Mylène Jansen

162 Chapter 8 some patients started antibiotics without actually having a pin tract infection, in which case the amount of pin tract infections might be lower than presented in this study. While this was a limitation of the current study, all patients taking antibiotics experienced infection- like symptoms and received antibiotics according to regular care protocol, so the significant reduction experienced after use of cadexomer iodine is clearly relevant in clinical practice and has direct implications for both patient wellbeing and general antibiotic use. It may, however, have been useful to not only compare the number of patients experiencing infections, but also the number of infected pins, as is often done in other studies. We did not collect this data, or different outcomes such as systemic biomarker levels to evaluate the effect of the ointment on general physiological functions, as this was a retrospective analysis. Another limitation of the current study was that it was not set up as a randomized controlled trial. Ideally, patients receiving cadexomer iodine would be compared to patients using a placebo ointment in a randomized controlled trial. Nevertheless, the 2 patient groups seem similar and do not show any statistically significant differences in baseline characteristics, including known risk factors for infections during fixation. At present, a randomized trial while knowing the difference in infections between both groups would be ethically unsound. However, an interesting future study may be a randomized controlled trial comparing Iodosorb® to 1 or more other agents or methods for pin tract infection prevention. Despite significant reductions in patients with infections, still a third of KJD patients experience pin tract infections. Further reduction of pin tract infections, which might be achieved by additional changes in the surgical technique, equipment (pins) or wound care protocol, is required to further reduce antibiotic use and the patients’ treatment burden during KJD. Literature on preventing pin tract infections associated with external fixators is limited, and studies that evaluated factors such as cleansing solutions, prophylactic antibiotic use, different types of dressings, pin coating, and pin care frequency generally found no significant effects. 10–12,21,22 However, combined with cadexomer iodine use, implementing other changes might result in a further reduction of pin tract infections. Although it was previously shown infections do not have an influence on clinical benefit, and patients undergoing TKA several years after KJD did not experience additional complications or decreased clinical benefit, prevention of pin tract infections could still have positive effects in decreasing the patients’ treatment burden during the fixation period. 9,23 While the use of cadexomer iodine in patients has been evaluated and shown positive results, these studies were all performed in patients with ulcers. 17,24,25 Based on the significant results found in the current study, the use of cadexomer iodine in other treatments that use external fixation frames could be considered and evaluated as well, as it is likely that these results are not specific to only KJD.