Kirschner wire pin site infection in hand and wrist fractures: incidence rate and risk factors

Comparative study of K-wire combined with screw vs. K-wire in the treatment of AO type B3.1 phalangeal fractures

PURPOSE

The purpose of this study was to introduce the surgical method of K-wire combined with screw in the treatment of Arbeitsgemeinschaftfür Osteosynthesefragen (AO) type B3.1 phalangeal fractures and to compare its clinical, radiological and functional outcomes with K-wire fixation.

METHODS

This was a retrospective comparative study. From January 2015 to February 2022, we treated 86 patients with AO type B3.1 phalangeal fractures. A total of 71 patients were finally included in the statistical analysis. Thirty-nine patients received K-wires combined with screw, and 32 patients received simple K-wires. The follow-up time was at least 6 months. Outcome measures included general information, operative time, total active motion (TAM), pinch strength, radiological union time, pain assessed by visual analog scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, cost, and complications.

RESULTS

The follow-up time was 6-12 months, with an average of 7.9 months. All patients achieved clinical and radiological union. Compared with the K-wire fixation group, the TAM, radiological union time and VAS score of the K-wire combined with screw group had obvious advantages. Compared with the opposite healthy hand, the grip strength of the two groups was similar, and there was no significant difference in the QuickDASH score. The incidence rate of complications in the K-wire combined with screw group (2/39) was lower than that in the K-wire fixation group (7/32).

CONCLUSIONS

Compared with simple K-wire fixation, K-wire combined with screw in the treatment of AO type B3.1 phalangeal fractures is a safer and reliable surgical method. K-wire controls the rotation and plays a role similar to a "lock". The screw can exert pressure and fix it more firmly. It shortens the time of fracture healing and has a higher TAM and fewer postoperative complications.

Peri-operative Antibiotic Prophylaxis in K-Wire Fixation: A Systematic Review and Meta-analysis

Introduction

There are currently no standardised guidelines on whether antibiotic prophylaxis is required for Kirschner wire (K-wire) fixation to minimise the risk of surgical site infection when used in patients undergoing clean orthopaedic surgery.

Purpose

To compare the outcomes of antibiotic prophylaxis versus no antibiotic in K-wire fixation when used in either in trauma or elective orthopaedics.

Methods

A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines and a search of electronic information was conducted to identify all randomised controlled trials (RCTs) and non-randomised studies comparing the outcomes of antibiotic prophylaxis group versus those without antibiotic in patients undergoing orthopaedic surgery in which K-wire fixation was used. Incidence of surgical site infection (SSI) was the primary outcome. Random effects modelling was used for the analysis.

Results

Four retrospective cohort studies and one RCT were identified with a total of 2316 patients. There was no significant difference between the prophylactic antibiotic and no antibiotic groups in terms of incidence of SSI (odds ratio [OR] = 0.72, P = 0.18).

Conclusions

There is no significant difference in administering peri-operative antibiotics for patients undergoing orthopaedic surgery using K-wire.

Carpometacarpal dislocation second to fifth with associated hamate fracture: A case report of rare injury

INTRODUCTION

Carpometacarpal (CMC) dislocation of the second to fifth metacarpals is an extremely rare hand injury that results from high-energy trauma. It is inherently unstable, especially if it is associated with concomitant carpal or metacarpal fractures.

CASE PRESENTATION

We report the case of an 18-year-old male who sustained a motorbike injury at the level of the second to fifth CMC joints, which was associated with a hamate fracture. The patient failed initial conservative treatment, and so one week later he underwent closed reduction of the second to fifth carpometacarpal dislocations and Kirschner wire fixations from the second to fifth metacarpals. He then underwent open reduction and internal fixation of the hamate fracture using a mini-fragment plate and screws.

DISCUSSION

This type of hand trauma is often overlooked due to radiological misinterpretations. It is important to pay attention to significant soft tissue swelling in this injury. Percutaneous pinning is still considered the gold standard and safest procedure for this injury.

