Plantar pressure and daily cumulative stress in persons affected by leprosy with current, previous and no previous foot ulceration.

Not only plantar pressure but also weight-bearing activity affects accumulated mechanical stress to the foot and may be related to foot ulceration. To date, activity has not been accounted for in leprosy. The purpose was to compare barefoot pressure, in-shoe pressure and daily cumulative stress between persons affected by leprosy with and without previous or current foot ulceration. Nine persons with current plantar ulceration were compared to 15 with previous and 15 without previous ulceration. Barefoot peak pressure (EMED-X), in-shoe peak pressure (Pedar-X) and daily cumulative stress (in-shoe forefoot pressure time integral×mean daily strides (Stepwatch™ Activity Monitor)) were measured. Barefoot peak pressure was increased in persons with current and previous compared to no previous foot ulceration (mean±SD=888±222 and 763±335 vs 465±262kPa, p<0.05). In-shoe peak pressure was only increased in persons with current compared to without previous ulceration (mean±SD=412±145 vs 269±70kPa, p<0.05). Daily cumulative stress was not different between groups, although persons with current and previous foot ulceration were less active. Although barefoot peak pressure was increased in people with current and previous plantar ulceration, it did not discriminate between these groups. While in-shoe peak pressure was increased in persons with current ulceration, they were less active, resulting in no difference in daily cumulative stress. Increased in-shoe peak pressure suggests insufficient pressure reducing footwear in persons with current ulceration, highlighting the importance of pressure reducing qualities of footwear.

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.

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.

Protective sensibility--its monofilament nylon threshold equivalents in leprosy patients.

An attempt has been made to definite the levels of "protective sensibility" in terms of perception thresholds to monofilament nylon induced touch/pressure stimuli. Certain problems were observed while interpreting the observations. There appears to be a range of threshold values instead of a clear cut-off point. We suggest that a monofilament nylon stimulus two times the normal threshold value for that patient be taken as cut-off point. This will make the observations of Birke and Sims (1986) and Hammond and Klenerman (1987) reasonable without having any need to exclude the cases who defy the boundaries laid by them. Since the genesis of plantar ulcer is multifactorial, it appears logical to include all patients who have a certain degree of hypoaesthesia, for special ulcer care program. The likely problems while using monofilament nylons in the field and their possible solutions have also been outlined.

The efficacy of podiatric orthoses as an adjunct to the treatment of plantar ulceration in leprosy.

This study examines the outcome of a management approach to plantar ulceration secondary to leprotic neuropathy. Locally-available resources were used to produce podiatric orthoses which were supplied to an experimental group. The effects on healing time and quality of healing were compared with a control group. Both groups were ambulant (the programme sought not to interfere with socioeconomic independence). Using standard nonparametric methods of analysis, it was demonstrated that the effects on healing rate, attributed to the experimental intervention, were highly significant. Over a 7-month period, 57% of the experimental group ulcers healed, while only 12.5% of the control group ulcers healed. The experimental intervention also demonstrated a positive effect on the quality of ulcer healing. This effect was not reflected in the control group.

[Results obtained by a mobile handicap-prevention unit at the Institut de Léprologie de Dakar]. / Résultats obtenus par une équipe mobile de prévention des invalidités à l'Institut de Léprologie de Dakar.

Of 584 leprosy patients known at the Institut de Léprologie Appliquée de Dakar because they suffered a nerve lesion with or without chronic plantar ulcer (CPU), 242 (41%) could be followed-up during a mean period of time of 8.2 years (range: 5 and 10 years) by the means of the mobile disability prevention team (health education, medical care and shoe workshop). Every two months a visit of the patients, at their home town, was organized, with the purpose to assess whether they could actually put into practice the foot and hand as having been trained for. At the same time, further advice and encouragement were given to the patients. Adapted footwear was brought to the patient, at reduced fee, the foot prints and special moulds having been taken during the previous visit. The local health worker were responsible for light surgical cares. Among the 242 followed-up patients: of 107 without CPU at beginning, 90 (84%) remained so, of 135 with CPU at beginning, 57 (42%) were cured, of 135 with CPU at beginning, 74 (55%) remained stable (no worsening), the last 21, of whom 17 showed severe foot deformities but without CPU, worsened (all presented one or more CPU at the last control). Of the 242 patients, 221 (91%) remained stable or showed substantial improvement. Therefore, it must be emphasized that careful follow-up of patients is essential to insure the improvement or care of CPU as well as to prevent the onset, worsening or reappearance of CPU. Such follow-up must consist of cares, health education and special shoe wearing.

