Establishing the indications for temporising knee‐spanning external fixation: A modified Delphi study of the International Knee Dislocation Study Group

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Abstract
Purpose: Knee dislocations (KDs) can be limb‐threatening injuries that may require a temporising knee‐spanning external fixator (KSEF) for stabilisation. Precise indications for this commonly utilised invasive immobilisation technique remain controversial and poorly defined. The purpose of this study was to establish consensus‐driven indications for temporising KSEF use in the initial management of KDs. Methods: A working group of fellowship‐trained orthopaedic surgeons generated clinical scenarios reflecting commonly debated indications for temporising KSEF application. Utilising a modified Delphi technique, 23 surgeons from the International Knee Dislocation Study Group completed two anonymous online survey rounds. Consensus was defined a priori as ≥70% agreement or disagreement. Results: Response rates were 100% for Round 1 and 96% for Round 2. Four scenarios achieved unanimous consensus: (1) KD without post‐reduction instability (100% disagreement), (2) inability to maintain tibiofemoral reduction in the sagittal/coronal plane with non‐invasive knee immobilisation (NIKI) after initial reduction (i.e., redislocation/subluxation) (100% agreement), (3) tibial plateau fracture‐dislocation with post‐reduction subluxation (100% agreement), and (4) in bilateral closed KDs where one limb is indicated and the other is NOT, span ONLY the indicated limb (100% agreement). Two scenarios achieved strong positive consensus (90%–99.9% agreement): (1) morbid obesity (BMI ≥ 40) without NIKI of sufficient size (91.3% agreement), and (2) extensor mechanism injury with post‐reduction subluxation (91.3% agreement). Four and one additional scenarios achieved positive and negative consensus, respectively. Conclusions: This modified Delphi study established consensus‐driven indications for temporising KSEF application in the initial management of KDs, which advocate for more selective use than what is demonstrated in the literature. Level of Evidence: Level V.

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