CONCLUSION

This is a rare hand injury that requires careful radiological assessment and meticulous and stable reduction. We believe that open reduction is advantageous in certain circumstances.

A Prospective Study Comparing the Infection Rate Between Buried vs Exposed Kirschner Wires in Hand and Wrist Fixations

INTRODUCTION

Kirschner wires (K-wires) are used in fracture fixations but are often associated with pin tract infections. This prospective study compared the infection rate between buried and exposed K-wires in closed injuries of the wrist and hands in individuals with no comorbidities.

METHODS

Fifteen patients were recruited with a total of 41 K-wires (21 buried K-wires; 20 exposed K-wires). Clinical and radiographic evidence of infection was assessed at three months based on the Modified Oppenheim classification.

RESULTS

Two out of 21 wires in the buried group developed grade 4 infection, while 20 wires in the exposed group did not have any significant infection. No significant difference in infection rate based on K-wire size or number in both groups.

CONCLUSION

There is no significant difference in infection rate between buried and exposed K-wires in healthy individuals with closed injuries of the wrist and hand.

Threaded intramedullary headless nail fixation for fractures requiring carpometacarpal stabilization

Carpometacarpal (CMC) fracture-dislocations are uncommon hand injuries, with few studies available regarding their treatment. The current operative treatment options include fixation with K-wires, mini-screws, or plates, though there is no standardized approach because of varying injury patterns and complications associated with each device. The INnate™ threaded intramedullary nail is a relatively novel treatment option that has shown promise in metacarpal fracture fixation by facilitating faster mobilization and recovery with enhanced rotational stability and no compression to prevent fracture displacement and shortening. This study assesses the efficacy of the INnate™ nail for fixation of CMC fracture-dislocations of the second through fifth joints. Nine patients with fourteen CMC fracture-dislocations treated with the INnate™ nail at the University Medical Center between 2019 and 2021 were enrolled in the study. We evaluated postoperative outcomes in terms of pain, total active range of motion (TAM), and return to normal activities. Of the nine patients, seven returned for follow-up. The average time to radiographic union was 11.5 weeks. At final follow-up, no patient reported pain (n = 6). Four patients had 100% TAM, 1 had 95% TAM, and 1 had 25% TAM. The average percentage of normal activity resumed was 84.0% (n = 5). No significant complications were reported. One patient had a dorsal spanning plate; hence, we were unable to record outcomes measures regarding the CMC injury. An additional patient had diminished ROM of the injured hand, but his last follow-up was only 1 month postop. Our pilot data overall suggest that the INnate™ threaded intramedullary nail has the potential to improve treatment algorithms for CMC fracture-dislocations.

Finger Amputation after Pinning of the Distal Interphalangeal Joint for Acute Closed Tendinous Mallet Finger: A Rare but Devastating Complication

The best treatment for mallet fingers is still a matter of debate. Numerous splints with different designs to keep the distal interphalangeal (DIP) joint in extension have been described in literature. The outcomes of splint treatment are generally good with occasional reports of minor skin complications. Percutaneous Kirschner-wire pinning of the DIP joint for closed tendinous mallet finger represents a alternative treatment modality that reliably immobilises the joint and does not need much patient compliance or use of an external splint. We report a rare but devastating complication of percutaneous pinning of the DIP joint for closed tendinous mallet finger.

