Compression strapping: the development of a novel compression technique to enhance compression therapy and healing for ‘hard-to-heal’ leg ulcers

ORIGINAL ARTICLE

Compression strapping: thedevelopment of a novelcompression technique toenhance compressiontherapy and healing for‘hard-to-heal’ leg ulcersAlison Hopkins, Fran Worboys, Richard Bull, Ina Farrelly

Hopkins A, Worboys F, Bull R, Farrelly I. Compression strapping: the development of a novel compression techniqueto enhance compression therapy and healing for ‘hard-to-heal’ leg ulcers. Int Wound J 2011; 8:474–483

ABSTRACTNon healing wounds of the lower limb continue to be a significant issue for both practitioners and patients.Failure of gold-standard management demands a creative response. This article describes the development of anovel and intuitive strapping technique overlying the compression bandage that appears to have an influence inhealing complex lower limb ulcers. A retrospective audit of 17 patients with 25 ulcers allows further analysis anddiscussion. The strapping technique uses cohesive inelastic compression bandaging; narrow strips of bandages arelayered in a fan distribution over the ulcer and oedema. This approach seems to offer an intuitive response to thesecomplex wounds, allowing management to be tailored to the site of the ulcer and oedema. Tolerance for this lessbulky compression therapy regime is excellent, thereby aiding healing and reducing all costs associated with nonhealing leg ulcers.

Key words: Compression therapy • Gait • Inelastic compression • Quality of life • Strapping • Venous ulceration

Authors: A Hopkins, MSc, East London Wound Healing Centre,Tower Hamlets Community Health Service, Mile End Hospital,London, UK; F Worboys, BSc Hons, East London WoundHealing Centre, Tower Hamlets Community Health Service,Mile End Hospital, London, UK; R Bull, MA FRCP, Barts andThe London NHS Trust, Homerton University Hospital, London,UK; I Farrelly, BSc Podiatry, East London Wound Healing Centre,Tower Hamlets Community Health Service, Mile End Hospital,London, UKAddress for correspondence: A Hopkins, MSc, East LondonWound Healing Centre, Tower Hamlets Community HealthService, Trust Offices, Mile End Hospital, Bancroft Road, LondonE14DG, UKE-mail: [email protected]

INTRODUCTIONThe challenge for many practitioners involvedin wound care is the management of nonhealing wounds of the lower limb. Despiteevidence-based care being provided woundscan become chronic because of the widevariety and complexity of issues involved.The authors are part of a multi-disciplinarywound team who routinely look after patientswith an array of hard-to-heal leg ulcers.Standard compression management has notbeen successful; the compression therapy hasnot been tolerated or the compression hasbeen used consistently but the ulcer has failedto heal. Thus, this has demanded a more

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Compression strapping for hard to heal leg ulceration

creative response in order to manage andheal these complex wounds. The focus hasbeen directed towards establishing objectivesbased upon knowledge of the physiologyof the lower limb and clinical observation.Team collaboration that includes nursing,dermatology and podiatry have facilitatedfurther understanding of the limb itself andenabled the practitioner to develop skill inthe art of bandaging. What has emerged is anovel and intuitive compression technique thatappears to have a major influence in healingthese complex wounds. This paper describesthe development of this novel technique,how it is used within practice and discussesthe findings of a retrospective audit of17 patients.

High compression therapy is consideredthe gold standard for the management ofvenous ulcers (1). The standard techniquesof multi-layer compression bandaging basedon a theory of graduated compression havebeen determined by empirical means and laterstandardised by guidelines. With consistentcompression therapy over 52 weeks an 83%healing rate has been shown (2). However,17% failed to heal, and Milic et al. (2) linkedthis to the impaired calf-muscle pump. Otherkey parameters are typically those ulcers oflong duration or where the limb has a fixedankle (3). Although clinicians recognise these‘hard-to-heal’ ulcers there has been no provenpathophysiological cause which can help directtreatment.

The general consensus on ‘hard-to-heal’wounds is that where compression therapyhas failed to heal the ulcer, the woundrequires advanced dressings, dressings thatmodulate the wound bed-to-aid healing (4).Prognostic indicators (3) have been developedto identify this group at an earlier stage sothat advanced therapies can be used in orderto improve healing rates (5,6). There are caseseries documenting that the use of advancedtherapies may improve healing rates in hard-to-heal ulcers. Despite the plethora of agentsmarketed for the modification of the dermalwound bed, clinicians continue to be frustratedby the ulcers that fail to heal. The hard-to-heal ulcer has remained a costly challengeto clinicians and the patient’s quality oflife.

