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Hi all, hoping to get some help with wound management/offloading for the following case:

PMH: 80 year old male patient with no diabetes, generally healthy. Has had numerous cervical spine surgeries and 2 hip replacement surgeries 30 years ago
Social: unremarkable, nonsmoker, limited alcohol intake
Current issues: ulcer to left medial malleoli - 2 1/2 years duration (prior to presentation to Podiatry). recent Xrays show periosteal reaction - hence currently being treated for osteomyelitis. Wound is overlying medial malleoli about 30mmX25mm in size, unable to probe to bone. Atypical granulation tissue in wound base, with thin layer of slough overlying - adhered, not easily removed. ? tendon present in wound. Surrounding tissues macerated with numerous satellite wounds (superficial). Recently biopsied and returned positive for HPV (GP managing this aspect of things).
Assessment: ABI within normal limits bilaterally. L/leg - LOPS distal to ankle, R/leg - LOPS only in toes. Pitting odema - measured and treating with compression stockings ?venous insufficiency
Biomechanics: the left ankle/rearfoot is enlarged and deformed medially - ?Query undiagnosed Charcot arthropathy (given the neuropathy in that foot) or stage 3/4 tib post tendonitis with advanced arthritic change. minimal ROM in ankle joint - foot is in slightly plantarflexed position. Appears to be putting lots of body weight through the medial aspect of the foot during gait

Would like to please hear some ideas on how to offload this wound - some current thoughts/queries
- use of medial flare or calliper on shoes to offload medial ankle/rearfoot deformity
- would the fact that the ulcer is overyling the region of the tib post tendon be aggravated with any supinatory movement of the foot (due to underlying tendon contraction) --> is the best method of managing this by use of total contact casting? (bearing in mind the client may be a falls risk)

this man is getting good nursing/wound care in his area - he lives rurally (2-2.5h drive from nearest major hospital) and I can only see him once/month during community podiatry visits. the nurses are happy to apply felt padding if required and instructed to in between appointments

thanks in advance :)