Journal of Orthopaedic Nursing (2005) 9, 218–225

www.elsevierhealth.com/journals/joon

Journal ofOrthopaedic Nursing

Comparison of povidone-iodine solution andsoft white paraffin ointment in the managementof skeletal pin-sites: A pilot study

Sheila Grant RN, MN, Nurse Researcher a,*, David Kerr RN, DipAppSc(Nursing), Clinical Nurse a, Marianne Wallis RN, PhD, Chair – ClinicalNursing Research b, Don Pitchford MB, BCh, FCS(SA)Orth, Director ofOrthopaedics a

a Gold Coast Hospital, Education Centre, 108 Nerang Street, Southport, Qld 4215, Australiab Gold Coast Hospital, Griffith University, Qld, Australia

Summary Povidone-iodine solution is currently employed for pin-site care in manyinstitutions. There are concerns that this agent reacts with the metal pins and canimpede healing. This study compared two different treatment protocols for the careof the skin surrounding skeletal pin-sites.

This practical clinical trial, employing stratified sampling, compared 10% cutane-ous povidone-iodine solution with soft white paraffin ointment for the treatment ofskeletal pin-sites. The end points of the study were the presence of clinical signs ofpin-site inflammation and/or infection and pin removed as treatment was com-pleted. Data were analysed on 116 pin-sites from 18 patients. Seventy-two pins(62%) were treated with povidone-iodine and 44 (37.9%) with paraffin ointment.The group treated with soft white paraffin ointment more frequently developedclinical signs of infection (n = 15; 34.1%) than the povidone-iodine treatment group(n = 13; 18.1%) (v2 (df) = 3.8(1); p = 0.05). Also, 43.8% of pin-sites on the medialaspect of the lower leg displayed inflammation/infection compared with 16.7% ofother lower limb pin-sites (v2 (df) = 9.28(1); p = 0.002).

The use of an antibacterial agent in the management of skeletal pin-sites reducesthe likelihood of infection. Further studies are needed to determine whether ana-tomical position of the pin-site is a risk factor for the development of pin-site infec-tion and whether intervention could reduce inflammation/infection at medial lowerlimb pin-sites.

�c 2005 Elsevier Ltd. All rights reserved.

KEYWORDSPin-sites;Povidone-iodine;Clinical trial;Soft white paraffin;Skeletal pins

1d

361-3111/$ - see front matter �c 2005 Elsevier Ltd. All rights reserved.oi:10.1016/j.joon.2005.09.005

* Corresponding author. Tel.: +617 5519 8490; fax: + 617 5519 8310.E-mail address: Sheila_Grant@health.qld.gov.au (S. Grant).

Comparison of povidone-iodine solution 219

Editor’s commentThe clinical practice questions arising form skeletal pin site care is recurrent and persistent. This study offers further evidence forpractitioners to peruse, digest and possibly lead them to change practice. PD

Introduction

A common and potentially serious complication ofskeletal pin insertion is infection of the tissue sur-rounding the pin-site. Such infections can causepain and discomfort and lead to osteomyelitis, de-layed fracture healing and non-union (McKenzie,1999), resulting in prolonged length of stay in hos-pital or readmission and increased patient carecosts (Jones-Walton, 1988; Sproles, 1985). To pre-vent such complications pin-sites are treated witha range of different protocols. This pilot studycompared two treatment protocols, the applica-tion of 10% povidone-iodine solution or sterile softwhite paraffin ointment, in the care of the skinaround skeletal pin-sites.