The authors have developed an alternativestrategy to this group of patients. By focus-ing on the patient’s limb, clinical observationsof the swelling and ulcer site, the clinicianshave responded to what the limb requiresand have dared to move away from a stan-dard compression regime. This paper presentsthe development of a novel bandaging tech-nique using an inelastic cohesive compressionbandage (Actico, Activa Healthcare, Burton-upon-Trent, UK) with cohesive strapping andreports on the experience of 17 patients.

METHOD: DEVELOPMENTOF THE STRAPPING TECHNIQUE:AN EVOLVING ARTThe development of the new strapping tech-nique can be charted through three phases.

Phase 1The multi-disciplinary team, composed of adoctor, nurses and a podiatrist, has man-aged patients with leg ulceration secondary tovarious aetiologies (e.g. chronic venous insuffi-ciency, mixed arterial and venous insufficiency,sickle cell disease, vasculitis and pyodermagangrenosum). The team resides within in pri-mary care trust with in-patient service, butalso provides an assessment centre for com-plex wounds for patients from the local areaand surrounding trusts. The ongoing manage-ment is carried out by local practitioners.

Experience shows that some ulcers prove‘hard to heal’ despite apparent optimal andconsistent compression bandaging. There arecommon clinical features: significant pain,extensive atrophie blanche, ulceration in theretro-malleolar fossa or the foot, localisedoedema, biomechanical changes in the foot,fixed ankle and altered gait. To target localisedoedema in the area below the gaiter region,we introduced lymphoedema bandaging tech-niques to our practice through the use ofinelastic compression bandages, the use ofnarrower bandages with a variety of appli-cation techniques, and the focus on match-ing the compression technique to the shapeof the leg and to the presence of localisedoedema. This appeared to help compressionand conformability with less hammockingacross bony prominences, thereby reducingoedema in the ankle and foot. Although thesetechniques seemed to be useful in the hands

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of experienced clinicians it proved hard totranslate these techniques into the communitysetting.

Phase 2About 6 years ago Actico (Activa Healthcare)a cohesive inelastic bandage came onto themarket. We started using the lymphoedematechniques with these 10-cm bandages but werewary of applying too many layers over thefoot. With the aim of focusing compressionwhere it was particularly required, rather thanmultiple layers toes to knee, our techniqueevolved into the application of short strips ofthe 10-cm cohesive inelastic bandage to specificareas of the foot or ankle, often in the form ofstrips or stirrups either side of ankle (7). Thiswas possible simply because of the cohesivenature of the bandage and its ability to allowadditional straps (Figure 1). At this stage,this technique was an intuitive developmentaimed at targeting specific areas of oedemathat the usual compression bandages were notmanaging successfully.

Outcomes for this technique appeared posi-tive but healing was not consistently achieved.

Phase 3The technique of strips and stirrups continuedto evolve, not only through a continuousprocess of review and evaluation but alsothrough discussion between the team and thepatients. The background of diverse clinicalknowledge has provided the context fordiscussions regarding its theoretical base andthe practical development of the technique.The straps have reduced in width as wehave recognised the need for increasing localpressure, enhancing the anatomical shape ofthe ankle and trying to retrieve the malleolalfossa; the concave appearance of the malleolalfossa is lost in patients with chronic ankleswelling. The fan distribution attempts toreestablish the normal concave architecture ofthe site and draw in the compression bandage.This method of strapping is composed of afan of narrow straps below and around themalleolar region overlying the compressionbandage but the exact application, both innumber and width of straps, depends on thesite of the ulceration, size of the foot andoedema. (See Figures 2 and 3; please note, abare limb is used to illustrate the placement

Figure 1. The straps have been outlined.

of the straps only. Straps are placed on topof the compression bandage as in Figure 3.)Foot position when applying straps has largelybeen set by the application of the compressionbandaging, that is with the ankle at a position of90◦ with the foot neither everted nor inverted.The straps are overlapped by 50% to maintaineven pressure over the targeted area. Theneed to change the bandage is determinedby dressing requirements, general slippage orexudate strike through. Information leafletsare provided for the patient and carer aswell as diagrams pertinent to the individualwhere necessary to ensure continuity ofthe management plan. It is important thatclinicians and patients are aware of the caveatthat no straps should be placed over thedorsum of the ankle or in a circumferentialposition; this is to reduce any possible effectsof a tourniquet effect or pressure damage overa high-risk area.

