Abstract
Background
Definitive external fixation is commonly used in the management of complex lower limb fractures. Holistic pre- and post-operative rehabilitation is considered essential; however, rehabilitation practices vary considerably, with limited supporting evidence and no validated outcome measures for this population.
Aim
To describe rehabilitation provision for adults with lower limb injuries managed with definitive external fixation at a single NHS Trust, with secondary evaluation of post-operative mobility outcomes, patient demographics, and exploratory factors associated with return to baseline mobility.
Materials and methods
A retrospective, single-site, service evaluation was conducted including adult patients treated with definitive external fixation between 2022 and 2025. Descriptive statistics summarised the data and univariate analyses explored factors associated with return to baseline mobility.
Results
Seventy-four patients were included, with a median age of 46 years. Fifty-three percent regained baseline mobility post-operatively. Rehabilitation showed poor compliance with national guidelines across multiple phases of recovery. Few individual rehabilitation variables were associated with return to baseline mobility in univariate analysis.
Conclusion
This study provides descriptive evidence regarding rehabilitation provision, patient characteristics, and mobility recovery following definitive external fixation at a single NHS Trust. Findings highlight variation in rehabilitation delivery, poor compliance with national guidelines, and ongoing uncertainty regarding optimal rehabilitation pathways for this patient population.
Clinical significance
These findings highlight the need for prospective, multicentre research to evaluate rehabilitation pathways, develop standardised outcome measures, and strengthen the evidence base for rehabilitation following definitive external fixation. Future research should capture acute and long-term recovery and include functional, psychological, and socioeconomic outcomes.
Keywords: External fixation, Lower limb trauma, Rehabilitation provision, Service evaluation, Trauma rehabilitation
Introduction
Complex lower limb fractures are severe injuries often associated with substantial morbidity, prolonged disability, and significant socioeconomic consequences.1,2 Early internal fixation in such injuries has been associated with increased risk of infection and suboptimal outcomes. Therefore, definitive external fixation is frequently used to reconstruct the limb. This technique involves percutaneous pins and wires inserted into fractured bones and attached to an external frame.3,4 This construct provides multi-planar stability at the fracture sites, enabling bone remodelling, and facilitating early weight-bearing to support functional recovery.3,5,6 Holistic, multidisciplinary rehabilitation following fixation is crucial to optimise mobility and independence with daily functional tasks.2 Current National Major Trauma Rehabilitation Group (NMTRG) guidelines provide broad recommendations across pre-operative, post-operative, and post-frame removal phases, but do not describe specific exercises, repetitions or outcome measures.7 As a result, rehabilitation practice remains largely guided by local protocols and clinician experience. Existing literature highlights considerable variability in rehabilitation strategies for patients managed with definitive external fixation, inconsistent reporting of rehabilitation interventions, and a lack of standardised outcome measures.2,5,6,8,9 Rehabilitation recommendations are largely based on expert consensus, case reports, and retrospective cohort studies which rank low in the evidence hierarchy.6–10 The variability in rehabilitation provision, combined with heterogeneous civilian trauma populations, continues to hinder the development of standardised rehabilitation protocols for prospective research.5,6,9 Consequently, rehabilitation provision may vary significantly between centres, and the clinical effectiveness of rehabilitation remains unclear. Furthermore, there is limited published evidence describing the population characteristics and recovery outcomes of patients treated with definitive external fixation. While some hospitals offer specialised rehabilitation pathways for these patients, others rely on non-specialist rehabilitation, creating disparity in national rehabilitation provision. A consensus-based research priority study by Graham identified the development of validated outcome measures and evaluation of specialist vs non-specialist rehabilitation as top research priorities.11 To address these priorities and improve current rehabilitation services, a clearer understanding of the patient population, existing service provision, and associated outcomes is required. This insight will help identify service gaps, inform local and national quality improvement initiatives, and support future multicentre research.
The aim of this study was to describe rehabilitation provision for adults with lower limb injuries managed with definitive external fixation at a single NHS Trust. To achieve the aim, the following objectives were set:
To audit the pre- and post-operative rehabilitation provision for adult patients with lower limb injuries managed with definitive external fixation against national NMTRG guidelines.7
To describe post-operative mobility outcomes in adult patients with lower limb injuries managed with definitive external fixation.
