Preparing for Your First External Fixator

Since the accident in February 2010, I've been through three external fixators. My wife and I have acquired unique knowledge and experience preparing for and living with one of these things for several months at a time.

There are primarily two areas where I think Brooke and I could provide some useful insight for someone about to get an external fixator:

1. Preparing your home for care and maintenance.
2. Preparing for your surgery.

Today we'll focus on what you're going to need to buy to prepare for life with an ex-fix. The prices I list here aren't necessarily what you'll run into -- I used Amazon.com for everything.

Before I go on, I should note that I'm not a doctor. My wife is a nurse -- studying to be a nurse practitioner -- but as always, you should consult with your surgeon on everything related to your ex-fix. We'll make another post in a few days to provide some ideas and questions to bring up with your surgeon to prepare for your surgery.

Here's the quick run down off my three external fixators. If you've been following this blog for a while, you can skip right past this section.

Ex-Fix Number One

• Installed February 13th, 2010
• Removed March 1st, 2010
• Non-weight bearing

This is the first ex-fix I received following my accident. The surgeon in Colorado performed an ORIF on the fibula and used the ex-fix to stabilize the tibia fracture while the swelling improved. The large, softball-sized blood blister is a fracture blister.

After two surgeries, I ended up with two plates and nineteen screws.

Ex-Fix Number Two

• Installed August 16th, 2010
• Removed November 10th, 2010
• Non-weight bearing

This ex-fix is my first Ilizarov frame. Due to the severity of my initial injury, and several complications, such as an infection, my fractures did not heal. Without knowing it -- you'd think the large amount of pain would have been an indication -- I was walking around and rehabbing on a fibila and tibia that had not healed. The two plates and screws in my ankle absorbed the majority of the stress from weight bearing. As a result, the fibula plate broke and several screws in the tibia plate snapped in half.

I still have a few broken halves of those screws hanging out in my tibia as a reminder.

Most of the broken pieces of plates and screws were removed from my ankle and a large piece of my pelvis was used as the missing puzzle piece to heal the non-union in my ankle. The ex-fix was used to hold everything in place.

Ex-Fix Number Three

1. Installed August 16th, 2011
2. Removal scheduled for November 3rd, 2011
3. Weight bearing and hinged for ankle movement when unlocked

Many of you are familiar with the situation surrounding the installation of this bad boy. Unfortunately, I ended up with an incomplete union from last year's ex-fix surgery.

My ankle is definitely a mess.

I'm trying out ankle distraction arthroplasty to see if we can address some of the severe osteoarthritis I developed after my second ex-fix was removed. It was also important to me to see the images of my ankle from the arthroscopic procedure. During our initial consultation, Dr. Jeng suggested the tibia bone was unhealthy and likely to incur numerous revision surgeries if any of the salvage options available to us, like a fusion or replacement, were attempted. I wanted him to go in and verify for himself that the bone was unhealthy.

After the surgery ended, he told us, "your ankle is terrible." That's what we expected, but we needed to know for sure.

Preparing For an External Fixator

Here's a gigantic list of things you're going to want and need to help adjust to life with an external fixator.

The Bathroom

The biggest adjustment you'll probably make will be in the bathroom. Below is an essential items list.

• Bath bench - $24.00
• Hand-held shower head - $33.90
• Plumber's tape - $8.49

Total: $66.99

The plumber's tape is needed to make sure the seal is water tight when you install the shower head. Having a nice long hose is absolutely crucial. I started out putting trash bags over my ex-fix, but that adds a good half hour of time to showers. I learned eventually you can just place your ex-fix out of the tub and use the shower curtains to hold the water in around your leg.

I also used a small stool to prop up my leg when I used the toilet. I needed that, however, because my initial injury was too severe to not somehow elevate my leg at all times. I don't think most people will need that setup.

Sitting, Sleeping, and Getting Around

Get ready to learn how to sleep on your back if you're not already comfortable doing that.

• Wedged pillow - $24.99
• Aluminum reacher with magnetic tip - $16.13
• Ice packs - $6.95
• Replacement crutch tips - $8.99

Total: $57.06

As your pin sites heal, you should start experimenting with sleeping on your side and stomach. Don't be afraid to rest your ex-fix on top of your half screws. I do it regularly without any issues.

We used wedge pillows for a while to help elevate my ankle, but two pillows ought to be enough for your ankle.

The picture above is from March 2010. I ended up not using the long grabbers that much. This is more of a novelty item. I'd encourage you to just get up and do it yourself. Always find excuses to motivate yourself to get up and exercise.

