2007 JBJS External Fixation How To Make It Work PDF

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External Fixation: How to Make It Work

Bruce H. Ziran, Wade R. Smith, Jeff O. Anglen and Paul Tornetta, III
J Bone Joint Surg Am. 2007;89:1620-1632.
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1619
Selected
Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
PAUL J. D UWELIUS
EDITOR, VOL. 57
C OMMITTEE
PAUL J. D UWELIUS
CHAIRMAN
FREDERICK M. A ZAR
KENNETH A. E GOL
J. L AWRENCE M ARSH
M ARY I. O’C ONNOR
E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF B ONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES
J AMES D. H ECKMAN
EDITOR-IN-CHIEF,
THE JOURNAL OF BONE AND JOINT SURGERY
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Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academy’s Annual Meeting, will be available
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1620
THE JOURNAL OF BONE & JOINT SURGER Y · JBJS.ORG E X T E R N A L F I X A T I O N : H OW TO M A KE I T WO R K
VO L U M E 89-A · N U M B E R 7 · J U L Y 2007
External Fixation: How to Make It Work

By Bruce H. Ziran, MD, Wade R. Smith, MD, Jeff O. Anglen, MD, and Paul Tornetta III, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
The external fixator has been in use then, better technology and under- principles of external fixation and de-
for more than a century. The first use standing have allowed for greater scribe healing under these conditions;
was recorded by Carl Wilhelm Wutzer versatility and better outcomes. Si- (2) review existing technology with spe-
(1789-1863), who employed pins and multaneous with developments in the cific attention to pin design, modular
an interconnecting rod-and-clamp Western world, Ilizarov developed the designs, and aspects of ring fixation for
system. Parkhill (1897) and Lambotte principles of external fixation with use the general practitioner; (3) outline the
(1900) used devices that were unilateral of ring-and-wire fixation. It was not paradigm of using the external fixator
with four pins and a bar-clamp system. until the late 1980s and early 1990s, for bone-healing; (4) discuss different
By 1960, Vidal and Hoffmann had popu- when more interaction and exchange types of external fixator applications,
larized the use of an external fixator to between the West and East (Russia) was including damage-control frames and
treat open fractures and infected pseud- possible, and with the help of Italians configurations of hybrid frames for the
arthroses. The problems encountered who embraced the philosophy of exter- tibia; and (5) review pin-care issues and
with external fixation in the late twenti- nal fixation, that the use of external present pin-care techniques that work.
eth century were predominantly due to fixation was proven to be successful.
a lack of understanding of the princi- Several variations of external fixation Principles of
ples of application, the principles of have been developed, and its use is External Fixation
fracture-healing with external fixation, now widespread. Unfortunately, in the External fixation is a minimally inva-
and the use of old technology. Its use United States, all but a minority of sur- sive technique whose application and
was reserved for the most severe inju- geons still have substantial apprehen- management have been refined so that
ries and for cases complicated by infec- sion about the use of external fixation. it is now another valuable tool in the
tion. Thus, pin problems, nonunions, The goals of this Instructional management of fractures and other
and malunions were common. Since Course Lecture are to (1) review the complicated musculoskeletal condi-
tions. From pin care to frame mechan-
ics, the fixator can be applied and
Look for this and other related articles in Instructional Course Lectures, adjusted to meet the needs in each clini-
Volume 57, which will be published by the American Academy of Ortho- cal context, and many of the problems
paedic Surgeons in March 2008: previously associated with its use can be
circumvented. Even so, it is not a pana-
• “Fractures of the Hip,” by Jeffrey C. Anglen, MD, and Michael cea and should not be used in situations
Baumgaertner, MD in which plates or nails are more suit-
able. Currently the external fixator has
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the
authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment
or agreement to provide such benefits from commercial entities (Synthes and Stryker). No commercial entity paid or directed, or agreed to pay or di-
rect, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the au-
thors, or a member of their immediate families, are affiliated or associated.
J Bone Joint Surg Am. 2007;89:1620-32