Level of Evidence: Level V (Therapeutic)

Traction splinting (EAVAST protocol) versus operative fixation of proximal phalanx fractures: a comparative study of patient outcomes

Introduction: Phalangeal fractures are common, frequently deformed and unstable, and are regularly managed operatively. However, closed methods of reduction are increasing. This study aimed to compare functional outcomes for a non-operative cohort using a skin traction method developed by the Nepean Hospital, Sydney, Australia, termed ‘early active vector adjustable skin traction’ or EAVAST, compared to operatively managed patients as a potential alternative for the management proximal phalanx fractures. Methods: A prospective cohort study of patients who underwent operative fixation or traction using the EAVAST protocol between January 2018 and January 2020. Patients were managed on a case-by-case basis by fracture type and mechanism of injury. Functional outcomes were assessed at three months post intervention using total active motion, mean strength and QuickDASH scores. Measurements were conducted by independent clinicians with patients wearing gloves to blind the assessor to signs of intervention. Results: Of 38 patients identified for inclusion in the study, 15 underwent operative fixation and 23 underwent traction. There were no significant differences found between the two groups for all outcome measures. The mean total active motion, mean strength and QuickDASH scores for the traction and operative groups were 90.8 per cent versus 90.7 per cent (P = 0.97), 84 per cent versus 79 per cent (P = 0.58) and 1.48 versus 2.5 (P = 0.54), respectively. Conclusions: We found no clinically or statistically significant difference between EAVAST protocol and operative management of proximal phalanx fractures. Future study is now warranted, ideally a multi-centre prospective randomised controlled trial with blinded assessment of outcomes in-cluding a cost–benefit analysis comparing standardised operative and traction techniques.

Reducing the incidence of pin site infection in hand surgery with the use of a protocol from Ilizarov

Reported pin site infection rates in Kirschner wire fixation in the hand and wrist vary from 2% to 35%. In our unit we follow a strict pin site management protocol adapted from the Russian Ilizarov Scientific Centre. This study aims to identify if our current protocol reduces the incidence of pin site infection in hand and wrist surgery, and improves wire survival rates, to a level where exposed wires can be used safely. A retrospective review of 200 patients, treated with 369 percutaneous wires, in our hand surgery department over a 6-year period was carried out. Nine patients (4.5%) were diagnosed with a pin site infection with a wire survival rate of 99.5%.In our unit using our current protocol, results support the safe use of exposed wires with appropriate pin site care initiated in theatre. Adherence to this protocol allows wires to remain in-situ throughout treatment with minimal complications.Level of evidence: IV.

Outcomes of an aseptic technique for Kirschner wire percutaneous pinning in the hand and wrist

INTRODUCTION

Kirschner wires (K-wires) have been shown to effectively stabilize fractures of the hand and wrist, but are associated with high infection rates, which may limit its use. Previous literature has attributed the risk of infection to many different aspects of a fixation technique. However, we introduce an approach to percutaneous K-wire pinning to mitigate the risk of infection.

METHODS

Patients undergoing K-wire fixation procedures of the hand and wrist were retrospectively queried. All cases were performed under the same principles of our technique. None of the K-wires were buried, nor bent and were covered with betadine-soaked alcohol pads as pin site dressings. Pins were removed in an outpatient procedure room up to 12 weeks postoperatively and were then assessed for signs of superficial or deep infection.

RESULTS

90 patients were included in this study across a variety of K-wire fixation operations in the hand and wrist. No patients presented with any signs of infection or other complications necessitating postoperative antibiotics, early pin removal, or reoperation.

DISCUSSION/CONCLUSION

The specific guidelines of our technique resulted in no cases of pin site infection, despite a largely underserved patient population. Our low incidence of infection was maintained without the use of prophylactic antibiotics and in patients with long periods of fixation. While the high infection rates in previous literature have often been associated with wires left exposed, the principles of our technique allow for K-wire fixations to be performed percutaneously without burying the wires. This may allow for improved cost and time efficiency, without compromising patient safety.

Isolated Dorsal Dislocations of the Fourth and Fifth Carpometacarpal Joints: A Case Report and Review of Literature

Dislocations of the carpometacarpal (CMC) joints without fracture are rare injuries. They commonly involve the fourth and fifth metacarpals of the dominant hand. Missed and incorrect diagnoses are quite frequent due to subtle clinical and radiological findings. Untreated cases may result in chronic disability due to long term pain and weakness in grip strength. Closed reduction is possible when performed early but can be unstable. We present a rare case of unstable dislocation of fourth and fifth carpometacarpal joints treated by closed reduction and percutaneous pinning.

