Point-Counterpoint: Is External Fixation Overutilized?
this author says technological advances with internal fixation may reduce the need for external fixation. He notes that ex-fix may not be as cost-effective as AO techniques in facilitating early weightbearing, and also cites the anesthesia risks associated with external fixation.
By Lawrence DiDomenico, DPM
In recent years, there has been an increase in the use of external fixation in lower extremity care. In the midst of the increased use of this modality, some surgeons have acquired “frame disease” and some patients have developed “cage rage.” This means the surgeons cannot wait to apply the next external fixation device and the patient cannot wait until the external fixation device is removed.
External fixation clearly offers a distinct number of advantages in certain surgical cases over standard AO internal fixation. Despite the increase of indications over the past 20 years, the use of external fixation will not completely replace the standard AO internal fixation techniques. Regardless of the distinct number of advantages, it appears that external fixation may be overutilized in the routine surgical care of the foot and ankle. Foot and ankle surgeons should be judicious and reserve the use of external fixation for the more severe and complex surgical cases.
A Guide To The Goals And Applications Of Ex-Fix With The Ilizarov Method
With the Ilizarov method of external fixation, one can accomplish a variety of objectives. These objectives include:
• facilitating constant external tension to bone and soft tissue;
• achieving compression in any direction, which can lengthen/compress bone and soft tissue;
• repairing fractures; or
• correcting complex deformities of the foot and ankle.
The Ilizarov method is based on the idea that growing bone changes can be facilitated by external stimuli (Wolff’s law). In other words, bone responds to compression and distraction forces from the apparatus.
There are many applications for this method for complex hindfoot and ankle deformities. Appropriate indications for the use of external fixation in foot and ankle surgery include but are not limited to temporary fixation or staged procedures, and patients who have experienced trauma (high energy fractures resulting in significant soft tissue injury, closed or open fractures). Other applications include bilateral lower extremity trauma, osteomyelitis, Charcot arthropathy, clubfoot deformities, equinus, varus and valgus deformities, arthritic conditions, limb length deformities, revision (failed surgery), soft tissue contractures, rheumatoid patients (with diseased upper extremities that will not allow their upper body to be supportive with crutches, walkers, etc.), direct exposure to wounds, nonunions, bone grafting and major reconstruction.
While these external fixation techniques have received fervent support, surgeons must be aware there is a very steep learning curve with external fixation techniques. Foot and ankle surgeons must have a high level of respect for this technique as it takes considerable time to sufficiently conceptualize the technique, which presents in a variety of ways.
Early Weightbearing: Is Ex-Fix Truly A More Cost-Effective Option Than Internal Fixation?
Proponents of external fixation endorse the method as an alternative option to more traditional AO techniques (rigid internal fixation). However, advances in the current technology of the AO locking plate systems may decrease the need and use of external fixation.
When it comes to external fixation, proponents cite early weightbearing as a benefit of using external fixation. For example, there are proponents who perform a Lapidus bunionectomy via external fixation and boast that they can achieve immediate or early weightbearing with their patients. In my experience, one can achieve full weightbearing at two weeks postoperatively with a cast boot in patients who undergo a Lapidus bunionectomy via traditional AO techniques. Accordingly, one should look at the cost comparison of the two techniques and ask if there really is much of an advantage.