1621
two common treatment configura- scribed as the era of early total care. We modulated to allow a progressive load
tions: the damage-control orthopaedic subsequently learned that, while early transfer or destiffening of the construct
frame, which was designed to be a total care was reasonable for the bone, to help stimulate bone-healing.
temporary device, and the definitive- it was not always optimal for every pa- Once there is evidence of bio-
treatment frame, which was designed tient because of numerous systemic logic activity (early fracture callus),
to be used for definitive management of issues. The evolution of collaborative there should be a slow and progressive
fractures and for posttraumatic recon- management of the trauma patient, for load transfer to the healing callus. As
struction. These two applications are whom orthopaedic treatment is carried hypothesized by Pauwels1 and later ex-
based on different principles of treat- out within the context of the “big pic- plained in different terms by Perren2
ment. When the damage-control frame ture,” heralded the modern era of (with his interfragmentary strain the-
is used, the impact of the fixator on the damage-control orthopaedics. In this ory), pure compression and hydrostatic
systemic state of the patient and on the era, there is appropriate stabilization of pressure will stimulate the mesenchymal
definitive intervention that may follow the essential bone injuries (usually with cells to differentiate toward chondro-
(e.g., plate or nail fixation) must be a damage-control orthopaedic frame), genesis and subsequently endochondral
considered. Also, it may become neces- until the patient’s systemic condition ossification. Strain will result in the for-
sary to use the external fixator as the becomes optimized, at which point de- mation of collagenous tissue and sub-
definitive treatment, so it is important finitive fracture stabilization is under- sequent intramembranous ossification.
to know how to convert the damage- taken, usually with nails or plates. While Combinations of these two temporally
control frame to the definitive-treatment- there remains controversy about the spaced events (compression then strain)
frame configuration. When the defini- timing of fixation, which is beyond the can manifest themselves as callus heal-
tive-treatment-frame configuration is scope of this lecture, a definitive indica- ing or, as is the case with use of the
used, it is critical to understand how to tion has been established for external Ilizarov principle, regenerate forma-
modulate the mechanical properties of fixation as a method with which to stabi- tion2. All of this, however, depends on
the fixator in response to the bone be- lize the skeleton during the early stages adequate blood flow because, in its ab-
ing treated. Thus, an understanding of of polytrauma. sence, there will be no bone-healing, re-
how to “read the bone” is important, as In this lecture, the application gardless of the type of fracture fixation.
is an understanding of the techniques of a damage-control orthopaedic Thus, as the initial construct with the
of application that allow long-term frame for the pelvis and extremities stiff fixator begins to demonstrate some
use of the fixator. Finally, since some will be described. Simple-to-remember biologic activity, the fixator undergoes
frames will need to be in place for a anatomic windows and simple frame a “controlled destiffening” so that there
prolonged period (e.g., those used for constructs that can be applied to most is a slow but definitive transfer of load-
limb-lengthening and salvage), effec- fractures will be presented. With the bearing from the fixator to the bone.
tive management of routine issues use of battery-powered drills, a single This load-sharing will gradually stimu-
(pin tracks, discomfort, and walking) “damage-control tray” can be assem- late the developing callus until solid
is necessary. bled to simplify application. bone-healing has occurred.
Several authors have examined
Damage-Control Frames Definitive-Treatment Frames both theoretical and practical methods
The early damage-control frames were When external fixation is used as defini- of analyzing healing in association with
used primarily for severe open fractures tive treatment, it should first be applied the use of external fixation2-10. Factors
because these fractures were not amena- in a configuration that provides the that contribute to the nature and speed
ble to the fracture fixation techniques maximum stability (a rigid construct) of osseous healing include the location
available at the time. Since external fixa- to the fresh fracture environment. This of the fracture, the nature of the blood
tion was used in the most extreme cases, is the best environment for healing of supply, and the method of fixation (pin
it was associated with the most compli- the soft tissues as well as for the early or wire configuration). While the expe-
cations, such as infection and nonunion. stages of bone-healing. However, this rience has not been well documented
Furthermore, effective principles of soft- environment should not be maintained in the English-language literature, those
tissue management and ways to obtain indefinitely because it will result in ex- who have visited the center in Russia
healing in the presence of exposed bone cessive stress-shielding of the fracture established by Ilizarov have seen re-
and bone loss were just being learned. site and can lead to an osteopenic non- markable work, all done with fine wire
Nonetheless, for lack of a better option, union. This type of nonunion is one of fixation. Metaphyseal healing within
external fixation was used. As plate and the most challenging to treat since there three to four weeks, massive reconstruc-
nail fixation methods improved, frac- is not only a problem with healing, but tions, and eradication of infection have
tures in most polytraumatized patients also challenges with regard to obtain- all been demonstrated (personal com-
were stabilized with definitive fixation ing a stable construct because of the munication). Again, as a result of the
immediately (in less than twenty-four changes in bone quality. Over time, the historic geopolitical issues, such infor-
to forty-eight hours). This has been de- external fixator should be changed or mation has not been well disseminated
1622
in the Western literature. What the clude beginning with a rigid frame along with threads with a cutting lead
Russians have demonstrated clearly is construct. As the construct with the edge for tapping, followed by threads
that appropriate concern regarding the stiff fixator begins to demonstrate some for fixation. This allows one-step place-
biology of the soft tissues as well as that biologic activity (fracture callus equals ment of pins that minimizes thermal
of the bone, along with stable frame evidence of vascularity), the fixator un- and mechanical complications. The pins
configurations and physiologic load- dergoes a “controlled destiffening,” so can be placed with a motorized device,
ing, can result in reliable healing with that there is a slow but definitive trans- and the controlled axial motion of in-
use of external fixation. Usually, frame fer of load from the fixator to the bone sertion minimizes the wobble of hand
constructs start out stiff and progres- during weight-bearing activities. In the- placement. Critics of one-step insertion
sively transfer load to healing bone. ory, this load-sharing gradually stimu- point to the difficulty in feeling the far
However, two crucial elements lates the developing callus until healing cortex as well as the theoretical possibil-
are not well known: how to optimize has occurred. If there is no evidence of ity of stripping the near-cortex threads
the load transfer (destiffening) and biologic activity or vascularity (i.e., when the cutting tip encounters the en-
how to know when it is complete and no callus), an intervention such as dosteal surface of the far cortex. How-
the fracture has healed. Still, the goal of bone-grafting or resection and trans- ever, the use of appropriate cutting tips
external fixation is to provide what has port should be considered. An atrophic as well as an appropriately designed
been called flexible stability. The stabil- nonunion will not heal regardless of thread pitch allows the advancement
ity is provided by the frame and the con- the device that is used. speed of the pin (determined by the
struct while the flexibility is added by thread pitch) to be controlled such that
manipulating the components. Inciden- Pin Technology, Design, and the pin engages and cuts through the far
tally, this is the same principle on which Method of Application cortex without problems. Furthermore,
modern plate-fixation techniques are There are many different pin designs, as a result of the brief resistance of the
based. As constructs began to include and there remains a philosophical rift pin tip as it encounters the far cortex,
longer plate spans with fewer screws, the among surgeons with regard to the best there is usually an audible and palpable
introduction of locked plates essentially way to place pins. What we have learned drain on the drill motor at such an in-
resulted in an internalized fixator. Now is that mechanical chipping and ther- stant. This alerts the surgeon that the
it is commonplace to use longer plate mal necrosis of the bone are deleterious far cortex has been reached so that over-
spans with a few widely spaced locked to pin longevity and that the most im- penetration can be avoided.
screws to obtain a flexible (long-span) portant factor may be the management Such theoretical advantages were
but stable (locked-screw) construct. of the soft tissues around the pin. Older demonstrated in a study of dogs by
The ring fixator is based on the pins were designed either to be placed Seitz et al., who found a 22% decrease
same principles, in that initial stability after predrilling or to be self-drilling in the pull-out strength of self-drilling
is achieved with multidirectional wires and threading. There are pros and cons pins placed with motorized power as
