Introduction and Background Diabetic foot problems have long been recognised as a serious health care challenge and many amputations may be prevented through attention to appropriate foot care. Research has shown neuropathy to be the predominant causative factor in the development of foot ulceration (Walters et al, 1992; Levin, 1995; Boulton, 1998; De et al, 2001). In combination with repeated minor trauma, it is the primary cause of diabetic foot ulceration, rather than ischaemia (Pecoraro et al, 1990). Diabetic foot problems can develop extremely quickly, are often complicated by infection and are often slow to heal. The normal course of wound healing in people with diabetes appears to be hindered. (Boulton, 1988; Pecoraro, 1991; Olerud et al, 1995) This paper focuses on our experience over seven years of using the Pressure Relief Ankle Foot Orthosis (PRAFO) in its standard and latterly the Anterior Posterior Upright (APU) configuration as part of a comprehensive treatment plan. The place of the PRAFO alongside other interventions is currently being considered in a review of cases of neuropathic and neuro-ischemic feet. Particular cases will highlight the value of combining podiatry and orthotic insights. Objectives The PRAFO has been used within our multi-disciplinary diabetic foot clinic for a period of seven years. A retrospective review of cases is underway to examine the role of ambulant and recumbent pressure relief as part of a comprehensive treatment rationale for lesions of the foot. Overall T reatment Plan The overall management plan involves a number of health care professionals. The aim is to deal with both the “internal” medical environment, managing optimum blood sugars and infection for example, and the mechanical environment. There is a need to protect the heel by eliminating any pressure or shear at the wound site and adjacent tissue. The PRAFO allows mechanical support to be provided without requiring the wound site to be enclosed. This allows for exudate wound dressings to be monitored and changed according to need. To be effective the treatment plan requires good co-operation between the podiatrist, nurse specialist and orthotist. Ambulation where possible, should be undertaken at the earliest opportunity to facilitate improved circulation. Controlled pressure distribution during stance phase allows the physiological norm to develop and aids venous return. Early work using motion analysis and pressure sensing technology allowed the orthotist to verify that controlled adjustment of the posterior upright of the PRAFO was of value. Such adjustments allow the orthotist to manage the foot-ankle position and the time history of pressure distribution at the foot and heel. The aim is to allow early, protected ambulation. Early mobilisation is good for patient morale and generally reduces pain.
Clinical Experience of the PRAFO in the Management of the Diabetic Foot CASE 1 Bishop Observations • Neuropathic diabetic foot • Problem initiated by RTA – fracturing right femur • Initial sloughy, septic ulcer created by long leg plaster cast • Oedematous and cellulitic up to knee level; painful limb.
W Munro D Stang D Jones S Benbow
Process • Debride ulcer, “Intrasite” dressing, IV antibiotics, and hospitalisation. PRAFO applied • Slow progress first 6 weeks, infection eliminated by 10 weeks • Granulating well, no slough, no pain after 12 weeks • Combination of wound dressing and antibiotics (18 - 32 weeks). • At 40 weeks still on oral antibiotics. Ulcer reducing. • At 44 weeks PRAFO for night use; IPOS Rear Foot for day use. • At 50 weeks ulcer healing well • At 56 weeks healed.
Orthotist, Munro Bolton Orthotics P odiatrist, Hairmyres Hospital Bioengineer, University of Strathclyde Consultant Physician, Hairmyres Hospital
Outcomes • Amputation prevented; More than one year to heal. • One PRAFO, with liner changes; One IPOS used in total • Highest costs associated with professional time, dressings, antibiotics
Timescale
CASE 2 Mitchell Observations • Painful neuroischemic foot – ulcer on right heel.
Process • Dressed with “Intrasite”, “Lyofoam” & crepe bandage • Given PRAFO and IPOS Hind Foot Relief Shoe for use in combination. • 2 weeks; improved ulcer size; slough reduced; less pain; antibiotics started • 3 - 18 weeks; regular debridement, dressings as ulcer improving • 25 weeks; advised to try own footwear; refused stock footwear • 32 weeks; healed.
Outcomes • Hospitalisation prevented; 32 weeks to heal using combined therapies. • One PRAFO, with liner changes; One IPOS used in total • Highest costs associated with professional time, dressings, antibiotics
Timescale
CASE 3 McNeil Observations • Severe, painful, neuropathic ulcer • Poor compliance and self care • Declined amputation
Process • Referral from community - painful, sloughy, black heel with medial ulcer worsening after 6 weeks treatment by GP practice • Wound drained, dressed, IV antibiotics, PRAFO at night • 2 weeks: painful, worsening ulcer, calcaneum exposed; amputation suggested • 2-24 weeks cycle of debridement and dressing; IPOS during day; PRAFO at night • 24 weeks: removal of piece of calcaneal bone • 54 weeks: no pain; callus debrided; area dressed; PRAFO still in use • 156 weeks: no pain; callus debrided; area dressed; PRAFO still in use
Outcomes • Amputation prevented • Long term multidisciplinary care required • Two PRAFO, with liner changes; One IPOS used in total
Results Three cases have been selected to highlight the potential for orthotic intervention in wound care. References Boulton AMJ (1998) Lowering the risk of neuropathy, foot ulcers and amputation. Diabetic Medicine 15 (Suppl 4): S57-9 De P, Kunze G, Gibby OM, Harding K (2001) Outcome of diabetic foot ulcers in a specialist foot clinic. The Diabetic Foot 4(3): 131-6 Edmonds ME, Blundell MP, Morris HE et al (1986) The diabetic foot: impact of a foot clinic. The Quarterly Journal of Medicine 232: 763-71 Levin ME (1995) Preventing amputation in the diabetic patient. Diabetes Care 18:1383-94 Pecoraro RE, Reiber GE, Burgess EM (1990) Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 13: 516-21 Pecoraro RE, Ahroni JH, Boyko EJ et al (1991) Chronology and extremities of tissue repair in diabetic lower-extremity ulcers. Diabetes 40: 1305-13 Veves A, Falanga V, Armstrong DG et al (2000) Graftskin, a human equivalent, is effective in the management of neuropathic diabetic foot ulcers. Diabetes Care 24(2): 290-5 Walters DP, Gatling W, Mullee MA et al (1992) The distribution and severity of diabetic foot disease: a community study with comparison to a non-diabetic group. Diabetic Medicine 9(4): 354-8
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Conclusions The three cases highlight situations where amputation or prolonged hospitalisation would be likely without orthotic intervention. The perception of some has been that orthoses and footwear are relatively expensive. In our study, orthoses represented a very small proportion of the total treatment costs. Increased orthotic use, with the intention of ulcer prevention, could 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.