To describe the demographic, injury-related, and surgical characteristics of the patient cohort.
To explore contextual factors associated with return to baseline mobility.
Materials and Methods
Study Design
The study was a retrospective single-centre observational service evaluation, registered with the local Audit Team (Registration Number: 1053). In accordance with Health Research Authority guidance, NHS Research Ethics Committee approval was not required.
Setting
The study was conducted at an NHS Trust in the United Kingdom (UK) that functions as a major trauma centre. As a major trauma centre, the study site is a specialist hospital equipped to receive severely injured trauma patients from a large catchment area.12,13 At the time of the study, the centre did not have a dedicated multidisciplinary rehabilitation pathway for patients undergoing definitive external fixation. A multicentre study was not locally approved and therefore could not be conducted as part of this service evaluation.
Study Population
Patients were included if they had a history of traumatic lower limb fracture treated with definitive external fixation, were aged 18 years or older at the time of injury and underwent definitive external fixation surgery at the study site between 1st January 2022 and 1st January 2025. Patients were excluded from the study if they underwent external fixation for non-trauma related limb reconstruction or upper limb injuries, if their injuries were managed with temporary external fixation prior to early internal fixation, if they were under 18 years of age at the time of injury (on the paediatric management pathway), if their definitive external fixation surgery was completed at a different hospital or outside the specified study period. Consent was not required as the data collection was retrospective, the project was classified as a service evaluation rather than research, and all the data had been anonymised before use.
Outcomes
The primary outcome was the proportion of patients who received rehabilitation consistent with the NMTRG guidelines across all phases of recovery (pre-operative, post-operative inpatient, post-operative outpatient, and post-frame removal).
The secondary outcomes included:
The proportion of patients who returned to baseline mobility status.
The distribution of demographic, injury-related, and surgical characteristics of the patient cohort.
Exploratory analysis of factors associated with return to baseline mobility.
Definitions
Definitive external fixation was defined as the use of an external fixator as the primary method of fracture stabilisation intended to remain in-situ until fracture union or planned frame removal.
Rehabilitation provision in line with NMTRG guidelines was defined as documented multidisciplinary rehabilitation input within each phase of care (pre-operative, post-operative inpatient, post-operative outpatient, and post-frame removal), identified through retrospective review of medical, physiotherapy, occupational therapy, and nursing records. Compliance was recorded on a binary (yes/no) basis for each intervention.
Baseline mobility was defined as the documented level of indoor mobility pre-injury, as recorded in the medical or physiotherapy records.
Return to baseline mobility was defined as recovery of the pre-injury indoor mobility status, as documented at least 4 weeks following frame removal in fracture clinic, surgical or physiotherapy records. This timepoint was selected to allow for early post-frame removal recovery, reducing the influence of transient peri-removal mobility limitation.
Data Collection
A list of patients who had undergone external fixation at the study site was identified using a local analytics programme by searching surgical codes and dates. Patients who met the exclusion criteria were then manually removed. Anonymised, retrospective data was manually collected by the first author from electronic medical records into a password-protected spreadsheet. Patients with missing or incomplete data were still included in the database. Variables with missing data for more than 20% of participants were excluded to avoid skewing the results. To evidence the validity of the data, a second researcher independently repeated data collection for 10% of participants, and no discrepancies were found. Details of all the data variables collected can be found in the Supplementary Appendices A and B.
Data Analysis
Data were analysed using Microsoft Excel and IBM SPSS software.14,15 Descriptive statistics were used to summarise the data, presented as frequencies (n) and percentages (%) for categorical variables and means with standard deviations or medians with interquartile ranges for continuous variables. Univariate analyses were performed to explore associations between independent variables and the dependent variable (return to baseline mobility). Fisher's exact test was used for categorical variables due to small sample sizes, and the Mann–Whitney U-test was used for continuous variables following assessment of normality using the Shapiro–Wilk test. Statistical significance was set at p < 0.05.
