The appliation of circular external fixation has been an effective an treatment method in orthopedic trauma, limb preservation, complex defotmity correction and limb reconstruction of the lower limb [1, 2, 3]. The choice to use circular fixation must be considered carefully, based on the level of skill and experience of the surgeon. Even then, unforeseen complications are to be expected. Compliance from the patient and an open line of communication are vital to increase the probability of a successful outcome. It is our goal in this article to aid the surgeon in treating and preventing many of the clinical complexities that arise by offering practical advice. Common questions and concerns throughout the preoperative period, patient/physician expectations, frame management and post-operative protocols will be discussed.
Effective communication regarding challenges that may be encountered is paramount. Any discussion should include:
|Orthopedic fractures||12–16 weeks|
|Orthopedic fracture with compromised host (DM, PVD)||20–24 weeks|
|Charcot Reconstruction||24 weeks minimum|
|Smoker or Tobaccco use||double the time in fixator|
The circular external fixator is constructed with no less than 2.0 cm of distance between the skin and the inside diameter of the ring, ensuring adequate stability of the bone segments. If additional clearance to the skin edges is needed, coning or funneling of the fixator rings is needed without compromising bone stability.
While there are myriad application techniques and constructs possible, several pearls warrant mention regardless of the aparatus chosen.
Note: Proper soft tissue management throughout the procedure is a primary concern. Soft tissues should be released and retracted during insertion of transosseous wires and half pins, preventing soft tissue irritation [2, 6].
Tramadol 50 mg, TID
Gabapentin 100 mg, TID
Acetaminophen 500 mg, TID
The combination of Tramadol, Acetaminophen, and Gabapentin work synergistically together to reduce/eliminate the need for schedule 2 opiates post-operatively. Patients gradually reduce the dosages over the course of 2–4 weeks.
The ability to bear weight immediately offers a practical advantage over other modalities . Patients are advised 20% weight-bearing, best explained as gentle touchdown, stabilizing the limb while ambulating with a walker or crutches. Once initial incisions have healed, our protocol increases weight bearing on the limb as tolerated.
It is important to remember that consistent weight bearing increases the forces around the wire, ring and limb. Therefore, the practitioner must ensure the tightness and the tension of the wires to construct at every clinical visit.
Pin site complications range from 0% to100% [2, 11, 12], with the majority of complications noted as “infection”. This broad range is problematic, due in part to the lack of a universal classification and optimal pin care protocols [2, 6, 11, 12, 13, 14].
Our classification is based on the algorithm devised by Checketts (2000)  and modified with subtle procedural guidelines:
Grade 1: Pin Tract Irritation
Grade 2: Pin tract irritation with drainage
Grade 3: Erythema >2 cm radius from pin with drainage and low grade constitutional symptoms
Grade 4: Erythema >2 cm radius, with drainage and radiographic evidence of localized osteolysis
Grade 5: radiographic osteolysis with soft tissue infection
Grade 6: Suspected osteomyelitis
Overall, pin-tract irritation is expected and should not initially be considered a complication [6, 10, 13]. infection is emergent when erythema, edema and induration exceed 2.0 cm around the perimeter of a given pin site. In these instances, patients begin a 3-to-4-day course of oral antibiotics and should undergo flouroscopy. If lucency is noted around the osseous portion of the wire or pin, the wire is removed and a bone resecton in the operating theatre is scheduled. If osseous structures are normal, the local pin site is adequately treated and the surgeon re-tensions the loose wire.
We assess the cleanliness and condition of the pin sites using the “peek technique”, visualizing pin sites directly only if the patient reports pain or drainage. Crusts or eschar around pins are not removed [16, 17]. In our experience, frequent and overzelous dressing changes can lead to skin irritation. First dressing changes occur at 10–12 days. In the case of flap reconstruction, dressing changes are done in 5–7 days. Transoseous wires and half pins are dressed with 4 guaze, cut in the center, saturated with isoprophyl alcohol.
Soft Tissue release: Problems can be minimized by avoiding tension on soft tissues during initial wire or halfpin placement. Proximal tibial wires should be assessed with the knee flexed and extended. Distal tibial and foot wires are assessed with the ankle flexed and extended. If impingement is noted between the skin and wire, the skin is released under local anesthesia. A soft tissue release consists of 1 cm incision through the skin and dermis superior, inferior, lateral and medial to the pin depending on the pull of the tissue. Remember: Proximal wires should always be inserted with the knee fully extended.
Loose Fixation: Progressive mechanical deterioration of the bone-pin interface can lead to instability and infection . As pins move within the soft tissue envelope, they compromise a biologically sealed insertion point, allowing microbes a portal to irritate and infect progressively deeper tissues. Wires that are found to be loose are tightened manually in a clinical setting.
Manual Wire Tensioning: Two 10 mm wrenches are used for manual wire tensioning. First, the corresponding nut is gently loosened. Using both wrenches, force is applied on both the nut and tension bolt, wrapping the wire in the direction that will apply tension. If clinical suspicion of a loose transosseous wire is noted, patients will stand and, If pain is noted at the wire, manual wire tensioning is performed. The patient is then asked to stand again. In these instances, pain reduction is a good clinical marker of a properly tensioned wire.
Edema is expected and should be managed actively. The mismanagement of post-operative edema can lead to dehiscence, lagging wound control, and infection . The Primary author recommends 10 minutes of ambulation per hour with subsequent limb elevation, ususally with 3–4 pillows underneath the extremity.
Neuritic pain can be the result of improperly placed wires that have directly penetrated, transected or implanted in close proximity to native nerve tissue . Any insult may show symptoms of intractable pain, palsy or numbness . Early recognition is critical. If Intractable neuritic pain is noted, the transosseous wire should be removed immediately.
Psychological Impact: The course of treatment utilizing circular external fixator is arduous and patients are often not prepared for the several months wearing an unwieldy construct . In some instances, counseling and pharmacotherapy should be discussed and implemented for patients with stress-related anxiety/depression associated with long term external fixator use.
The day a patient is freed from the construct after a successful outcome marks a milestone. It is not the end of the patient’s care, however, and challenges still remain. It is important that patients remain faithful to their clinical appointments so progress may be monitored and, if necessary, the clinical course altered.
Our patients are discharged only after physical benchmarks are completed. Information on longterm goals is provided and, if warranted, follow up appointments are scheduled for 6 months and 1 year after initial discharge.
Although the purpose of this article is to share our current management applications, we continue to develop new protocols as our experience grows and new literature emerges. As a result, we have found the Orthofix Truelok circular ring fixation system to be an effective tool for deformity correction and limb salvage in the complex patient population.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Edgardo Rodriguez Collazo: Speaker Bureau, Orthofix Mikhail Samchekov: Royalties, Orthofix.
Allesandro Thione, MD.
This is a non-commissioned paper that has undergone external peer review according to journal policy.
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