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Introduction: Host factors affecting pin site infections were selected by The Pin site Consensus Group, using a modified Delphi approach, to be one of the top 10 priorities to investigate how to reduce rates of pin site infections, improve clinical management, and inform research. The aim of this study was to perform a systematic literature review of the association between host factors and pin site infection, focused on age, smoking, body mass index, and comorbidities, in particular diabetes. Materials and Methods: The literature search strategy was developed as advised in the Cochrane Handbook for Systematic Reviews of Interventions following the PRISMA guidelines with the help from a scientific librarian. The protocol was registered in the International Register of Systematic Reviews, PROSPERO (ID: CRD42021273305). The literature search was executed in three electronic bibliographic databases, including Embase MEDLINE (1111 hits) and CINAHL (2066 hits) through Ovid and Cochrane Library CENTRAL (387 hits). Results: A total of 3564 titles were found. 3162 records were excluded by title and abstract screening. 140 studies were assessed for full-text eligibility. All excluded studies were not reporting specific numbers of patients with pin site infection and the associations of interest. 11 studies were included for data extraction. The included studies were all designed retrospective, and the risk of bias assessment was done using Joanna Briggs Institute risk appraisal tool. The extracted data are presented as results in tabular summaries. This review reveals an increased risk of pin site infection associated with increased HbA1C level in diabetic patients and congestive heart failure in diabetic patients. An increased risk of pin site infection was associated with a lower ASA score. None of the included studies found any association between pin site infection and smoking, age, or body mass index. Conclusion: This systematic literature search identified a surprisingly low number of studies examining the association between pin site infection and the specific host factors. Thus, this review most of all serves to demonstrate a gap of evidence about the correlation between host factors and risk of pin site infection, and further studies are warranted.

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Introduction: External fixation is used for a wide variety of surgical treatments. The transcutaneous pins used in external fixation, however, provide a route for bacterial migration from the external to subcutaneous space, and high rates of pin site infection have been reported. The material of which the pin is composed, or any surface coating that is applied, may significantly influence tissue integration and pin site infection. However, clinical data are scarce. The aim of this systematic review and meta-analysis was to summarize the clinical evidence for the role of pin material, and surface coatings, on the incidence of infection at external fixator pin sites. Materials and Methods: A systematic review was performed following registration with PROSPERO. A search was performed using Medline, Embase, and Cochrane. Inclusion criteria were (1) recorded diagnosis of infection, (2) involved external fixation, (3) any bone, (4) English language, (5) human subjects, (5) pin material known, and (6) all levels of evidence. All stages of the review process were performed by two independent reviewers. A meta-analysis was performed using a random effects model meta-analysis to produce odds ratios. Study bias was assessed using the Cochrane risk of bias tool Rob II. Strength of evidence was based on the American Academy of Orthopaedic Surgeons methodology for defining the strength of recommendation. Results: After exclusion, 8 studies were further analyzed. One study compared stainless steel and titanium with an odds ratio of 1.00 (95% confidence interval [CI]: −0.70–2.70). Three studies compared stainless steel to hydroxyapatite (HA)-coated pins with an odds ratio of 0.25 (95% CI: −0.52–1.02). Two studies analyzed titanium compared to HA-coated pins with an odds ratio of 1.12 (95% CI: −4.25–6.48). Two studies analyzed silver compared to stainless steel with an odds ratio of 0.12 (95% CI: −0.89–1.12). However, the strength of evidence was limited for all studies. Overall, 0 studies had a low risk of bias, 4 studies had an unknown risk of bias, and 4 studies had a high risk of bias. Conclusion: There is currently limited evidence of the effect of different pin material or coatings on the incidence of pin site infection, with the available studies showing contrasting results. Further high-quality and adequately powered studies are required to provide definitive guidance.