Results
Cohort Selection
A total of 320 patients were identified using a local analytics programme. The following patients were removed after application of the inclusion and exclusion criteria: 18 paediatric patients, 136 treated with temporary external fixators, 86 undergoing non-trauma related reconstruction procedures, and six who had surgery outside the study period. The remaining 74 patients were included in the study (n = 74). A subset of 36 patients (49%) received outpatient physiotherapy at the study site and were included in outpatient rehabilitation analyses. No dataset exceeded the 20% missing data threshold. Detailed results for all variables are shown in the supplemental content.
Cohort Characteristics
Table 1 summarises a selection of the demographic, injury, and surgical characteristics for the patient cohort (n = 74). The median age was 46 years. There was a high proportion of males, and just under half of the cohort were smokers. Over half (57%) were employed or studying at the time of injury. Most injuries were isolated and very few patients had a concurrent central neurological injury. Most patients were treated with a Taylor spatial frame, and a majority had no post-operative weight-bearing restrictions. Documentation regarding the rationale for weight-bearing restrictions was incomplete in approximately one-fifth of cases.
Table 1.
A selection of the demographic, injury and surgical characteristics (n = 74)
| Patient demographics | Total patients | Percentage |
|---|---|---|
| Age-grouping | ||
| 18–34 | 17 | 23% |
| 35–49 | 32 | 43% |
| 50–64 | 15 | 20% |
| 65–79 | 8 | 11% |
| 80–95 | 2 | 3% |
| Ethnicity | ||
| Any white background | 38 | 51% |
| Any black background | 8 | 11% |
| Any Asian background | 8 | 11% |
| Any other background | 20 | 27% |
| Gender | ||
| Male | 53 | 72% |
| Female | 21 | 28% |
| Baseline mobility | ||
| Independent unaided | 65 | 88% |
| Independent housebound | 2 | 3% |
| Independent with aid indoors and outdoors | 7 | 9% |
| Employment status prior to injury | ||
| Carer/childcare | 1 | 1% |
| Employed | 40 | 54% |
| Retired | 8 | 11% |
| Student | 2 | 3% |
| Unemployed | 14 | 19% |
| Missing (not documented) | 9 | 12% |
| Smoking status | ||
| Current smoker | 33 | 45% |
| Non-smoker | 38 | 51% |
| Missing (not documented) | 3 | 4% |
| Mechanism of injury | ||
| Fall from height over 2 m | 16 | 22% |
| Fall from height under 2 m | 12 | 16% |
| Fall on stairs | 5 | 7% |
| Road traffic collision | 35 | 47% |
| Sports injury | 4 | 5% |
| Other (crush/gunshot wound) | 2 | 3% |
| Injury classifications | ||
| Closed proximal tibia/fibula fracture | 19 | 26% |
| Closed distal tibia/fibula fracture | 17 | 23% |
| Open distal tibia/fibula fracture | 24 | 32% |
| Open proximal tibia/fibula fracture | 14 | 19% |
| Concurrent injury | ||
| Isolated injury | 47 | 64% |
| Multiple injuries ipsilateral limb | 6 | 8% |
| Polytrauma (with central neurological injury) | 6 | 8% |
| Polytrauma (non-neurological injuries) | 15 | 20% |
| Type of frame | ||
| Stryker Hoffmann limb reconstruction frame | 18 | 24% |
| Ilizarov frame | 2 | 3% |
| Orthofix hexapod frame | 1 | 1% |
| Taylor spatial frame | 53 | 72% |
| Post-operative weight-bearing status | ||
| Unrestricted weight-bearing | 42 | 57% |
| Limited weight-bearing | 14 | 19% |
| Non-weight-bearing | 15 | 20% |
| Missing (not documented) | 3 | 4% |
| Reason for weight-bearing restriction | ||
| Not applicable (no restriction) | 42 | 57% |
| First stage operation (partial frame) | 5 | 7% |
| Ipsilateral injury | 8 | 11% |
| Severe infection and bone loss | 1 | 1% |
| Soft tissue injury | 4 | 5% |
| Missing (not documented) | 14 | 19% |
The mean duration of external fixation was 187 days, however, there was a high degree of variability, as indicated by the standard deviation of 103 days. Post-operative complications were inconsistently documented. Most patients did not experience non-union or contracture, however more than half of the cohort experienced at least one documented infection. Four patients (5%) had missing data regarding post-operative complications, with two cases deemed not applicable and two lacking clear documentation.
