When Traditional Offloading Is Not an Option, Could an External Fixator be a Solution?

A Case Report

Abdulaziz A. Kimawi, MD, DPM; Robert J. Snyder, DPM, MSc, CWS; Mario A. Cala, DPM; Cherison Cuffy, DPM, CWS


Wounds. 2017;29(2):46-50. 

In This Article

Abstract and Introduction


Offloading is a cornerstone in managing diabetic plantar foot ulcers; however, it often represents one of the most challenging aspects of treatment for clinician and patient alike. The authors present a case of a 61-year-old African American man with type 2 diabetes and a limb-threatening plantar foot ulcer that required aggressive wound and surgical management. Due to the heavy drainage and patient adherence issues, traditional offloading techniques such as total contact cast, DH Pressure Relief Walker (Össur, Foothill Ranch, CA), and wedge shoes, among others, were not viable options. Without offloading, healing will be difficult to achieve and will take a long time, carrying a higher risk of limb loss. The decision was made to apply an Ilizarov circular frame with footplate to facilitate offloading and weight bearing in tandem with negative pressure therapy. Although this is still considered an unusual use of this device, the results were positive and the wound progressed to complete reepithelialization.


Monsen et al[1] have shown that approximately 25% of patients with diabetes will develop foot ulcerations during their lifetime, while a staggering 85% of lower limb amputations are preceded by a lower extremity ulcer.

Although amputation is perceived as an appropriate treatment option for addressing complex diabetic foot wounds and at times necessary, choosing this route often puts patients at risk of contralateral limb loss and a shortened life expectancy.[2] Aulivola et al[3] found that the survival rate for below-the-knee amputations to be 74.5% and 37.8% at 1 and 5 years, respectively. Therefore, there have been a multitude of different algorithms and methodologies proposed in the literature to approach these ulcerations with the goal of preventing amputation.[4] Snyder et al[4] opine that reestablishing vascular blood supply, controlling infection, and offloading pressure forces remains a critical part of any limb preservation protocol.

The purpose of this case report is to stress the importance of pressure offloading surrounding diabetic foot ulcers (DFUs) and to highlight the authors' use of an external fixator as a possible tool to accomplish this.