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Keywords:

  • complication;
  • discharge training;
  • external fixator;
  • pin site infection

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

The present study aimed to determine the effect of long-term care and follow-up on complications in patients with external fixators. This study was conducted as a study research. The study sample included a total of 60 patients treated with external fixators for fractures, of whom 30 were in the control and 30 were in the study group. No intervention was made on the control group patients. The patients in the study group received external fixator pin site wound care, pin site massage and neurovascular follow-up. The study group patients were also given discharge training about external fixator pin site care two days before their discharge and were also provided with training manuals to guide their home care. Both groups were visited weekly at their homes to record their complications. Nine complications developed in eight patients (26.7%) in the study group, and 19 complications developed in 19 patients (63.3%) in the control group. Pin site infections were 11.6% of the total sample. The percentage for pin loosening, stiff joint, nerve and vessel injury and pain and swelling was 5%, 25%, 1.7% and 3.3%, respectively.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

External fixation is defined as fixing on a fractured bone with fixation instruments using aluminium, metal, titanium or nylon pins.[1, 2] External fixators have been increasingly used not only in fracture treatment, but also in correction of deformities, extremity lengthening, non-unions, osteomyelitis or tumours. Pin site infection is the most important and most frequent complication observed in external fixator applications. Some studies have reported infection rates at external pin sites as high as 86.5%.[3-7] Pin site infection is associated with surgical technique when it occurs at an earlier stage, while it is associated with postoperative patient care when it occurs at a later stage.[4, 8] In order to minimize complications in the postoperative period, patients with external fixators should be provided with health care not only in the hospital environment but also in their homes.[8] Thus, it has been noted that the patient and his/her family should be given relevant health-care training.[9, 10] Previous research demonstrated that patients with external fixators receive care during their hospital stay but discontinue care in their homes.[8] Underlining this point, the National Association of Orthopedic Nurses (NAON) in the United States and the Royal College of Nursing, Society of Orthopaedic and Trauma Nursing in the United Kingdom note that it is of great importance to teach self-care to patients and their families and to use this care technique at home.[8, 11] Before being discharged from the hospital, patients and their families should receive applied training about the care of the external fixator pin site, which they themselves should implement at home.[8, 11]

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Aim

The present study aimed to determine the effect of long-term care and follow-up on complications in patients with external fixators.

The sample

The study sample included a total of 60 patients (30 in the control and 30 in the study group) treated with external fixators for fractures at the Orthopedics and Traumatology Clinics in a public hospital run by the Ministry of Health. The data were collected between January and June 2008. Patients with diabetes mellitus, those who developed complications in the hospital environment, patients under 18 years of age and those with mental problems were excluded from the study. The patients were assigned to either the study or control groups after they were homogenized for age, gender, educational status, body mass index, chronic diseases, smoking status, antibiotic treatment, musculoskeletal system diseases, external fixator site, pin diameter and number of pins applied. To avoid any possible bias between the control and study group patients, we first collected data about the control group to initiate their follow-up.

Procedures in the control group patients

Researchers observed the control group patients to see whether they developed any infections around the pin sites until the patients were discharged from the hospital. Routine treatment and care has been applied to these patients by the nurses and physicians of the clinic. Routine pin site care with 10% povidone-iodine was applied within 48–72 h after surgery for routine hospital treatment and care. Pin site care was provided every other day for the period patients remained in the hospital. When discharged from the hospital, patients were told to come to the outpatient clinic twice a week to have their wounds dressed. At discharge, the control group patients were not provided with discharge training and training manuals prepared by the researcher. Their physician told the control group patients to receive pin site care of the external fixator twice a week, which they could have at an outpatient clinic or a public health centre. After their discharge, weekly home visits were made to the control group patients by the researcher, during which the type of complications—if any—and the day of their occurrence were recorded. In cases where external fixator pin site infection was recorded as a complication during home visits, the patient's physician was informed to identify and record the degree of infection.

Six patients in the control group who developed external fixator pin site infections were treated with first generation oral cephalosporins. Weekly home visits were continued until the external fixators were removed from the control group patients.