Adherence to NMTRG Rehabilitation Guidelines
Pre-operative Phase
Half of the patient cohort were seen by a physiotherapist pre-operatively, however, only two patients (3%) received specific pre-operative rehabilitation interventions as recommended by the NMTRG guidelines.7 The interventions included smoking cessation, discussion of living with an external fixator, provision of written information, and expectation setting for rehabilitation.
Post-operative Inpatient Phase
Figure 1 shows the proportion of patients who received post-operative rehabilitation as an inpatient. Most patients (88%) were reviewed by a physiotherapist within 24 hours post-operatively. However, delivery of specific rehabilitation interventions varied, with fewer than half of patients receiving each individual intervention. Almost half of the total patients (47%) were given a resting ankle orthosis for passive stretching. Compliance with providing the resting ankle orthosis was lowest in 2022 at 31% but gradually improved to 43% in 2023 and reached 67% in 2024.
Fig. 1.
Post-operative inpatient variables
Post-operative Outpatient Phase
Of the cohort, 36 patients (49%) attended outpatient musculoskeletal physiotherapy at the study site and were included in the outpatient physiotherapy data, which is shown in Figure 2. Within this subgroup, the provision of specific rehabilitation interventions was more consistent, with most patients completing goal setting, gait re-education, and receiving independent exercise programmes. However, no patients were offered peer support. The mean time from hospital discharge to the initial outpatient physiotherapy appointment was 102 days, and the longest duration was 502 days. Only two patients were seen within 14 days of discharge, and 42% of patients waited longer than 3 months.
Fig. 2.
Post-operative outpatient variables
Post Frame-removal Stage
Approximately half of the patients (51%) were seen by a physiotherapist following removal of the fixation device, however, 42% were not referred for any ongoing rehabilitation following frame removal.
Return to Baseline Mobility
Thirty-nine patients (53%) achieved return to baseline mobility post-operatively. Four patients had missing data (7%). The mean time to return to baseline mobility was 418 days with a standard deviation of 567 days. The median time to return to baseline was 256 days with an interquartile range of 195–482 days, demonstrating a high degree of variability in recovery times.
Factors Associated with Return to Baseline Mobility
Univariate analysis revealed no significant differences in the demographic or injury characteristics between patients who did or did not return to their baseline function. Year of surgery showed a significant difference between patients who did and did not return to baseline mobility (p = 0.006), with those operated on most recently in 2024 being least likely to have regained baseline mobility.
Post-operative weight-bearing status showed a significant difference between groups (p = 0.006), with patients who were permitted unrestricted weight-bearing immediately post-operatively being more likely to return to baseline mobility than those with restrictions.
The documented reason for weight-bearing restriction also showed a significant difference according to mobility outcome (p = 0.034), with patients requiring restriction due to ipsilateral injuries less likely to return to baseline mobility.
Pre-operative rehabilitation interventions did not significantly differ according to return to baseline mobility status. Provision of a resting ankle orthosis during post-operative inpatient rehabilitation phase showed a significant difference according to return to baseline mobility (p = 0.016), with a lower proportion of patients who received an orthosis returning to baseline mobility compared with those who did not.
Documented inpatient discussion regarding psychological wellbeing also showed a significant difference according to return to baseline mobility on univariate analysis (p = 0.046). No significant differences were observed between onward rehabilitation referral completion and return to baseline mobility, or between mobility status at discharge and return to baseline mobility.
Attendance at outpatient physiotherapy at the study site differed significantly according to return to baseline mobility status (p = 0.03), however, none of the specific outpatient rehabilitation interventions individually showed a significant difference. There was a significant difference in time to first outpatient physiotherapy appointment between groups (p = 0.035), with shorter intervals observed in patients who returned to baseline mobility.
Completion of onward rehabilitation referrals following frame removal initially showed a significant difference between those who did or did not return to baseline mobility (p = 0.031), although this difference was no longer significant following exclusion of patients referred for community-based rehabilitation (p = 0.599).
Post-operative complications including non-union (p = 0.001) and contracture (p = 0.004) showed significant differences according to return to baseline mobility status, whereas the presence of infection did not.
