Efficacy of Biomechanics-based Decompression Therapy in Managing Recurrent Diabetic Plantar Ulcers.

OBJECTIVE: The objective of this study is to assess the efficacy of decompression nursing based on biomechanical principles in managing recurrent diabetic plantar ulcers. METHODS: Sixty-seven patients experiencing recurrent diabetic plantar ulcers who sought medical attention at Huadong Hospital Affiliated to Fudan University between January 2021 and December 2022 were selected as participants for this study. The participants underwent biomechanics-based decompression nursing. We compared pre-intervention and post-intervention data to assess the differences in relevant observational indexes. RESULTS: Post-intervention, patients showed significant improvements in foot comfort scores and adherence to pressure reduction behavior compared with their pre-intervention status, with statistical significance (P < 0.05). The intervention was effective in 41 cases (61.19%), with 18 cases (26.87%) showing improvement and 8 cases (11.94%) deemed ineffective, culminating in an overall efficacy rate of 88.06%. All 67 patients achieved complete ulcer healing within an average duration of 58.63 ± 18.13 days, without any recorded recurrences. CONCLUSION: Biomechanics-based decompression nursing demonstrates effective facilitation of wound healing, yielding expeditious recovery, enhanced comfort, and a reduced incidence of recurrence.

Pre- and post-surgical evaluation of the impact on Hansen disease sequealae patients' quality of life submitted to orthopedic surgery for closure of chronic plantar ulcers.

INTRODUCTION: Leprosy is a chronic infectious disease that still persists as a public health problem in Brazil. Plantar ulcers are serious complications due to leprosy neuropathy and intensify the isolation and stigma of these individuals. The difficulty in closing these lesions associated with the fetid odor negatively impact the quality of life of people with these lesions. OBJECTIVE: To evaluate the clinical, socioeconomic conditions, degree of satisfaction and quality of life (QoL) of patients after healing of chronic ulcers on feet submitted to orthopedic surgery. METHODOLOGY: This is a qualitative, exploratory, descriptive and observational study carried out with 92 people after surgical treatment of chronic leprosy plantar ulcers. These patients were submitted to a semi-structured questionnaire raising questions of an epidemiological, socioeconomic and perception of quality-of-life order, comparing before and after the surgical procedure. RESULTS: Decrease in indicators - alcohol consumption, tobacco consumption, average monthly cost of analgesic medications, fetid wound odor, foot pain and number of dressings performed weekly; Recurrence of lesions in 55.4 % of cases, related to irregular use or lack of shoes and insoles; Improvement in self-perception of Quality of Life (QoL) in 89.1 % of patients after surgery. CONCLUSION: Orthopedic surgical treatment with resection of plantar bony prominences and skin grafting is an effective therapeutic method for closing chronic plantar ulcers in leprosy, resulting in a decrease in the financial costs employed and in an important improvement in the Quality-of-Life parameters of the individuals undergoing to this procedure. The availability and regular use of shoes and insoles is crucial to prevent recurrence of these injuries.

Prevalence of plantar ulcer and its risk factors in leprosy: a systematic review and meta-analysis.

BACKGROUND: Plantar ulcers are a leading complication of leprosy that requires frequent visits to hospital and is associated with stigma. The extent of burden of ulcers in leprosy and its risk factors are scant impeding the development of targeted interventions to prevent and promote healing of ulcers. The aim of this review is to generate evidence on the prevalence of plantar ulcer and its risk factors in leprosy. METHODS: Databases (Medline, Embase, Web of Science, CINAHL, BVS), conference abstracts and reference lists were searched for eligible studies. Studies were included that reported a point prevalence of plantar ulcer and/or its "risk factors" associated with development of ulcers (either causatively or predictively), including individual level, disease related and bio-mechanical factors. We followed PRISMA guidelines for this review. Random-effects meta-analysis was undertaken to estimate the pooled point prevalence of ulcers. Reported risk factors in included studies were narratively synthesised. This review is registered in PROSPERO: CRD42022316726. RESULTS: Overall, 15 studies (8 for prevalence of ulcer and 7 for risk factors) met the inclusion criteria. The pooled point prevalence of ulcer was 34% (95% CIs: 21%, 46%) and 7% (95% CIs: 4%, 11%) among those with foot anaesthesia and among all people affected by leprosy, respectively. Risk factors for developing ulcers included: unable to feel 10 g of monofilament on sensory testing, pronated/hyper-pronated foot, foot with peak plantar pressure, foot with severe deformities, and those with lower education and the unemployed. CONCLUSIONS: The prevalence of plantar ulceration in leprosy is as high as 34% among those with loss of sensation in the feet. However, the incidence and recurrence rates of ulceration are least reported. The inability to feel 10 g of monofilament appears to be a strong predictor of those at risk of developing ulcers. However, there is a paucity of evidence on identifying those at risk of developing plantar ulcers in leprosy. Prospective studies are needed to estimate the incidence of ulcers. Identifying individuals at risk of ulcers will help design targeted interventions to minimize risk factors, prevent ulcers and promote ulcer healing.