At the study site, the Gold Coast Hospital (GCH),between 15 and 26 patients are discharged each yearwith one or more skeletal pins or wires in situ. Fol-lowing discharge from hospital, care of the pin-sitesis the responsibility of the patient, with supportfrom the GCH Discharge Services Unit. The Directorof Orthopaedics and members of the Discharge Ser-vices had questions about the effectiveness of andpatient compliance with the existing pin-site careprotocol, which involved cleaning the pin-site withnormal saline and applying a 10% alcohol basedpovidone-iodine cutaneous solution to the skin sur-rounding the pin-site, for the duration of the pins’insertion. An alternative protocol based on theprinciples of wound healing was proposed, in whichsterile, soft white paraffin ointment was employedinstead of povidone-iodine. Performed on a dailybasis, this methodwas seen to be less invasivewhilstmaintaining the integrity of the skin. However,evidence for this practice change was required.

Literature review

A number of pin-site protocols, used to preventinfection, were described in the literature (McKen-zie, 1999; Paley and Jackson, 1985; Sproles, 1985)which used a variety of solutions for cleaning andtreating pin-sites. A Cochrane review (Templeand Santy, 2004) found only one methodologicallyappropriate randomised controlled trial, Henry(1996), to guide protocol development. In mostpublished studies protocols had been developedeither as a result of surveying practice in other sur-

gical units or by consensus of opinion (Brereton,1998; Celeste et al., 1984; Jones-Walton, 1991;Lee-Smith et al., 2001).

At the time the study commenced the literatureon pin-site dressings did not provide any compel-ling evidence that povidone-iodine solution wasthe most appropriate solution for reducing theincidence of pin-site infection. A review of the lit-erature conducted by Olsen (1996) identified sev-eral studies that associated povidone-iodine withan increased incidence of infection (Becker,1986; Burke et al., 1986; Maki et al., 1991). Otherstudies found it had a negative effect on the skin�snormal flora with an increase in Gram-positivecocci (Chevalier and Cremieux, 1992) and that itsaction was ineffective when exposed to pus, ser-um and other wound components (Rodeheaver,1988; Thompson, 1985). Rutecki and Seligson(1980) advised against the use of povidone-iodineclaiming that it corrodes the pins. Neidner (1997,p. 90), however, challenged this advice claimingthat in vivo studies showed, if used correctly,‘‘povidone iodine . . . does not lead to any celldamage even in a 10% concentration’’. Only onearticle reviewed the use of ointments and thesewere perceived to block the drainage of fluid atthe pin-site, increasing the risk of infection (Ce-leste et al., 1984).

The aims of this pilot study were to developsound data collection and protocol implementationprocesses, examine the relationship between twopin-site management protocols, as applied toexternal fixation devices used on adult orthopaedicpatients, to determine whether there are any dif-ferences in the incidence of pin-site infection indifferent anatomical locations, and to determinethe treatment effect so a power analysis could beundertaken to inform sampling for future random-ised controlled trials. The two hypotheses thatwere tested in this study were:

1. Irrigating the pin-site with normal saline andapplying soft white paraffin ointment will resultin a lower incidence of clinical signs of infec-tion ± antibiotic use than current practice(cleaning with normal saline and applying povi-done-iodine).

2. There will be no difference in the incidence ofclinical signs of infection ± antibiotic use inpin-sites in different anatomical positions.

220 S. Grant et al.

Method

This study utilised a non-blinded, no crossover clin-ical trial design with patients allocated to one oftwo different pin-site treatment groups.

Study setting

This pilot study was conducted at the Gold CoastHospital, a 579 bed general public hospital situatedin the south east corner of Queensland, Australia.This is the major hospital for the district, with a res-ident population of approximately 380,000 and atransient population of approximately 500,000 holi-daymakers. It has the second busiest EmergencyDepartment in the State of Queensland, an IntensiveCare Unit, Coronary Care Unit, and general medicaland surgical wards, including a 30 bed OrthopaedicUnit. Ethical approval to conduct the study was ob-tained from the Gold Coast Health Service District(GCHSD) Human Research Ethics Committee.

