A systematic analysis of the research literature on skeletal pin site care was conducted, and the opinions of an expert panel were obtained.
Although there were two experimental studies regarding pin site care, they addressed different aspect of care. One study addressed cleansing solutions and the other study addressed the frequency of site care. The methodologic quality of the first study was judged by widely accepted criteria to be fair and the other study to be good. Of the five case series studies, one reported a comparison of two methods of pin site care; it was judged to be of high quality. The other four studies reported on only one method of pin site care.
Beyond the issue of the two experimental studies addressing different aspects of site care is the fact that the populations studied were quite diverse. In all seven studies, patients had external fixators of some type but were diverse in age and condition being treated.
None of these studies examined fixator pins in multi-trauma patients or in patients with pelvic fractures, upper extremity problems, or Halo braces. Thus, the universe of populations treated with skeletal pins is not represented in the research literature.
The studies were diverse in other ways:
- Pin site infection was not consistently defined.
- Pin site infection rates were reported on different basis (i.e., by pins, by fixators, and by patients). This variation made comparisons of infection difficult.
- Most of the studies did not clearly report antibiotic protocols.
- The length of time fixators were in place varied widely, as did the type of hardware and whether corrections were carried out. The length of hospital stay was not included in most study reports.
The combination of the diverse nature of the research evidence and the weak designs used lead the authors to conclude that there is insufficient evidence on which to recommend pin site care as beneficial in any way or to make strong recommendations regarding any particular aspect of pin site care. Nevertheless, the research evidence does provide a basis for recommending several specific actions over others until more definitive answers become available.
Recognizing that clinicians must have a clinical approach for dealing with pin sites, the authors decided to go beyond the main findings of the studies to also glean incidental findings from the studies. To include incidental findings in the evaluation of the evidence, a Levels of Evidence Support categorization system that recognized them was developed. The rationale for this approach was that a unique Levels of Evidence Support system would capture the subtle differences which were reviewed by the panel, amended, and then finalized. This process resulted in three recommendations that have some research support and one that has strong expert panel support. For each recommendation, the level of supporting evidence is explicitly stated and the research evidence and panel opinion are briefly described.
