Abstract
Background:
Despite the safety and versatility of circular external fixators (CEFs) for many indications, there is limited information on their contemporary usage and the factors contributing to their potential underutilization. This study aims to estimate the prevalence of contemporary CEF use, characterize barriers to adoption, and identify potential solutions among American Orthopaedic Foot & Ankle Society (AOFAS) members.
Methods:
A multibranched survey was designed for distribution to all active practicing members of the AOFAS to collect data on demographics, training background, CEF usage profile, provider opinions, barriers to device adoption, and factors that could encourage greater use. Data were collected through Qualtrics XM. Statistical analysis analyzing respondent differences included descriptive statistics, χ2 tests for independence, and unpaired t tests.
Results:
Of 169 participants, 27.81% reported not using CEFs in their practice despite 94.08% of respondents agreeing that their use is critical for certain patients. Overall, 70.21% of nonusers believed it could have a role in their practice but had hesitations. In addition, 59.76% of participants received minimal to no exposure in residency, and this was a significant predictor for current usage (P = .0119). CEFs are most commonly used for Charcot neuroarthropathy (86.07%), infection management (83.60%), and other deformity corrections (65.67%). Nonusers are more likely to believe CEFs take too long to assemble intraoperatively, express greater concern about postoperative burden, and are less confident in postoperative care compared to users (all P < .01). The most popular interventions that would facilitate usage were access to longitudinal mentorship, further technological advancement, and attending non–industry-sponsored courses.
Conclusion:
Perceived lengthy operative time, postoperative burden, and lack of postoperative management confidence were predominant reasons for the lack of CEF use. This survey suggests that these barriers could be addressed by more exposure during training, attending non–industry-sponsored courses, and longitudinal mentorship.
Level of Evidence:
Level IV, cross-sectional study.
Introduction
Circular external fixators (CEFs), alternatively known as ring fixators or Ilizarov frames, were first designed in 1948 by Dr Gavriil Ilizarov.5,6 These instruments have vast indications among orthopaedic surgeons for a wide range of diagnoses in the foot and ankle.1,2 They may be used as stabilization devices for complicated trauma cases that require an attenuation of the local inflammatory response to preserve soft tissue integrity. 3 Other uses include wound management, neuropathic fracture stabilization, Charcot management, fusions, deformity corrections, and limb lengthening procedures.3,6
Many qualities of CEFs make them desirable alternatives to internal fixation and other typical instrumentation methods. Advantages include decreased deep infection risk due to no permanent indwelling hardware, the ability for early weight bearing (particularly in non-compliant patients), early patient mobilization, and optimal management of soft tissue wounds and complications.6,9,11 Despite these advantages, CEF use may be relatively low among orthopaedic surgeons in the United States. A multi-institutional study conducted in 2025 reported the use of external fixation for open lower-extremity fractures to be approximately 23.5%, although this study did not distinguish between circular and monolateral external fixation. 10 A commonly posited reason for physician aversion to CEFs is that proficiency in ring application requires excessively thorough knowledge of the 3D relationships between bone, neurovasculature, and joint capsule margins and requires experience, focused training, and a comprehensive care team.5,6 Alternative explanations for lack of CEF use among American physicians may exist, but they have not been documented in current literature.
There are large gaps in knowledge of the prevalence and specific usage profile of CEFs as well as explanations for their subjectively low use among American foot and ankle surgeons. This study seeks to investigate the use of CEFs among foot and ankle–trained orthopaedic surgeons and evaluate their indications and hesitations to implement as part of their practice. A cross-sectional survey study was designed for distribution to members of the American Orthopedic Foot & Ankle Society (AOFAS) to evaluate the frequency of CEF usage, categorize the major indications that physicians use CEF for, and elucidate the barriers to usage for physicians who do not.
