Radiological outcome of calcaneo-cuboid-cuneiform osteotomies for planovalgus feet in cerebral palsy children: Relationship with pedobarography.

BACKGROUND: Calcaneo-cuboid-cuneiform (triple C) osteotomies correct all levels of deformity of flexible planovalgus feet (PVF) in patients with cerebral palsy (CP). The objective was assessing short term results and the hypothesis was that static pedobarography correlates with radiological parameters as outcome measures. METHODS: A prospective case series of consecutive skeletally immature ambulatory spastic CP patients above the age of 4 years who underwent triple C for PVF. Assessment was done using static pedobarography and standing dorsoplantar (DP) and lateral radiographs. The calcaneal pitch, lateral talocalcaneal, lateral and DP talo-first metatarsal, and DP talonavicular coverage angles were measured. RESULTS: Eighteen feet (12 patients) were analyzed. Postoperative changes in lateral and DP talo-first metatarsal, and DP talonavicular coverage angles were statistically significant (P-value=0 with paired T-test). Post operative foot pressure changes were significant and highest in mid-foot. Both outcomes were related together with a p-value of 1 using McNemar test. CONCLUSIONS: The triple C and associated soft tissue procedures reliably corrected PVF deformities. Static pedobarography can be used for postoperative assessment of adequate correction.

Coalition resection and medial displacement calcaneal osteotomy for treatment of symptomatic talocalcaneal coalition: functional and clinical outcome.

PURPOSE: The purpose of this study was to evaluate the functional and clinical outcome of combined TCC resection and medial displacement calcaneal osteotomy for treatment of symptomatic talocalcaneal coalition. METHOD: This is a prospective case series study on 27 patients (30 feet) who had symptomatic rigid pes planovalgus due to talocalcaneal coalition. All patients were treated by coalition resection and medial displacement calcaneal osteotomy. Pre-operative clinical and radiological assessment was done. Pain was assessed by visual analogue scale (VAS) and the functional assessment was done by the American Foot and Ankle Society score (AOFAS) for the hind foot. Pre-operative and postoperative plantar pressure assessment was done for all patients barefoot using the mat scan (Tekscan, Inc., vs. 6.34, Boston, USA). RESULTS: The mean follow-up period was 27.44 months (±2.47, range 23-33). Heel valgus improved from 15.03 (±6.9) degrees pre-operative to 3.09 (±2.3) degrees postoperatively. There was a statistically significant improvement in the VAS from 8.48 (±0.70) pre-operative to 3.70 (±1.13) postoperative. The mean AOFAS score showed statistically significant improvement from 39.88 (±6.09) pre-operative to 84.37 (±7.06) postoperative. There was a statistically significant decrease in mid foot pressure during standing from 48.05 kPa pre-operative to 35.30 kPa postoperative, and during walking from 148.08 kPa pre-operative to 90.22 kPa postoperative. CONCLUSION: A combination of medial displacement calcaneal osteotomy with TCC resection showed statistically significant improvement in VAS and AOFAS scores, as well as decreasing the plantar pressure on the mid foot during standing and walking.

Localization of composite prosthetic feet: manufacturing processes and production guidelines.

Amputation levels in Egypt and the surrounding neighborhood require a state intervention to localize the manufacturing of prosthetic feet. Amputations are mainly due to chronic diseases, accidents, and hostilities' casualties. The prosthetic foot type is traditionally classified according to the number of axial rotational movements, and is recently classified according to the energy activeness of the foot. The localization of this industry needs a preliminary survey of the domestic technological levels with respect to the foot type. Upon the results of this survey, the energy storage response foot has appealing metrics to proceed with its manufacturing. A prototype manufacturing chain is designed and a set of these feet with a certain commercial size of 27 is manufactured. Resin impregnation technology for carbon fiber composites is followed in this work. The feet are tested according to ISO 22,675. Based on the dimensional and mechanical results, a manufacturing value chain is proposed with the prospective resin transfer molding technology. This value chain will guarantee the required localization as well as the natural growth of this value chain with all related activities like accreditation of practices as well as manpower certification.

Endoscopic plantar fascia release by hooked soft-tissue electrode after failed shock wave therapy.

PURPOSE: The purpose of this study was to assess the outcome of endoscopic plantar fascia release (EPFR) after failed extracorporeal shock wave therapy (ESWT). METHODS: Eighteen patients (twenty-one feet) had persistent painful heel after treatment by ESWT for at least 6 months. The treatment protocol included 2,000 pulses of 0.12 mJ/mm(2) given in 1 session weekly for 7 sessions. Preoperative and postoperative assessment of pain and functional evaluation were done blindly by the second author using a visual analog scale (VAS) score and the modified American Orthopaedic Foot & Ankle Society (AOFAS) score for the hindfoot. EPFR was done without the use of a tourniquet under local ankle block. A monopolar hooked soft-tissue electrode (ConMed Linvatec, Largo, FL) was used to sever the plantar fascia and to control bleeding. The mean follow-up period was 25.8 months. Only 17 patients (20 feet) completed 2 years' follow-up. RESULTS: The mean preoperative VAS score was 72.52, and the mean preoperative modified AOFAS score was 24.23. There was a statistically significant improvement in VAS score, modified AOFAS score, and morning pain at 2 years' follow-up (P < .05). Of the patients, 9 (50%) had excellent results, 6 (35%) had good results, 1 (10%) had a fair result, and 1 (5%) had failure of improvement of pain. No major complications were found; 2 patients had hyperkeratosis at the portal site, and 1 patient had paresthesia at the lateral border of the foot. CONCLUSIONS: EPFR yielded good to excellent outcomes in 85% of 17 patients with plantar fasciitis resistant to treatment by ESWT after 2 years' follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Bone Mineral Density in Type 2 Diabetes Patients with Charcot Arthropathy.