Recruitment and sampling

All subjects in the sample had been admitted to thehospital with an acute injury. Subjects had to beover the age of 18 years, reside within the bound-aries of the Health Service District and able to pro-vide written informed consent. During the periodfrom June 2002 to June 2003, the Principal Investi-gator (PI) was informed by ward staff when patientswere admitted to the ward following insertion of askeletal pin or wire, under aseptic conditions inthe operating theatre. Once the patients had recov-ered from the anaesthetic they were provided witha verbal and written explanation of the study andwere invited to participate. Every patient has agauze swab soaked in 10% povidone-iodine solutionapplied to each pin-site whilst in the operatingtheatre, which is removed approximately 72 h aftersurgery, patients therefore had sufficient time toconsider the proposal prior to the commencementof their pin-site treatment protocol. Once recruitedinto the study each participant, together with allhis/her pins, was randomly allocated to an inter-vention group and provided with a written explana-tion of the appropriate treatment protocol.

Intervention

Intervention group one received the pin-site treat-ment protocol used at the Gold Coast Hospital. Thisintervention involved the twice daily cleansing ofthe pin-site with normal saline and application of

a 10% povidone-iodine solution, employing a non-touch technique and aseptic principles, for a periodof approximately two weeks post-operatively oruntil the patient was discharged from hospital. Thiswas followed by daily treatments until such time asthe pins were removed. Any clinical signs of pin-site infection for this group were to be treatedaccording to the current protocol, which involvedobtaining a wound swab of the pin-site for cultureand sensitivity testing and prescription of antibiot-ics by the treating medical officer or generalpractitioner.

Intervention group two received a pin-site treat-ment protocol which involved the application ofsterile soft white paraffin ointment from a singleuse vial, to the skin surrounding the pin-site for 14days post-surgery. This protocol was developedusing the principles of wound healing, in the beliefthat the skin around the pin-site would have sealed.This intervention also employed a sterile dressingpack, metal forceps and a non-touch technique.The pin-site was cleaned with a normal saline flushand dried serous ooze removed with metal forceps.Sterile soft white paraffin ointment from a singleuse tube was then applied by a gloved fingertip tothe tissue surrounding the pin-site. Treatment onspecific pin-sites continued if they oozed and/or acrust formed. If an inflammatory response was re-ported the following variance path was employed.

1. Participant notified the primary nurse or pre-sented to the Emergency Department.

2. A swab for culture of the pin-site obtained.3. Chlorhexidine Cream 1% commenced. (Chlorhex-

idine Cream 1% applied in the same manner assoft white paraffin ointment and continued untilsymptoms resolved in conjunction with pre-scribed antibiotics).

Ward staff were informed to which protocol thepatient had been assigned and the pin-site protocolwas commenced 72 h post-operatively. As skeletalpins can remain in situ for as long as six months, par-ticipants were educated in and encouraged to per-form pin-site care whilst in hospital as they wouldbe responsible for the care of the pin-sites oncedischarged. Where the participant was unable toperform their pin-site care, a reliable friend or fam-ily member was educated to perform the careaccording to the protocol. However, if for some rea-son a patient was considered to be unable to care fortheir pin-sites in an aseptic manner, following dis-charge from hospital, a community health nurse ora member of the Discharge Services would visitthe participant�s home to conduct the pin-site care.The majority of patients were however, self-caring.

Comparison of povidone-iodine solution 221

Prior to discharge participants in both groupswere reviewed by the principal investigator andprovided with sufficient materials to allow themto perform pin-site care at home. Once discharged,members of the Discharge Services would providesupplies of the necessary materials until the pinswere removed. Each patient had an individually de-signed follow-up protocol negotiated with theirOrthopaedic Consultant. This involved some combi-nation of outpatients� clinic appointments andhome visits from the Discharge Services. They werealso advised to consult their GP if they were con-cerned about a pin-site and were unable to contacta member of the Discharge Services or OrthopaedicUnit.

