Anatomical Concepts (UK)
Masters of Rehabilitation Engineering

Derek Jones: Anatomical Concepts (UK) Blog

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Dealing with pressure ulcers - then and now

We started Anatomical Concepts more than 20 years ago after I saw a great product (The PRAFO Ankle Foot Orthosis) which we still deal with today.  It's not quite as "sexy" as some of the products we deal with, but in terms of it's clinical signficance and impact it is by far the best product range we have.

It has a number of imitators these days but the PRAFO generally has some advantages which I wont discuss here. Ill present these in an upcoming article. In this article I want to stick to the basics of pressure relief around the heel.

652 PRAFO Ankle Foot Orthosis

652 PRAFO Ankle Foot Orthosis

The PRAFO Ankle Foot Orthosis has evolved and improved over these 20 plus years but it still represents the leader when it comes to providing pressure relief around the heel and ankle.  In fact the PRAFO trademark is an acronym for Pressure Relief Ankle Foot Orthosis and it is the only design that can use that designation.

What's the big deal with pressure ulcers?

In 1995 when we were starting out, pressure sores and diabetic foot ulcers were a big problem for the NHS.

Actually they are still a massive and growing problem for the NHS.  A pressure ulcer is an area of damage to the skin and underlying tissue that is caused by unrelieved pressure, friction and/or shear forces.

A severe ulcer is susceptible to infection and may be life-threatening.  Estimates suggest that one in five hospital inpatients has a pressure ulcer and this means that at least 20,000 hospital patients are affected at any one time. 

As many more individuals are cared for at home or in residential/nursing homes we suspect that the incidence in these locations is higher still.

Heel ulcers can be prevented with appropriate pressure relief

Heel ulcers can be prevented with appropriate pressure relief

In the UK we expect around 400,000 individuals to develop a pressure ulcer annually with a cost of £1.8 billion to £3 billion to the NHS each year.  If you do the sums, the cost per patient just for treating the wounds is £4,300 to £6,400.  These costs are associated with staff time, wound dressings and related costs.

The reason that the PRAFO Ankle foot orthoses can be effective here is that the heels are particularly susceptible to tissue breakdown as the heel is a bony area with little flesh covering the bony prominence. Patients can also be relatively immobile and nutritionally compromised which raises the risk of damage. 

The reason the PRAFO is so effective is it cradles and positions the foot and ankle so that there is no possibility of pressure or shear force at the heel. This is absolutely essential for prevention or wound healing.  There is a very true saying that it is not what you put on an ulcer that heals it (lotions and potions) it is what you take off (the pressure)

The cost figures above also exclude the costs associated with treating diabetic foot disease which is a an area of significant concern.  The Scottish National Diabetic Foot Coordinator often shows this slide below which is fairly sobering. It compares the 5 year mortality rate for a number of conditions including that for persons with a neuropathic ulcer (associated with diabetic foot disease).  This shows that life expectancy of somebody with a diabetic foot ulcer is worse than somebody with breast cancer or testicular cancer.

foot ulcer risk

As we frequently hear, diabetes is a growing world-wide epidemic with foot disease one of the series complications of this condition.  Around the world someone loses a limb every thirty seconds due to the late complications of diabetes. Consequently every clinician involved in diabetic foot care understands the importance of active prevention of foot ulceration.  That doesn't always mean that we are good at prevention yet.

With all these foot ulcers around and the stated aim to prevent and treat these you would think we were "PRAFO millionaires". The truth is many clinicians do not understand the importance of mechanical pressure relief or - if they do - choose to apply inferior strategies.

A few years ago we carried out a clinical study which utlised the PRAFO in wound healing with three cases where the individuals were advised to elect for amputation due to severe foot ulceration. The individuals refused this and so the clinic team deployed alternative methods to attempts healing. The image below shows the heel area with bone exposed and severe tissue damage with one of these cases.

Same heel after 156 weeks of treatment

Same heel after 156 weeks of treatment

This patient presented from the community with a painful, black heel which worsened after 6 weeks treatment by the GP.  The wound was dressed, drained and the patient received IV antibiotics and a PRAFO Ankle Foot Orthosis was applied to eliminated pressure at the heel.

To cut a long story short, after 156 weeks of treatment (a total of two PRAFO's were used alongside intensive podiatry and nursing care) the wound was virtually healed.

One of the reasons we carried out this study is that we were tired of hearing "these orthoses are expensive".  We wanted to examine the true nature of costs associated with wound healing in these extreme situations.

The study we conducted, which won a clinical excellence prize, basically illustrated three cases where amputation or prolonged hospitalisation would be likely without orthotic intervention. Of couse antibiotics, wound debridement and nursing were important but without pressure relief these feet would not have healed.  The cost impact of the PRAFO's was tiny compared with overall treatment costs.

Increased orthotic use, with the intention of ulcer prevention, would be cost-effective in high risk groups. The availability of pressure relief devices has reduced the need for prolonged hospitalisation or the need for specialised total-contact casting skills. In some cases, amputation can be avoided. In addition, experience of the “mechanical” factors in healing has directly improved our understanding of how to design footwear for prophylaxis and rehabilitation.

In early stages of treatment for an established lesion, the PRAFO provides recumbent protection. The advantage of this device has been the ability to eliminate pressure on areas of risk at the heel of the foot and provide an opportunity to protect the foot once mobility is restored.
The orthotist may also customise and fine tune the structure to suit changing clinical priorities