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Introduction: Pin site infections (PSIs) are frequent complications encountered with the use of circular external fixators. PSIs range in severity, and the numerous factors have been suggested to affect the incidence. We aim to perform a systematic review of all comparative studies including circular external fixation applied to the tibia diaphysis in adult patients and to explore frame and fixation factors that may be associated with the development of PSI. Materials and Methods: We conduct a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess the available data with the specific focus on frame factors that might contribute to the development of PSI. A literature search of major electronic databases was conducted to identify journal articles. A scoping review process was adopted due to the expected broad variation of studies in our research topic using the PRISMA for Scoping Reviews guidelines. Results: The initial electronic database search produced 360 publications. After a review process, only four publications were retained for final analysis. Type of fixation pins and wires, frame fixation configurations, and reconstructive methods were compared in these studies. There are very few clinical studies comparing the different frame and fixation factors that can influence PSI rates in circular external fixation. The available studies reflect a significant degree of bias and confounding, representing a low level of evidence. Conclusion: Further research is needed, and with the present paucity of data, it is not possible to make any firm recommendations. Within the same frame construct, it appears that tensioned wires may carry a lower risk of PSI than half-pins.

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Background: Pin site infection is a frequent complication after external fixation. However, no consensus on the optimal pin site care protocols exists. Objectives: This study aimed at providing an overview of currently applied pin site care protocols and evaluating their efficiency in terms of infection rates. Data Sources: A systematic search of PubMed, Medline, Embase, and Cochrane Library databases was performed. Study eligibility criteria, participants, and interventions: Comparative studies of pin site care protocols reporting the infection rate as complication related to external fixator application as an outcome were eligible for inclusion. Study Appraisal and Synthesis Methods: The ROBINS-I tool was used to assess the risk of bias in nonrandomized studies. The Effective Public Health Practice Project (EPHPP) tool and Coleman Methodology Score were applied for publication quality assessment. Results: A total of 380 manuscripts were screened, yielding an inclusion of 20 articles reporting on 1428 patients. Of these, 17 (85%) studies compared different materials and antimicrobial agents, whereby 9 of these found significant differences. Three studies compared pin site care with no pin site care, and the optimal pin site care frequency was addressed in three studies. None of them reported a statistically significant difference between daily or weekly pin site care. Limitations: Pin site care protocols in the literature are heterogeneous. Conclusions and Implications of Key Findings: No recommendation can be drawn regarding the optimal cleansing solution and dressing type. However, based on this review, a benefit of pin site care compared to no pin site care is suggested. Further, minimal pin care was not associated with significantly worse outcomes, and hence, the need of laborious protocols including frequent cleaning or the use of antimicrobial agents remains questionable.

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Introduction: This review article discusses the published methods of identification of fine wire and half-pin loosening. The evidence is reviewed and presented for the clinical, radiological and histological analysis of the half-pin and fine wire to bone interface. Materials and Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant systematic review was conducted. Studies investigating the use of external fixators with descriptions on measurement of half-pin and fine wire loosening were included in this review. Results: Eight studies were eligible and included. No randomized controlled trials were identified. Torque measurement was most frequently used to quantify the half-pin to bone interface, histological analysis was performed by three studies, and radiographic analysis was performed by five papers including plain film and micro-computed tomography (CT) techniques. Discussion: The available evidence was of poor quality, with a lack of homogeneity in quantitative data for torque measurements and a prevalence of arbitrary figures for the definition of loosening. There was no mechanical analysis of fire wire loosening, and the most common clinical measure used for loosening was a scale validated for infection. Micro-CT was validated against torque figures and appears to be the most repeatable measure which could be applied clinically, however has only been used in canine studies. We recommend a study to compare the clinically relevant measurement of loosening against a standard model to provide a validated method of identification or prediction of half-pin and fine wire loosening.

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Introduction: Pin site infection continues to be a very common problem when treating patients with external fixators. Wire and half-pin insertion technique may influence the risk of developing a pin site infection and the aim of this study is to investigate existing literature in relation to this. Methods: A systematic review of the literature reporting on surgical techniques in relation to pin site infection was conducted. Studies evaluating the effect of a surgical technique with proposed preventive measures to minimize pin site infection in adults and children undergoing an external fixation for trauma or reconstruction were eligible for inclusion. The primary outcome was pin site infection rate. MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched for the period 1970 to August 2021. Study quality was assessed using the modified Downs and Black checklist. A narrative synthesis was undertaken. Results: Two studies describing two different surgical methods were found eligible for inclusion (one cross-sectional study and one prospective cohort). Neither of the two surgical techniques seemed to affect the pin site infection rate. Conclusion: Literature on this topic is sparse, and at present, there is no convincing evidence to support that one surgical technique applying wires and pins is preventive in relation to pin site infection.