Data collection

From the commencement of the treatment proto-col a pin-site evaluation sheet was developedbased on the literature pertaining to pin-site stud-ies in which signs and symptoms of pin-site inflam-mation/infection were discussed (Celeste et al.,1984; Jones-Walton, 1991; Sproles, 1985). Datacollected using this instrument included patientdemographics, medical history of patient, detailsof the surgical procedure, site of pin, type ofpin, type of frame, type of wound, type of frac-ture, details of antibiotic therapy prescribed byhospital medical officer or GP, the frequency ofcleaning and/or dressings, an on-going record ofpin-site observation (colour, presence of swelling,presence of crust, presence and colour of ooze,presence of pus) and the date and reason for pinremoval.

The pin-site evaluation sheet was completeddaily for each pin-site for a period of 14 days or un-til the patient was discharged from hospital, andwas then completed by a registered nurse once aweek when the patient was visited by a memberof the Discharge Services, or the participant at-tended the Orthopaedic Outpatients Clinic, untilsuch time as the patient met one of the two studyendpoints.

The two end points identified for this study were:

1. Clinical signs of infection at pin-site ± prescrip-tion of antibiotics (not all pins-sites that showedsigns of infection were swabbed to confirm theclinical signs but as many patients were beingtreated by GPs in the community their clinicaljudgement was accepted as the end point). Forease of reporting this end point will be referredto as ‘‘Infected’’ or ‘‘Clinical signs of infection’’throughout the paper.

2. Routine removal of pin indicating completedtreatment.

Data analysis

Data were entered into SPSS v.11.5. Descriptivestatistics were used to analyse demographic andclinical data. The outcomes of the two treatmentgroups were compared using v2 analysis.

Results

Of the 26 patients who had undergone surgery dur-ing the study period for the insertion of a skeletalpin, 21 met the eligibility criteria. One patientwas eligible but declined to be involved. Of thosewho were ineligible, three patients did not meetthe criteria for residency and two were unable togive informed consent as they were intubated atthe time. Thus, 20 subjects with 131 pins were en-rolled in the study. However, 15 pins in the softwhite paraffin protocol were removed from thestudy as outlined in Fig. 1.

Data were analysed on 116 pin-sites from 18 pa-tients. The mean age of the people in the samplewas 44.8 years (SD = 17.1; range = 23–86). The num-ber of pin-sites per patient varied from 2 to 17. Sev-enty-two pins sites (62%) were treated according tothe povidone-iodine protocol and 44 (38%) were inthe soft white paraffin arm of the study. Prophylac-tic antibiotics were prescribed in the intraoperativeor immediate post-operative period for 15 (83%) ofthe patients. The length of time the pins remainedin situ until removal was 4–120 days.

To ensure that there were no between-groupdifferences, patient demographic and clinical char-acteristics were compared. Tables 1 and 2 indicatethat there were no statistically significant differ-ences in gender, types of fractures, externalframes employed, type of pin, location of pin andwound type, between the two groups. Table 1 indi-cates that the majority of participants were men,half the sample had closed fractures, a variety offrame types were used and the majority of woundswere closed. Table 2 shows that four types of pinswere inserted with the majority being half pins andfine wires. Most of the pins were positioned in thelower limb with the remaining positioned in theupper limb or pelvis. In addition, the mean agewas similar for the paraffin group (47.2 years) andpovidone-iodine group (42.5 t(df) = 0.61 (18);p = 0.55). The length of time between admissionand surgery, in hours, between the two groups,showed no significant differences with a mean of

para p

in-sites

1 patient with4 pin-sites withdrawn as non-compliant

1 patient with2 pin-sites asked to bewithdrawn from study

9 pin-sites withdrawn because the protocolchanged as result of infection in other close p

44 pin-sites in softwhite paraffin group

72 pin-sites inpovidone-iodinegroup

116 pin-sites include in finalanalysis

15 pins withdrawn fromstudy – all from soft white

ffin grou

131 pins admitted to trial

Figure 1 Trial profile.

