Insights on Core Principles of External Fixation

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Ali Rahnama, DPM:

My name is Ali Rahnama. I'm a foot and ankle surgeon. My practice is mainly in a large academic tertiary health system through Georgetown University, the School of Medicine, and Washington Hospital Center.

One of the things that I can tell you is that as a resident, as a fellow, external fixation was incredibly intimidating. One of the things that I found, even in practice, to help myself with these external fixator-based cases was to keep it simple. I think in terms of construct selection, you do not need to have a million rings. I think as long as sound principles are adhered to, you can keep the construct selection simple, minimal rings, and minimal number of wires or half pins, depending on your preference.

I think pin site infections are probably the biggest thing that poses a challenge to treating practitioners and surgeons. One of the things that I could tell you is that there's no right or wrong way. There's many ways to skin a cat when it comes to pin care. I personally have found that the number one thing that leads to pin site irritation and infection is pistoning at the interface, between the soft tissue and the wire or the half pin.

So to minimize that, my pin care is to utilize strips of 4 x 4s, that we all have in our clinic. We cut them up, and then I douse it in Betadine, ring it out. I wrap it individually around every pin, and then I push it down. And if you use something, like a stopper or something, that some of the companies have, even better. But if not, just pushing it down against the skin, and allowing it to dry there, forms a cast and it minimizes that movement. So it's really been a game changer in my practice to help minimize soft tissue irritation and pin site infection.

I would, again, go back to adhering to sound principles, and again, making sure that your construct is meant and designed to do what you set out for it to do. I think it comes down to comfort level. If you're not comfortable with external fixation, then I think it's best to probably just avoid it. And if you think you are comfortable with it, but not necessarily getting the outcomes that you want, I think it's important to go back to the basics, and looking at critically evaluating your constructs, and looking at what else could you be doing? What could you be doing differently?

One of the things that I personally have started to do in my practice is increase the use of half pins. I tried to stay away from them for a very, very long time. But one of the things that I can tell you is that since I've started to incorporate them more and more, I've noticed a huge difference in terms of the incidence of irritation and infection, and the need for further revision surgery.

One of the things is, I think a lot of times we get overwhelmed when we get into the operating room with these frame cases. I would say have a preset way that you do it. In terms of every single frame that I put on, I do it in the same way. I try. Prebuilts are great, but it doesn't necessarily have to be. I start with the heel, I go to the tibia, and I work my way down into the mid-shaft, and then into the forefoot. I tension everybody the same way, in the same order. I think having a regimented way to do things helps to keep things flowing, helps to minimize wasted time in the operating room. And it helps you to find yourself less frustrated, or less chance for wasting time in the operating room, which I think is very important.