Advertisement

Is pin-plate overlap in tibial plateau fractures associated with increased infection rates?

Published:January 11, 2022DOI:https://doi.org/10.1016/j.injury.2022.01.017

      Highlights

      • High energy tibial plateau fractures remain a difficult problem to treat despite advances in soft tissue management and fixation strategies.
      • Overlap between external fixator pin site and internal fixation in tibial plateau fractures is associated with increased rate of infections.
      • Surgeons treating high energy tibial plateau fractures should carefully consider definitive fixation construct when placing external fixation.

      Abstract

      Introduction

      Despite advances in the treatment of high energy proximal tibia fractures, including the utilization of staged management with external fixation, the infection rate remains high. Overlap between external fixator pin sites and definitive internal fixation has been proposed as a risk factor for infection.

      Methods

      This retrospective study reviews 244 patients with staged knee-spanning external fixation followed by delayed definitive internal fixation at two separate level one trauma centers. Presence of pin-plate overlap as well as several other known risk factors for infection were recorded and measured to include open fractures, compartment syndrome, operative time and number of incisions. Development of deep infection was the primary outcome. Both univariate and multivariate statistics were applied to determine differences in rates of infection.

      Results

      65 (26.6%) patients had presence of pin-plate overlap while 179 (73.4%) patients had no overlap. There were no differences between overlapping and non-overlapping groups with respect to other infectious risk factors. Deep infection occurred in 34 (13.9%) total patients, 18 (27.7%) were in patients with pin-plate overlap and 16 (8.9%) in those without overlap. (P = 0.003; RR 3.01, 95% CI 1.51–4.76).

