J Reconstr Microsurg 2006; 22 - A022
DOI: 10.1055/s-2006-958670

Use of External Fixation for Soft Tissue Reconstruction of Foot and Ankle Wounds in the Non-Compliant Patient

Pranay M Parikh 1, Christopher E Attinger 1, Melanie M Hall 1
  • 1Georgetown University Hospital, Washington, DC, USA

Soft tissue reconstruction in the lower extremity frequently fails because of inadequate off-loading or excess joint mobility. The standard methods of casting or splinting often fail because of poor patient compliance, ischemia, morbid obesity, or spasm. External fixation presents an alternative method that effectively immobilizes joints and offloads the foot and ankle.

The authors reviewed their limb salvage database from 1999 to 2004 and identified 12 consecutive patients who were placed in multiplanar external fixation solely to help insure successful soft tissue reconstruction. There were 8 males and 4 females who were an average of 55.6 years of age at presentation and who all were unable to comply with the normal postoperative offloading and/or immobilization protocol. Nine patients had diabetes, 4 were morbidly obese, 3 had renal failure, and 3 were on chronic steroids. Seventy-five percent of the wounds involved the heel or midfoot; 58% were pressure ulcers; and 66% were osteomyelitic. The wounds had been open for an average of 284 days, with an average of 1.6 procedures attempted. An average of 3 procedures were performed on the wounds after placement of the frame, which remained on an average of 108 days. The wounds healed in an average of 128 days. There was a 58% complication rate including pin tract infection (25%), and two below-knee amputations. Forty-two percent of patients had recurrent wounds after having remained healed an average of 192 days.

The multiplanar external fixator was effective in healing lower extremity wounds in patients unable to comply with a rigid non-weight-bearing regimen. Failures that led to amputation occurred in the large heel ulcers of the noncompliant, diabetic, morbidly obese patient. Recurrent wounds occurred in those patients who did not change the level of activity that had led to the initial ulcer formation.

While the multiplanar external fixator is an effective adjunct for healing difficult soft tissue foot and ankle wounds in noncompliant patients, an overall long-term healing rate of 40% suggests that stricter criteria should be used before applying this expensive technique. The authors reviewed these criteria, as well as 12 additional patients in whom monoplanar external fixators were used for joint immobilization to protect soft tissue reconstruction.