RESULTSWe have used the current fan strapping tech-nique since July 2009. This article provides aretrospective review of the first 17 patientswith 25 hard-to-heal ulcers in whom this tech-nique was used. Table 1 shows the aetiologies;the same strapping technique was used inall patients. They had common characteris-tics (Table 2), and all patients had experienceda variety of compression regimens includ-ing long stretch, multi-layer light and high

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Figure 2. The strapping technique.

compression bandaging, short-stretch systemsand hosiery. There were also commonly expe-rienced treatment modalities and regimenssome of which continued with the new strap-ping techniques (Table 3). This shows the com-plexity of this patient group and the array ofmodalities tried. However, it is important tonote that no new modalities were introducedat the same time as the strapping or afterthey were commenced. Time to healing wasrecorded from commencement of the strappingtechnique (Table 4). Of interest is the patientwho had a non healing left medial malleolalulcer for 55 years (case study 2).

Duration of ulceration ranged from under1 year to over 55 years (mean 5·8 years, median<4 years). Time to healing ranged from under3 months to 1 year for 23 ulcers (median of5 months); two ulcers remain unhealed.

The ‘strapping’ technique.

1. Examine the limb, ulcer and location of oedema: decide whether focused compression is required

2. Apply standard cohesive inelastic compressionfrom toe to knee applied at full stretch using aspiral technique and 50% overlap. Underlyinglayer of sub-bandage wadding used asstandard. If the leg is large, then a 2nd layerof compression bandage can be used startingat the ankle or toes

3. Prepare 3–8 straps of the inelastic bandage 2to 4 cm wide and 20–30 cm long (width andlength can vary according to limb size).Theankle must be in dorsiflexion.

4. To treat medial ulceration the first strap isapplied starting at the lateral plantar-metatarsalpad, running diagonally across the plantar foot,across the proximal plantar arch, onto thelowest point of the medial heel, then movingacross the posterior heel before anglingupwards onto the lateral gaiter. The strappingis applied at full stretch in the direction ofvenous drainage, thereby lifting, supportingand compressing the oedematous areas. (Forlateral ulceration start medially).

5. The starting point of each subsequent strapmoves medially in increments, with a point ofoverlap in the region of the plantar arch thatbecomes roughly a 50% overlap at the medialankle forming a fan pattern.

6. The origin point and the trajectory of thestrapping may be adapted to accommodate thelocation of ulceration / oedema and shape offoot. Narrower straps are required if theclinician is trying to restore the anatomicalfeature of the maleolal fossa because they aremore conformable.

To avoid limb trauma, the straps must never be placedover the dorsum of the ankle or allowed to overlapcircumferentially to form a tourniquet.

Figure 3. Straps in place.

Patients tolerate the strapping well, find itcomfortable and supportive and the regime isa positive development in the management oftheir complex ulcers. With the use of diagramsand good communication with the patient’s



Table 1 Ulcer aetiology

AetiologiesNumber of

patients

Sickle cell 3VenousVenous with significant atrophie blanche

12[8]

Mixed venous/arterial venous 1Rheumatoid arthritis 1

RA, rheumatoid arthritis.

Table 2 Common characteristics

Common characteristics included Number of patients

Oedema of foot and ankle 17Severe or very painful 17Recurrent infections 14Foot deformities and/or gaiter issues 13Fixed ankle 12Previous ulceration 12Dermatitis 11

Table 3 Modalities used

Most common management and modalitiesinclusive of compression therapy Patients

Wound care admissions that included bed rest, painmanagement, intensive compression, IPC andmedication regimens

11

Antibiotics 14Prontosan irrigation 13Topical negative pressure therapy 12Anti-microbial dressings 12Footwear – orthotics and/or custom made 11Topical steroids 11IPC 7

IPC, intermittent pneumatic compression.

community nurse, continuity of managementhas been achieved. The patients have also beenencouraged to direct their care and ensure thestraps are put on in the correct position forthem, often doing the task themselves.

Case example 1A 37-year-old woman with bilateral sicklecell ulceration; the left lateral maleolal ulcerhad been present for 13 years (Figure 4). Keyfactors for her are that she has limited anklemobility and retro-malleolal oedema. She hadreceived all of the management listed in Table 3with variable effects including consistent high

Table 4 Ulcer duration and time to healing

Duration ofulceration

Numbersof ulcers

Time to healingfrom starting straps

Numbersof ulcers

<1 year 3 <3 months 91–5 years 16 3–8 months 10>5 years 5 9–12 months 455 years 1 Not healed 2Total 25 Deterioration 0

Total 25

Figure 4. Commencing straps (25 June 2009).