or pins and little initial weight-bearing is to both methods. With predrilling, well as a substantial wobble with pins
allowed to obtain a stable environment. the cutting should be done with sharp, placed by hand11. Since pull-out is rarely
Then, as weight-bearing is initiated, well-designed drills, and the thermal a mode of failure and loose pins are a
there is a controlled axial micromotion necrosis and mechanical issues are mini- frequent cause of pin and/or soft-tissue
that provides the stimulus for fracture- mized. (It is important for the surgeon problems, the potential downside of
healing. Since the device is inherently to check the drills to ensure a sharp bit.) wobble makes power insertion an at-
flexible and yet stable, it achieves the However, there is definitely a wobble tractive option. The downside of power
same end result. In fact, as tensioned during the subsequent hand placement insertion is mainly related to the use of
wires are loaded, they often loosen and of the pins. This wobble can result in a improper technique.
serendipitously transfer more load to small but meaningful conical deforma- The issue of heat generation with
the construct. If this occurs too quickly, tion of the near cortex, which reduces self-drilling pins was studied with ther-
the subsequent excessive instability will the initial stability of the pin in the near mocouples used near each cortex and
result in pin-related problems and dis- cortex and increases the stress in the far measurement of heat generation dur-
comfort; hence, the saying among expe- cortex. On the other hand, the older ing several modes of pin insertion and
rienced users of ring-and-wire fixators spade-tipped pin (also called a trocar), was determined to depend on numer-
has been: “A stable frame is a comfort- which was drilled directly into the bone, ous factors12. In that study, comparison
able frame, and a comfortable frame is a resulted in chipping of the bone and suf- of predrilling with hand insertion, hand
stable frame.” ficient heat generation to cause necrosis insertion of self-cutting pins, and power
Because use of ring and wire fix- of the bone. Thus, their poor design de- insertion revealed no apparent differ-
ators is complex, in this lecture, we will feated their advantage (except in meta- ences among the three methods of
only discuss the use of the simpler hy- physeal bone). insertion. In fact, power insertion
brid frame. With use of this frame, the Subsequently, pin designs have in- appeared to generate less heat. The ob-
principles that should be followed in- cluded a modified drill point with flutes vious question is why would the place-
1623
Fig. 1
Representation of different types of fixator constructs. Left = modular half-pin; center = unibody, monolateral;
and right = hybrid.
ment of self-cutting, self-tapping pins change in the drill-motor pitch when cessful performance of other designs,
with power generate less heat than the the far cortex is reached. The advance the practical value of tapered pins is
other methods? The most likely conclu- should be stopped at that point. If resis- questionable at this juncture.
sion would be that the time in contact tance is encountered and excessive drill-
with bone causes frictional heat during ing is required, something is wrong and Fixator Designs: Comparison
insertion. Thus, although power inser- the pin may need to be repositioned. of Modular, All-in-One,
tion appears more aggressive, because it Another recent advance has been and Hybrid Designs
involves less time of frictional contact the use of pin coatings both to enhance There are various designs of external fix-
with the bone it theoretically creates less fixation and to reduce infection. Silver- ators. Outdated, single-bar devices had
heat. Modern self-drilling pins placed coated pins have been shown to be asso- difficulty in maintaining fracture align-
with power have been in use clinically ciated with less bacterial colonization ment. The improved manufacturing
for many years and have demonstrated than uncoated pins, but their clinical and design of clamps (such as those
good performance. One compromise is performance has not been found to be made by Stryker, Synthes, or Smith and
to predrill the holes with a sharp drill definitively superior to that of uncoated Nephew) have led to newer modular
and use power to place the pins to avoid pins. There is also a potential for sys- designs that are very user-friendly and
the wobble that can occur with manual temic silver absorption with their use13. adaptable to a wide variety of clinical
placement. Hydroxyapatite-coated pins have had scenarios. The modern so-called uni-
Since the late 1990s, we have an excellent track record with regard to lateral alternatives, such as those with
used battery-powered drills to place fixation and longevity and have outper- multidirectional connections and clus-
self-drilling, self-tapping half-pins formed standard titanium pins with re- tered pin clamps on each side (EBI and
(thus, there has been no hand inser- gard to both infection and longevity14. Orthofix types), have had an equal
tion or predrilling), but we have paid Finally, tapered pins were developed to amount of success when used properly
diligent attention to soft-tissue care. It increase radial preload and insertion and have even been expanded to be
is important to feel and listen to the torque, both of which have been found more modular. We are not aware of any
pins during insertion. Usually, there to improve pin longevity. However, if the study demonstrating clinical superior-
is a brief delay as the drill point cuts pins are backed up, even a slight amount, ity of any one design. We prefer modular
through the near cortex, after which their benefit is lost because of the taper, designs because they are light, are easy
it steadily progresses. Then there is a and they need to be well monitored. As to apply, and provide the maximal ver-
slight sensation of resistance and a a result of these issues as well as the suc- satility in most clinical situations. Their
1624
application will be outlined below. nuted articular segments was doomed ator does not generate any deleterious
The circular fixator has a long to fail and, in short, the application of effects (no known hazards) in any mag-
history and was popularized by those these frame designs was pushed beyond netic resonance environment. Mag-
who followed Ilizarov’s philosophy. their abilities. Thus, it was less the fix- netic resonance imaging-conditional
Because of a long learning curve, main- ator and more the indication or appli- means that the individual parts do not
tenance problems, and other difficul- cation that was at fault. If applied for generate any deleterious effects in spe-
ties, this device was accepted by only a the proper indication, hybrid frame cifically defined (e.g., 1.5-T) magnetic
minority of orthopaedic surgeons. In designs can work well15. Furthermore, resonance environments. There are
response, the hybrid frame was devel- application of these fixators is not like three issues related to safety during
oped to provide some of the advantages insertion of a plate or nail (passive magnetic resonance imaging:
of the ring design with the ease of ap- management) since it requires active 1. The magnetic field causes a
plication of standard fixators, particu- (but simple) management. The recom- diret force on magnetic materials. It is
larly for periarticular fractures. The mended application and management not a problem with nonmagnetic steel,
hybrid frame was initially popular and of a hybrid frame (Fig. 1) will be out- aluminum, carbon, or plastic.
then quickly went out of favor because lined later. 2. Induced electric currents can
of high rates of complications and fail- be produced in a magnetic field. Most
ures. If the literature is critically re- External Fixators and modern fixator components are not
viewed, it is apparent that most of the Magnetic Resonance Imaging individually magnetic, but when the
failures of ring fixators, both Ilizarov A new issue that has arisen is the safety components are linked together, as in a
and hybrid devices, occurred in the of external fixator parts during mag- standard fixator frame, a closed circuit is
treatment of more severe injuries. Use netic resonance imaging of either the created and an electric current can be in-
of such methods to treat severely dis- limb or other body parts. Magnetic res- duced by the magnetic field. This is true
rupted soft tissues and highly commi- onance imaging-safe means that a fix- even when carbon fiber or other non-
metallic material is used because virtu-
ally all elements have some degree of
conductivity and inductivity. A circuit
of magnetic resonance imaging compo-
nents with carbon rods and a loop into
the patient can generate clinically rele-
vant currents16,17.
3. Heating of materials can occur.
The induced current can cause heating
of the device and perhaps local tissue
damage. There is little to no clinical
data regarding this phenomenon, and
the United States Food and Drug Ad-
ministration is yet to rule on what is
considered “safe.” Currently, there is no
industry standard for what is consid-
ered magnetic resonance imaging-safe
or what is clinically safe. Only one com-
pany to date has attempted to “insulate”
the construct against any inductive cur-
rents, but there is still a known temper-
ature gradient that forms.
The resultant interaction of the
frame with the machine itself can dis-
turb the calibration of the magnetic
resonance machine, which can be
damaging and costly to repair. Finally,
even when it is possible to perform
Fig. 2 magnetic resonance imaging on a pa-
Clinical photograph of a ring fixator in the completely dynamic mode. The inner nuts are turned tient with an external fixator, clamps
back a few millimeters when the fracture is thought to be almost completely healed. This maneu- located near the field being scanned,
ver dynamizes the fixator and stimulates maturation of the healing callus. Note that tape (arrow) even when several centimeters from
has been applied to the nuts to prevent drift. the skin, can result in enough interfer-
1625
Fig. 3-A Fig. 3-B

