York, UK
4 King James IV Professor, The Royal College of Surgeons of Edinburgh, Lead Surgeon, Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Honorary Senior Lecturer, University of Oxford, Oxford, UK

Correspondence Address:
Hemant K Sharma
Hull University Teaching Hospitals, Anlaby Road, Hull

How to cite this article:
Sharma HK, Ferreira N, McDaid C, McNally M. International pin site consensus: Time to develop common grounds and collaborate?.J Limb Lengthen Reconstr 2022;8:1-2

How to cite this URL:
Sharma HK, Ferreira N, McDaid C, McNally M. International pin site consensus: Time to develop common grounds and collaborate?. J Limb Lengthen Reconstr [serial online] 2022 [cited 2023 Jan 29 ];8:1-2
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Full Text

Since the advent of external fixation, pin site infection has been a constant problem for patients and surgeons alike. Prof. Gavriil Ilizarov[1] was not the first to use external fixation, but he laid down the principles ensuring consistent results from circular frames. Since then, external fixation has gradually increased for various indications; however, pin site complications remain a significant concern for the limb reconstruction surgeon. Pin site complications can lead to serious consequences, including poor outcomes and treatment failure.

Reporting of pin site infections has been variable using numerous unvalidated classifications. What constitutes an infection is often debated.[2] Published literature on pin site infection is of poor quality[3],[4] and unreliable to formulate evidence-based guidelines. This has led to variable pin site care regimens and treatment, all based on insufficient quality literature and almost all without robust scientific evidence.

Pin site infection is a complex issue with multiple factors to consider, ranging from patient-related, surgical technique, pin–bone interface, pin–skin interface, and choice of the external fixator. This is further complicated by the material properties of metals used, the surface properties, and coatings of pins and wires. These factors aim to decrease bacterial adhesion, improve pin-bone fixation and reduce pin site loosening and infection. Patients' immunity and certain comorbidities are reported to lead to increased infections; however, there are few studies which investigated the role of the skin in pin site infections.[5] Ferguson's analysis, although a randomized controlled trial (RCT), was underpowered to show a clinically relevant difference.[5]

In 2018, members of the Global TrueLok Masters Club met in Cape Town, South Africa, to discuss external fixator pin site complications, leading to the establishment of the Pin Site Consensus Group and the “International Pin Site Consensus Study.” A modified Delphi approach was used to establish clinical question consensus among an international group of limb reconstruction health-care providers on the most critical factors affecting pin site longevity during circular external fixation. The process used an expert panel (Pin Site Consensus Group) to guide question development through three rounds. An initial collection of around 1000 individual questions from more than 150 participants were reviewed and thematically grouped. Themes were ranked according to relevance and eventually identified nine key aspects concerning external fixator pin sites. These nine questions were then assigned to international volunteer researchers who undertook systematic literature reviews in an attempt to reach a consensus statement for each question.

In this special issue of the Journal of Limb Lengthening and Reconstruction, the authors review and analyze the literature regarding pin site infections in nine articles. Through their comprehensive search of the main online databases, they describe pin site cleaning techniques and solutions, pin site dressing types, technical- and implant-related factors related to infection, host-related risk factors of pin site infection, classifications of pin site infections, and future directions in this hot topic.

This special issue highlights the paucity of high-quality literature available to surgeons to inform evidence-based decisions for this clinical problem. Through the International Pin Site Consensus Group, we hope to galvanize surgeons to work together and with methodologists to improve evidence-based future research. The research design used should be appropriate to the research question and it is likely that a range of methods may be required, including RCTs, high-quality prospective cohort studies, and other designs. A pragmatic trial design can be useful to inform day-to-day clinical practice. Observation, with careful prospective data collection, may offer a broader knowledge in this complex field. This approach was most effectively applied by Charles Darwin[6] in elucidating his theory of evolution. He noted, “I am turned into a sort of machine for observing facts and grinding out conclusions”.[6] It will be important to shift from single-center studies, which were common across the reviews, to collaborative multicenter research, using registered protocols with consistent, robust data collection, and pooling of data from large centers' outcomes. Predictive modeling, along with new technologies, can further help our patients.

These nine articles have shown that there is wide interest in the topic. We look forward to developing the consensus group and presenting future studies to inform practice, simplify decision-making, and help patients. You could say something like – We look forward to (or we plan to) building on the work of the consensus group and the nine reviews by undertaking a research prioritization exercise to identify the research questions to focus on over the coming years.


1Gavril A Ilizarov: Transosseous Osteosynthesis: Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue: Springer-Verlag New York Inc., 1998.
2Santy J. Recognising infection in wounds. Nurs Stand 2008;23. doi:10.7748/ns2008.
3Stinner DJ, Hsu JR, Iobst C. The half-pin and the pin tract: a survey of the Limb Lengthening and Reconstruction Society. Am J Orthop (Belle Mead NJ). 2013;42:E68-E71.
4Kazmers NH, Fragomen AT, Rozbruch SR. Prevention of pin site infection in external fixation: a review of the literature. Strategies Trauma Limb Reconstr. 2016;11:75-85. doi:10.1007/s11751-016-0256-4.
5Ferguson D, Harwood P, Allgar V, et al. The PINS Trial: a prospective randomized clinical trial comparing a traditional versus an emollient skincare regimen for the care of pin-sites in patients with circular frames. Bone Joint J. 2021;103-B(2):279-285. doi:10.1302/0301-620X.103B2.BJJ-2020-0680.R1.
6Charles Darwin: Theory of Evolution / Selected Letters by Darwin