Figure 5. 12 weeks later (17 September 2009).

compression therapy; she was admitted to ourunit on three occasions over the last 4 yearsfor intensive management and compressionbecause she lived out of the borough. Thenarrow strapping was introduced in July 2009during an admission; this was the only changein her management and thus the reason whywe attribute the strapping to her healing. Shewas healed by the end of September 2009, lessthan 10 weeks later with ongoing managementprovided by her district nurse (Figure 5). Thisshows the transferability of this technique. Sheremains healed 20 months later.

Case example 2An 86-year-old lady with a staggering 55-yearcontinuous history of left medial ulceration(Figure 6); significantly her key features are a



Figure 6. Commencing straps (15 September 2009).

Figure 7. 5 months later (22 February 2010).

rigid ankle with no mobility, a withered calf-pump and severe and painful atrophe blancheulceration over her left lateral malleolus. Thespecialist service has been involved with hermanagement since 1997, and she has hadconsistent high compression therapy (elastic orinelastic) for over 13 years. Recurrent infectionand severe pain have been common featuresin her life. Since commencing the narrowstrapping (the only change to the management)the lateral atrophe ulceration, present for18 months, healed in 10 months and remainshealed 10 months later. The main medial ulcer,present for 55 years has healed but three smallerosions remain (Figures 7 and 8); however,her quality of life has change dramatically ashas the impact on costs associated with herdebilitating ulcers (Figure 8).

Case example 3A 76-year-old gentleman with a long his-tory of recurrent bilateral ulceration; his rightmedial maleolal ulcer had been present for5 years despite consistent management withmulti-layer elastic compression. He has a

Figure 8. Small erosions remain (7 January 2011).

reduction in ankle mobility but is an activeman; recurrent infection and pain were acommon feature in these years. The strap-ping regime commenced on 3 November 2009(Figures 9 and 10), and he was completelyhealed by 24 June 2010; he remains healed11 months later and is using flat-bed compres-sion hosiery.

Figure 9. Commencing straps (3 November 2009).

Figure 10. 11 weeks later (28 January 2010).



DISCUSSIONThis paper describes a novel compressiontechnique for hard-to-heal leg ulcers. Thetechnique described has evolved from thedirect clinical observation of ulcerated limbs,the patient’s experience and the need tofocus on reducing oedema in the foot andankle and getting optimum compression. Theauthors believe that this technique has provedsuccessful because it works with the anatomyof the lower limb and enhances compressionover the site of ulceration, the localised oedemaand fibrotic tissue.

The importance of oedema managementOur key contention is that untreated oedemais a major component in ‘hard-to-heal’ ulcers.This contention is based on clinical observationof the localised oedema near hard-to-healulcers and the understanding that standardcompression bandaging does not apply evensub-bandage pressures because of the anatomyof the leg (8). Clinicians often fail to recognisethe role that uncontrolled oedema plays inthe delayed healing of lower limb ulcers.One of the main principles of wound bedpreparation is the reduction of bacterialload (9). The presence of local oedema isa major factor in increasing this bacterialburden. In clinical practice, a common scenariois the presentation of a ‘wet ulcer’ becauseof uncontrolled oedema-accompanied by ahistory of recurrent infection, pain, macerationand lack of tolerance for treatment. When thecompression tried is ineffective, both patientand staff lose heart; they stop trusting therationale behind compression therapy andmay accept chronicity. Perhaps the role of thewound bed preparation has been over-stressedallowing a plethora of agents to be marketedwithout reviewing how compression can beimproved in the first instance.

