The validity and reliability of a simple semantic classification of foot posture.

INTRODUCTION: The Simple Semantic Classification (SSC) is described as a pragmatic method to assist in the assessment of the weight bearing foot. It was designed for application by therapists and technicians working in underdeveloped situations, after they have had basic orientation in foot function. OBJECTIVE: To present evidence of the validity and inter observer reliability of the SSC. METHOD: 13 physiotherapists from LEPRA India projects and 12 physical therapists functioning within the National Programme for the Elimination of Hansen's Disease (PNEH), Brazil, participated in an inter-observer exercise. Inter-observer agreement was gauged using the Kappa statistic. The results of the inter-observer exercise were dependent on observations of foot posture made from photographs. This was necessary to ensure that the procedure was standardised for participants in different countries. The method had limitations which were partly reflected in the results. RESULTS: The level of agreement between the principle investigator and Indian physiotherapists was Kappa = 058. The level of agreement between Brazilian physical therapists and the principle investigator was Kappa = 0.70. CONCLUSION: The authors opine that the results were sufficiently compelling to suggest that the Simple Semantic Classification can be used as a field method to identify people at increased risk of foot pathologies.

Role of flaps and skin grafts in the management of neuropathic plantar ulcers

In the neurologically impaired foot pressure ulcers are common. Pressure point reduction must always be addressed. Most ulcers, perhaps with the exception of huge heel ulcers, will heal by secondary intention if treated conservatively in the right manner. However, conservative treatment can be very time consuming and might sometimes leave unstable scars. For those with recurrent ulcers, the time taken off work to heal these ulcers can be economically debilitating. Skin grafting and flep coverage can be rewarding in selected cases. Follow up with proper footwear is of uttermost importance. Soft tissue coverage can only occur when all signs of infection have resolved and the foot has an adequate blood supply.

Techniques for covering soft tissu defects resulting from plantar ulcers in leprosy: Part V - use of the flap in the inguinal region and latissimus dorsi musculocutaneous flap

The area of distribution of the superficial cicunflex iliac, superficial epigastric and superficial external pudental arteries is large and flaps based on them can meet the requirement of different recipient sites. We have transplanted free flaps based on the superficial epigastric artery for repairing plantar soft tissue defects in six leprosy patients. During the follow up examination 58 to 118 months later there has been no recurrence of ulceration in any of these cases. The latissimus dorsi muscle, is mainly nourished by the thoracadorsal artery and the latissimus dorsi musculocutaneous flap is a large sized, composite structure with abundant blood provision and strong anti infectious property. The latissimus dorsi flap can be used as a muscle graft. because ofits constant vascular position, wide outer diameter of the vessels and long pedicle. It can therefore be utilized for repairing soft tissue defect or replacement of paralyzed muscle. We have used the latissimus dorsi musculotacutaneous free flap for repairing large skin and soft tissue defects resulting from plantar ulceration in three leprosy patients. During the follow up period, one patient who had complete drop foot and had refused corrective surgery had recurrence of the ulcer in the 12 post operative month. No ulcers had recurred in the other two cases during the follow up at 48 and 114 months

Transplantation of fibula with vascular pedicle for fusion of ankle in leprotic drop-foot

Devascularized bone grafts are pieces of dead bone they simply serve as scaffods for new bone to grow and fill the gap, taking a long time when they succeed in doing so. In constrast, vascularized grafts being living tissues have short healing time, great vitality and strong infection resisting capacity. We report here the successful use of vascularized grafts of the lower end of fibula for fusing the ankle in five leprosy patients

Mechanics of tarsal disintegration and plantar ulcers in leprosy by stress analysis in three dimensional foot models.

This paper describes three dimensional two arch models of feet of a normal subject and two leprosy subjects, one in the early stage and the other in the advanced stage of tarsal disintegration, used for analysis of skeletal and plantar soft tissue stresses by finite element technique using NISA software package. The model considered the foot geometry (obtained from X-rays), foot bone, cartilages, ligaments, important muscle forces and sole soft tissue. The stress analysis is carried out for the foot models simulating quasi-static walking phases of heel-strike, mid-stance and push-off. The analysis of the normal foot model shows that highest stresses occur at push-off over the dorsal central part of lateral and medial metatarsals and dorsal junction of calcaneus and cuboid and neck of talus. The skeletal stresses, in early state leprosy with muscle paralysis and in the advanced stage of tarsal distintegration (TD), are higher than those for the normal foot model, by 24% to 65% and 30% to 400%, respectively. The vertical stresses in the soft tissue at the foot-ground interface match well with experimentally measured foot pressures and for the normal and leprosy subjects they are the highest in the push-off phase. In the leprosy subject with advanced TD, the highest soft tissue stresses and shear stresses (about three times the normal value) occur in push-off phase in the scar tissue region. The difference in shear stresses between the sole and the adjacent soft tissue layer in the scar tissue for the same subject is about three times the normal value. It is concluded that the high bone stresses in leprosy may be responsible for tarsal distintegration when the bone mechanical strength decreases due to osteoporosis and the combined effect of high value of footsole vertical stresses, shear stresses and the relative shear stresses between two adjacent soft tissue layers may be responsible for plantar ulcers in the neuropathic leprosy feet.

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part III. Use of plantar skin or musculocutaneous flaps and anterior leg flap.

Anatomical studies suggest that five types of plantar flaps namely, the lateral and medial plantar flaps, the Abductor hallucis-, the Flexor digitorum brevis-, and the Abductor digiti minimi-myocutaneous flaps, can be incised from the central section of the sole. The advantages of a plantar flap are recognizable neurovascular bundles of the sole, wide calibre of constantly located blood vessels, identical histological structure of the donor and the recipient sites, hidden donor site and absence of functional deficit. We have used the plantar flaps in seven cases. There has been no recurrence of ulceration in any of them during the follow-up period of 12 to 108 months. An anterior leg flap based on the cutaneous branches of the anterior tibial artery, with firmly anchored vessels, a long pedicle with wide vessels may be used not only as a free flap graft for reconstruction of moderate degree distant defects but also as a retrograde island flap graft for the reconstruction of adjacent tissue defect. We have used the retrograde island flap graft based on the anterior tibial artery in five cases of plantar ulceration with satisfactory results. There was no recurrence of ulceration during the follow-up period of 48 to 72 months.

Foot pressure measurement in leprosy and footwear design.

Leprosy patients deprived of sensory feedback allow excessive pressures to be applied to feet, thereby cause foot ulcers. Quantitative knowledge of the pressure distribution under leprotic feet is helpful to prevent further damage to foot by designing suitable footwear. This paper describes barographic technique for measurement of pressures under the leprotic feet and the design of special footwear for prevention of foot ulcers.