Methodology
Data Collection
The survey design and subsequent data collection were conducted through Qualtrics XM software (Qualtrics, Provo, UT). A branched survey was designed to capture specific opinions and medical training data from both users and nonusers of CEF. The survey was approved by the AOFAS and then first distributed via email to Active, Candidate, and Associate members of the AOFAS on February 11, 2025. A second survey blast was sent 6 weeks later to increase response rates. The survey was then closed 100 days later. All recipients were informed of the voluntary nature of the survey, its purpose and content, the risks and benefits of participation, confidentiality statements, and intended data use.
Preliminary Information and Demographics
All participants were asked about basic demographics, region of training (organized by United States Census Bureau designations), medical degree, exposure during training, binary current usage of CEFs, and 2 basic opinion questions on the utility of CEFs. Each question was structured into multiple-choice options to reduce the amount of free-response entries.
Indication Profile
For respondents who reported using CEFs, clinical indications were assessed using a multiple-response “select-all-that-apply” question format with a free-response option for other miscellaneous indications. Approximate usage rates per year were also recorded.
Physician Perceptions and Opinions
Perceived barriers to CEF usage were assessed using several questions assessing potential difficulties pertaining to the device, financial sponsorship, medical indications for treatment, patient perceptions, financial burdens, and technical difficulties. Each response included a subjective 5-point Likert scale, structured as strongly disagree, slightly disagree, neither agree nor disagree, slightly agree, and strongly agree. Each response was converted into a value ranging from 1 to 5 to be used in intergroup statistical analysis. To explore potential strategies for increasing CEF use among nonusers, participants rated how likely each proposed intervention would increase their usage on a 3-point Likert scale: not likely at all, slightly likely, and highly likely.
Statistical Analysis
Most results were reported descriptively with percentages between groups of respondents. For physician perceptions and opinions, converted Likert scale scores were used to provide average agreement scores between groups, which were tested for statistical significance using unpaired t tests. Questions posed in a binary format were analyzed between users and nonusers using χ2 tests for independence given large sample sizes. All calculations were conducted with RStudio (version 2024.04.2+764).
Results
Preliminary Information and Demographics
There were 181 respondents overall. Twelve surveys were incomplete and excluded from analysis, yielding a total of 169 completed surveys. Although 94.08% of all respondents agreed that CEFs are a critical aspect of care for some patients, only 72.19% of respondents reported some degree of incorporation of CEFs in their practice. More than half (52.07%) of the respondents stated that no other physician in their practice uses CEFs. The majority of respondents held MD degrees (92.30%) and had greater than 10 years of experience in practice (60.95%). In addition, 46.72% of current CEF users reported moderate or extensive exposure during advanced training compared to only 19.15% for nonusers; the majority of nonusers reported minimal exposure (Table 1). There was a significant positive association between CEF usage and both the degree of exposure during training (P = .012) and the presence of other physicians in practice who also use CEFs (P = .002); no association was observed with years in practice (P = .623) (Table 2).
Demographic and Training Information Among Survey Respondents.
Comparison of Training Exposure and Defining Opinions Between Users and Nonusers.
Abbreviation: CEF, circular external fixator.
Geographically, the highest usage rates among survey respondents were seen in the Mountain region (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming) with a 100% usage rate (n = 15) and East North Central (Illinois, Indiana, Michigan, Ohio, and Wisconsin) regions with a 77.78% usage rate (n = 27). The lowest use rate was seen in the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) with only a 46.15% usage rate among respondents (n = 13). There is no statistically significant association between usage rates and geographic region (P = .095) (Figure 1).
Geographic distribution of CEF respondents and usage rate by census region. This figure outlines the total amount of respondents and the usage rate with the aid of a geographical map of the United States.
Indication Profile
The most common reason for CEF use in modern practice is for the management of Charcot neuroarthropathy, with 86.07% of users stating it was a primary indication. This was followed by infection management (83.60%), deformity correction (65.57%), wound offloading (49.18%), acute trauma (38.52%), limb lengthening (21.31%), or other miscellaneous indications (5.74%). Regarding frequency of use, 68.03% of physicians report using CEFs at least twice per year, but 14.75% of physicians describe usage of more than 10 times annually.