Surgical site infections after distal radius fracture surgery: a nation-wide cohort study of 31,807 adult patients

BACKGROUND

Surgical site infections (SSI) after distal radius fracture (DRF) surgery have not previously been studied as the primary outcome in a large population with comparative data for different surgical methods. The aims of this study were 1) to compare SSI rates between plate fixation, percutaneous pinning and external fixation, and 2) to study factors associated with SSI.

METHODS

We performed a nation-wide cohort study linking data from the Swedish national patient register (NPR) with the Swedish prescribed drug register (SPDR). We included all patients ≥18 years with a registration of a surgically treated DRF in the NPR between 2006 and 2013. The primary outcome was a registration in the SPDR of a dispensed prescription of peroral Flucloxacillin and/or Clindamycin within the first 8 weeks following surgery, which was used as a proxy for an SSI. The SSI rates for the three main surgical methods were calculated. Logistic regression was used to study the association between surgical method and the primary outcome, adjusted for potential confounders including age, sex, fracture type (closed/open), and a dispensed prescription of Flucloxacillin and/or Clindamycin 0-8 weeks prior to DRF surgery. A classification tree analysis was performed to study which factors were associated with SSI.

RESULTS

A total of 31,807 patients with a surgically treated DRF were included. The proportion of patients with an SSI was 5% (n = 1110/21,348) among patients treated with plate fixation, 12% (n = 754/6198) among patients treated with percutaneous pinning, and 28% (n = 1180/4261) among patients treated with external fixation. After adjustment for potential confounders, the surgical method most strongly associated with SSI was external fixation (aOR 6.9 (95% CI 6.2-7.5, p < 0.001)), followed by percutaneous pinning (aOR 2.7 (95% CI 2.4-3.0, p < 0.001)) (reference: plate fixation). The classification tree analysis showed that surgical method, fracture type (closed/open), age and sex were factors associated with SSI.

CONCLUSIONS

The SSI rate was highest after external fixation and lowest after plate fixation. The results may be useful for estimation of SSI burdens after DRF surgery on a population basis. For the physician, they may be useful for  estimating the likelihood of SSI in individual patients.

Effect of buried vs. exposed Kirschner wire osteosynthesis on phalangeal, metacarpal and distal radial fractures: A systematic review and meta-analysis

Background

During Kirschner wire osteosynthesis for phalangeal, metacarpal and distal radial fractures, a key clinical decision is whether to leave a Kirschner wire exposed or bury it beneath the skin. Therefore, we conducted a meta-analysis to evaluate the clinical effect of buried and exposed Kirschner wire osteosynthesis on phalangeal, metacarpal and distal radial fractures.

Methods

PubMed, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched and clinical trials that evaluated buried and exposed Kirschner wire osteosynthesis for phalangeal, metacarpal and distal radial fractures were identified. Methodological qualities of studies were assessed by using the Cochrane Collaboration tool and Newcastle-Ottawa Scale. Publication bias was detected using Begg’s test and Egger’s test. Sensitivity analyses were performed by excluding one study at a time to determine whether overall results were reliable.

Results

Two randomized controlled trials (RCT) and five case-controlled studies involving 1446 patients were included in the analysis. Sensitivity analyses indicated that the results of each study were statistically robust. Begg’s test or Egger’s test revealed no significant publication bias. Our meta-analysis indicated that exposed Kirschner wire osteosynthesis had a significantly higher infection rate than its buried counterpart. Additionally, buried Kirschner wire osteosynthesis resulted in a significantly higher rate of Kirschner wire removal in operating room than the exposed one. Our meta-analysis exhibited no statistical differences between the two procedures in the rate of early pin removal.