Procedures in the study group patients

Povidone-iodine 10% dressings applied during surgery to the external fixator pin sites were removed from the study group patients 48–72 h postoperatively. Various studies in the literature recommend removing intraoperative dressings after 48–72 h.[8, 11] Subsequently, the researcher started external fixator pin site care. External fixator pin site care, massage in accordance with the NAON to provide pin-tract drainage and neurovascular follow-up was continued in the study group patients until their discharge. Povidone-iodine 10% solution was used for wound care with the help of sterile cotton swabs for pin-tract care and sterile gauze pads to clean the outer parts of the fixator. The study group was given two sessions of external fixator pin site care training during the last 2 days before discharge. The discharge training was carried out in accordance with the information given in the discharge manual. The discharge training contained information about the following:

  • Pin site wound care at home,
  • Applying massage on the pin site,
  • The signs and symptoms of most common complications,
  • Neurovascular follow-up,
  • Pain control,
  • Exercises applied to the joints close to the pin-tracts and
  • Daily life activities.

On their day of discharge, the patients were given homecare manuals prepared by the researchers to guide their external fixator pin site self-care at home. The training booklet instructed the patients to remove scabs appearing at the pin site if they can be removed easily, but should leave the scabs if there is difficulty during removal. Physicians did not give any advice to the study group patients concerning their external fixator pin site care. Patients performed their pin site care by themselves during home period. Their physician approved this procedure.

The study group patients were provided at their discharge with three containers of 50 mL povidone-iodine 10% solution, three packs of sterile gauze strips (100 pieces/pack) and 10 packs of sterile cotton sticks (10 pieces/pack), the costs of which were covered by the researcher.

Weekly home visits by the researcher were also made to the study group patients after discharge, during which the type of complications—if any—and the day of their occurrence were recorded. In cases where external fixator pin site infection was recorded as a complication during home visits, the patient's physician was informed to identify and record the degree of infection. During each visit, the researcher checked the care materials and provided more, if necessary. The researcher checked the dressing materials during home visits, both for availability and whether or not the dressings were applied. In this study, the Checketts-Otterburns classification system that grades the level of pin site infection was used for defining infection.[8, 12, 13]

The Statistical Package for the Social Sciences for Windows 15.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analyses. Data were presented as number, percentage, mean and standard deviation. Fisher's exact test was applied to examine the homogeneity of the groups and to examine the patients’ external fixator pin site complications. The Mann–Whitney U test was used to examine the relationship between the mean external fixation duration and complication incidence, the Kruskal–Wallis test was used to examine the relationship among external fixation duration, mean duration of external fixation and complication types, and the Fisher's exact test was used to examine the relationship between complication incidence and discharge training offered to the patients and to examine the relationship between pin site infection and discharge training offered to the patients.

Ethical considerations

Written permissions have been obtained from the Institutional Review Board of the Ege University Medical Faculty and School of Nursing and from the Hospital Management to conduct the research. The patients in the study sample were provided with necessary information about study purpose and its implementation, after which their oral and written consent was obtained.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

The experiment group patients had a mean age of 41.30 ± 16.66, the mean of the control group patients was 47.66 ± 13.31. The Chi-Square Test revealed no inter-group difference for age groups (X2 = 6.432, P = 0.169).

Table 1 shows the sociodemographic characteristics of the patients. No statistically significant difference was found between the study and control groups (Table 1).

Table 1. Sociodemographic characteristics of the patients
CharacteristicsStudy groupControl group
n(%)n(%)
Age group
18–271136.7310.0
28–3726.7310.0
38–47413.3826.7
48–57620.0723.3
58<–67723.3930.0
 X2 = 6.432 P = 0.169 P > 0.05
Gender
Female1136.71240.0
Male1963.31860.0
 Fisher's Exact Test P = 0.500 P > 0.05
Educational status
Elementary2066.72066.7
High School930.01033.3
College13.3
 X2 = 1.053 P = 0.591 P > 0.05
Body mass index
Normal weight (18.5–24.9)2170.01550.0
Slightly overweight (25–29.9)930.01550.0
Fisher's Exact Test P = 0.094 P > 0.05
Chronic disease
Yes (Hypertension)26.7310.0
No2893.32790.0
Fisher's Exact Test P = 0.500 P > 0.05
Smoking
Yes1240.01446.7
No1860.01653.3
Fisher's Exact Test P = 0.397 P > 0.05
Total30100.030100.0

Table 2 presents the distribution of the data concerning fracture types, causes of fractures and external fractures in the patients. The Chi-square test revealed no statistically significant inter-group difference for fracture type, cause of the fracture, external fixator site and the diameter and number of external fixators.