Compromised neuromuscular function of walking in people with diabetes: A narrative review.

AIM: This review summarizes recent studies that have investigated the neuromuscular dysfunction of walking in people with diabetes and its relationship to ulcer formation. METHODS: A comprehensive electronic search in the database (Scopus, Web of Science, PsycINFO, ProQuest, and PubMed) was performed for articles pertaining to diabetes and gait biomechanics. RESULTS: The Achilles tendon is thicker and stiffer in those with diabetes. People with diabetes demonstrate changes in walking kinematics and kinetics, including slower self-selected gait speed, shorter stride length, longer stance phase duration, and decreased ankle, knee, and metatarsophalangeal (MTP) joint range of motion. EMG is altered during walking and may reflect diabetes-induced changes in muscle synergies. Synergies are notable because they provide a more holistic pattern of muscle activations and can help develop better tools for characterizing disease progression. CONCLUSION: Diabetes compromises neuromuscular coordination and function. The mechanisms contributing to ulcer formation are incompletely understood. Diabetes-related gait impairments may be a significant independent risk factor for the development of foot ulcers.

Dr E W Price, the discoverer of podoconiosis.

A straightforward biography of Dr E W Price, the discoverer of podoconiosis, a medical missionary who was also the first to elucidate plantar ulcers in leprosy.

Efficacy of topical epigallocatechin gallate (EGCG) 1% on the healing of chronic plantar ulcers in leprosy.

BACKGROUND: Chronic plantar ulcers in leprosy (CPUL) occur in areas that have a sensory and an autonomic nerve impairment where the wound healing takes longer. Framycetin gauze dressing (FGD) is best used in the wound healing process during the inflammatory phase because it contains antibiotics. Epigallocatechin gallate (EGCG) is the highest component in the extract of green tea that can accelerate blood vessel formation, has an anti-inflammatory effect, and reepithelialization. OBJECTIVE: To investigate the effect of topical EGCG 1% on the healing of CPUL. MATERIALS AND METHODS: An analytical experimental approach comparing the topical EGCG 1% and FGD applied every 3 days up to 8 weeks on the healing of CPUL. Size of the ulcers, side effects and possible complications from both approaches were monitored weekly. RESULTS: Ulcer healing in the EGCG group was significantly better than the FGD group with significant clinical and statistical differences (p < .032). There were no side effects in both the study groups. Complications, such as an increase in the size of the ulcer, were noted in one subject in the control group. This may have been caused by FGD and claw foot condition. CONCLUSIONS: EGCG 1% is more effective than FGD in accelerating the healing process of CPUL.

Development of a multivariable prediction model for plantar foot ulcer recurrence in high-risk people with diabetes.

INTRODUCTION: Forty per cent of people with diabetes who heal from a foot ulcer recur within 1 year. The aim was to develop a prediction model for plantar foot ulcer recurrence and to validate its predictive performance. RESEARCH DESIGN AND METHODS: Data were retrieved from a prospective analysis of 171 high-risk patients with 18 months follow-up. Demographic, disease-related, biomechanical and behavioral factors were included as potential predictors. Two logistic regression models were created. Model 1 for all recurrent plantar foot ulcers (71 cases) and model 2 for those ulcers indicated to be the result of unrecognized repetitive stress (41 cases). Ten-fold cross-validation, each including five multiple imputation sets, was used to internally validate the prediction strategy; model performance was assessed in terms of discrimination and calibration. RESULTS: The presence of a minor lesion, living alone, increased barefoot peak plantar pressure, longer duration of having a previous foot ulcer and less variation in daily stride count were predictors of the first model. The area under the receiver operating curve was 0.68 (IQR 0.61-0.80) and the Brier score was 0.24 (IQR 0.20-0.28). The predictors of the second model were presence of a minor lesion, longer duration of having a previous foot ulcer and location of the previous foot ulcer. The area under the receiver operating curve was 0.76 (IQR 0.66-0.87) and the Brier score was 0.17 (IQR 0.15-0.18). CONCLUSIONS: These validated prediction models help identify those patients that are at increased risk of plantar foot ulcer recurrence and for that reason should be monitored more carefully and treated more intensively.