Discussion
This study examined a wide range of variables collected at multiple phases of the patient journey and has produced insight into rehabilitation provision and recovery of mobility following definitive external fixation. The study found that rehabilitation for patients treated with definitive external fixation at the study site generally did not align with the NMTRG guidelines.7 Compliance was lowest in the pre-operative phase, although suboptimal adherence was also observed during the post-operative inpatient, outpatient and post-frame-removal phases. The NMTRG guidelines stipulate that outpatient physiotherapy should commence within 14 days of hospital discharge, however, most patients waited considerably longer than this to commence their outpatient rehabilitation.7
Given the heterogeneous nature of the cohort, encompassing variation in injury patterns, surgical techniques, and rehabilitation pathways, return to baseline mobility was used as a pragmatic, contextual indicator of recovery following definitive external fixation. As such, these findings should be interpreted descriptively, providing insight into overall recovery patterns rather than enabling direct comparison of recovery across subgroups. Just over half of patients in the cohort had regained their baseline mobility during follow-up, although the patients were at different stages of recovery as their surgeries were performed in different years. To the author's knowledge, no studies have directly examined the expected mobility recovery rate in this patient population, and so it is not possible to make direct comparisons or determine whether the observed outcomes are comparable to other cohorts. The observed proportion of patients returning to baseline mobility is broadly similar to that reported in a longitudinal study of ankle fracture recovery in a similar age cohort, which reported that 52% of patients had returned to baseline activity levels 1 year post-injury.16 However, that study was also single-site in design, limiting generalisability.16 Similarly, research examining recovery trajectories following complex tibial plateau fracture fixation has demonstrated substantial improvement in functional ability within the 1st year after surgery, although baseline function had not been achieved even after 5 years.17 This suggests that future research should consider an extended longitudinal design, ideally spanning more than 5 years.
The demographic profile of patients treated with definitive external fixation at the study site differed from the broader trauma population in England, with a 12% higher proportion of male patients and an average age over 10 years younger.18 A national study on open fractures reported a similar demographic profile, including baseline function and median age, however the proportion of males remained 6% higher in the study site cohort.19 These similarities may improve the generalisability of the study's findings to the national population who have sustained complex fractures. Demographic characteristics, including smoking status, were not significantly associated with mobility recovery. This contrasts with previous orthopaedic research, where smoking has been consistently associated with worse outcomes.20 In contrast, patients who experienced complications such as non-union were less likely to return to baseline mobility, which is in-line with other research as non-union is well-documented as a cause of substantial morbidity.21 The non-union rate within the cohort was notably higher than reported in other studies.21 This could be due to the complex nature of these fractures or alternatively could be due to small sample sizes.
None of the individual rehabilitation interventions in the pre-operative, post-operative outpatient, or post-frame removal stages demonstrated a statistically significant association with return to baseline mobility in univariate analysis. This highlights the need for further prospective research to better understand the role of these interventions. Among the post-operative inpatient rehabilitation interventions, provision of a resting ankle orthosis was the only factor significantly associated with return to baseline mobility in univariate analysis, with a negative association observed. This finding contrasts with clinical expectations and current national guidelines, which recommends routine provision of such orthoses for patients treated with definitive external fixation.7 This discrepancy could be due to the small sample size and uncertain compliance with the prescribed orthoses. Additionally, the observed effect could be influenced by the increased provision of orthoses to patients who had more recent surgeries, suggesting that the negative effect may be related to the recency of the surgery rather than the orthosis itself. To the author's knowledge, there is no direct research on the use of splinting in patients with external fixation devices, and evidence supporting passive splinting in broader trauma recovery is very limited. A small, single-site study investigating splinting after neurological injury reported no measurable benefit.22 These results highlight the need for further research to evaluate the clinical effectiveness and cost-benefit justification of splinting in patients treated with definitive external fixation.
Patients managed with post-operative non-weight-bearing restrictions were less likely to regain their baseline mobility in univariate analysis. This finding is consistent with evidence from other trauma populations, including a meta-analysis of ankle fracture management, which demonstrated that early weight-bearing is associated with faster functional recovery and earlier return to work.23 Although long-term functional outcomes were not affected in this meta-analysis, multiple other studies have highlighted the benefits of early return to employment on overall patient wellbeing.23–25 Over half of the patients who had undergone definitive external fixation at the study site were employed at the time of injury, and this would be an important functional recovery component to incorporate into an outcome measure for definitive external fixation patients. Due to the retrospective nature of the study, return-to-work data were not consistently available and therefore could not be described for the cohort.
