1296 THE BONE & JOINT JOURNAL  GENERAL ORTHOPAEDICS Life- and limb-threatening infections following the use of an external fixator J. J. Jauregui, N. Bor, R. Thakral, S. C. Standard, D. Paley, J. E. Herzenberg From Sinai Hospital of Baltimore, Baltimore, Maryland, United States  J. J. Jauregui, MD, Orthopaedic Research Fellow  S. C. Standard, MD, Pediatric Orthopaedic Surgeon  J. E. Herzenberg, MD, Director, International Center for Limb lengthening Sinai Hospital of Baltimore, Baltimore, Maryland, USA.  N. Bor, MD, Orthopaedic Surgeon Emek Medical Center, Afula, Israel.  R. Thakral, MD, Assistant Professor, Adult Reconstruction University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.  D. Paley, MD, Director Paley Advanced Limb Lengthening Institute, West Palm Beach, Florida, USA. Correspondence should be sent to Dr J. E. Herzenberg; e-mail: jherzenberg@ lifebridgehealth.org ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B9. 35626 $2.00 Bone Joint J 2015;97-B:1296–1300. Received 21 December 2014; Accepted after revision 18 May 2015 External fixation is widely used in orthopaedic and trauma surgery. Infections around pin or wire sites, which are usually localised, non-invasive, and are easily managed, are common. Occasionally, more serious invasive complications such as necrotising fasciitis (NF) and toxic shock syndrome (TSS) may occur. We retrospectively reviewed all patients who underwent external fixation between 1997 and 2012 in our limb lengthening and reconstruction programme. A total of eight patients (seven female and one male) with a mean age of 20 years (5 to 45) in which pin/wire track infections became limb- or life-threatening were identified. Of these, four were due to TSS and four to NF. Their management is described. A satisfactory outcome was obtained with early diagnosis and aggressive medical and surgical treatment. Clinicians caring for patients who have external fixation and in whom infection has developed should be aware of the possibility of these more serious complications. Early diagnosis and aggressive treatment are required in order to obtain a satisfactory outcome. Cite this article: Bone Joint J 2015;97-B:1296–1300. External fixators have been widely used in both trauma and elective surgery. These fixa- tors use percutaneous transosseus pins and/or wires to obtain fixation of fractures or osteot- omies. 1 Complications include non- or mal- union, loosening of the pins, nerve damage and infection. 2-4 The most commonly reported complication associated with external fixation is pin site infection. 5 This can range from a simple super- ficial pin tract infection to life- or limb-threat- ening infections, such as necrotising fasciitis (NF) or toxic shock syndrome (TSS). 5,6 The incidence of pin tract infection with the long- term use of external fixators is reported to range from 11.3% to 100%, with authors focusing on the prevention and treatment of these specific infections. 4,5,7 Many organisms have been implicated, but most commonly reported are Staphylococcus (Staph.) aureus and Staph. epidermidis. Many strategies have been described to reduce the incidence of these infections. Prophylactic antibiotics may decrease the incidence of pin tract infections and osteomyeleitis. 6-9 Several authors have classified pin infection in patients with external fixation, primarily considering the involvement of local soft-tissue and/or bone. 5,10-12 However, these studies and classification systems have ignored those infec- tions which are associated with systemic involvement. Few studies describe these rare, yet more serious and potentially limb- or life- threatening infections. Thus, this paper will describe the recognition and treatment in eight patients who developed NF or TSS following the use of an external fixator. Our aim is to increase the awareness of orthopaedic sur- geons to these infective complications of exter- nal fixation, and the need for early recognition and treatment. In addition, we have proposed a modification to two existing classification systems to include these potentially limb- or life-threatening infections. Patients and Methods A retrospective review of the practice of a sin- gle group of limb reconstruction specialists between January 1997 and December 2012 was performed to identify patients who had life- or limb-threatening complications follow- ing the use of an external fixator. The inclusion criteria were simply any patient who presented with NF or TSS. There were eight patients; four with NF and four with TSS. Their mean age was 20 years (5 to 45); seven were female. Institutional review board approval was obtained. Results The summary of the reported patients is provided in Table I.