Within the UK, clinicians are trained to applylight tension to the foot and avoid any applica-tion of firm compression because of the dangerof creating a tourniquet at the ankle (10); fullextension or compression commences at theturn coming out of the ankle, thereby ensuringthat high compression therapy focuses on thegaiter region and the impact on the calf-musclepump. Unfortunately this can result in swellingof the forefoot and lower ankle, thus with thepreviously described ‘difficult ulcers’, standardcompression can bring additional problems

and becomes limited in its effectiveness. Whilethese compression regimes will be working onincreasing venous return, it is the author’s con-tention that greater compression is requiredin complex ulcers. Standard compressionregimes whether inelastic or elastic will applya hammock effect from the heel to the malle-olus, thereby avoiding any compression overthe retro-malleolal fossa; if there is an ulcerin this area then there will be no sustainedlocalised compression over the wound bedthus ensuring the therapy has reduced efficacy.Also, with little compression on the foot thestandard compression is ineffective for venousfoot ulceration. To compensate for this ineffi-ciency, various methods have been used. Themost common methods are the application ofrubber pads to the malleolar fossa to increasethe compression to the wound bed or vary-ing standard compression by increasing thelayers and/or types of compression bandage;this will increase the total compression to thelimb but again will create a hammocking effectover the malleolal fossa despite the additionallayers. The effect of the additional layers isto create bulk which in turns may reduceankle mobility. Lentner (11) found that com-pression bandaging led to a ‘marked restrictionin mobility of the ankle joint’ and the thickerthe layer of bandages the greater the restric-tion. This bulk will thus reduce ankle mobility,limit footwear choice and decrease toleranceof compression therapy. Any reduction inankle function will impact on calf-muscle func-tion (12), further reducing venous return. Animpaired calf-muscle pump was found to be akey feature on non healing venous ulcers (2)and thus clinicians must ensure that treat-ment regimes do not further restrict it. Withregard to the maleolal pads, the authors hadseen little demonstrable change with theirapplication.

Thus, it appears that this strapping techniquehas a relative advantage over standard com-pression therapy regimes. The introductionof strapping overlying the compression ban-dage does not increase total bandage bulk butfocuses additional pressure where required,whilst leaving the dorsum of the ankle free ofadditional restrictive layers. It is possible thatstandard UK compression techniques do notreflect important physiological and anatomi-cal factors of the ankle and foot. The placingof additional straps enhances the compression



therapy where it is required, re-shapes the footand ankle, promoting the anatomical shapeof the malleolal fossa and thereby promotinghealing in those who have failed with gold-standard compression therapy.

The need to improve compressionefficacyClark (13) recognised the difficulty in applyingthe ideal compression bandage at the correctpressure. Industry has focused on enablingclinicians to achieve the correct sub-bandagepressure using bandage guides or various sub-bandage monitors. Yet, while these are theuseful ways of ensuring that the bandage isapplied correctly they again will only dealwith a classic venous ulcer in the gaiter region.Also it is clear that clinicians vary widely intheir technique and the sub-bandage pressuresachieved when applying compression ther-apy (8). The pressures in this study by Schurenand Mohr were often sub-optimal which chal-lenges the premise that a specific bandage willapply an expected amount of compression; it isthe practitioner who dictates the sub-bandagepressure through their technique.

There is also an underlying assumption thatapplication of a correct bandage system is equalto effective compression, even when the ulcerdoes not respond or the oedema is not reduced.This has led clinicians to the conclusion thatlong-standing wounds require active agents toinitiate healing (5). This erroneous assumptionhas meant that there has been no emphasisin the literature on the need to review orimprove compression therapy even in theabsence of progress. Yet clinicians need tolook at both the ulcer and the position ofthe oedema and evaluate the efficacy of thecompression system on that limb and ulcer.The presence of guttering is a highly effectiveway of establishing efficacy (14). Guttering,translated as linear creases running down thelimb (Figure 11) shows that dermal oedemais being reduced effectively from the limb.However, with standard compression therapy,guttering is predominantly seen in the gaiterregion but not over the ankle or foot becauseof the reduced compression applied to theseareas.

It is also clear that compression therapy isnot just for venous ulceration but any typeof ulcer on the lower limb which is notcompromised by significant ischaemia. The

Figure 11. Guttering.

strapping technique has proved successful forthose whose pain has prevented tolerance tohigh compression therapy, such as those whohave vasculitis, pyoderma gangrenosum orsickle cell ulceration.

The role of muscle pump and gaitWhile compression strapping was originallydeveloped to control oedema below themalleolus to aid healing, patients have reportedthat they feel more stable when walking.Ankle taping has been used in various footand ankle pathologies, and in particular forflat foot deformity associated with excessivepronation. Biomechanical abnormalities of thearch and foot are also particularly associatedwith chronic venous disease (15–17); this isnot unexpected because the area above theposterior tibial tendon, which holds the medialarch up curves around the back of the medialmalleolus, is the most common site of fibrosisand ulceration. Clinically, it would make sensethat this tendon would be part of the fibroticdamage occurring in this area, although nospecific research has been performed to provethis.