Table 2. Distribution of the fracture types and causes, and external fixators in patients
 Study groupControl group
n(%)n(%)
Fracture type
Open fracture723.3826.7
Closed fracture2376.72273.3
Fisher's Exact Test P = 0.500 P > 0.05
Cause of fracture
Traffic accident1446.71136.7
Falling1653.31860.0
Work Accident13.3
X2 = 1.478 P = 0.478 P > 0.05
External fixator site
Wrist1136.71033.3
Humerus26.7413.3
Tibia1136.71343.3
Femur620.0310.0
X2 = 1.881 P = 0.597 P > 0.05
Type of external fixator pins
Schanz pin2790.02893.3
Kirschner wire310.026.7
Fisher's Exact Test P = 0.500 P > 0.05
Diameter of external fixator pins
2 mm310.026.7
3 mm1136.71033.3
4 mm26.7310.0
5 mm1446.71550.0
X2 = 0.482 P = 0.923 P > 0.05
Number of external fixator pins
4 pins723.3723.3
5 pins1033.31343.3
6 pins930.0930.0
7 pins13.3
10 pins13.3.13.3
11 pins26.7
X2 = 3.391 P = 0.640 P > 0.05
External fixation duration
35–49 days620.0516.7
50–64 days723.3516.7
65–74 days13.3516.7
75–84 days930.0516.7
85 and longer723.31033.3
X2 = 4.256 P = 0.372 P > 0.05
Total30100.030100.0

The duration of external fixation was a minimum of 45, a maximum of 96 and a mean and standard deviation (SD) of 68.16 ± 16.96 days in the study group; while it was a minimum of 36, a maximum of 97 and mean and SD of 71.96 ± 18.87 days in the control group. No inter-group difference was found for the duration of external fixation (X2 = 4.256, P = 0.372) (Table 2).

The researcher provided the study group patients with a minimum of two, a maximum of 9 and a mean and SD of 4.70 ± 2.03 pin site care sessions. Table 3 displays the distribution of the data concerning complication incidence in the patients. Eight patients (26.7%) in the study group (nine complications in eight patients) and 19 patients (63.3%) in the control group developed complications. Fisher's exact test revealed a statistically significant difference between both groups for complication incidence (Table 3). It is believed that this difference results from the training and care offered to the patients by the researcher. The overall complication rate was found to be 45.0% among all patients.

Table 3. Distribution of the complication incidence in the patients
 Study groupControl group
n(%)n(%)
Complication incidence
Developed826.71963.3
Not developed2273.31136.7
Fisher's Exact Test, P = 0.004 P < 0.05
Total30100.030100.0

According to Table 4, two patients in the study group had pin loosening, six had stiff joints and one had pin site infection. The complications of pin loosening and pin site infection occurred in the same patient, so there were nine complications in eight patients in the study group.

Table 4. Distribution of the types of complications occurring in the patients
 Study groupControl group
n(%)n(%)
  1. †Pin site infection and pin loosening occurred in the same patient. For this reason 9 complications occurred in 8 patients.

Complication type
Pin site infection13.3620.0
Pin loosening26.613.3
Stiff joint620.0930.0
Nerve and vessel injury13.3
Pain and swelling26.7
X2 = 4.508 P = 0.342 P > 0.05

Of the patients in the control group, six had pin site infections, one had pin loosening, nine had stiff joints, one had vessel-nerve injury and two had pain and swelling (Table 4). Among all the patients, the incidence of pin site infection was found to be 11.6%, stiff joint incidence 25%, and the overall rate of complication incidence was found to be 45%.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

The relevant literature reports that pin site infection is the most important and most frequent complication observed in external fixator applications.[3-7, 11] Pin site infection incidence rates were reported as follows in the following studies: 24.1% by Grant et al.,[14] 28.4% by Ocguder et al.,[15] 37.5% by Altay et al.,[16] 26% by W-Dahl and Toksvig-Larsen,[7] 40% by Ozdemir et al.,[17] 21% by Arazi et al.,[18] 11.3% by Kesemenli et al.,[19] 20% by Arazi and Kutlu[20] and 10.9% by Hay.[21] Our findings are consistent with the literature. The overall incidence rate of pin site infection was found to be 11.6% among all the patients in our study.

