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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 8
| Issue : 1 | Page : 84-87 |
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Hydrosurgical debridement of Grade VI external fixator pin site infection
Aaron Kumar Saini, JP Grey, Rudolph Venter, Nando Ferreira
Department of Surgical Sciences, Division of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| Date of Submission | 22-Mar-2022 |
| Date of Decision | 19-May-2022 |
| Date of Acceptance | 19-May-2022 |
| Date of Web Publication | 30-Jun-2022 |
Correspondence Address:
Aaron Kumar Saini
Department of Surgical Sciences, Division of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Stellenbosch 7505
South Africa
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jllr.jllr_6_22
Background: Pin site infection is a common complication with external fixation, with a reported incidence of 26%–71% in the context of limb reconstruction. The Checketts and Otterburn (C&O) classification is frequently used, with minor infections (C&O I–III) treated with pin site care and enteral antibiotics. Major infections (C&O IV–VI) require removal of the infected pin or fine wire. Surgical debridement is indicated where the infection persists following pin removal (C&O grade VI). The Versajet hydrosurgery system (Smith & Nephew, Memphis, Tennessee) utilizes a saline jet to debride biological tissue. Methods: A retrospective review was conducted on all patients who underwent Versajet hydrosurgery debridement with C&O grade VI pin site infections between January 2011 and January 2021. Data regarding patient demographics, fixator type, indication for the initial surgery, and treatment outcome were recorded. Results: The cohort comprised seven males (87.5%) and one female (12.5%) with a mean age of 41.4 years ± 17.74 (range 16–61). Mean follow-up was 11.8 months ± 6.2 (range 7–25). The mean time in external fixator was 155 days ± 85.19 (range 83–354), and the mean time between fixator removal and Versajet debridement was 46 days ± 33.83 (range 3–116). No perioperative complications were experienced, and all patients (n = 8, 100%) were found to be infection-free at the last clinical review, with healed overlying soft tissue. Conclusion: The Versajet hydrosurgical debridement system is effective in managing C&O grade VI pin site infections. The method is reproducible and provides long-term clearance of infection, allowing subsequent soft tissue healing.
Keywords: Hydrosurgery, pin site infection, ring fixator, ring sequestrum
How to cite this article:
Saini AK, Grey J P, Venter R, Ferreira N. Hydrosurgical debridement of Grade VI external fixator pin site infection. J Limb Lengthen Reconstr 2022;8:84-7 |
| Introduction | |  |
External fixators have a range of applications, including deformity correction, limb lengthening, and management of trauma. Pin site infection is one of the most commonly reported complications with external fixation, with an incidence of up to 100% in general use,[1] and more specifically, between 26% and 71% in the context of limb reconstruction.[2],[3] The definition of pin site infection varies, and multiple classification systems exist, including that of Checketts and Otterburn (C&O)[4] [Table 1].
Minor infections (C&O I–III) are generally treated with pin site care and enteral antibiotics directed at staphylococcal infections. Major infections (C&O IV–VI) typically require removal of the infected pin or fine wire. In rare instances where the infection persists following the pin or wire removal, surgical debridement of the pin site is indicated; this situation is denoted as a C&O grade VI pin site infection. These have been described as ring sequestrum based on their radiographic appearance.
The Versajet hydrosurgery system (Smith & Nephew, Memphis, Tennessee) utilizes a saline jet to debride biological tissue. Its use in the management of ring sequestrum has previously been described.[5] No data or series has been published on the clinical outcomes of patients treated with this method for the debridement of C&O grade VI pin site infection.
We present our experience using the Versajet hydrosurgery system (Smith & Nephew, Memphis, Tennessee) in the surgical management of C&O grade VI pin site infection.
| Methods | | |
A retrospective chart review of all patients who underwent Versajet hydrosurgery (Smith and Nephew, Memphis, Tennessee) debridement of Checketts and Otterburn grade VI pin site infections between January 2011 and January 2021 was conducted. Data regarding patient demographics, fixator type, initial surgery indication, and treatment outcome were recorded. Institutional ethics committee approval, as well as hospital board approval, was obtained before data collection.
After the ring sequestrum has been identified on clinical and radiological grounds [Figure 1], the patient is prepared for theater. Antibiotics are ideally avoided until deep tissue specimens have been obtained for microbiological analysis. Patients were placed supine on a radiolucent surgical table, and the affected limb was prepped and draped. Intraoperative fluoroscopy was used to localize the ring sequestrum [Figure 2]. The sinus tract was excised via a longitudinal elliptical incision. All nonviable soft tissue was debrided, and the samples were sent for microbiological analysis. The 45° Versajet handpiece was inserted into the bony defect, and hydrosurgical debridement was performed by circumferential rotation of the head within the pin site [Figure 3]. The debridement is continued until all nonviable tissue has been removed [Figure 4]. Incisions were closed using nonabsorbable interrupted sutures and dressed with a nonadherent dressing. The patients were allowed to mobilize without restriction with removal of the sutures at the 2-week outpatient follow-up visit. Antistaphylococcal antibiotics were prescribed for 2 weeks postsurgery. This strategy represents our current standard of care for these pin site complications. | Figure 1: Lateral tibial radiograph of a patient presenting with clinical features suggestive of a ring sequestrum postframe removal
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 | Figure 3: Intraoperative clinical picture and radiograph of the Versajet hydrosurgery device being used to debride a ring sequestrum
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 | Figure 4: Intraoperative radiograph of the site of sequestrum postdebridement
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| Results | | |
Eight patients with C&O grade VI pin site infection were treated by Versajet hydrosurgical debridement during the study period. The cohort comprised seven males (87.5%) and one female (12.5%) with a mean age of 41.4 years ± 17.74 (range 16–61) [Table 2]. Mean follow-up was 11.8 months ± 6.2 (range 7–25).
