The Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona has recenttly proposed the utilization of the "SALSA Stand" for surgical off-loading difficult to heal plantar and posterior heel wounds and flaps.

Please See video.

What  techniques or devices do you utilize to offload difficult to heal wounds?  What pearls can you share with our online community toward that end?

We have consistently used the SALSAstand on our patients.  It not only effectively eliminates  post-operative heel decubitus ulcer formation, but it also allows gradual elongation of  the Achilles tendon in addition to its other functions.

 To learn more, please read the original SALSAstand article on eplasty.com:

http://www.eplasty.com/index.php?option=com_content&task=view&id=299&Itemid=36

Janice P. Clark, DPM

We've had success using an external ring fixator  for the management of posterior ankle wounds involving the Achilles tendon.  The frame serves several purposes- it  completely offloads the wound and immobilizes the ankle and Achilles tendon.   Also, the patient may weightshare on the affected extremity.  In addition, the device allows for daily management of the wound and we've had cases where, in conjunction with the frame, we used negative pressure wound therapy and  a split thickness skin graft to obtain closure.

Personally, I like these... foam-based heel suspension devices. This one is called "Heel Lift" by the DM systems. It's much cheaper, and since it's fairly soft and comfortable, I don't get too much complaints from my patients. It can be customized by cutting away the foam. It is definitely cheaper than Ex-fix + OR fee!

Most of my patients are 70+ yo geriatric patients, so I get away with these soft devices.

I totally understand that some of our younger patients are unreliable in off-loading, and you need to use an ex-fix "stand" to force compliance, as in total contact casting.

I may be too paranoid, but I do have my reservation in inserting wires through the limbs with cellulitis... and possibly transferring osteomyelitis to the tibia and beyond.  

 

I hadn't seen the SALSA stand before, but it's an interesting offweighting modality.  Dr Roukis discussed a "kickstand" fixator in a similar fashion (J Foot Ankle Surg. 2003 Jul-Aug;42(4):240-3).  Using an external fixator definitely forces compliance, assuming the patient can tolerate the device.  Compliance with pressure reduction is definitely the key to healing these decubitus ulcers. 

I've used the Heel Lift system previously, but found they would roll around the leg while the patients were in bed.  I've had some success with PRAFOs (multi-podos boots) - see picture.  Patients can walk with it due to the metal frame and treaded sole.  I would recommend the use of a walker at all times with this due to the increased fall risk.

I found success in one patient by using the Wound Vac directly on the heel ulcer without bridging it.  This patient was very noncompliant with offweighting instructions, but with the Vac track pad on the heel she couldn't comfortably bear weight.  It was a gamble, but luckily it worked.  It shows us the power of compliance.  If they would just listen to us....

I've had a similar experience with the heel lift system.  Patients would often seem to take them off, or they would somehow get rotated around so as to be ineffective in offloading the appropriate areas.

Patient compliance is always going to be an issue with a removable boot --numerous studies have demonstrated this --so we have also implemented the use of an offloading removable cam-walker (RCW) which has been wrapped with coban to limit the patients ability to remove it, in a manor described by Armstrong et al. in 2005.  We have had good results with this modality.  In addition to pressure offloading, I suspect the bulky nature of the device limits patient actively somewhat, allowing for additional reduction of  forces across the wound site.  For posterior heel wounds, we build out the posterior aspect of the boot with foam to allow for offloading in both weight bearing and nonweight bearing.

Yes, in defense of the foam heel lift and PROFO boots, the fitting has to be just right, and I instruct the patient, family and the nursing staff to check it frequently. 

I do use the "instant total contact cast" or iTCC (Trademark: DG Armstrong), and I agree with Ryan that the "bulk" and weight of the device actually force the compliance with off-loading, as they are less likely to go to the Disneyland with it.

I think Wound VAC works great in DM foot wounds, partially because of the "cumbersome" factor, as in a ball-and-chains. Recently, one of my patient's wife confessed to me that, they are less likely to go out since you can see blood through the VAC's clear tube, and the machine does "burp" once in a while... and I said, "GREAT!"

Jarrod, have you tried the VAC's new bridge dressing? You can apply it directly on the heel, and it saves time to bridge to the dorsum foot. Check it out...




 

I have used the VAC bridge dressing.  My comment above was emphasizing an attempt to prevent patient ambulation.  I think the ability to bridge the VAC dressing is a significant advantage over other systems (ex. Regenex).  I'll use just about anything that has even a slim chance to improve my patients' compliance.  I'd hang my venous leg ulcer patients upside down if it weren't for that pesky blood running to the head!

All are good options.  Just to clarify- I do not use external fixation to offload the typical decubitus heel ulcer.  However, I will consider it in posterior ankle wounds with exposed Achilles tendon.  The device will immobilize the ankle (and tendon) and offload the area.   Obviously, not all patients are candidates for external fixation and in these patients I will use a device (iTCC) to offload AND immobilize the ankle.