Mastering Complications In External Fixation

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Why Appropriate Patient Selection And Education Are Essential

Patient selection and education are paramount to a successful outcome. A truly avoidable and unnecessary complication is early removal of a fixator because the patient cannot tolerate it. Patients need to be aware that they are active participants in the healing process. If they cannot comply with instruction or are unwilling to take responsibility for their role in this process, the surgery is not a viable treatment option. Visual aids, dummy frames and a conversation with a veteran frame wearer might ease apprehension and answer pertinent questions or concerns about this treatment modality.

It is not uncommon for some patients to develop a fear and aversion to the presence of the fixator after undergoing the procedure. The device publicly presents as an oddity and is likely to generate numerous inquiries and opinions.

An educated patient is less likely to be swayed and influenced by remarks if one ensures that the patient has a strong understanding of how the device interacts with the body. Surgeons should also educate patients and caregivers about the early clinical and systemic signs of complications as related to infection. They need to understand clearly that wires are literally the pathway to the bone. Applying the motto “Early detection facilitates early treatment” in clinical practice will aid in resisting the spread of infection.

Examine the frame as a general overview of the construct and evolve that into a more detailed evaluation of its components. Question the patient upon follow-up visits if he or she is experiencing any discomfort or drainage. If they are having these problems, find out where they are occurring and proceed to address these areas. This thorough approach to patient education can streamline the visit time needed for frame care.

Here one can see plantarflexion of the foot when driving a wire from an anterior to posterior direction.
Plantarflexing the toes helps to clearly delineate the metatarsal parabola.
Here is a one-week post-op view of multiple pin tract infections. One can reduce the incidence of these complications by ensuring a judicious application of wires and having a sufficient number of wires to produce a stable construct.
Proper wire handling must emphasize sterile technique. It is important to pass wires with a dampened saline/alcohol gauze pad.
Postoperatively, it is important to evaluate the components of the external fixation device prior to applying a dressing.
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Author(s): 
By David Kanuck, DPM, and Gary Jolly, DPM

   Any surgical procedure carries a risk of complications. Whether one opts to utilize internal or external fixation, there is both a common and yet unique set of problems based on hardware design and usage. Therefore, it is imperative to obtain an intimate working knowledge of the equipment and its capabilities in order to maximize the true potential of each method and hopefully minimize the risk of complications.

   The ability to control an internal surgical environment by external manipulation is a powerful tool that is unique to external fixation. This “third dimension” empowers the surgeon to perform functions such as distraction, compression and neutralization in order to address suboptimal positioning postoperatively. It also enables one to extend the surgical procedure intentionally into the postoperative phase to facilitate gradual correction of deformities. Specifically, surgeons can accomplish this through frame morphing and adjustments via wire and ring modification. This distinction allows surgeons to address many problems in a “bloodless” fashion.

   Therefore, it is not unreasonable for the initial frame setup to vary in construction prior to its final removal. This article focuses on the wire, the single most important component of external fixation. After all, it is the interface of wire and human tissue where most common complications occur.

   The wire serves as an interface between an internal biological environment and an external mechanical one. This marriage between two subsystems results in the creation of a new entity that exists in a delicate balance. One should view the wire as the foundation to frame construction. A poor foundation will ultimately result in an unstable structure and lead to complications. Pin tract infection, nonunion, malunion, delayed union, hardware failure and neurovascular embarrassment are all complications that can be traced to this frame component.

   The wire’s anatomic location serves as a passageway for organisms to colonize and possibly infect soft tissue and bone. This unique feature is why pin tract infections (PTI) are considered the most common complication associated with external fixation.

   The key to treating and reducing the number of PTIs is understanding the etiology. A loose wire has a tendency to toggle, which irritates the bone and surrounding soft tissue. This action may provoke an inflammatory response and increases the susceptibility and passage of opportunistic pathogens. Therefore, one should strive to prevent wire loosening. One can reduce the incidence of PTIs through the judicious application of wires in terms of location, attachment to the ring, crossing angle and having a sufficient number of wires to produce a stable construct.

Key Insights In Designing The Ex-Fix Device

   After the patient has agreed to undergo the procedure (see “Why Appropriate Patient Selection And Education Are Essential” below), one should form a preoperative plan. Evaluate clinical and radiographic exams, and proceed to address decisions regarding components (such as wires and rings) of the frame construct.

   The type of wire one selects is important because not all bones and not all parts of a bone have the same density (medullary vs. cancellous). Wires, by design, are engineered to cut bone differently, generating variations in heat production. Therefore, when one is working with the metaphyseal sections of long bones, use trochar tipped wires and bayonet tipped wires for diaphyseal bone if the choice is available.

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