Also notice I have a giant water container nearby. This is huge. While I said getting up is always good, having a giant water bottle nearby is essential.

Keep in mind that you'll be moving from your bedroom to your living room. It can be a pain in the butt to carry pillows back and forth, so doubling up on pillows is not a bad idea. The bottom line is it's time to stock up on pillows.

But stock up on even more ice packs.

I have tried several types of ice packs -- including bags of frozen vegetables. I think the best option is gel packs. Just make sure you don't have direct skin contact with the ice packs.

Renting a wheel chair is awesome. I usually rent one through my insurance before surgery and keep it the entire time I have the ex-fix. This allows me to go on walks with my wife at night when we let the dog out. Check out your insurance first, but for several months I'll only end up paying about $40.

However, it's extremely important to avoid relying on a wheel chair to get around. You want to focus on building up your crutching strength and endurance. The more you use the chair, the harder it will be to crutch around and get your strength back. Only use the chair for those times when you're going out and aren't sure whether a seat is guaranteed -- like a bar or a ball game.

Lastly, I've gone through uncountable sets of crutches. The tread usually wears out after six weeks if you're using your crutches for eight to ten hours a day. Replacement tips are essential. Always check your crutches for wear and tear. It can be extremely dangerous to crutch on worn out tread.

Pin Site Care

Depending on how long you have an ex-fix, pin site care can be one of the more expensive aspects to life with an erector set around your ankle. If you've got a flexible spending account through work or some other means, it's time to put it to work.

Also, as I've said before, always ask your surgeon about what he or she prefers you do for pin site care and management. Let me first give you a list and then we'll talk about a few of these items. Some of them are obvious (latex gloves), while others are not.

• Latex gloves - $8.24
• Nurse scissors - $3.95
• Saline wound wash - $5.41
• Xeroform - $15.50
• Iodine - $14.94
• Chlorascrub swabs - $33.66
• Gauze pads (2" x 2") - $5.82
• Gauze pads (4" x 4") - $5.40
• Cotton-tipped applicators - $8.98
• 3M surgical tape - $13.96
• Foot brush - $3.25
• Skin lotion - $27.97
• 2" gauze roll dressings - $3.08
• Stretch bands - $13.41
• Tennis ball - $5.70

Total: $169.27

The stretch bands are awesome for keeping your toes loose. Once you're in an ex-fix, the tendons under your foot will tighten up as they atrophy. Run this by your surgeon, but if you get an ex-fix that you can walk on, these bands are also useful to help ensure you don't stub your toes as you walk.

Another thing to ask your surgeon is whether you can take a shower with your ex-fix. I was unable to do this with my first and third ex-fix, so skin care and maintenance became something for us to focus on. Scrubbing the dead skin off your leg and keeping it clean and healthy is crucial. Just make sure you don't start peeling skin away from new skin. If it isn't flaking off on its own, it isn't ready to come off.

We've never used xeroform around our pin sites. That stuff is fairly expensive, but it's a good way to keep bacteria out of the pin site while a scab and crust builds up around the pin.

When you get your ex-fix removed, a tennis ball is awesome at loosening up the tendons under your foot and stretching out your toes. I keep one at work to roll my foot on while I'm sitting at the computer.

One thing I didn't list above was a Dynasplint.

The idea behind this splint is to give you a slow and steady stretch while you sleep. Here you see the Dynasplint configured to improve my dorsiflexion while I sleep. You'll have to work with your surgeon or physical therapist to get one of these. I never got to a point where I could go a whole night with this thing on. However, this was during the period of time when I was walking on a broken ankle.

Lastly, managing the infinite number of medications, shots, laxatives, and more medications you'll have to take on regular schedules can be difficult. I recommend you put them on a Google Calendar and set your phone to remind you when something is due.

So that's just a little bit of insight from our experience. Our next post will provide some details on how to prepare for your surgery and what questions to ask your surgeon. It's always important to keep in mind that even though your surgeon works for you, you have to come to each appointment prepared.

I usually showed up with an iPad with pictures and a list of questions. If your surgeon sees that you're putting work into the relationship, he or she is more likely to appreciate your attitude and reciprocate the attention and focus.

I found a few links related to pin site care. While these aren't specifically for ankle external fixators, the principles are still the same.

• Pin Site Care from Orthofix
• University of Wisconsin Home Care for Pin Sites
• External Fixators Information from Royal Children's Hospital