Pin site infection is reported to be the most common complication that causes pain and discomfort, complex and delayed recovery and sometimes death.[3-7, 11] Pin site infections are also under the category of health care-associated infections. Therefore, it is very crucial to diagnose and treat it as early as possible. However, the diagnosis of infection is problematic, especially in percutaneous wounds, such as pin and wire sites, because there is no valid diagnostic tool, including the Checketts–Otterburns classification system, which was used in this study.[11] Therefore, it is very difficult to compare the results of findings.

There was no statistically significant difference between the mean pin number used and complications occurring (Z = −1.47, P = 0.140) in this study. Similarly, in Grant et al.'s[14] study, it has been found that the relationship between the mean pin number and occurrence of complications was not statistically significant. Our finding is in parallel with the results of Grant et al.'s study.

It has been stated in the literature that the choice of an unsuitable pin diameter in particular may lead to complications, such as vascular-tendon injury, pin loosening and pin site infection.[1, 22, 23] However in this study, it has been found that there was no statistically significance relationship between the pin diameter and pin site infections in patients having pin site infections (X2 = 3.052, P = 0.384).

Pin loosening is a complication rarely observed in external fixator applications.[22-25] Our study detected a total pin loosening rate of 9.9% among patients. This rate was reported as 8.3% by Anderson et al.[26] and 11% by Ahlborg and Josefsson.[27] Our results are in parallel with the results of these studies.

In the present study, the patients were also instructed on the massage technique during their discharge training, to prevent pin site infection in accordance with the literature.[3, 28-31] Infection could cause the pin to loosen or require its removal. However, pin loosening occurred in one patient in the control group as opposed to two patients in the study group. It could be supposed that massaging affects pin site infection. The study group patients applying the massage technique at home had a pin site infection rate of 3.3%, although it was 20% among the control group patients who did not use the technique. However, previous studies do not recommend massaging for either preventing infection or pin loosening.[11]

It has been stated in the literature that the stiff joint complication in external fixator applications is generally observed as a result of unsuitable framing, oedema and inadequate physiotherapy.[23, 25, 32, 33] There might be a limitation of movement on those joints close to the detected muscles. Previous studies have stressed the importance of early physiotherapy in order to prevent the development of stiff joint.[8, 17, 19, 33-35] The study by Akyuz[33] observed a stiff joint incidence of 15.9%. The present study found a stiff joint incidence of 20% in the study group and 30% in the control group. The discharge training and training manual provided to the study group patients included exercises with the aim of preventing stiff joint. However, given the proximity between the stiff joint incidence of the study and control group patients, it is not possible to suggest that stiff joint results from inadequate physiotherapy. There is not any statement about physiotherapy or stiff joint complication in the guideline released by the Royal College of Nursing, Society of Orthopaedic and Trauma Nursing in the United Kingdom.[11]

The study group patients developed complications the earliest on day 33, the latest on day 68, averaging at 43.00 ± 13.11 days; while the control group developed complications the earliest on day 2, the latest on day 80, averaging at 35.36 ± 17.73 days. The study found that complications occurred in 31–40 days in six patients, and in 51 days and later in two patients in the study group. On the other hand, for the patients in the control group, complications occurred in 0–10 days in one patient, in 11–20 days in one patient, in 21–30 days in eight patients, in 31–40 days in four patients, in 41–50 days in one patient and in 51 days and later in four patients. The Chi-squared test was performed and revealed no statistically significant difference between the two groups (X2 = 9.095, P = 0.105).