The bacteriostatic effect of controlled-flux electrolyzed acidic solution on healthy hallucal skin.

BACKGROUND: There are various treatment protocols to manage the increased bacterial load in plantar ulcers. Recently, Controlled-Flux Electrolyzed Acidic Solution (CFEAS), with a pH less than 3, has appeared to be an effective option since its antimicrobial effect could help in the healing of those ulcers. In order to evaluate its potential in this sense, the aim of the present study was to compare bacterial growth on healthy hallucal skin using two types of bandaging (control and Controlled-Flux Electrolysed Acidic Solution). MATERIAL AND METHODS: In a sample of 19 healthy subjects, two experiments were performed. In the first, for each subject, two identical hallux bandages were applied in the early morning. At random between left and right foot, either physiological saline (wetting every 2 h) was applied or nothing (control). In the second, two days later, new bandages were applied as before, but now either wetting with Controlled-Flux Electrolysed Acidic Solution (experimental, again wetting every 2 h) or nothing (control). In each experiment, the bacterial load in the nail fold was assessed at the first moment and after 10 h from standard counts of bacterial colony forming units (CFU). RESULTS: In the first experiment, the CFU counts had increased significantly (p < 0.05) in both toes after the 10-h period. In the second experiment, while the bacterial load increased significantly (p = 0.001) from 0.68 ±â€¯0.8 × 104 CFU/cm2 (the "pre" sample) to 1.3 ±â€¯0.9 × 104 CFU/cm2 (the "post" sample) in the control toe, in the experimental CFEAS toe, the pre sample bacterial load was 0.61 ±â€¯0.6 × 104 CFU/cm2, and the post sample 0.9 ±â€¯0.8 × 104 CFU/cm2, with no significant difference between them (p = 0.221). Negative cultures were obtained in 3 cases (15.78%) of the experimental toe post sample, and equal post and pre counts in 2 cases (10.5%). CONCLUSION: Controlled-Flux Electrolyzed Acidic Solution has an effect on healthy hallucal skin that is bacteriostatic, and in some cases bactericidal. This effect could be very helpful in treating plantar ulcers when there is a greatly increased bacterial load in the wound, thus potentially favoring the normal formation of granulation tissue in the skin and normal healing and closure of the ulcer.

Effective Healing of Leprosy Chronic Plantar Ulcers by Application of Human Amniotic Membrane Stem Cell Secretome Gel.

BACKGROUND: Chronic plantar ulcers are common problems for leprosy patients with numb feet due to their prolonged healing time. Chronic plantar ulcers affect the quality of life of patients and can lead to more serious complications, such as disability and deformity, if not handled appropriately. Wound-care products in the market, however, give unsatisfactory results. One factor in the delayed healing of chronic plantar ulcers due to leprosy is the lack of growth factors and cytokines in the wound due to reduced blood supply. We speculated that application of human amniotic membrane stem cell (hAMSC) secretome, which contains growth factors and cytokines, could improve wound healing. AIM: To evaluate the effect of topical application of a hAMSC secretome gel on wound healing of chronic plantar ulcers due to leprosy. MATERIALS AND METHODS: We recruited 11 patients after leprosy treatment with chronic plantar ulcers due to leprosy. hAMSC secretome gel was applied topically to ulcers every 3 days for up to 2 months. Ulcer size and possible side effects or complications from gel application were evaluated weekly. RESULTS: The ulcers of 8 of 11 patients (72.7%) completely healed, the ulcers of 2 patients (18.2%) partially healed, and the ulcers of 1 patient (9.1%) persisted. No ulcers became worse. CONCLUSION: hAMSC secretome was found to be an efficacious and well-tolerated alternative therapy for chronic plantar ulcers due to leprosy.

Plantar pressure changes in hindfoot relief devices of different designs.