Physician Perceptions and Opinions
Among nonusers, the most commonly cited reason for not adopting CEFs was the belief that internal fixation provides adequate treatment for the conditions they treat. The next most reported reasons included the perception that external fixation is too time- and labor-intensive to manage perioperatively and the opinion that internal fixation is technically easier to perform. Additionally, nonusers were compared to users on certain opinions pertaining to the general perception of CEF use (Figure 2). Among 8 opinions, 3 yielded significantly differing levels of agreement between users and nonusers. Compared with those who use CEFs, those who do not are more likely to worry about clinical burden (P = .003), believe they take too long to assemble and adjust in the operating room (P = .001), and are less comfortable with postoperative management (P < .001).
Statement and opinion alignment between CEF users and nonusers. This figure demonstrates the opinion/statement alignment pertaining to aspects of circular external fixator (CEF) usage between users and nonusers. Degrees of alignment are recorded by 5-point Likert scales, with a value of 5 corresponding to “strongly agree” and 1 corresponding to “strongly disagree.” The square on each Likert scale represents CEF users whereas the triangle represents nonusers.
Nonusers were asked several questions regarding what they believed would best encourage their adaptation and use of CEFs. The most frequently cited intervention that could increase CEF adoption and usage among nonusers was improved access to longitudinal mentorship for device troubleshooting and consultation, with 69.69% of respondents stating it was either “slightly likely” or “highly likely” to increase their usage. The next most strongly endorsed strategies included the development of new technological advancements and increased opportunities to attend non–industry-sponsored courses (eg, AAOS, AOFAS), respectively. Other reasons that were less agreed upon by the survey respondents were the attendance of industry-sponsored courses, increased reimbursement rates, and the acquisition or development of CEFs by a different company.
Discussion
The results from our survey characterize and quantify common themes among foot and ankle surgeons who do not use CEFs through opinion alignment and comparison to current users. In general, surgeons who do not use CEFs have limited exposure during residency and have no other physician in their practice who uses these devices. They also share sentiments that they are not comfortable with their intraoperative assembly, postoperative management, and expected clinical burden. It follows logically that nonusers identify internal fixation use as the primary reason why they do not use CEFs. These findings show that limited exposure in training and current practice is strongly associated with the lack of use and concurrent negative opinions about CEFs.
Our study has identified that nonusers of CEFs generally have a lack of exposure during training and current practice, which potentially leads to a lack of confidence in perioperative management and ensuing reliance on internal fixation. In light of these findings, nonusers accordingly agreed that increasing mentorship availability, creating technological advancements, and attending non–industry-sponsored courses would be the most appropriate and effective methods to implement. Although not directly assessed in the form of a question, early and more substantial exposure to CEFs in residency may be another method to increase usage rates, as this is evidenced by the statistically significant association between exposure rates in residency between users and nonusers.
Although identifying strategies to improve access to and adoption of CEFs is important, the true significance lies in the potential impact of applying these solutions. Our survey quantified this potential impact by evaluating how proposed interventions aligned with 2 critical physician perspectives: (1) the belief that CEFs are essential for certain patients and (2) the recognition that although circular fixation may have a role in their practice, significant hesitations currently limit their use. The overwhelming majority of nonuser respondents affirmed both sentiments, indicating that they recognize the clinical value of CEFs and at least imagine a niche for it in their practice. These responses do not suggest an outright rejection of the device or its associated surgical principles, but rather a general readiness to adopt it if key barriers to usage are addressed. This supports the rhetoric that enacting targeted interventions would lead to meaningful increases in adoption and usage rates. The alignment of our proposed solutions with clearly expressed physician beliefs provides a valid and pragmatic proxy for forecasting real-world clinical practice changes if they were to be effectively implemented in the future. In other words, if barriers were removed to the implementation of CEFs in current practice, the majority of physicians would actually begin to use them.