Schematic illustrations of humeral (Fig. 3-A) and elbow (Fig. 3-B) frames.
ence to make the scan meaningless. We signs. In these designs, a ball is eccentri- this method, each fixation segment has
recommend judicious use of magnetic cally turned to lock an interference fit a stable configuration of pins or wires
resonance imaging, with the fixator into place, but if there is even minimal and an external fixation module (ring,
clamps placed as remote from the area loosening the entire mechanism may clamp, or bar). Then individual stable
of interest as possible18. In addition, it suddenly release; therefore, we prefer bases are connected to each other in
should be remembered that magnetic locking mechanisms other than the the desired orientation. Frequently, a
resonance imaging safety with regard ball-cam design. common bar or clamp can be used for
to the individual components of the The technique for definitive fixa- more than one segment (transport
fixator does not ensure safety of the tion is based on the concept of the sta- frames), but ensuring that each inde-
magnetic resonance imaging when the ble base as taught by James Hutson, pendent segment has a stable configu-
frame is assembled into a closed circuit, MD (personal communication). With ration is important. Our preference is
and one should beware of misleading
marketing claims in this regard.
Use of the External Fixator

as Definitive Fixation
The external fixator is an ideal device
with which to obtain healing because it
is one of the only devices that provides a
stable construct in which the mechani-
cal parameters (rigidity and alignment)
can be modulated as needed through-
out treatment. The frame is usually ap-
plied to create as much stability as
possible at the fracture site. Later, with
minimal adjustments, the system can be
made more flexible to allow micromo-
tion or macromotion to help stimulate
healing of the fracture. Furthermore, if
problems develop with parts other than
the pins or wires, those parts are easily
replaced. With modern designs, there
have been very few reported failures or
broken parts, although exceptions do Fig. 3-C
occur with some of the ball-cam de- Clinical photograph of an elbow damage-control frame.
1626
previously, the first stage of application

