Image-guided surgical simulation--a proven improvement.

Copyright © Taylor & Francis 2004. ISSN 0001–6470. Printed in Sweden – all rights reserved. Sir—In a paper by W-Dahl et al. (2003), the authors describe rather intricate routines for the care of external fixators. During the last two decades, I and most of my colleagues at three hospitals have used a simple protocol which has also also been taught at several courses on fracture treatment with external fixators. After surgery, the pins (or, rather, screws) are bandaged with small dry sterile gauzes which are left in place for 10–14 days. Then the patient is instructed to wash the wounds with liquid soap and ordinary tap water when he/she takes a daily shower. If the screws require cleaning, this is easily done with a clean new toothbrush and the wounds, screws and external fixator are flushed with the shower. When the skin and wounds have dried (if necessary, with the help of a hair-dryer), small dry gauze bandages are applied around the screws, but circular bandages are not used. The crusts on the skin are left in place. Dry crusts fall off by themselves. There is no use of cotton buds, and no care from a district nurse is required, most patients can manage these daily routines themselves. By using this simple protocol for postoperative care of external fixators, we have reduced the number of “pin” tract infections to a minimum. There is no need of prophylactic antibiotics after the day of surgery. Dry wounds around stable screws do not become infected. A few of our patients carrying external fixators for long time have even omitted bandages altogether, but have practiced daily cleaning as described. The two most common causes of a “pin” tract infection are skin tension around a screw and/or loosening of a screw. Skin tension is treated by a sharp incision, and loose screws should be replaced. According to my personal experience, conical screws are less reliable than e.g. straight apex screws which are safely anchored in both cortices. In the metaphyseal parts of the tibia, a half-ring montage with four screws applied in different directions, thereby locking each other, or an Ilizarov ring is mechanically safer than two parallel screws.