For anyone who has suffered a severe fracture and undergone corrective surgery, the thought of eliminating the need for plates and screws and spending weeks on crutches while still speeding the healing process may sound too good to be true.

But a handful of Iowa surgeons are hoping increased use of external fixation devices to correct fractures and deformities will enable more patients to enjoy to those post-operative benefits.

“It’s pretty much limitless what you can do with these,” said Dr. Kevin Smith, a podiatric physician at Des Moines University Clinic, one of a handful of clinics statewide using external fixation devices.

External fixation devices were originally developed in the 1960s by Russian surgeon Gavriel Ilizarov using parts from a bus factory. Though the Ilizarov method has been used in the United States for close to 20 years, it is now being used more frequently in Iowa to correct fractures and deformities.

“From the early ’80s, the devices have improved significantly to where it’s a pretty safe, confident alternative to other options,” said Dr. Scot Freschi, also a podiatric physician at Des Moines University Clinic.

In applying an external fixation device, the surgeon drives a series of small pins into the bone, which are then anchored by a small rail or series of circular frames that surround the limb. Freschi and Smith use the devices on patients at DMU’s new Foot & Ankle Institute, but they can be used on other parts of the body as well.

“It’s pretty much limitless what you can do with these things,” Smith said.

A large external fixation device uses a series of carbon fiber rings on the foot and lower leg or other extremity, and is often used to correct a deformity or fracture or to reconstruct a foot damaged by diabetes. The device is applied during surgery and kept on for one to four months. A smaller device, which doesn’t stay on as long, consists of a small, inches-long rail that is secured to the bone with just four pins, which can often be installed without an incision. Though it can use compression to heal a fracture, its most common use is to draw apart arthritic joints, eliminating the need for an implant.

“If you put a screw through (the bone), that’s six to eight weeks with crutches,” Freschi said. “With the rail, my patient walks the next day.”

External fixation devices provide superior compression and stability not provided by traditional plates and screws, he said, and also distribute pressure. Walking creates pressure throughout the foot and leg, but the external fixation devices take the pressure away from the bones and spread it out across the device. Many patients equipped with larger external components can walk immediately or within days after surgery. A patient with internal fixation devices would likely be on crutches for two to three months.

“They’d have this big thing on their leg, but they would be mobile after surgery, which would aid their recovery and speed their recovery,” Smith said.

Some patients can’t use crutches, Freschi said, either because they lack the needed stability or have a career or lifestyle that prohibits them from being on crutches for several weeks. For those patients who are less stable on crutches, an external fixation device eliminates some fear for the physician. Should patients fall, they could put too much pressure on their fracture, causing the plate or screw to move, thus requiring a second surgery to correct it.

The devices also allow the physician to make postoperative adjustments to increase the amount of compression or improve the alignment of a fracture. “If I didn’t like how a fracture looked, I could make an adjustment after surgery by using this external fixture,” Smith said. “I couldn’t do that if I had a plate or screws in there.”

Physicians can make those adjustments in their office, but in certain cases, the patients can adjust the devices themselves at their home or office. In some instances in which a small rail is used to draw apart the joint space in an arthritic toe or compress a fractured metatarsal, the patient is given a small wrench in order to make regular adjustments to slowly compress or distract the site.

The devices impose a higher learning curve on physicians, leaving some reluctant to make it a part of their practice. Some are also fearful of potential complications.

“If someone didn’t have the technical expertise to do it, you could hit a nerve with one of these pins,” said Smith, who underwent training on the procedure in Chicago and has also applied the devices during medical mission trips in Mexico. Freschi’s residency training included instruction on the devices. This treatment option is becoming a more common subject at medical schools, including DMU. “It is something nationwide that is becoming more popular, so we want to make sure our students are current,” Smith said.

Manufacturing companies have released guides to aid physicians in placing pins in order to reduce the risk of complications. Today’s devices also require fewer pins, and the frames have become lighter through a transition from steel to carbon fiber. New technologies are emerging, including one that allows the frame to be adjusted via computer.

Despite decades of modifications and improvements, physicians acknowledge these devices aren’t suitable for every patient.

“Don’t throw these external fixation devices on everybody,” Smith said. “You can’t take a square peg and put it in a round hole. There’s a fit; there’s a patient that this is indicated for.”

Some professionals, such as real estate agents, whose careers require them to be mobile, may be better off with an external fixation device. But some physicians are concerned about putting the devices on some patients where there is a concern about proper hygiene. Patients can shower with the devices on, but, because there is an object from outside the body traveling inside the body, they must clean around the pins to prevent infection.

Some patients may also experience a psychological effect, referred to by physicians as “cage rage,” that comes with having a large device, one that cannot be easily removed, attached to an extremity.

“The biggest fear is that someone is going to have to wear this for three months and halfway through they say, ‘Get it off,’” Smith said.

Though insurance companies will cover the cost of external fixation devices, he said it is far more expensive than using internal devices.

“How do you put a price on healing?” Smith asked. “Being able to walk the day after surgery in some instances, mobility – for some people, it’s tough to put a price on that.”