of the external fixation should achieve
a rigid construct to allow the earliest
stages of the fracture-healing process to
begin as well as to allow the soft tissues
to recover. Once there is early callus for-
mation, the frame needs to be progres-
sively “destiffened” to transfer more
and more load to the developing callus.
If the construct is made too flexible too
early, the resultant strain may exceed
the local limits of the developing callus
and produce a nonunion. In contrast,
if there is insufficient load transfer,
there will be inadequate callus forma-
tion, bone resorption, and disuse os-
teopenia. Both of these situations are
undesirable. Removing bars, adjusting
the locations of bars, or removing pin
and/or wire components can destiffen
the construct in a systematic way to
achieve fracture-healing.
With use of ring designs, the load
transfer is usually a repetitive stimulus
that occurs with increased physiologic
Fig. 4 loading. As healing progresses, wires
Diagram of pin placement into the pelvis. The bold lines demonstrate the direction of desired and half-pins can be removed or sup-
pin placement (in the case of imperfect pin placement) for two fracture types. If the pelvis is port struts can be loosened. Finally,
being “closed” (right part of picture), then pin placement should not traverse the ilium to the intervening struts can be removed alto-
outside (non-bold lines) but instead should traverse to the inside. The forces on the pin-bone gether, and the patient can have a trial
interface during reduction are better resisted in this fashion. Likewise, on the left side, the of weight-bearing. This is done so that,
pelvis is being “opened” and the opposite is true. This situation is relatively rare. if pain occurs with weight-bearing, the
struts can be reapplied with the pre-
sumption that healing is incomplete
to place at least three or four fixation nized or necrotic tissue that could and a repeat trip to the operating room
wires or half-pins (for a metaphyseal increase the risk of infection. We to reapply removed “stable bases” is not
segment) or three half-pins (for a dia- also treat the patient with a broad- required.
physeal segment) so that one or two spectrum antibiotic for one or two If a modular or monolateral de-
can be removed if necessary without weeks before placing the internal fixa- sign is used in the tibia, the key element
destabilizing the construct. In the tion. Although there is little evidence is the anteromedial stabilizer since the
event that the fracture does not heal or on which to base this recommenda- center of gravity is medial during single-
another problem requires removal, the tion, we believe that the morbidity and limb stance. Having main fixator struts
frame should be removed and the frac- costs of a subsequent infection justify or bars near the center of gravity mini-
ture should be controlled with external the use of such a protocol19. mizes the cantilever load on the fixator
bracing for one to two weeks prior to There have been several studies in pins. With a true monolateral system,
internal fixation. The infection rate as- which the different healing patterns of the frame is placed in the anteromedial
sociated with intramedullary nailing fractures have been measured while the quadrant of the leg, and, as healing
after external fixation is relatively low extremity was in an external fixator3-6. progresses, the fixator is either manu-
(8%) in the absence of a true pin-track In these studies, the stiffness and strain ally compressed or progressively dyna-
infection, but most traumatologists of the fracture callus were measured mized. In modular hybrid constructs,
recommend an interval of frame re- during the healing process and the au- there is an anteromedial strut and a sec-
moval, pin-track curettage, and per- thors outlined how healing occurs. The ondary bar that connects to the lateral
haps antibiotic coverage prior to common finding of these studies is that, side of the leg and creates a triangular
placement of the intramedullary nail. if the fracture is to heal, a proper load or delta-shaped construct. In these con-
We recommend drilling and curettage transfer from the external fixator to the figurations, the delta bars are the first
of the pin tracks to remove any colo- developing callus is necessary. As noted to be removed. This is followed by mov-
1627
Fig. 5-A Fig. 5-B