INTRODUCTION: Charcot arthropathy is one of the disabling diabetes complications. There are enigmatic areas concerning its underlying pathophysiology and risk predictors. Osteoporosis and local osteopenia have been postulated to have a role in Charcot arthropathy development, but it is still controversial. BACKGROUND: The study aims to compare bone mineral density among type 2 diabetics with and without Charcot arthropathy. METHODS: Two groups with type 2 diabetes participated in this study; Group I [30] patients with Charcot arthropathy while Group II [30] patients without charcot arthropathy. All patients underwent full clinical examination and complete history taking with special emphasis on foot problems. Laboratory investigations were done that included fasting blood sugar, postprandial blood sugar, glycosylated hemoglobin, serum calcium, serum phosphorus, and alkaline phosphatase. All patients underwent MRI for both feet and dual energy X-ray absorptiometry scan of the lumbar spine and femur. The demographic data, clinical data, the presence or absence of comorbidities and bone mineral density were compared for both groups. RESULT: Bone mineral density was significantly lower in Group I than Group II with median lumber T score (-0.15, 1.99 p <0.001), median Femur T score (0.050, 2.400, p <0.001). Group I showed higher propensity for hypertension, neuropathy, micro-albuminuria with peripheral arterial disease (23.33 %) compared to Group II (p <0.001). Multiple logistic regression analysis revealed that female gender and low femur bone mineral density can be risk predictors of the condition. CONCLUSION: Bone mineral density is lower in patients with Charcot arthropathy with female gender and Femur T score as risk predictors. Peripheral arterial disease shows greater incidence in Charcot patients than was previously reported.

Relationship of planter pressure and glycemic control in type 2 diabetic patients with and without neuropathy.

INTRODUCTION: Foot disease is a common complication of type 2 diabetes that can have tragic consequences. Abnormal plantar pressures are considered to play a major role in the pathologies of neuropathic ulcers in the diabetic foot. AIM: To examine Relationship of Planter Pressure and Glycemic Control in Type 2 Diabetic Patients with and without Neuropathy. MATERIALS AND METHODS: The study was conducted on 50 type 2 diabetic patients and 30 healthy volunteers. BMI calculation, disease duration, Hemoglobin A1c and presence of neuropathy (by history, foot examination and DN4 questionnaire) were recorded. Plantar pressure was recorded for all patients using the Mat-scan (Tekscan, Inc.vers. 6.34 Boston USA) in static conditions (standing) and dynamic conditions (taking a step on the Mat-scan). Plantar pressures (kPa) were determined at the five metatarsal areas, mid foot area, medial and lateral heel areas and medial three toes. RESULTS: Static and dynamic plantar pressures in both right and left feet were significantly higher in diabetic with neuropathy group than in control group in measured areas (P<0.05). Static and dynamic pressures in right and left feet were significantly higher in diabetic with neuropathy group than in diabetic without neuropathy group in measured areas (P<0.05). On comparison between controls and diabetic without neuropathy group there was a significant difference in plantar pressures especially in metatarsal areas (P<0.05). No significant correlations were present between the studied variables age, disease duration, BMI and HbA1c and plantar pressures in all studied areas. CONCLUSION: Persons with diabetic neuropathy have elevated peak plantar pressure (PPP) compared to patients without neuropathy and control group. HbA1c% as a surrogate for glycemic control had no direct impact on peak planter pressure, yet it indirectly impacts neuropathy evolution through out disease duration eventually leading to the drastic planter pressure and gait biomechanics changes.

Role of neopterin as a biochemical marker for peripheral neuropathy in pediatric patients with type 1 diabetes: Relation to nerve conduction studies.