Table 1 Descriptive statistics and cross tabulations comparing patient demographics and clinical data byexperimental group

Characteristic Totalsample n (%)

Povidone-iodinen (%)

Paraffinointment n (%)

Inferentialstatistic

P value

GenderMale 16 (89.0) 8 (80.0) 8 (100.0) v2 (df) = 1.8(1) 0.180Female 2 (11.0) 2 (20.0) 0

Type of fractureComminuted 7 (39.0) 5 (50.0) 2 (25.0) v2 (df) = 1.9(2) 0.383Closed 8 (44.4) 3 (30.0) 5 (62.5)Compound 3 (16.7) 2 (20.0) 1 (12.5)

Type of frameUni 8 (44.4) 5 (50.0) 3 (37.5) v2 (df) = 3.65(4) 0.455Hybrid 3 (16.7) 2 (20.0) 1 (12.5)Bi 1 (5.6) 1 (10.0) 0Traction 4 (22.2) 2 (20.0) 2 (25.0)Illazarov 2 (11) 0 2 (25.0)

Wound typeClosed 15 (83.3) 9 (90) 6 (75.0) v2 (df) = 1.4(2) 0.50Open Grade 1 1 (5.6) 0 1 (12.5)Open Grade 3A 2 (11.1) 1 (10) 1 (12.5)

222 S. Grant et al.

117.4 h for the povidone-iodine group and 107.9 hfor the soft white paraffin group (Mann–WhitneyU = 49.0; p = 0.94).

The two end points used in this study were pinsremoved as treatment completed and documentedclinical signs of infection and/or the prescription ofantibiotics. In this study, 75.9% (n = 88) of the

pin-sites had no documented clinical signs of infec-tion and remained in situ on the designated proto-col until treatment was completed. Overall theproportion of the pin-sites that developed clinicalsigns of infection was 24.1% (n = 28). Of the in-fected pin-sites, 15 were in the soft white paraffingroup and 13 in the povidone-iodine group with 22

Table 2 Descriptive statistics and cross tabulations comparing pin-site characteristics by experimental group

Characteristic Total sample(n = 116)

Povidone-iodine(n = 72)

Paraffin ointment(n = 44)

Inferential statistic P value

Pin typeFine wire 45 30 15 v2 (df) = 1.3(3) 0.707Half pin 55 34 21Steinman 12 6 6Denham 4 2 2

Position of pinLeg/ankle/foot 86 54 32 v2 (df) = 5.1(2) 0.075Arm/wrist/hand 24 12 12Pelvis 6 6 0

Comparison of povidone-iodine solution 223

in the lower limb and six in the pelvis. None of theupper limb pin-sites became infected. Clinical signsof infection were detected between 6 and 60 daysfollowing injury with an average of 26.4 days(SD = 13.0) for the povidone-iodine group and 26.7days (SD = 12.9) for the paraffin ointment group.

Swabs were sent for microscopy and culture froma total of 22 pin-sites. Only six of the nine pinsswabbed for culture in the povidone-iodine groupshowed bacterial growth. All of them were positivefor Staphylococcus aureus. In the soft white paraf-fin group nine of the 13 swabs showed bacterialgrowth. All were positive for Staphylococcus aureusand six also cultured other organisms (Staphylo-cocci (3), Pseudomonas aeruginosa (1) and Strepto-coccus agalinae and Pseudomonas aeruginosa (2)).

The end-point analysis comparing the outcomesfor the two treatment groups indicated that thegroup treated with soft white paraffin ointmenthad a higher incidence of clinical signs of infection(n = 15; 34.1%) than the povidone-iodine treatmentgroup (n = 13; 18.1%) and the differences betweenthe end-points for the two treatment groupsreached statistical significance (v2 (df) = 3.8(1);p = 0.05). Subgroup analysis was generally notconsidered appropriate due to small sample size;however, pins sited in the lateral aspect had thelowest rate of infection for lower limb pin-sites.When pin-site infection rates in the lower limb werecompared 43.8% (n = 14) were situated on themedial aspect of the limb compared to 14.8%(n = 8) on anterior and lateral aspects of the lowerlimb (v2 (df) = 8.8(1); p = 0.003).