Limitations
This study has several limitations that should be considered when interpreting findings. Data collection was based on retrospective clinical documentation, which varied in quality and may have affected the accuracy of the findings. For instance, assessment of time taken to return to baseline mobility depended on a clearly documented mobility status. It is possible that patients reached their baseline mobility earlier than recorded due to inconsistencies or delays in documentation. Similarly, pre-operative rehabilitation discussions, including education regarding external fixation and rehabilitation expectations, were infrequently documented and may have been undertaken as part of routine consenting processes without formal recording. The study also relied on a pragmatic, non-validated outcome measure of return to baseline mobility, which, while commonly documented in clinical records, does not capture broader domains such as psychological wellbeing, ability to perform daily activities, return to work, and resumption of social roles. These factors were not consistently documented in the available records, making it impossible to assess them in this study. The relatively small sample size reduced statistical power and increased variability in the data. This was particularly evident in subgroup analyses, including outpatient physiotherapy variables. The reduced sample size limited the ability to explore associations within a more detailed statistical model. The cohort demonstrated heterogeneity in injury patterns, surgical approaches, and rehabilitation provision, reflecting real-world clinical practice but limiting the ability to develop multivariate models and contributing to statistical instability. As a result, analyses were limited to univariate methods and findings should be interpreted as exploratory rather than causal. Finally, the single-centre design limits the generalisability of findings to other institutions with patient populations and different rehabilitation pathways.
Conclusion
This service evaluation describes the patient population undergoing definitive external fixation at a single NHS Trust, alongside an evaluation of current service provision and patient outcomes. At the study site, compliance with the national rehabilitation guidelines for this group was consistently low across all stages of the patient journey, which highlights gaps within current local service provision. Despite poor compliance with rehabilitation guidelines, over half of the patients regained baseline mobility. This highlights the need for further research to better understand how specific rehabilitation interventions contribute to recovery in this patient population.
Clinical Significance
This study provides clinically relevant descriptive data regarding rehabilitation provision and recovery following definitive external fixation in a UK trauma population, an area that remains under-reported in the existing literature. It highlights variation in rehabilitation delivery and reinforces the need for improved standardisation of care pathways. The findings support further prospective, multicentre research to compare rehabilitation models, particularly across specialist limb-reconstruction services. Future studies should include longer-term follow-up and capture functional, psychological and socioeconomic outcomes, supported by the development of a standardised, validated outcome measure for this patient population.
Data Availability Declaration
Data variables are presented in the supplementary materials. Additional data are available from the corresponding author on reasonable request.
Artificial Intelligence (AI) Disclosure
Artificial intelligence tool ChatGPT (OpenAI) was used solely for grammar and language refinement. No AI tools were used for data analysis, interpretation, or generation of scientific content. The authors take full responsibility for the final manuscript.
Authors' Contributions
Lydia A Heins conceived the service evaluation, collected and analysed the data, and drafted the manuscript. Ceri E Battle provided supervision, critical revision, and approved the final manuscript.
Acknowledgements
This work was undertaken at Imperial College Healthcare NHS Trust (ICHNT). The authors would like to thank the following staff from ICHNT: Vicky Newey (Clinical Service Lead) and Amanda Hutchinson (Clinical Lead Physiotherapist) for supervision and manuscript review and editing; Priya Gami (Senior Physiotherapist) for assistance with independent data validation; and Edward Matthews (Consultant Limb Reconstruction and Hip Surgeon) for providing technical guidance.
Supplementary Materials
All the supplementary materials are available on its journal website www.stlr.com
Orcid
Lydia A Heins https://orcid.org/0009-0002-2076-2806
Ceri E Battle https://orcid.org/0000-0002-7503-1931
Footnotes
Source of support: Nil
Conflict of interest: None
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data variables are presented in the supplementary materials. Additional data are available from the corresponding author on reasonable request.