BACKGROUND: It is frequently observed that overloading the foot can impair bone and soft tissue healing and can lead to harmful sequelae (i.e. ulcers, stress reactions) in context of pre-existing tissue disabilities. In terms of offloading, hindfoot relief devices are commonly applied as a non-operative treatment as well as after various surgical procedures for hindfoot disorders. Despite their common use, there is a paucity of data comparing different orthotic devices with respect to changes in plantar pressure distributions. The aim of this study was to investigate plantar loadings in hindfoot relief devices of different designs. METHODS: Twenty-five healthy participants (13 women, 12 men; (mean ± SD) age 37 ± 14 years; BMI 23 ± 4 kg/m2) were recruited. Plantar pressure distributions were collected using i.) a neutral shoe, ii.) a hindfoot relief shoe (HRS) and iii.) a hindfoot relief orthosis (HRO). Peak pressure values were measured via dynamic pedobarography during walking and were analysed from four different plantar regions: the hindfoot, midfoot, metatarsal I-V and forefoot. As a reference standard, the normal walk using neutral shoes served as the condition for full weight-bearing. RESULTS: Concerning the hindfoot, using the HRS as well as the HRO resulted in significant decreases in plantar pressures compared to baseline values that were obtained with the neutral shoe (- 52% for the HRS and - 52% for the HRO, p < 0.001). Significant increases in peak pressures were found in the midfoot region for both devices (HRS: 32%, p = 0.002; HRO: 47%, p < 0.001). For the metatarsal region, peak pressures were found to decrease significantly (HRS: - 52%, p < 0.001; HRO: -17%, p = 0.034). With respect to the forefoot, a significant reduction in peak pressures using the HRS (- 41%, p < 0.001) was detected, whereas the HRO did not lead to significant changes (- 4%, p = 0.691). CONCLUSIONS: Both the HRO and HRS significantly reduced plantar hindfoot pressure, corresponding to a relative decrease of nearly 50% of the baseline. Nevertheless, the adjacent midfoot zone displayed a significant increase in plantar pressure values for both devices. Supported by these findings, physicians should cautiously consider a substantial increase in midfoot loading, especially in patients affected by additional midfoot injuries or accompanying impairments of tissue healing. LEVEL OF EVIDENCE: IV, Case series.

Plantar ulcer occurrence among leprosy patients in Northern Nigeria: A study of contributing factors.

Background: The study was conducted in three major leprosy referral hospitals in Northern Nigeria, which are NKST Rehabilitation Hospital, Benue State, Yadakunya Leprosy Hospital, Kano, and National Tuberculosis/Leprosy Training Hospital, Zaria. The main objective of the study was to investigate factors responsible for the occurrence of ulcers among leprosy patients reporting to the leprosy referral hospitals. Materials and Methods: An analytic study of case-control design was used, with patients having plantar ulcers as cases and those without as control. Semi-structured was administered to all cases and controls. Results: A total of 242 patients were studied; 124 patients (51.2%) had plantar ulcers whereas 118 (48.8%) had no ulcers (controls). A Chi-square test was used in the analysis to compare cases and controls. The study found differences between cases and controls with respect to patients release from treatment (RFT), gender, availability and utilization of footwear, age, occupation, and educational status. Footwears were provided to most patients, i.e. 60.8% late (i.e., after developing plantar ulcers); however, there was very good utilization of the footwears among those who had the footwears, 65.3%. Knowledge of self-care was higher among 64.5% of cases compared to only 28.1% of the controls. Conclusion: Ulcer still remains a major problem among leprosy patients, especially RFT (76.6%) and most cases are provided with footwear late. Self-care knowledge is higher among cases than controls.

