Does burying Kirschner wires influence infection rate following fixation of upper extremity fractures? A systematic review Justin C.R. Wormald (1), Matthew D. Gardiner (1,2), Hawys Lloyd-Hughes (2,3), Sonya Gardiner (3), Abhilash Jain (1,2) IFSSH & IFSHT Triennial Congress, 24-28th October 2016, Buenas Aires, Argentina (1) Department of Plastic and Reconstructive Surgery, Imperial College Healthcare NHS trust, St Mary’s Hospital, London, W2 1NY (2) Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Roosevelt Drive, Oxford, OX3 7FY, UK (3) Royal Free Hospital, Pond Street, London, NW3 2QG Mr. Justin CR Wormald MBBS MRes MRCS Core Surgical Trainee (CT1) Chelsea and Westminster Hospital NHS Foundation Trust London justinwormald@gmail.com

Buried vs. Non-buried K-wires Advantages of buried K-wires: Patient comfort Reduced infection rate? Disadvantages of buried K-wires Wire removal – second procedure (LA/GA) Financial implications Advantages of non-buried K-wires: Quick and easy removal More cost-effective? Disadvantages of non-buried K-wires: Higher rate of post-operative infection? Delayed mobilisation

Research Objective Buried versus non-buried K-wires for upper extremity fracture – to review the literature and provide clinical guidance Methods: Systematic review +/- meta-analysis Registered with PROSPERO Primary outcome: Post-operative infection

Search Strategy

Results Demographics 3 adult studies; 5 paediatric studies Male > female Closed fractures > open fractures Intervention and Comparison Buried versus non-buried K-wires Outcome Rate of post-operative infection (all studies) Study design 1 RCT and 7 case series Study n Methods Shoemaker 1999 Forearm 32 Case series Hargreaves 2004 Distal radius 56 RCT Rafique 2006 Metacarpal/phalangeal 60 Chan 2011 Lateral condyle elbow 75 Koc 2012 104 McGongagle 2012 69 Das De 2012 235 Kelly 2014 170

Post-operative infection – Forest Plot

Post-operative infection (by site of K-wire) %

Discussion Conclusions Quality of literature: RCT data for wrist, case series data for all others Post-operative infection: apparent difference in metacarpo-phalangeal fracture (case series) and in distal radius (RCT) Cost: Two of the studies reported the additional costs associated with burying K-wires compared to non-buried Skin erosion: A major cause for return to theatre lateral condyle elbow fracture Systematic review – likely difference in infection rate between buried and non-buried K-wires for metacarpo-phalangeal fractures Evidence for buried versus non-buried K-wires in hand fractures is poor Question has not been answered – question has been established Identified need for joint orthopaedic and plastic RCT to answer question First phase underway - national survey of practice with RSTN