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Introduction: Pin site infection is a commonly encountered complication. There is no universally accepted definition or classification system which impairs data interpretation and the development of evidence-based practice. The aim of this systematic review is to investigate the existing classification systems and the quality of reporting pin site infections in the current literature. Materials and Methods: The systematic review protocol was prospectively registered (PROSPERO; National Institute for Health Research and University of York, 2015) and conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A comprehensive search strategy was executed. Data were extracted pertaining to clinical, radiological, microbiological, and mechanical elements alongside associated grading and demographics. The scope of the classification systems was considered. Results: Twelve reports of classifications were included in the synthesis. Four classifications provide information for guiding decision-making and management while the remainder are descriptive or informative in nature. There is no classification with prognostic inference. Four of the classifications can only be applied retrospectively as they are outcome derived. Staging relies on a single variable in six of the classifications. It relies on multiple variables (maximum of four) in the remainder. Conclusion: There is a lack of a clear definition of pin site infection and a lack of a universally accepted grading system. Existing classifications focus on different aspects and have a number of limitations. Establishing standard reporting guidelines will allow for future development of a meaningful and universally accepted definition and classification.

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Introduction: Infection at the pin site connecting an external fixator to the limb is a common and potentially serious complication of frame treatment. Impacted by many patient and injury factors, further variables exist in terms of the way in which pin sites are cared for. Timing and techniques used to clean pin sites vary substantially and are an attractive domain in which to intervene to decrease infection due to the extent of the associated complications and number of patients involved. Through this review, we explore the impact of cleaning techniques and solutions on pin site infection. Methodology: A systematic literature review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, MEDLINE, Cochrane Controlled Trials Register (1996–2022), and EMBASE (1974–2022) were searched in January 2022. Results: Thirty-two articles were identified and following eligibility criteria application 14 studies were analyzed. Nine hundred and fourteen adult and child patients undergoing external fixation treatment 2003–2021 in 12 countries were included. Nine studies used an outcome measure and of these, five different outcome measures were used. The literature was graded as having either some or high concerns of bias. No pooling of data was enabled. Discussion: The literature investigating variables impacting on pin site care in terms of solutions used, technique, and timing of care is poor. Variance in methodology, populations compared, interventions, and outcomes preclude meaningful analysis or conclusions. In particular, the lack of consensus on diagnosis and classification compromises studies relating to this question. Conclusions: Pin site infection is a significant issue in patients undergoing external fixation. The available literature cannot be used to guide care. We strongly recommend a consensus is derived on methodology for studies investigating pin site care. A well-designed randomized controlled trial would carry huge value due to the numbers of patients whose care could be improved through a reduction in pin site infection. Objective: To estimate the impact of pin site cleaning techniques and solutions in preventing pin site infection in patients treated with external fixation. The question which this systematic review address is: “Does pin site cleaning techniques and solutions affect pin site infection rate in external fixation?”

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Context: Pin-site infections are a common complication associated with the use of external fixators. While many different pin-site care protocols have been described, there is no universally accepted and effective method to eliminate this issue. Further research in this area is necessary. Aims: This scoping review evaluates published research dedicated to investigating potential new methods of pin-site infection prevention. Settings and Design: A scoping review was performed with a structured search of MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (EBSCO platform), Scopus, Web of Science, and the Cochrane Library using a range of terms related to pin-site infection. Methods: A qualified librarian carried out the search between February 7, 2021, and September 7, 2021. Studies involving human and animal experiments as well as in vivo and in vitro experiments that evaluated modifications to the pin–skin and bone–pin interface, as well as pin surface morphology, were included. Studies based on the type of intervention and the reported outcomes of infection prevention were evaluated. Results: Four thousand six hundred and twenty-two studies using this search strategy were identified. Following screening and full-text review, 33 studies fit the criteria and were included in this review. Thirty studies involved research that evaluated integration at the bone–pin interface and three studies assessed the pin–skin interface. Conclusions: The review identified a very diverse group of modalities. The majority of the research focused on coating with compounds that possess antibacterial properties or modifications to surface morphology to improve the integration of the pin or wire at the bone–pin interface. While most of the researches did not involve human trials, this review highlights the future directions of pin- and wire-site management in an effort to eliminate or minimize the risk of pin-site infections.

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