RésuméContexte: L'étude a été menée dans trois hôpitaux majeurs de référence pour la lèpre dans le nord du Nigéria, qui sont l'hôpital de réadaptation NKST, l'État de Benue, l'hôpital de la lèpre de Yadakunya, Kano et l'hôpital national de la tuberculose et de la lèpre, Zaria. L'objectif principal de l'étude était d'étudier les facteurs responsables de l'apparition d'ulcères chez les patients atteints de lèpre signalant des hôpitaux de référence pour la lèpre. Matériaux et méthodes: une étude analytique de la conception cas-témoins a été utilisée, les patients ayant des ulcères plantaires comme cas et ceux qui n'ont pas le contrôle. Semi-structuré a été administré à tous les cas et contrôles. sRésultats: Au total, 242 patients ont été étudiés; 124 patients (51,2%) avaient des ulcères plantaires tandis que 118 (48,8%) n'avaient pas d'ulcères (témoins). Un test du Chi-carré a été utilisé dans l'analyse pour comparer les cas et les témoins. L'étude a révélé des différences entre les cas et les contrôles par rapport aux patients libérés du traitement (RFT), le sexe, la disponibilité et l'utilisation de la chaussure, l'âge, la profession et le statut scolaire. Les chaussures ont été fournies à la plupart des patients, soit 60,8% en retard (c'est-à -dire après développement d'ulcères plantaires); cependant, il y avait une très bonne utilisation des chaussures parmi ceux qui avaient les chaussures, soit 65,3%. La connaissance de l'autosoins était plus élevée chez 64,5% des cas que dans seulement 28,1% des témoins. Conclusion: L'ulcère reste un problème majeur chez les patients atteints de lèpre, en particulier les TF (76,6%) et la plupart des cas sont munis de chaussures en retard. La connaissance des soins personnels est plus élevée parmi les cas que les témoins.

The efficacy of topical human amniotic membrane-mesenchymal stem cell-conditioned medium (hAMMSC-CM) and a mixture of topical hAMMSC-CM + vitamin C and hAMMSC-CM + vitamin E on chronic plantar ulcers in leprosy:a randomized control trial.

BACKGROUND: Healing of chronic plantar ulcers in leprosy (CPUL) typically takes a long time due to impaired neurological function, thereby reducing the levels of growth factors and cytokines. Cytokines can be found in metabolite products from amniotic membrane stem cells. Chronic ulcers are frequently characterized by high levels of reactive oxygen species. Vitamin E (α-tocopherol) is widely used in skin lesions, owing to its antioxidant and anti-inflammatory properties. Vitamin C also has antioxidant, anti-inflammatory, and collagen synthesis properties which are useful in wound healing. Herein, we compared the effects of topical human amniotic membrane-mesenchymal stem cell-conditioned medium (hAMMSC-CM) alone and with vitamins C and E on healing of CPUL. METHODS: In this randomized controlled trial, topical agents were applied every 3 days for up to 8 weeks. Ulcer size, side-effects, and possible complications were monitored weekly. RESULTS: Healing percentage increased each week in all groups. Mean difference in ulcer size was highest in the hAMMSC-CM + vitamin E group, implying better progress of wound healing. There were no side-effects or complications. CONCLUSIONS: hAMMSC-CM + vitamin E is best for healing of CPUL.

Fatores de risco para a ocorrência das úlceras plantares decorrente da hanseníase / Factors for plantar ulcers caused by leprosy

A hanseníase é doença infectocontagiosa de evolução lenta, causada pelo Mycobacterium leprae. A afinidade do bacilo da hanseníase por células do sistema nervoso periférico acomete, principalmente, os nervos superficiais da pele e dos nervos periféricos, causando neuropatia autonômica, sensitiva e motora que acarreta a diminuição ou ausência da sensibilidade e fraqueza muscular nos olhos, mãos e pés. Se não forem tratadas a tempo, podem provocar o surgimento de incapacidades físicas. Uma das incapacidades físicas mais comuns, vistas na prática clínica, são as úlceras na região plantar, que ocorre devido o comprometimento do nervo tibial, ocasionando déficits motores, sensitivos e autonômicos no trajeto do mesmo. O objetivo do estudo foi identificar os fatores de risco para a ocorrência das úlceras plantares em pacientes diagnosticados com hanseníase no Hospital Eduardo de Menezes da Fundação Hospitalar do Estado de Minas Gerais no período de 2005 a 2016. Trata-se de um estudo epidemiológico, do tipo observacional, transversal e analítico. A população foi composta pelos casos de hanseníase notificados no Hospital Eduardo de Menezes, no período de 2005 a 2016. Para a análise univariada foram utilizados os testes Qui-quadrado de Pearson ou teste exato de Fisher e teste de Mann-Whitney, com significância estatística de 5% (p < 0,05). Na análise multivariada por meio da árvore de decisão utilizando o algoritmo CHAID. Os resultados mostraram que forma clinica, grau de incapacidade física na alta, nervo acometido e o não uso de palmilhas ou calçado adaptado antes de surgir à úlcera se mostraram fatores de risco para a ocorrência de úlcera plantar. Foi identificado que entre os pacientes com grau de incapacidade 0 na alta, não existem casos de úlcera. Já entre aqueles com grau 1, e a forma clínica é DD ou DV a probabilidade de úlcera aumenta para 8,7%. Os pacientes com grau de incapacidade 2 na alta, nervo acometido tibial ou nervos fibular e tibial, mas que usavam palmilha ou calçado especial tem probabilidade de úlcera de 65,9%. Se o paciente não usava palmilhas ou calçados especiais antes de surgir à úlcera a probabilidade de ocorrência da úlcera aumenta para 95,7%. O presente estudo evidenciou a necessidade do diagnóstico precoce da hanseníase, como também da eficiente associação das intervenções medicamentosas e não medicamentosas por meio das técnicas de prevenção de incapacidade e uso de palmilhas acomodativas e/ou calçados especiais.(AU)

