External fixators in austere environments under surge capacity conditions: A systematic review

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.

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.

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 %).

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.