Inelastic or short-stretch bandage systemsoffer various attributes of specific worth whenconsidering the lower limb. The workingcompression pressures are increased throughstatic stiffness index (18) without increas-ing bulk. The strapping produces a per-ceived increase in localised pressure to thepatient without increasing bulk throughoutthe bandage system. However, the actual sub-bandage pressures under the strapping needsinvestigation.

Patients using the narrow straps havereported greater stability to the ankle thereby



improving mobility; this seems an importantfeature because ankle mobility and efficacyof the calf-muscle pump function have beenshown to be essential in reducing sustainedvenous pressure at the ankle (19). However, theactual effect on gait needs to be investigated.The greater rigidity of the inelastic bandagingregime with greater stiffness over the retro-malleolar region may improve the function ofthe foot and calf-muscle pumps. Movementfrom one pump to another relies on availableankle movement (16,20,21); a loss of range ofmotion at the ankle increases an individual’srisk of developing ulceration and reducedhealing (17,22).

We have had no patients who could nottolerate the additional pressure from thestraps and they reported that they enjoyedthe individualized approach that the strapsprovide, encouraging them to be partnersin the management. Interestingly, the healedarea appears to have a better texture andless hyperkeratosis than normally seen post-healing. The technique has proved easy to teachto community staff and to patients to ensureconsistency and minimise the risk of adverseevents; diagrams and individualised teachinghave been provided.

It is clear that we need to differentiatebetween the effect of the strapping and theeffect of an expert and enthusiastic team. Thelimitation of this presentation is provisionof retrospective data and case examples toillustrate the outcomes. The authors are awarethat the group described is uncontrolled witha possible selection bias. We have attempted tolimit this by the following:

• Selecting the first 17 patients in whom thistechnique was used.

• To ensure no other modalities wereintroduced at the same time, so the effectof the strapping was clear.

• That the patients had been receivingconsistent elastic or inelastic compressiontherapy before the change to inelasticcompression and strapping.

• We did not have patients who did nottolerate the strapping and thus wereexcluded from the audit.

From our experience of patient outcomeswith this technique, we are concluding thatlocalised pressure over and around the ulceris important. However, it is clear that in

order to both understand and show efficacyof this intervention we need to undertakesub-bandage pressure measurements and arandomised trial.

CONCLUSIONWe have described the development of astrapping technique to enhance compressiontherapy over areas of the foot or malleolalfossa not addressed with conventional or gold-standard compression. This paper shows howthis technique appears to offer a relative advan-tage over conventional compression therapywith improved patient outcomes and healingof these ‘hard-to-heal’ ulcers. Typically, thepatient groups that will benefit from this addi-tional strapping are those that cannot toleratehigh compression therapy or where the com-pression is used correctly but healing remainselusive often because of the site of the ulcer-ation or oedema. This strapping techniquehas been an intuitive development evolvedfrom observation by a multi-disciplinary teaminvolved in complex wound care. However,it is not a standard regime therapy but istailored to the patient, their anatomy, ulcersite and extent of oedema. The authors havedescribed the reason for this development, whywe believe that we have found a solution thatneeds investigating. The worth of the techniqueneeds to be assessed more formally but wefirmly believe that it offers improved healingin hard-to-heal ulcers, greater patient comfortand better patient tolerance with high compres-sion; costs associated with these groups shouldbe significantly reduced, and clinicians do nothave to resort to expensive advanced woundtherapies. This is an exciting developmentwithin compression management. Finally, thisdevelopment does question the premise thatstandardised compression regime or aimingfor a standardised sub-bandage pressure isthe key to improving therapy; we believe are-focus on individualised compression ther-apy would offer clear benefits to patients andprovide a cost-effective management of hard-to-heal leg ulcers. The authors have foundthat tailored management is the way for-ward for this ‘hard-to-heal’ group. Creativ-ity based on sound theoretical rationale haschanged their futures and given the patientsthe expectation of life without debilitatingulceration.

Key Points

• narrow straps of 2–4 cm areoverlapped in a fan presenta-tion, tailored and modified tothe patient’s leg shape, oedemaand ulcer presentation

• no strapping is applied to thedorsum of the ankle

• the achilles has extra paddingfor protection if required

• practitioners and patients aretaught in their use



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Compression strapping: the development of a novel compression technique to enhance compression therapy and healing for ‘hard-to-heal’ leg ulcers