Leprosy is an infecto-contagious disease caused by Mycobacterium leprae. Leprosy bacillus' affinity for neural system cells affects mainly superficial skin nerves and periferal nerve roots, resulting in autonomic, sensitive and motor neuropathy, that leads to reduction or absency of sensitivity, and muscular weaknessin the eyes, hands and feet. If not timely treated, these can result in physical disabilities. Amid the most frequent physical disabilities seen in clinical practice are plantar ulcers, wich are caused by tibial nerve impairement, leading to motor, sensitive and autonomic deficits along tibial nerve trajectory. The objective os the present article was to identify risk factors for plantar ulcers in patients who were diagnosed for leprosy at Eduardo Menezes Hospital, Minas Gerais State Hospital Foundation, from 2005 to 2016. This is an epidemiological, observational, transversal, analytical study.The studied population was made of notified cases of leprosy, diagnosed at Eduardo de Menezes Hospital from 2005 to 2016. Pearson's qui-square, Fisher's exact test and Mann-Whitney's test, with 5% statistical significancy (p < 0,05), where used for univariate analysis. For multivariate analysis, CHAID algorythm decision tree was used. Results showed that clinical type, physical disability grade at the time of discharge, impaired nerve and absence of use of insoles or adapted shoes before the appearance of ulcers where risk factors for plantar ulcers ocurrence. For patients with 0 disability grade at discharge there where no cases of plantar ulcers. For those with grade 1 disability, clinical type was a relevant risk fator. For patients with grade 1 disability and type V or DT clinical types, probability was also zero. On the other hand, for DD and DV clinical types, probabilities rise up to 8,7%. Patients with grade 2 at discharge with or without fibular or other nerve impairement also have no probability of plantar ulcers ocurrence. AMong patients with grade 2 disability, tibial nerve impairment or both tibial and fibular nerve impairment, but who made use of insoles ou adapted shoes had a 65,9% probability of developing ulcers. In patients who do not use insoles ou special shoes before ulcer formation,probability of developing ulcers rises up to 95,7%. Present study has highlighted the need of early diagnosis of leprosy, and also the need of the use of efficient association of drug and non-drug techniques of disability prevention and use of insoles and/or special shoes.(AU)

Immobilization-induced osteolysis and recovery in neuropathic foot impairments.

BACKGROUND: Neuropathic foot impairments treated with immobilization and off-loading result in osteolysis. In order to prescribe and optimize rehabilitation programs after immobilization we need to understand the magnitude of pedal osteolysis after immobilization and the time course for recovery. OBJECTIVE: To determine differences in a) foot skin temperature; b) calcaneal bone mineral density (BMD) after immobilization; c) calcaneal BMD after 33-53weeks of recovery; and d) percent of feet classified as osteopenic or osteoporotic after recovery in participants with neuropathic plantar ulcers (NPU) compared to Charcot neuroarthropathy (CNA). METHODS: Fifty-five participants with peripheral neuropathy were studied. Twenty-eight participants had NPU and 27 participants had CNA. Bilateral foot skin temperature was assessed before immobilization and bilateral calcaneal BMD was assessed before immobilization, after immobilization and after recovery using quantitative ultrasonometry. RESULTS: Before immobilization, skin temperature differences in CNA between their index and contralateral foot were markedly higher than NPU feet (3.0 degree C versus 0.7 degree C, respectively, p<0.01); BMD in NPU immobilized feet averaged 486±136mg/cm2, and CNA immobilized feet averaged 456±138mg/cm2, p>0.05). After immobilization, index NPU feet lost 27mg/cm2; CNA feet lost 47mg/cm2 of BMD, p<0.05. After recovery, 61% of NPU index feet and 84% of CNA index feet were classified as osteopenic or osteoporotic. CONCLUSIONS: There was a greater osteolysis after immobilization with an attenuated recovery in CNA feet compared to NPU feet. The attenuated recovery of pedal BMD in CNA feet resulted in a greater percentage of feet classified as osteoporotic and osteopenic.