      Discussion

      This large, multicenter study demonstrated a statistically significant association between pin-plate overlap and the development of deep infection in tibial plateau fractures. On multivariate analysis, pin-plate overlap was identified as an independent risk factor for infection. When treating these complex injuries, surgeons should consider the definitive fixation construct when placing external fixation pins.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Berkson E.M.
        • Virkus W.W.
        High-Energy Tibial Plateau Fractures.
        J Am Acad of Orthop Surg. 2016; 14: 20-31
        • McNamara I.R.
        • Smith T.O.
        • Shepherd K.L.
        • Clark A.B.
        • Nielsen D.M.
        • Donell S.
        • et al.
        Surgical fixation methods for tibial plateau fractures.
        Cochrane Database Syst Rev. 2015; 15CD009679
        • Malik S.
        • Herron T.
        • Mabrouk A.
        • Rosenberg N.
        Tibial Plateau Fractures.
        StatPearls. 2021; (internet)
        • Moore T.M.
        • Patzakis M.J.
        • Harvey J.P.
        Tibial plateau fractures: definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction.
        J Orthop Trauma. 1987; 1: 97-119
        • Watson J.T.
        High-energy fractures of the tibial plateau.
        Orthop Clin North Am. 1994; 25: 723-752
        • Egol K.A.
        • Tejwani N.C.
        • Capla E.L.
        • Wolinsky P.L.
        • Koval K.J
        Staged Management of High-Energy Proximal Tibia Fractures (OTA Types 41): the Results of a Prospective, Standardized Protocol.
        J Orthop Trauma. 2005; 19: 448-455
        • Haidukewych G.J.
        Current State of the Art: temporary External Fixation for the Management of Complex Intra- and Periarticular Fractures of the Lower Extremity.
        J Orthop Trauma. 2002; 16: 678-685
        • Norris G.R.
        • Checketts J.X.
        • Scott J.T.
        • Vassar M.
        • Norris B.L.
        • Giannoudis P.V
        Prevalence of Deep surgical site infection after repair of periarticular knee fractures: a Systematic Review and Meta-analysis.
        JAMA Network Open. 2019; 2e199951
        • Haller J.M.
        • Holt D.
        • Rothberg D.L.
        • Kubiak E.N.
        • Higgins T.F.
        Does Early versus Delayed Spanning External Fixation Impact Complication Rates for High-energy Tibial Plateau and Plafond Fractures?.
        Clin Orthop Related Res. 2016; 474: 1436-1444
        • Schalamon J.
        • Petnehaxy T.
        • Ainoedhofer H.
        • Zwick E.B.
        • Singer G.
        • Hoellwarth M.E.
        Pin tract infection with external fixation of pediatric fractures.
        J Pediatr Surg. 2007; 42: 1584-1587
        • Behrens F.
        • Searls K.
        External fixation of the tibia. Basic concepts and prospective evaluation.
        J Bone Joint Surg Br. 1986; 68: 246-254
        • Ferguson D.
        • Harwood P.
        • Allgar V.
        • Roy A.
        • Foster P.
        • Taylor M.
        • et al.
        The PINS Trial: a prospective randomized clinical trial comparing a traditional versus an emollient skincare regimen for the care of pin-sites in patients with circular frames.
        Bone Joint J. 2021; (103-B): 279-285
        • Shah C.M.
        • Babb P.
        • McAndrew C.M.
        • Brimmo O.
        • Badarudeen S.
        • Tornetta P.
        • et al.
        Definitive plates overlapping provisional external fixator pin sites: is the infection risk increased?.
        J Orthop Trauma. 2014; 28: 518-522
        • Laible C.
        • Earl-Royal E.
        • Davidovitch R.
        • Walsh M.
        • Egol K.A.
        Infection After Spanning External Fixation for High-Energy Tibial Plateau Fractures: is Pin Site-Plate Overlap a Problem?.
        J Orthop Trauma. 2012; 26: 92-97
        • Potter J.M.
        • Van der Vliet Q.M.
        • Esposito J.G.
        • McTague M.F.
        • Weaver M.
        • Heng M.
        Is the Proximity of external fixator pins to eventual definitive fixation implants related to the risk of deep infection in the staged management of tibial pilon fractures?.
        Injury. 2019; 50: 2103-2107
        • Hadeed M.M.
        • Evans C.L.
        • Werner B.C.
        • Novicoff W.M.
        • Weiss D.B.
        Does external fixator pin site distance from definitive implant affection infection rate in pilon fractures?.
        Injury. 2019; 50: 503-507
        • Dombrowsky A.
        • Abyar E.
        • McGwin G.
        • Johnson M.
        Is Definitive Plate Fixation Overlap with External Fixator Pin Sites a Risk Factor for Infection after Pilon Fractures?.
        J Orthop Trauma. 2021; 35: e7-e12
        • Zhang J.
        • Yu K.F.
        What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes.
        JAMA. 1998; 280: 1690-1691
        • Hayek K.R.
        • Parikh H.R.
        • McCreary D.L.
        • Westberg J.R.
        • Mirik G.
        • Baynard T.
        • et al.
        Cost Variation in Temporizing External Fixation of Tibial Plateau Fractures.
        J Orthop Trauma. 2019; 33: S5-S10
        • Mahan J.
        • Seligson D.
        • Henry S.L.
        • Hynes P.
        • Dobbins J.
        Factors in pin tract infections.
        Orthopedics. 1991; 14: 305-308
        • Clasper J.C.
        • Parker S.J.
        • Simpson A.H.
        • Watkins P.E.
        Contamination of the medullary canal following pin-tract infection.
        J Orthop Res. 1999; 17: 947-952
        • Stapleton J.J.
        • Zgonis T.
        Surgical Treatment of tibial plafond fractures.
        Clin Podiatr Med Surg. 2014; 31: 547-564
        • Antoci V.
        • Ono C.M.
        • Antoci V.J.
        • Raney E.M.
        Pin-tract infection during limb lengthening using external fixation.
        AM J Orthop. 2008; 37: E150-E154
        • Colman M.
        • Wright A.
        • Gruen G.
        • Siska P.
        • Pape H.C.
        • Tarkin I.
        Prolonged operative time increases infection rate in tibial plateau fractures.
        Injury. 2013; 44 (Feb): 249-252
        • Hutson J.J.
        • Zych G.A.
        Infection in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixation.
        J Orthop Trauma. 1998; 12: 214-218
        • Parameswaran A.D.
        • Roberts C.S.
        • Seligson D.
        • Voor M.
        Pin tract infection with contemporary external fixation: how much of a problem?.
        J Orthop Trauma. 2003; 17: 503-507
        • Morris B.J.
        • Unger R.Z.
        • Archer K.R.
        • Mathis S.L.
        • Perdue A.M.
        • Obremsky W.T.
        Risk factors of infection after ORIF of bicondylar tibial plateau fractures.
        J Orthop Trauma. 2013; 27: 196-200
        • Naik M.A.
        • Arora G.
        • Tripathy S.K.
        • Sujir P.
        • Rao S.K.
        Clinical and radiological outcome of percutaneous plating in extra-articular proximal tibia fractures: a prospective study.
        Injury. 2013; 44 (Aug): 1081-1086
        • Singleton N.
        • Sahakian V.
        • Muir D.
        Outcome After Tibial Plateau Fracture: how Important Is Restoration of Articular Congruity?.
        J Orthop Trauma. 2017; 31 (Mar): 158-163
        • Parkkinen M.
        • Lindahl J.
        • Mäkinen T.J.
        • Koskinen S.K.
        • Mustonen A.
        • Madanat R.
        Predictors of osteoarthritis following operative treatment of medial tibial plateau fractures.
        Injury. 2018; 49 (Feb): 370-375
        • Momaya A.M.
        • Hlavacek J.
        • Etier B.
        • Johannesmeyer D.
        • Oladeji L.O.
        • Niemeier T.E.
        • et al.
        Risk factors for infection after operative fixation of Tibial plateau fractures.
        Injury. 2016; 47 (Jul): 1501-1505
        • Ruffolo M.R.
        • Gettys F.K.
        • Montijo H.E.
        • Seymour R.B.
        • Karunakar M.A.
        Complications of high-energy bicondylar tibial plateau fractures treated with dual plating through 2 incisions.
        J Orthop Trauma. 2015; 29 (Feb): 85-90
        • Lin S.
        • Mauffrey E.
        • Hammerberg M.
        • Stahel P.F.
        • Hak D.J.
        Surgical site infection after open reduction and internal fixation of tibial plateau fractures.
        Eur J Orthop Surg Traumatol. 2014; 24: 797-803