All patients were initially treated in circular external fixators [Table 3]. The mean time in external fixator was 155 days ± 85.19 (range 83–354), and the mean time between fixator removal and Versajet debridement was 46 days ± 33.83 (range 3–116). All incidence of C&O VI pin site infections occurred at a previous half pin insertion site.
No perioperative complications were experienced, and all patients (n = 8, 100%) were found to be infection-free at the last clinical review, with healed overlying soft tissue.
| Discussion | | |
The aim of this study was to present our experience of the use of the Versajet hydrosurgery system (Smith and Nephew, Memphis, Tennessee) in the surgical management of C&O grade VI pin site infections. We have described a simple and reproducible technique and shown its use in eradicating pin site infection of this class, with sustained long-term results in all our cases.
The Versajet system has been shown to reduce the number of debridement required in the acute management of open fractures.[6] Its use in the debridement of ulcered diabetic feet has also been reported.[7] While the technique for bony debridement in the context of chronic osteomyelitis secondary to pin site infection has been described,[5] we were unable to find reports in the literature of the clinical outcomes of these patients. A single case report exists of its successful use for the debridement of chronic osteomyelitis and septic arthritis of the hallucal joint of a juvenile foot.[8] Emphasis was placed on its versatility in use in a confined geometric and anatomical area.
The described technique is a management strategy after the occurrence of osteomyelitis at the pin site. We would emphasize that prevention is better than cure. Numerous prevention measures have been described.[9] Meticulous insertion techniques, including drill speed for wires, predrilling for half pins, and irrigation, are advised. Unicortical fixation traversing the anterior cortex of the tibia should be avoided. Surrounding soft tissues should be tension-free, and this may require relieving incisions.
Much has also been published regarding optimal pin site care regarding its commencement time in relation to surgery, frequency, duration, and agent used. Multiple strategies have shown successful and acceptable infection rates; it would appear as a method with a proven track record in an institution is adequate when reproducible and confer satisfactory rates of infection.
While this is the only series to report on the clinical outcomes of patients undergoing Versajet hydrosurgical debridement for C&O VI pin tract infections, we appreciate our limitations. The cohort is small, although this must be taken in the context of the treatment being for a very rare pathology, with a reported incidence of <1% of all pin site infections in circular fixators.[2] Traditional treatment includes over-drilling of the affected tracts. The cost of a drill bit would be less than that of the hydrosurgical debridement apparatus, including consumables and possible loan costs if not kept in regular stock at an institution. However, we were unable to find objective published outcomes of the over-drilling method, making a comparison with our cohort impossible. We appreciate that the series is retrospective in nature. Again, the rarity of the pathology would likely mean that adequately powered prospective trials between treatment methods will be difficult to achieve.
| Conclusion | | |
The Versajet hydrosurgical debridement system is effective in managing C&O grade VI pin site infections with ring sequestrum presenting after pin site removal. The method is reproducible and provides long-term clearance of infection, allowing subsequent soft tissue healing.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Iobst C. Pin-track infections: Past, present and future. J Limb Lengthening Reconstr 2017;3(2):78-84.  |
| 2. | Ferreira N, Marais LC. Pin tract sepsis: Incidence with the use of circular fixators in a limb reconstruction unit. SA Orthop J 2012;11:40-48. |
| 3. | Mostafavi HR, Tornetta P 3rd. Open fractures of the humerus treated with external fixation. Clin Orthop Relat Res 1997;337:187-97. |
| 4. | Checketts RG, MacEachem AG, Otterburn M. Pin track infection and the principles of pin site care. In: De Bastiani, G. Apley AG, Goldberg A. (eds) Orthofix External Fixation in Trauma and Orthopaedics. Springer, London. 2000. |
| 5. | Bibbo C, Brueggeman J. Prevention and management of complications arising from external fixation pin sites. J Foot Ankle Surg 2010;49:87-92. |
| 6. | Oosthuizen B, Mole T, Martin R, Myburgh JG. Comparison of standard surgical debridement versus the VERSAJET PlusTM Hydrosurgery system in the treatment of open tibia fractures: A prospective open label randomized controlled trial. Int J Burns Trauma 2014;4:53-8. |
| 7. | McCardle JE. Versajet hydroscalpel: Treatment of diabetic foot ulceration. Br J Nurs 2006;15:S12-7. |
| 8. | Bhattacharyya M, Bradley H, Gerber BE. Hydrosurgery: Alternative treatment technique for management of chronic osteomyelitis and septic arthritis of hallucial joint of a juvenile foot. Int J Low Extrem Wounds 2010;9:155-9. |
| 9. | Ferreira N, Marais LC. Prevention and management of external fixator pin track sepsis. Strategies Trauma Limb Reconstr 2012;7:67-72. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]
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