Plantar pressures increase with raising body weight: A standardised approach with paired sample using neutral shoes.

BACKGROUND: Plantar pressure leads to stress on plantar tissue and can be seen as risk factor for metatarsal stress fractures or plantar ulcers and is associated with prolonged and complicated recurrence of existing tissue damages. A clear demarcation of a systematic raise of body load regarding its effect on plantar pressure has not been described. OBJECTIVE: Assessing plantar pressure patterns in different conditions of body weight, comparing data to initial body weight. METHODS: Seventeen healthy volunteers were asked to participate. Peak pressure values were assessed during walking with dynamic pedobarography and analysed from three foot sections. Body weight was loaded up gradually with 10%, 20% and 30% of the individual initial weight by using a weighted vest. RESULTS: We were able to detect a statistically significant increase of plantar pressure for all foot regions in case of loaded body weight of 20% and 30% comparing to initial weight (p< 0.05). The midfoot area displays a significant increase for peak pressure for the preferred foot even for 10% body load. CONCLUSIONS: Peak plantar pressure increases with loaded body weight. The midfoot area seems to be a sensitive area in case of adapting increasing foot load. Considering the clinical relevance, loaded body weight has to be seen as risk factor for increasing plantar pressure patterns and should be considered in recurrence of plantar ulcers or stress fractures.

Plantar pressures are higher in cases with diabetic foot ulcers compared to controls despite a longer stance phase duration.

BACKGROUND: Current international guidelines advocate achieving at least a 30 % reduction in maximum plantar pressure to reduce the risk of foot ulcers in people with diabetes. However, whether plantar pressures differ in cases with foot ulcers to controls without ulcers is not clear. The aim of this study was to assess if plantar pressures were higher in patients with active plantar diabetic foot ulcers (cases) compared to patients with diabetes without a foot ulcer history (diabetes controls) and people without diabetes or a foot ulcer history (healthy controls). METHODS: Twenty-one cases with diabetic foot ulcers, 69 diabetes controls and 56 healthy controls were recruited for this case-control study. Plantar pressures at ten sites on both feet and stance phase duration were measured using a pre-established protocol. Primary outcomes were mean peak plantar pressure, pressure-time integral and stance phase duration. Non-parametric analyses were used with Holm's correction to correct for multiple testing. Binary logistic regression models were used to adjust outcomes for age, sex and body mass index. Median differences with 95 % confidence intervals and Cohen's d values (standardised mean difference) were reported for all significant outcomes. RESULTS: The majority of ulcers were located on the plantar surface of the hallux and toes. When adjusted for age, sex and body mass index, the mean peak plantar pressure and pressure-time integral of toes and the mid-foot were significantly higher in cases compared to diabetes and healthy controls (p < 0.05). The stance phase duration was also significantly higher in cases compared to both control groups (p < 0.05). The main limitations of the study were the small number of cases studied and the inability to adjust analyses for multiple factors. CONCLUSIONS: This study shows that plantar pressures are higher in cases with active diabetic foot ulcers despite having a longer stance phase duration which would be expected to lower plantar pressure. Whether plantar pressure changes can predict ulcer healing should be the focus of future research. These results highlight the importance of offloading feet during active ulceration in addition to before ulceration.

Gait parameters of people with diabetes-related neuropathic plantar foot ulcers.