Effective solutions to increase CEF usage should be multifaceted and aim to address both the lack of early exposure and the lack of sustained peer exposure in current practice as suggested by our data. Addressing insufficient exposure during training may require earlier and more structured integration of CEF principles and techniques into residency education or the implementation of a direct mentorship program. Direct mentorship programs have proven to be extremely effective in increasing resident professional development and teaching methods of best practice and may also be useful for technical skill development. 4 Solutions targeting the lack of peer exposure or mentorship in current practice must be addressed with an ongoing program or recurring events to train, update, and refresh surgeons on the latest principles and techniques. It has been well-established that non–industry-sponsored courses can improve technical skills among surgeons, especially in orthopaedic surgery. 7 Specialty-specific mentorship programs for junior and senior attending physicians have also proven to be valuable tools for practice improvement as well.7,8 Other smaller interventions that may lower the barrier for CEF use may include training operating room staff on how to help assemble these devices, providing more in-depth patient education, or designing fast-tracked and checklist-based postoperative clinic visits for patients with CEFs.
Future studies should assess the effectiveness of targeted interventions, such as longitudinal mentorship programs and non–industry-sponsored educational courses, on improving surgeon comfort and confidence with perioperative aspects of CEFs. Evaluating whether these efforts lead to increased clinical adoption and improved patient outcomes will be essential in validating their utility and can be potentially generalized to other devices among foot and ankle surgeons. Additional research should also explore what specific content, structure, or delivery methods would be most beneficial in such courses.
This study is subject to several limitations inherent to its survey-based design and specific methodologic practice. First, the response rate was modest and introduces the potential for nonresponse bias. Respondents may differ systematically from nonrespondents in their opinions or clinical exposure to CEFs, which limits the generalizability of the findings to the broader AOFAS population. Second, the overall level of evidence in survey research is relatively low, as it only captures perceptions and is subject to recall bias. Additionally, limitations specific to the survey structure should be acknowledged. The inherent multibranched flow of the survey precluded data collection among some respondents and made statistical comparisons between some groups difficult.
Conclusion
The majority of AOFAS members use CEFs and most commonly use them for Charcot neuroarthropathy, infection management, and other deformity corrections. Members who do not use them cite perioperative burden and unfamiliarity with postoperative care as the most common reasons. Providing early exposure in residency, opportunities for longitudinal mentorship, and non–industry-sponsored courses may reduce perceived obstacles to use and encourage CEF usage in appropriate situations.
Supplemental Material
sj-pdf-1-fao-10.1177_24730114251394013 – Supplemental material for Circular External Fixation Use Among Orthopaedic Foot and Ankle Surgeons: A National Survey Study
Supplemental material, sj-pdf-1-fao-10.1177_24730114251394013 for Circular External Fixation Use Among Orthopaedic Foot and Ankle Surgeons: A National Survey Study by Michael W. Stickels, Matthew Scheller, David Vier and David E. Jaffe in Foot & Ankle Orthopaedics
Footnotes
Ethical Considerations
This study precluded IRB review because no protected health information was collected and no human subjects were involved.
Consent to Participate
Participation in this study was voluntary. Informed consent was obtained implicitly through the completion of the survey.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project received a $1000 grant from Johnson and Johnson (SR-TECA-2024-0290) to cover research-related expenses to conduct the survey and draft the manuscript. This was an investigator-initiated grant proposal.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: David Vier, MD, reports general disclosures of MEDLINE, consultant. David E. Jaffe, MD, reports general disclosures of Synthes/Johnson and Johnson, consultant; Arthrex, consultant; Fusion Orthopaedics, consultant. Disclosure forms for all authors are available online.
Data Availability Statement
Study data is available from the corresponding author upon request.
References
Supplementary Material
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