Podometry: a critical evaluation of its use in Hansen's disease

O objetivo deste trabalho é avaliar a eficácia da podometria na prevençäo do mal perfurante plantar em pacientes hansenianos. Foram avaliados 13 pacientes hansenianos com comprometimento da sensibilidade táctil e dolorosa da planta do pé e 17 pacientes normais. Todos os pacientes foram submetidos à avaliaçäo estática através do podômetro. O sistema utilizado foi o podômetro comercial Midcapteur, constituído de uma plataforma para aquisiçäo dos dados analógos, capaz de registrar as pressöes segmentares aplicadas nos pés. Estes dados säo lidos num computador IBM/PC 386 compatível, que registra o mapeamento gráfico das pressöes desenvolvidas assim como calcula a distribuiçäo desta mesma pressäo nos 4 quadrantes do pé. Estes dados obtidos através da podometria estática foram comparados com a avaliaçäo clínica da sensibilidade táctil e dolorosa dos pés, nos pacientes hansenianos. Os resultados mostraram que o podômetro é bom método para se avaliar os pés com deficiência de sensibilidade em hanseníase e também como um método de avaliaçäo que ajuda na prevençäo do desenvolvimento do mal perfurante plantar: foi sensível na identificaçäo dos pontos de hiperpressäo nas áreas anestésicas e em regiöes anômalas, das assimetrias e na correlaçäo entre a presença de úlceras e hiperpressäo

[Apropos of a case of perforating, leprous plantar ulcer occuring at 15 years of age]. / A propos d'un cas de mal perforant plantaire lépreux survenu à l'âge de 15 ans.

Perforating ulcers of the foot occurring in leprosy are frequent, chronic, often giving mutilations. They usually affect the adult. Plantar ulcer occurred in a 15 year-old young patient affected by tuberculoid leprosy has incited us to report it.

Podometry: a critical evaluation of its use in Hansen's disease.

The aim of this paper is to evaluate the effectiveness of podometry to measure the pressure developed over the feet and the value of these findings to help in the prevention of the plantar neuropathic ulcer in patients bearing Hansen's disease. We evaluated 13 patients with impaired plantar pain and touch sensations and 17 normal patients. All the patients were submitted to static evaluation using the podometer. The system employed was the "Midcapteur" commercial podometer composed of a platform for acquisition of analogic data capable of registering the segmental pressures applied to the feet. These data are read by a 386 IBM/PC compatible computer that registers the graphic patterns obtained from the pressures developed and also calculates the modes of pressure distribution in the four quadrants of the foot. These data obtained by means of static podometry were compared to the clinical evaluation of pain and touch sensation of the feet in hansenian patients. The results demonstrate that podometery is an efficient method for evaluating the pressure in impaired feet in Hansen's disease and is a progression of neuropathic ulcer; it is sensitive in the identification of the spots of increased pressure in anesthetic and anomalous areas, asymmetries and in correlating the presence of ulcers with increased pressure.

Transtornos neurológicos associados ao mal perfurante plantar leprótico

Os autores analisam os distúrbios neurológicos sensitivos, motores e tróficos em 100 pacientes de lepra, 32 dos quais portadores de mal perfurante plantar. Concluem ser o m.p.p. complicação tardia do processo patológico hanseniano que se manifesta tôda vez que profundas modificações sensitivas, motoras e tróficas, devidas principalmente a transtornos da inervação profunda dos pés, alteram a arquitetura dos segmentos distais dos membros inferiores.

Ulcera perforante plantare negli hanseniani: trattamento medico e nuovo e semplice trattamento chirurgico

L`auteur, au cours d`une description rapide des ulcères perforants plantaires que L´on rencontre chez les hanséniens, fait remarques les associations possibles, avec les > ou mieux avec les > et étude les différents aspects, causes et mécanismes des sièges d`élection et de développement cliniques de ces ulcères. En mentionnant les bons effects d`un traitement aux enzymes pancréatiques des cas initiels, il décrit une méthode nouvelle et simple d´intervention chirurgicale qui s`est rèvélée, dans une prémiére série de cas, utile pour le traitment des cas avancés. Il souhaite que la méthode soit pratiquée sur une plus grande échelle pour mieux étudier et si possible confirmer les résultats

Plantar ulcers in leprosy / ?

In two papers an attempt has been made to present a concept of the natural history of plantar ulcers in leprosy with the main stress on factors dependent on anaesthesia of the foot. A rational therapy based on these findings has been described