The earliest observed complication was vessel injury, while the latest observed complication was pin site infection, both occurring in the control group. Our results are similar to those reported in the literature.[1, 22-25]

Of the patients in the study group, 13 had 5–7 weekly home visits, 13 were visited 8–10 times, and four were visited 11 times or more. It was found that the number of the weekly home visits made to the study group was a minimum of five, a maximum of 12, averaging 8.16 ± 2.11 visits. Of the control group patients, 10 had 5–7 weekly home visits, 10 were visited 8–10 times, and 10 were visited 11 times or more. The number of home visits for the control group was a minimum of five, a maximum of 12, averaging 8.76 ± 2.34 visits. The results of the Chi-squared test showed no intergroup difference for home visits (X2 = 3.354, P = 0.187). During these weekly home visits made by the researcher, the control group patients were followed up only as to whether or not they developed any complications. However, the study group was followed up on whether or not they developed any complications, as well as whether or not they applied the external fixator pin site care for which they were trained by the researcher. In Grant et al.'s study, the patients were trained for external fixator pin site care during their discharge.[14] Patients who were unable to apply home care by themselves were told that a public health nurse would make home visits to help them. However, all of the patients performed their external fixator pin site care by themselves and had their routine outpatient clinic follow-ups. In contrast to the present study, patients were not followed up with home visits for the external fixator pin site care they applied on their own.

For the patients in the study and control groups, no statistically significant difference was found between complication incidence and age groups (X2 = 6.497, P = 0.165), education levels (X2 = 3.110, P = 0.211), fracture types (Fisher's exact test, P = 0.228), number of pins (Z = 1.477, P = 0.140), types of pins (Fisher's exact test, P = 0.596), pin diameter (X2 = 3.052, P = 0.384), external fixator site (X2 = 2.352, P = 0.503) and external fixation duration (Z = 0.781, P = 0.435).

Nevertheless, a statistically significant difference was observed between gender (Fisher's exact test, P = 0.046) and complication incidence, and external fixation duration and the type of complication observed (Kruskal–Wallis test, P = 0.006).

Complications developed in eight of the 30 patients (26.7%) in the study group, all of whom were given discharge training, while 19 of the 30 patients (63.3%) in the control group, none of whom received discharge training developed complications. The difference between the study and control group patients for discharge training and complication incidence was found to be statistically significant (Fisher's exact test, P = 0.004).

Along with the surgical technique, it has been noted that training patients and their families so that their care will not be confined to the hospital environment, but continued at home as well, is also important in order to minimize the complications caused by external fixators.[8, 11] Studies demonstrate that patients with external fixators receive hospital care but do not continue their care at home.[8, 10, 29, 36, 37] It is of great importance to teach self-care to patients and their families and to support the use this care technique at home.[8, 11]

The patients in the study group were provided with pin site care by the researcher during their hospital stay. The study group patients were also given discharge training about external fixator pin site care two days before their discharge and were also provided with training manuals to guide their home care.

Complications were observed in eight patients (26.7%) in the study group who received discharge training and training manuals, while complications developed in 19 patients (63.3%) in the control group who were not given discharge training and training manuals. A statistically significant difference was found between the two groups for the provision of discharge training and training manuals and complication incidence. It can be suggested that the training provided to the patients could reduce complication incidence.

Pin site infection is the most common and one of the most important external fixator complications. An examination of the data regarding discharge training given to patients and their incidence of pin site infections reveals that pin site infections occurred in only one patient (3.3%) among the study group patients receiving discharge training and in six (20.0%) of the control group patients who were not given such training. However, the difference between discharge training and the incidence of pin-tract infections in the patients was not found to be statistically significant, which might have resulted from using a small study sample.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

In this study, it was found that the most important and frequent complication regarding external fixators is stiff joint. It was found that complications were reduced by applying external fixator pin site care in the hospital by the researcher to the study group patients, training them about this type of care before they were discharged, providing them with training manuals to guide their home care, their application of self-care in their homes and their follow-up by the researcher through weekly home visits.

Orthopaedic nurses should apply external fixator pin site care in the hospital, train patients about this type of care before they are discharged and provide them with training manuals to guide their home care.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References
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