Fig. 5-A Schematic of a femoral frame. Fig. 5-B Montage of external fixator placement in the intensive care unit for damage-control. Local prepara-
tion and sterile technique are used to place pins percutaneously. Two stable bases are created (bottom left) and connected to stabilize the femur
(bottom right).
ing the anteromedial bar farther from Humerus: Five-millimeter pins rotate in the iliac crest, leaving the frac-
the skin or by reducing the number should be placed in the anterolateral ture unreduced. Also, such pins will
of pins and/or wires in each segment. quadrant of the proximal part of the become loose and contribute to skin
While there are several methods avail- humerus and in the posterolateral problems. In these cases, it is preferable
able to decrease stiffness and allow load quadrant of the distal part of the hu- to err with the pin exiting the inner ta-
transfer to the healing callus, these ac- merus. Fine wires and 4-mm pins can ble so that, during the reduction ma-
tions are done only when there is am- be used in very distal fragments (Figs. neuver, pin rotation is resisted by the
ple radiographic and clinical evidence 3-A, 3-B, and 3-C). inner table of the ilium (Fig. 4). Con-
of healing (callus progression and pain- Forearm: In most of the forearm, versely, if the fixator will be used to
free function). Before complete dynam- the subcutaneous border of the ulna “open” the pelvis, as in the treatment
ization occurs, a trial of disconnection can be used as a suitable landmark, but of a lateral compression injury, pin
with weight-bearing (usually in the only 3-mm (distal) or 4-mm (proximal) placement should err to the outer cor-
physician’s office or for one week) is pins should be employed. The radius is tex for similar mechanical and soft-
carried out to ensure that clinical heal- not as suitable for percutaneous fixa- tissue reasons. If needed, a superior
ing is occurring (Fig. 2). tion, and an open approach is recom- acetabular pin can be placed 5 to 10
mended if such fixation is used. cm proximal to the tip of the greater
External Fixator Configurations Pelvis: The anterior superior il- trochanter in line with the femur to
for Damage-Control Frames iac spine is an excellent landmark, and provide fixation. Care should be taken
These are the simplest of frames, and 5-mm pins should be directed medially that this pin does not penetrate into the
many configurations are possible. The and posteriorly. If the fixator is to be soft tissues of the pelvis. Alternatively,
ones described here allow percutane- used to reduce an “open-book” type of through an open approach, the anterior
ous placement (away from vital struc- pelvic fracture (e.g., internal rotation inferior iliac spine can be used for pin
tures) while providing adequate initial of the hemipelvic segments), the pin placement with the pin directed posteri-
stability and wound access and mini- should not exit the iliac wing laterally orly. We recommend against placing
mizing the risks associated with de- because, with manipulation of the dis- pins in the greater trochanter because
layed internal fixation. placed pelvic fracture, the pins can just of the high risk of infection.
1628
without the addition of 4-mm midfoot and 9-B). The hybrid frame is best
or metatarsal pins. Because of problems used for extra-articular or very simple
with loosening of transfixion pins in fractures (C1 according to the AO/OTA
the calcaneus, we now prefer to use classification system). Originally, one
two posterior calcaneal pins attached to would use two or three wires and/or
a u-shaped bar or ring. These pins seem one or two half-pins in the articular
to create fewer problems. We would cau- segment with a longitudinally parallel
tion against placing two transverse pins support member in the anteromedial
into the calcaneus because of the risk of quadrant of the leg and a delta sup-
damage to vital structures on the me- port bar. As soft tissues stabilize and
dial side, such as the flexor tendons and weight-bearing is initiated, the surgeon
the neurovascular bundle20,21 (Fig. 8). monitors the radiographs for evidence
of healing. If callus is present (at ap-
Stable Base proximately two to four weeks), load
When building an external fixation transfer is initiated by one of several
frame, one should first create a stable methods. Having the patient bear
base in each bone segment. To achieve weight statically while the delta bar
this, a single bar is placed between the is loosened and then retightened re-
two pins in each fragment. Then an- sets the load on the bar and effectively
other bar (an intercalary bar) is con-
nected to the bars in each base. For
example, when two pins are placed into
the femoral fragments, there should be
a bar that connects the two pins in each
fragment, and then an additional bar is
used to stabilize the fracture. If the inter-
calary bar is connected to only one of
Fig. 6 the two pins in each base, the resultant
Schematic of a tibial frame. Note that pins stability of the construct may be inade-
are placed anteromedially when possible. quate because the holding power and
the stability of a bar-to-bar connection
is greater than that of a bar-to-pin
Femur: Along the entire length of connection. Another strong recom-
the femur, the anterolateral quadrant is mendation is to place the compart-
best suited for placement of 5-mm pins. ment, through which a pin is passing,
The anterolateral aspect of the thigh on stretch during insertion. For exam-
contains no vital structures, and the pin ple, if a wire is passing across the distal
tracks do not interfere with subsequent part of the femur from posterior-lateral
surgical approaches (Figs. 5-A and 5-B). to anterior-medial, the knee is straight-
Tibia: The anteromedial quadrant ened (to place the posterior muscle-
is best suited for 5-mm pins, as there is tendon units on stretch) during initial
little soft tissue and easy access. We place insertion; then, as the pin exits antero-
the pins perpendicular to the anterome- medially, the knee is flexed (to place the
dial face of the tibial cortex (Fig. 6). medial quadriceps muscle-tendon units
Knee: The knee can be stabilized on stretch). This maneuver not only
with placement of pins into the antero- helps maintain motion around the ad-
medial aspect of the tibia and the ante- jacent joint but also minimizes irrita-
rolateral aspect of the femur to create a tion by the pin during such motion.
stable base in each segment. A single This can help minimize irritation of
large bar should be connected to each the tissues and facilitate pin care.
pin pair with adequate length to connect
to another bar. An intercalary bar com- Application of a Hybrid
pletes the zigzag or z construct (Fig. 7). Frame to the Tibia Fig. 7
Ankle: The ankle can be stabilized The application of a hybrid frame to Schematic of a knee frame. The femoral
with use of a single 4 or 5-mm trans- either the proximal or the distal part of pins are anterolateral, and the tibial pins
fixion pin across the calcaneus, with or the tibia is relatively simple (Figs. 9-A are anteromedial.
1629
mately six weeks), more load is trans-

ferred by increasing weight-bearing
further and by removing the delta bar.
With dynamic components, more mo-
tion can be dialed in. This process is
continued so that, by twelve weeks,
some half-pins can be removed and/or
more motion can be dialed in. At six-
teen weeks, if the radiographs and clini-
cal status warrant it, the components
are disengaged while the metaphyseal
and diaphyseal stable bases are main-
Fig. 8 tained. This allows full load transfer
A loose calcaneal transfixion pin associated with infection (left) and a pin inserted posteri- while keeping the frame components in
orly and attached to a u-shaped bar or ring (right). the leg but not connected in case heal-
ing is incomplete and more time in the
fixator is required. The remainder of
transfers some load to the bone. Re- the skin (bone), which would effectively the device is removed one week later if
moval of a wire or pin will also des- decrease the stiffness of the frame and the patient has no symptoms and the
tiffen the construct, but we recommend result in greater load transfer at the site fracture remains aligned. With use of
against this method in case any prob- of callus. this algorithm, if there is satisfactory
lems develop with the remaining pins. Progressive weight-bearing in- initial reduction, progressive physio-
If a dynamic component has been used, creases load transfer. When a dynamic logic loading, and progressive dynam-
it can be dynamized as described be- device is used, as is our preference, load ization (load transfer), fracture-healing
low. In the absence of a dynamic transfer can be started by dialing 1 mm can frequently be expected. In our ex-
component, another, more practical of axial motion into the system. As perience with a series of proximal and
method is to move the bar farther from healing progresses (i.e., at approxi- distal tibial fractures, this method was
Fig. 9-A Fig. 9-B