Conclusions

Meta-analysis of available RCTs and case-controlled studies demonstrated that buried Kirschner wire osteosynthesis had a lower infection rate but tended to lead to more frequent Kirschner wire removal in the operating room as compared to its exposed counterpart.

Trial registration

PROSPERO (CRD42018105249).

The Incidence of Pin Tract Infections and Septic Arthritis in Percutaneous Distal Femur Pinning

BACKGROUND

Retrograde percutaneous pinning often involves intra-articular pin placement. Classic teaching has cautioned about the risk of septic arthritis with intra-articular pins, although an incidence has not been reported for this complication. The purpose of this study was to determine the incidence of pin tract infections and septic arthritis following retrograde percutaneous pinning of the distal femur.

METHODS

A retrospective review identified patients who underwent retrograde percutaneous pinning of the distal femur for osteotomy or physeal fracture fixation at a tertiary pediatric hospital from 2006 to 2017 and had at least 3 months follow-up. The incidence of pin site infections and septic arthritis was determined.

RESULTS

In total, 163 patients met criteria, 142 patients with osteotomies and 21 with physeal fractures. The mean pin duration was 33.2±9.0 days (range: 18 to 68 d). Pin duration of ≥30 days was associated with an increased rate of pin tract infections (11.2% vs. 1.4%, P=0.01). The incidence of pin tract infections was 6.7% (11/163), including 9.5% (2/21) in those with fractures and 6.3% (9/142) following osteotomy (P=0.64). There were no cases of septic arthritis. Of the 11 patients with pin tract infections, 9 were treated successfully with oral antibiotics and 2 patients (1.2%) underwent surgical intervention for infection. Treatment of pin infections with oral antibiotics alone was successful in all 7 patients whose pins were removed within 35 days of surgery, but in only 2 of 4 whose pins were removed later (P=0.11). Of the 2 patients who required irrigation and debridement, one had a superficial pin site infection and retained subcutaneous pin and the other had a pin tract abscess and osteomyelitis at the osteotomy site.

CONCLUSIONS

Of 163 patients who underwent retrograde percutaneous pinning of the distal femur, no patient developed septic arthritis and the incidence of pin site infections was 6.7% (11/163). Intra-articular retrograde percutaneous pinning of the distal femur is a safe technique with a low risk of septic arthritis.

LEVEL OF EVIDENCE

Level III-case-control study.

Postoperative Management and Rehabilitation of the Replanted or Revascularized Digit

Postoperative care of amputated digits begins before replantation. Detailed informed consent should be obtained and completion amputation discussed if revascularization is not ultimately successful. Complications and failure of the replanted digit should also be addressed. Postoperative pharmacologic treatment should consist of aspirin, at minimum. Complications, such as venous congestion or occlusion, and arterial thrombosis, should be dealt with expediently. Digital motion rehabilitation should start after 5 to 7 days of digital viability and splinting of the affected digit. Early protective motion protocol is implemented to maintain digital motion with emphasis on tendon glide and joint motion.

Headless Screw Fixation of Metacarpal Neck Fractures: A Mechanical Comparative Analysis

BACKGROUND

The purpose of this study was to compare the mechanical properties of metacarpal neck fracture fixation by headless compression screw (HCS) with that of Kirschner wire (KW) cross-pinning and locking plate (LP) fixation.

METHODS

A metacarpal neck fracture was created in 30 fourth-generation composite Sawbones metacarpal models. A volar-based wedge was removed using a custom jig to simulate a typical apex dorsal fracture, unstable in flexion. The models were divided into 3 equal groups based on the method of fixation: retrograde cross-pinning with two 1.2-mm KWs, 2.0-mm dorsal T-plate with six 2.0-mm locking screws (LP), and a 3.0-mm retrograde HCS. Models were fixed at the proximal end, mounted in a material testing machine, and loaded through a cable tensioned over the metacarpal head, simulating grip loading. Cyclic loading from 0 to 40 N was performed, followed by loading to failure. Load, displacement, and failure mode were recorded.