Discussion

It is difficult to compare the incidence of pin-siteinfection in this study with those in other studiesas the definition of pin-site infection/reaction isvaried. Infections have been classified as minor or

major (Green, 1983; Sproles, 1985; Jones-Walton,1988), superficial or deep (Parameswaran et al.,2003) with infections in the major/deep categoriesrequiring the patient to be admitted to hospital foreither parenteral antibiotic therapy or pin removal,or graded according to initial signs of redness tochronic osteomyelitis (W-Dahl et al., 2003; Simset al., 2000; Sims and Saleh 2000; Sims, 1996).Using these classifications, all of the pin-site infec-tions in this study would have been minor or lowgrade. None of the pins were removed until thetreatment was completed and none of the patientswere placed on parenteral antibiotic therapy.Henry (1996) identified pin-sites as infected ifthere was pain, redness and swelling and ‘‘whena significant number of pathogenic bacteria werecultured’’ (p. 17). Our study classified pin-sites asinfected if they displayed clinical signs of infectionsuch as redness, induration, haemo-serous oozeand pain. Twenty-eight pin-sites (24.1%) met thiscriterion, however, only 12.9%, of all the pin-sitesin the study grew pathogenic bacteria.

Henry (1996) reported 16.6% of the pin-sites inher study met her criteria for being infected, andW-Dahl et al. (2003) reported a 15% infection ratein their study. Themajority of these infections werelow grade, with 30% developing positive bacterialcultures. In her study, Sproles (1985) classified13.1% of the pin-sites in the experimental groupand 26.6% in the control group, as infected. Theinfection rate in this study would appear to bewithin a similar range to those reported in otherrandomised studies.

The use of prophylactic post-operative oral anti-biotics may have had a beneficial effect on the inci-dence of pin-site infection. The majority of theparticipants in our study received post-operativeantibiotic cover (83%). Other studies reported anti-biotics being prescribed for their participants.

This study found that skeletal pin-sites clean-sed with normal saline and swabbed with 10%

224 S. Grant et al.

povidone-iodine solution for the duration of theskeletal pin insertion had a lower infection rate(18%) than skeletal pin-sites cleansed with normalsaline and treated with soft white paraffin ointment(34.1%) for 14 days post-surgery. As a topical solu-tion, povidone-iodine has been shown to have somecumulative action with regular use and has a broad-spectrum biocidal activity against Gram-positiveand Gram-negative bacteria (Gardner and Peel,1998). The soft white paraffin ointment was an inertsubstance and employed to promote granulation. Aspreviously stated, some of the literature suggeststhat the use of povidone-iodine in the care of pin-sites is inappropriate as it reacts with the stainlesssteel pins (Farrell, 1986; Rutecki and Seligson,1980) and can denature protein (Brennan et al.,1986). No evidence of either was observed in thisstudy and none of the other studies on pin-site carehave reported these complications. Celeste et al.(1984) reported no evidence of corrosion of stain-less steel pins with povidone-iodine. In addition,according to the Corrosion Data Survey (Nelson,1968), the penetration rate of iodine on stainlesssteel is less than 20/1000 of one inch per year. Burks(1998) reports that the American Agency for HealthCare Policy and Research recommends that povi-done-iodine and other skin cleansers not be usedto clean ulcer wounds. However, it also states thatit is relatively safe on small acute wounds. As skel-etal pins are seldom in situ for as long as a year andthe povidone-iodine is applied to skin, these appar-ent side effects are unlikely to occur.

Only one previous study has set out to compare asolution that does not have antibacterial or bacte-ricidal activity with a solution that does have theseproperties. Henry (1996) found pin-sites cleanedwith 0.9% normal saline had a higher infection ratethan those cleaned with 70% alcohol or not cleanedat all. However, povidone-iodine was then appliedto all the pin-sites in the study. In our study, all ofthe pin-sites were cleaned with normal saline andit would appear that a bactericidal solution shouldbe employed in pin-site care.