BACKGROUND: Foot ulceration associated with diabetic peripheral neuropathy is a global concern. Biomechanical investigation allows the identification of gait abnormalities that may adversely affect ulcer healing. The objective of this case-control study was to compare the gait parameters of cases with diabetes-related foot ulcers to controls. METHODS: Three-dimensional movement analyses were performed on 21 people with diabetes-related neuropathic plantar foot ulcers (cases), 69 people with diabetes without a foot ulcer history (diabetes controls) and 56 healthy controls. Outcome data were reported as mean differences, 95% confidence intervals and Cohen's d effect sizes. Binary logistic regressions were used to adjust for age, sex and body mass index. FINDINGS: People with foot ulcers had a smaller plantar flexion (Cohen's d=-0.6 vs. diabetes controls and d=-0.8 vs. healthy controls), knee flexion (d=-0.6 vs. diabetes controls and d=-1.0 vs. healthy controls) and pelvic obliquity (d=-0.9 vs. diabetes controls and d=-0.7 vs. healthy controls) (all P<0.05). They also had a significantly greater range of anterior-posterior ground reaction force (d=1.0 vs. diabetes controls and d=1.7 vs. healthy controls) and total vertical ground reaction force (d=0.9 vs. diabetes controls and d=1.1 vs. healthy controls) and significantly slower walking speed and smaller step length compared to controls (all P<0.05). INTERPRETATION: People with plantar foot ulcers have considerably different gait parameters to controls. Whether the observed gait parameters contributed to the ulcer development or are a response to the ulcer is currently unclear and needs further investigation.

Orthopedic complications in diabetes.

Diabetes is associated with a number of lower extremity orthopedic conditions and complications including fractures, Charcot neuroarthropathy, plantar ulcers, and infection. These complications are of significant clinical concern in terms of morbidity, mortality, and socioeconomic costs. A review of each condition is discussed, with particular emphasis on the clinical importance, diagnostic considerations, and orthopedic treatment recommendations. The goal of the article is to provide a clinical picture of the challenges that orthopedic surgeons confront, and highlight the need for specific clinical guidelines in diabetic patients.

American Society of Biomechanics Clinical Biomechanics Award 2012: plantar shear stress distributions in diabetic patients with and without neuropathy.

BACKGROUND: The exact pathology of diabetic foot ulcers remains to be resolved. Evidence suggests that plantar shear forces play a major role in diabetic ulceration. Unfortunately, only a few manuscripts exist on the clinical implications of plantar shear. The purpose of this study was to compare global and regional peak plantar stress values in three groups; diabetic patients with neuropathy, diabetic patients without neuropathy and healthy control subjects. METHODS: Fourteen diabetic neuropathic patients, 14 non-neuropathic diabetic control and 11 non-diabetic control subjects were recruited. Subjects walked on a custom-built stress plate that quantified plantar pressures and shear. Four stress variables were analyzed; peak pressure, peak shear, peak pressure-time and shear-time integral. FINDINGS: Global peak values of peak shear (p = 0.039), shear-time integral (p = 0.002) and pressure-time integral (p = 0.003) were significantly higher in the diabetic neuropathic group. The local peak shear stress and shear-time integral were also significantly higher in diabetic neuropathic patients compared to both control groups, in particular, at the hallux and central forefoot. The local peak pressure and pressure-time integral were significantly different between the three groups at the medial and lateral forefoot. INTERPRETATION: Plantar shear and shear-time integral magnitudes were elevated in diabetic patients with peripheral neuropathy, which indicates the potential clinical significance of these factors in ulceration. It is thought that further investigation of plantar shear would lead to a better understanding of ulceration pathomechanics, which in turn will assist researchers in developing more effective preventive devices and strategies.

Examination and clinical care of the patient with neuropathy.

Examination of a patient with peripheral neuropathy starts with careful questioning of the patient about the history of symptoms and signs and of a possible familial disorder. Several steps are required during examination of the patient with peripheral neuropathy: first the pattern of neuropathy and site of lesions should be determined: roots, nerve trunks, focal, multifocal, length-dependent generalized polyneuropathy, the type of nerve fibers predominantly affected, the association with trophic changes and autonomic dysfunction, the course of the disease ranging from acute inflammatory polyneuritis or fulminant multifocal neuropathy to an extremely slow progression as in Charcot-Marie-Tooth syndromes. At the end of this first contact with the patient, the neurologist must decide which investigations seem necessary and their timing including electrophysiological tests, imaging, CSF examination, blood tests, nerve and muscle biopsy, DNA testing, etc. In some cases, life-threatening manifestations, including weakness of respiratory muscles or swallowing difficulty, or autonomic dysfunction, require urgent therapeutic decisions.