RESULTS

Stiffness of the HCS (7.3 ± 0.7 N/m) was significantly greater than the KW (5.8 ± 0.5 N/m) but significantly less than the LP (9.5 ± 1.9 N/m). With cyclic loading to 40 N, the LP exhibited significantly less displacement (0.2 ± 1.3 mm) compared with the HCS (2.5 ± 2.3 mm) and KW (2.8 ± 1.0 mm). Load to failure for the HCS (215.5 ±3 9.0 N) was lower than that of the KW (279.7 ± 100.3 N) and of the LP (267.9 ± 44.1 N), but these differences were not statistically significant.

CONCLUSIONS

The HCS provided mechanical fracture fixation properties comparable with KW fixation. The LP construct allowed significantly less displacement and had the highest strength of the 3 fixation methods.

Buried Versus Exposed Kirschner Wires Following Fixation of Hand Fractures: l Clinician and Patient Surveys

Background:

Fractures of the metacarpals and phalanges are common. Placement of Kirschner wires (K-wires) is the most common form of surgical fixation. After placement, a key decision is whether to bury the end of a K-wire or leave it protruding from the skin (exposed). A recent systematic review found no evidence to support either approach. The aim of study was to investigate current clinical practice, understand the key factors influencing clinician decision-making, and explore patient preferences to inform the design of a randomized clinical trial.

Methods:

The steering group developed surveys for hand surgeons, hand therapists, and patients. Following piloting, they were distributed across the United Kingdom hand surgery units using the Reconstructive Surgery Trials Network.

Results:

A total of 423 hand surgeons, 187 hand therapists, and 187 patients completed the surveys. Plastic surgeons and junior surgical trainees preferred to leave K-wires not buried. Ease of removal correlated with a decision to leave wires exposed, whereas perceived risk of infection correlated with burying wires. Cost did not affect the decision. Hand therapists were primarily concerned about infection and patient-related outcomes. Patients were most concerned about wire-related problems and pain.

Conclusion:

This national survey provides a new understanding of the use of K-wires to manage hand fractures in the United Kingdom. A number of nonevidence-based factors seem to influence the decision to bury or leave K-wires exposed. The choice has important clinical and health economic implications that justify a randomized controlled trial.

[Kirschner wire osteosynthesis for fractures in childhood: bury wires or not? : Results of a survey on care reality in Germany]

INTRODUCTION

Kirschner wire osteosynthesis is considered to be the standard technique for surgical fixation of displaced supracondylar humeral and distal radial fractures in children. The Kirschner wires can be left exposed or buried under the skin. Advantages of the epicutaneous technique are, e. g. the efficiency (cost, effort) and the possibility for wire removal without the necessity of a second anesthesia. On the other hand, there is a concern about higher infection rates as well as traumatization of the children due to externally visible wires.

METHODS

A web-based survey of members of the DGU, DGOU, DGOOC, and the pediatric traumatology section of the DGU (SKT) was performed to evaluate current treatment concepts in Germany. The pros and cons for each technique were recorded and the need for a clinical study was examined. In addition, a cost analysis was performed for both methods. The results from the literature are summarized and discussed.

RESULTS

A total of 710 questionnaires were evaluated. The majority of the respondents were trauma surgeons working in a hospital (80%). The buried technique was superior in both fracture groups (supracondylar humeral fractures 73% and distal radius fractures 69%), whereas a relevant difference could be found depending on the profession. The main reason for the subcutaneous technique was anxiety or observed higher infections using the epicutaneous technique.

CONCLUSION

In Germany, the majority of wires are buried under the skin due to a fear of higher infection rates. In addition, other influencing factors such as pain and traditional approaches play a significant role. With respect to the results in the literature as well as a possible improvement of efficiency and avoidance of a second anesthesia, a multicentric clinical study seems necessary in the future to compare both techniques.