External fixators in austere environments under surge capacity conditions: a systematic review
File(s)
Published version
Author(s)
Bull, David
Sykes, Mark
Saeidi, Mehdi
Bull, Anthony
Type
Journal Article
Abstract
Background
High-energy trauma causing open fractures can take place in low-resource settings (“austere” environment) and mainly affects the lower limbs. In these environments, external fixators often provide definitive surgical treatment. This systematic review identifies those external fixators for use on lower limbs as a definitive treatment that are most clinically effective in the austere environment.
Methods
Multiple databases were searched to identify studies investigating outcomes of external fixators used in austere environments. Case reports were excluded. Hand searching and expert input identified additional references.
Findings
33 publications met the inclusion criteria. These were used worldwide. Commercially available fixators were used in 18 publications, and non-commercial ones including Balkan-designed devices in 6. The remaining non-commercial devices had 1 or 2 publications each. Union rates, where reported, varied from 47 to 100 % with no discernible difference between devices or location of use. Clinical complications varied from infection (0–79 %) through to nonunion and delayed union (0–22 %), loosening (0–36 %), osteomyelitis (0–19 %), construct stability (27–100 %), and amputation (0–50 %).
Interpretation
The variability in union and complication rates highlights the variability in severity of injuries, type of austere environment, and variability in fixator device efficacy. The non-commercial or “one-off” devices show promise, with comparable or better outcomes to the commercial devices, whereas others did not work well, with poor outcomes. The need for surge capacity availability in these austere environments would enable locally manufactured devices to be quickly made which are fit for purpose, yet regulation and quality control of these remains a challenge in their rollout.
High-energy trauma causing open fractures can take place in low-resource settings (“austere” environment) and mainly affects the lower limbs. In these environments, external fixators often provide definitive surgical treatment. This systematic review identifies those external fixators for use on lower limbs as a definitive treatment that are most clinically effective in the austere environment.
Methods
Multiple databases were searched to identify studies investigating outcomes of external fixators used in austere environments. Case reports were excluded. Hand searching and expert input identified additional references.
Findings
33 publications met the inclusion criteria. These were used worldwide. Commercially available fixators were used in 18 publications, and non-commercial ones including Balkan-designed devices in 6. The remaining non-commercial devices had 1 or 2 publications each. Union rates, where reported, varied from 47 to 100 % with no discernible difference between devices or location of use. Clinical complications varied from infection (0–79 %) through to nonunion and delayed union (0–22 %), loosening (0–36 %), osteomyelitis (0–19 %), construct stability (27–100 %), and amputation (0–50 %).
Interpretation
The variability in union and complication rates highlights the variability in severity of injuries, type of austere environment, and variability in fixator device efficacy. The non-commercial or “one-off” devices show promise, with comparable or better outcomes to the commercial devices, whereas others did not work well, with poor outcomes. The need for surge capacity availability in these austere environments would enable locally manufactured devices to be quickly made which are fit for purpose, yet regulation and quality control of these remains a challenge in their rollout.
Date Issued
2025-04-01
Date Acceptance
2025-03-20
Citation
Clinical Biomechanics, 2025, 124
ISSN
0268-0033
Publisher
Elsevier
Journal / Book Title
Clinical Biomechanics
Volume
124
Copyright Statement
© 2025 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
License URL
Identifier
10.1016/j.clinbiomech.2025.106500
Publication Status
Published
Article Number
106500
Date Publish Online
2025-03-21