Fig. 9-A Example of initial hybrid application with use of an anteromedial strut and a delta bar. This con-
figuration established initial rigidity for both soft-tissue healing and initiation of the fracture-healing cas-
cade. Fig. 9-B After two to four weeks, when there are some radiographic signs of callus formation, the
fracture is progressively loaded in a controlled fashion. The fixator is destiffened with use of one of sev-
eral methods. These include removal of the delta bar; changes in the bar-bone distance (farther equals
less stiff); removal of pins or wires; or, in the present example, use of a dynamic axial bar that allows
controlled spring loaded axial micromotion.
1630
well tolerated and resulted in a healing any one modality or chemical works The patient is instructed to
rate of >95%15. It should be noted, how- better than another, but we recom- shower daily after he or she is dis-
ever, that this method is indicated for mend a non-tissue-toxic cleaner such charged and to clean the fixator with
only specific fracture types. In order as soap. It would seem that pin site ir- soap and water in the shower as part of
to avoid the problems reported in the ritation leading to inflammation is a a daily routine. The skin and pins are
past with use of a hybrid device, it is probable mechanism that results in in- dried with a clean towel, and the pin
important to understand the appropri- fection and, finally, loosening of the sites are wiped with an alcohol pledget.
ate indications for its use. As the saying pin. Therefore, minimizing mechanical The skin is then stabilized as described
goes, one needs “the right tool for the skin motion may be more important above. Bath water, fresh-water lakes,
right job.” than the frequency of cleaning or type and sea water are avoided.
of cleaning agents24 (Fig. 10). Problems with pin-track infec-
Pin Care We developed a pin-care protocol tion should be managed as quickly as
Localized pin-track infection has been that has served us well but is not based they are identified. We use the classifi-
the nemesis of external fixation and one on scientific data. As previously de- cation of Checketts et al.25,26. While the
of the primary reasons many surgeons scribed, when a pin is being inserted, literature often describes relatively high
avoid its use. The anatomic sites that are the soft-tissue compartment should be rates of “pin-track infection,” close in-
most prone to pin-related problems are placed on stretch and the skin should be spection will demonstrate that the ma-
those with a large soft-tissue sleeve and released if needed so that there is no skin jority of pin-related problems fall into
those subject to motion of the soft tis- tension. The pin sites are covered and, to the Checketts grade-I and II categories,
sues. Excessive motion of the muscle ensure that there is no pistoning of the which are very mild. A problematic pin
and skin around the bone results in lo- soft tissue, we use bolsters, spacers, or is one associated with ongoing exu-
cal inflammation that leads to a pin- sponges to stabilize it. The pin sites are dates or purulent discharge with sur-
track infection and in turn can progress left covered and are not inspected for as rounding inflammation and subsequent
to infect the bone. What appears to be long as the patient is in the intensive loosening. When a pin site looks irri-
clear to most experienced surgeons is care unit. If the pins are cleaned during tated, we first assess the nature of the
that the most important parameter is the inpatient stay, we use saline solution pin care being provided. We then check
the control of soft-tissue motion. Stabi- or alcohol and do not probe the tracks the stability of the pin in bone and of
lizing the soft tissues around the pin with cotton swabs. Nursing staff and the entire construct. If the pin or con-
to prevent motion is probably more aides do not provide pin care. The pin struct is loose, any and all pin care will
important than the method or agent sites are gently wiped with an alcohol usually be futile. We stratify our pin
of cleaning. There are numerous meth- pledget and then covered. The sur- problems in two ways, according to sta-
ods with which to stabilize the skin. rounding skin is stabilized by placing a bility and inflammation. Any pin that is
One of the best is application of a gentle bolster between the bar and skin that unstable and associated with inflamma-
compressive dressing between the bar applies gentle pressure to the skin and tion is removed. Pins associated with
and skin. With this method, it is im- prevents motion with routine activity. inflammation and transudate that are
portant to avoid excessive pressure
and skin necrosis.
Pin-care protocols range from
doing nothing to washing the site of en-
try three times a day with cotton swabs
and peroxide. Temple and Santy per-
formed a comprehensive review of
studies on pin care in the literature22.
They found one randomized, con-
trolled study in which saline solution,
alcohol, and no cleaning were com-
pared, and no cleaning resulted in fewer
infections. Another study demonstrated
no difference between daily and weekly
pin care23. There is now sufficient evi-
dence that elaborate pin care is not nec-
essary and that simple and occasional
attention to the pins may be sufficient.
Most practitioners recommend daily Fig. 10
pin care performed for personal hy- Three pins, with no associated infection, with pin clips that were used to hold the
giene reasons. There is no evidence that dressings in place.
1631
ment. Advanced applications can be

used to treat deformity, infection, and
fractures that are not healing. The poor
reputation of external fixation, espe-
cially in the United States, is due to mis-
understandings, misapplication, and
mismanagement. The principles of ap-
plication and management are fairly
straightforward and versatile. The tech-
nique does require more attention than
internal fixation, and careful clinical
and radiographic monitoring is needed.
External fixation is not the best treat-
ment for the typical fracture, but its
use can be of benefit in well-selected
situations.
Fig. 11 Bruce H. Ziran, MD

