SLR - May 2023 - Callie Morlock, DPM
Title: Primary Closure or Secondary Wound Healing of Pin Sites After External Fixator RemovalReference: Roth F, Cagienard F, Link BC, Hodel S, Lehnick D, Babst R, Beeres FJP. Primary or secondary wound healing of the pin sites after removal of the external fixator: study protocol for a prospective, randomized controlled, monocenter trial. Trials. 2020 Feb 19;21(1):205. doi: 10.1186/s13063-020-4087-8. PMID: 32075685; PMCID:PMC7031911.
Level of Evidence: Level 1, Therapeutic
Scientific Literature Review
Reviewed By: Callie Morlock, DPM
Residency Program: North Colorado Medical Center, Greeley, CO
Podiatric Relevance: Temporary external fixation is a powerful tool that can be utilized for a wide range of pathologies. Surgeons are often faced with a dilemma of how to address the pin sites after removal to ensure appropriate healing. While some anatomic locations may be more forgiving with primary closure of pin sites, there is no consensus on primary versus secondary wound healing. The literature remains unclear if primary versus secondary wound closure is preferred for pin site wounds.
Methods: A randomized control trial at a level 1-trauma center in Switzerland included patients who underwent temporary application of an external fixator for approximately 1 week after an upper or lower extremity trauama. Patients were required to have a minimum of 2 wounds to be included in order to designate an index wound. The primary outcome was pin-site infection with secondary outcomes measured at 2, 6, 12, 24, and 52-weeks regarding complications, time to wound healing, patient satisfaction, VAS score, and Vancouver Scar Scale. The first group received primary closure of the most proximal wound, designated as the index wound, using a vertical mattress suture while the second group did not receive primary closure of the index wound. For the back of the hand or foot, the most medially located pin was considered the index pin site. The pin site wounds from proximal to distal were alternated between closed and open depending on the treatment group.
Results: A total of 70 patients with 241 pin sites were included with 123 pin sites primarily closed and 118 left to secondary wound healing. A total of 83 pin sites were in the upper extremity and 158 in the lower extremity. There were no pin site infections in either group and there was noted to have faster time to healing with primary closure in the lower extremity. At the first follow up, 82% of the wounds treated with primary closure were healed and only 61% of the wounds treated with secondary wound healing were healed. There was a significant difference in wound healing between the primary and secondary groups with the primary closure group showing faster resolution of the wound. No significant difference with the Vancouver Scar Scale and patient satisfaction was found between the two groups.
Conclusion: Primary closure of external fixation pin sites after removal healed significantly fast compared to secondary wound healing, but there was not found to be any pin site infections in the two groups. There was not a significant difference between satisfaction of primary versus secondary healing, but patients were more satisfied with primary closure. If primary closure of a wound site is possible, does not have an increased risk for infection, and provides higher patient satisfaction, it seems reasonable to discuss primary closure as an option. Although there is data supporting either method of wound healing, careful consideration of each patient can continue to provide the best outcomes and least amount of complications after external fixation removal.