In this study, pin-sites in the control group weretreated daily until the pin was removed. Pin-sites inthe experimental group were treated daily for 14days or until a seal had formed around the pin-site.Participants in both groups were advised to inspecttheir pin-sites daily for signs of clinical infectionand to contact the principal investigator or theirGeneral Practitioner if such signs were positive.One previous study has evaluated the frequency ofpin-site care and found that weekly treatments areas effective as daily treatments (W-Dahl et al.,2003). Several studies have identified the frequencyof conducting pin-site care (Henry, 1996; Sproles,

1985; Celeste et al., 1984) but did not discuss its sig-nificance in their results. Surveys conducted toestablish frequency of care have identified that itmay be conducted anywhere between daily to every4 h (Sims, 1996; Jones-Walton, 1991). In this study,daily pin-site care was more effective at preventinginfection than no care after 14 days post skeletalpin insertion. It is also possible that pin-site careneeds to be conducted for more than 14 days partic-ularly as Sproles (1985) suggests that the longer thepin is in situ the greater the risk of pin-site infection,and whilst Henry (1996), did not perceive length oftime to be an issue, it is interesting to note that noneof the pins in the upper limb in either group becameinfected, and achieved end point 2 within 45 days ofinsertion (mean = 38.5 days).

This study found that medial pins in the lower partof the leg had thegreatest incidenceofpin-site infec-tion. This contradicts the findings of both Henry(1996) who reported that the femoral pin-sites be-came infected more often than those below oraround the knee and Sproles (1985)who found lateralpins showed more than twice the adverse responsestomedial pins. In this study, twoof the eight pin-sitessituated in the femur became infected (25%) one ofwhich was on the medial aspect. In the lower leg,14 of the 56 pin-sites became infected with an infec-tion rate of 73% for medial pin-sites as opposed to7.3% for the pin-sites in the anterior and lateral lowerleg.We concluded that thismight have resulted fromthe participants’ poor showering technique and theexposure of their pin-sites to run-off from the peri-neum, whilst showering.

Limitations of the research

Patients who require the insertion of skeletal pinsto treat a fracture invariably have multiple inser-tion and exit sites for the pins. All or any of thesesites can exhibit signs and/or symptoms of inflam-mation and infection and the response of the med-ical staff is to prescribe intravenous or oralantibiotics in an attempt to halt the infection andprevent it spreading to the bone. This intervention,however, indirectly affects other pin-sites in that,as the antibiotics are systemic they will probablybe active at any other site within the body, at whichan infection is developing. It is therefore possiblethat without early antibiotic therapy other pin-sitesmay have displayed clinical signs of infection.

Some participants and nursing staff had reserva-tions about the use of a substance without antibac-terial properties and this may have led a fewparticipants to modify the soft white paraffin pro-tocol when they felt it was not achieving the de-sired outcomes.

Comparison of povidone-iodine solution 225

Implications

The variety of pin-site care protocols employed bynurses shows considerable uncertainty regardingthe most effective means of treating skeletal pin-sites. This controlled studyhas helped todispel somedoubt about the use of an antibacterial solution in apin-site care protocol. Furthermore, clear and spe-cific guidelines for patient�s to follow once patientsare discharged from hospital are essential.

Further research comparing the effectiveness ofbactericidal agents such as alcohol, chlorhexidineor povidone-iodine, the frequency and manner inwhich they are applied, could provide a protocolfor pin-site care that could be employed in a vari-ety of settings. However, any chart used forrecording pin-site reactions should be tested priorto its introduction for inter-rater reliability andits ability to collect the necessary data accurately.

Conclusions

Given the statistical evidence resulting from thispilot study it would appear that there is a role forthe application of a bactericidal solution such as10% povidone-iodine solution to the skin surround-ing pin-sites. Furthermore, pin-sites in the medialaspect of the lower limb require particular atten-tion and treatment.

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