Suppuration around a pin that requires aggressive treatment. Modalities include
Northeastern Ohio Universities College of
Medicine, St. Elizabeth Health Center, 1044
more frequent cleaning, the application of Bactroban (mupirocin) cream, and a full Belmont Avenue, Youngstown, OH 44501.
dose of oral antibiotics. The pin should be tested for tightness. If it is loose, it E-mail address: [email protected]
should be removed or replaced.
Wade R. Smith, MD
Department of Orthopaedics, Denver Health
Medical Center, 777 Bannock Street, Denver,
stable (Checketts grades I and II) are we then check the stability of the pin
CO 80204
retained25. We begin by ensuring proper again, and if it is loose we remove it.
skin stability, and we frequently apply Also, as noted previously in our de- Jeff O. Anglen, MD
Bactroban (mupirocin) ointment. Pins scription of the method of application, Department of Orthopaedics, Indiana Univer-
that are associated with inflammation the use of three or four fixation points sity, 541 Clinical Drive, Suite 600, Indianapo-
and purulence are at greater risk. In ad- in each segment provides the latitude of lis, IN 46202
dition to all of the interventions pro- being able to remove one or two pins
Paul Tornetta III, MD
vided for grade-I and II problems, we during treatment without compromis- Department of Orthopaedic Surgery, Boston
add oral antibiotics in adequate doses ing the outcome or necessitating a re- Medical Center, 850 Harrison Avenue, D2N,
(Keflex [cephalexin], 500 mg four times turn to the operating room. With this Boston, MA 02118
a day, or Levaquin [levofloxacin], 500 methodology, we have substantially lim-
mg daily) because suboptimal antibiot- ited the need to revise pins, and patients Printed with permission of the American
ics are not only ineffective but also can have tolerated fixators very well. Academy of Orthopaedic Surgeons. This arti-
lead to the development of resistant or- cle, as well as other lectures presented at the
Academy’s Annual Meeting, will be available in
ganisms (Fig. 11). We also increase the Overview March 2008 in Instructional Course Lectures,
frequency of cleaning if there is accu- The external fixator is a useful tool Volume 57. The complete volume can be or-
mulation of dried exudates. If after such for a number of applications, from dered online at www.aaos.org, or by calling
interventions there is no improvement, damage-control to definitive treat- 800-626-6726 (8 A.M.-5 P.M., Central time).
References
1. Pauwels F. [A new theory on the influence of me- 3. Aro HT, Chao EY. Biomechanics and biology of 6. Bourgois R, Burny F. Measurement of the stiff-
chanical stimuli on the differentiation of supporting fracture repair under external fixation. Hand Clin. ness of fracture callus in vivo. A theoretical study.
tissue. The tenth contribution to the functional anat- 1993;9:531-42. J Biomech. 1972;5:85-91.
omy and causal morphology of the supporting struc-
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515. German. by loading, fracture fragment stability, fracture type, cke M. Modifications of electric potentials of the
and fracture site compression. Clin Orthop Relat pins of Hoffman’s “fixateur externe” during fracture
2. Perren SM. Evolution of the internal fixation of Res. 1993;293:8-17. healing. Acta Orthop Belg. 1978;44:732-7.
long bone fractures. The scientific basis of biologi-
cal internal fixation: choosing a new balance be- 5. Egger EL, Gottsauner-Wolf F, Palmer J, Aro HT, 8. Huiskes R, Chao EY. Guidelines for external
tween stability and biology. J Bone Joint Surg Br. Chao EY. Effects of axial dynamization on bone heal- fixation frame rigidity and stresses. J Orthop Res.
2002;84:1093-110. ing. J Trauma. 1993;34:185-92. 1986;4:68-75.
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9. Burny F, Bourgois R. [Biomechanical study of the Proceedings of the Eighteenth Annual Meeting of 21. Santi MD, Botte MJ. External fixation of the cal-
Hoffman external fixation device]. Acta Orthop Belg. the Orthopaedic Trauma Association; 2002 Oct 11- caneus and talus: an anatomical study for safe pin
1972;38:265-79. French. 13; Toronto, Ontario, Canada. insertion. J Orthop Trauma. 1996;10:487-91.
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gens C. Three-dimensional load measurements in jad A, Shellock FG, Rezai AR. MRI and implanted fections associated with external bone fixators and
an external fixator. J Biomech. 2004;37:1361-9. medical devices: basic interactions with an empha- pins. Cochrane Database Syst Rev.
11. Seitz WH Jr, Froimson AI, Brooks DB, Postak P, sis on heating. IEEE Trans Dev Mater Reliab. 2004;(1):CD004551.
Polando G, Greenwald AS. External fixator pin inser- 2005;5:467-80.
23. W-Dahl A, Toksvig-Larsen S, Lindstrand A. No dif-
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cal relevance. J Hand Surg [Am]. 1991;16:560-3. evaluation of large external fixation clamps and randomized study of 50 patients with external fixa-
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EY. Thermal response and torque resistance of five Biomed Mater Res B Appl Biomater. 2006;[Epub
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use of hybrid fixators in proximal tibia fractures. In: 18(8 Suppl):S39-42. p 97-103.

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This is an enhanced PDF from The Journal of Bone and Joint Surgery

External Fixation: How to Make It Work

This information is current as of February 8, 2011

Printed with permission of the American Academy of

External Fixation: How to Make It Work

J Bone Joint Surg Am. 2007;89:1620-32

Fig. 3-A Fig. 3-B

Use of the External Fixator

previously, the first stage of application

Fig. 5-A Fig. 5-B

mately six weeks), more load is trans-

Fig. 9-A Fig. 9-B

ment. Advanced applications can be

Fig. 11 Bruce H. Ziran, MD

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