BACKGROUND: Neopterin, a marker of inflammation and cellular immune response, is elevated in conditions of T-cell or macrophages activation. Diabetic peripheral neuropathy (DPN) is associated with inflammatory/immune processes and therefore, we hypothesized that neopterin could be used as a marker of neuropathy in type 1 diabetes mellitus (T1DM). AIM: To measure neopterin levels in children and adolescents with T1DM and assess its possible relation to DPN and nerve conduction studies (NCS). METHODS: Sixty patients aged ≤18 years and >5 years disease duration were subjected to neurological assessment by neuropathy disability score (NDS) and NCS for median, ulnar, posterior tibial and common peroneal nerves. Mean fasting blood glucose, lipid profile, HbA1c, high sensitivity C-reactive protein (hs-CRP) and serum neopterin levels were assessed. Patients were compared with 30 age- and sex-matched healthy controls. RESULTS: The frequency of DPN according to NDS was 40 (66.7%) patients out of 60 while NCS confirmed that only 30 of those 40 patients had this complication (i.e. 50% out of the total studied patients). Neopterin levels were significantly higher in patients with DPN than those without (median [IQR], 53.5 [35-60] nmol/L versus 17 [13-32] nmol/L) and healthy controls (5.0 [3.2-7.0] nmol/L) (p < 0.001). Significant positive correlations were found between neopterin levels and HbA1c (r = 0.560, p = 0.005), serum creatinine (r = 0.376, p = 0.003), total cholesterol (r = 0.405, p = 0.026) and hs-CRP (r = 0.425, p = 0.012) among patients with DPN. Neopterin levels were positively correlated to motor latency of tibial and common peroneal nerves as well as motor and sensory latencies of median and ulnar nerves. Logistic regression analysis revealed that neopterin was a significant independent variable related to DPN (Odds ratio, 2.976). Neopterin cutoff value 32 nmol/L could differentiate patients with and without DPN with 100% sensitivity and 96.7% specificity. CONCLUSIONS: Neopterin could be used as an early reliable serum biomarker for DPN in pediatric patients with T1DM.

Diagnostic Ultrasound of the Vagus Nerve in Patients with Diabetes.

BACKGROUND AND PURPOSE: Autonomic neuropathy is a serious and common complication of diabetes mellitus. The vagus nerve is the longest autonomic nerve, and may be affected in diabetes as a part of generalized neuropathy. Our objective was to assess for possible sonographic changes of the vagus nerve in diabetic patients. METHODS: The vagus nerve was bilaterally scanned in 20 healthy volunteers and 54 patients with diabetes in the axial plane at the lateral neck. RESULTS: The mean cross-sectional area of the vagus nerve was significantly smaller in patients with diabetes compared with controls. Receiver operating characteristic curve analyses revealed an area under the curve of .96, and an optimum cutoff point of 3 mm2 with a sensitivity of 85.2% and specificity of 100%. CONCLUSIONS: This study demonstrates a degree of vagus nerve atrophy in patients with diabetes. This finding may have relevance in the diagnosis and treatment of diabetic neuropathy if further validated.

The role of a total contact insole in diminishing foot pressures following partial first ray amputation in diabetic patients.

BACKGROUND: In diabetic subjects, reulcerations following first ray amputations are particularly frequent. Treatment usually includes an in-shoe intervention to reduce plantar pressure. OBJECTIVE: To investigate the effects of a total contact insole on the plantar pressure reduction in patients with partial first ray amputations. MATERIAL AND METHODS: Twenty diabetic subjects (mean age 60 years, mean body mass index 27kg/m(2)) with partial first ray amputation of one foot. Plantar pressure data was recorded using Matscan system (Tekscan vers. 6.34, Boston, USA) while standing and taking a step for three conditions (shoe, shoe with total contact insole, and shoe with flat insole). Plantar pressures were determined at the five metatarsal areas, mid foot area and medial and lateral heel areas. RESULTS: Pressures diminished significantly (P<0.05) in tested areas using the total contact insole while standing and walking. While using the flat insole, significant pressure changes were only seen while walking (P<0.05) (P<0.05). A highly significant change in pressures with the total contact insoles during walking in all areas except for the M1 area (P<0.001) as compared to that of flat insole. CONCLUSION: The conforming total contact insole showed significant reduction in plantar pressures in patients with first ray amputation.

A pilot study to assess the effectiveness of orthotic insoles on the reduction of plantar soft tissue strain.

BACKGROUND: Plantar ulcers pose a frequent serious complication in the neuropathic foot. Previous studies suggested that ulcer initiation occurs within the plantar soft tissue rather than on the plantar surface. This study investigated the effectiveness of different shaped silicone insoles on the reduction of both plantar soft tissue strain and pressure. The authors have found no previous experimental studies on the effectiveness of insole shape on reducing plantar soft tissue strain during standing. METHODS: A custom molded silicone insole which allowed passage of ultrasound to the plantar surface of the foot was prototyped for this study. Soft tissue strain was computed from soft tissue thickness measured using ultrasound in five conditions: unloaded, barefoot, wearing a prefabricated silicone insole, wearing the custom molded silicone insole alone then with a metatarsal pad. Plantar pressure was measured for the same conditions. FINDINGS: The custom molded insole was found to significantly reduce soft tissue strain and plantar pressure relative to both the barefoot condition and the prefabricated insole under the second and third metatarsal heads. The metatarsal pad was found to significantly reduce soft tissue strain but not significantly affect plantar pressure. INTERPRETATION: A custom molded silicone insole can effectively reduce both soft tissue strain and plantar pressure and is thus preferable to a prefabricated insole. It is suggested that quantifying the reduction of soft tissue strain is an essential design requirement for orthotic insoles since plantar pressure may not be a sufficient indicator of the effectiveness of an insole in preventing ulcer initiation.