Search

Background: The contralateral foot in Charcot arthropathy or neuroarthropathy (CN) is subject to increased plantar pressure. To date, the clinical consequences of this pressure elevation are yet to be determined. The aim of this study was to evaluate ulcer and amputation rates of the contralateral foot in CN., Methods: We abstracted the medical records of 130 consecutive subjects with unilateral CN. Rates of contralateral CN development and recurrence, contralateral ulcer development, and contralateral amputations were recorded. Statistical analysis was performed to identify possible risk factors for contralateral CN and ulcer development, and contralateral amputation. Mean follow-up was 6.2 (SD 4) years., Results: After a mean of 2.5 years, 19.2% patients developed contralateral CN. Female gender was associated with contralateral CN development (odds ratio 3.13, 95% confidence interval 1.27, 7.7). Overall, 46.2% patients developed a contralateral ulcer. Among the patients who developed contralateral CN, 60% developed an ulcer. Sanders type 2 at the index foot (midfoot CN) was significantly associated with contralateral ulcer development. Ulcer-free survival (UFS) differed significantly between patients with diabetes type 1 (median UFS 5131 days) and patients with diabetes type 2 (median UFS 2158 days). A total of 25 amputations had to be performed in 22 (16.9%) patients. Three of those 22 patients (2.3%) needed major amputation., Conclusion: Almost 20% of patients developed contralateral CN. Nearly half of people with CN developed a contralateral foot ulceration. Patients with type 2 diabetes had significantly shorter UFS than patients with diabetes type 1. Every sixth patient needed an amputation, with the majority being minor amputations. The contralateral foot should be monitored closely and included in the treatment in patients with CN., Level of Evidence: Level IV, retrospective study.

Background: Patients with chronic limb threatening ischemia (CLTI) and end-stage renal disease (ESRD) have greater risk of limb loss compared to those with CLTI alone. We investigated angiographic patterns in patients with CLTI and evaluated for differences based on ESRD status., Methods: We reviewed lower extremity angiograms of 152 CLTI patients at a single academic medical center from 2011 to 2017 and analyzed them based on the Graziani and Bollinger classification systems. We used these classification systems to evaluate for angiographic patterns and arterial disease severity categorized by the presence or absence of ESRD., Results: The analysis included 152 CLTI patients (161 angiograms). Patients' mean age was 63.4 ± 11.3 years and 20 (12.4%) patients had ESRD. In our study population, infrapopliteal arterial disease was more severe than femoropopliteal disease. Disease of the arteries providing direct flow to the plantar arch was more severe in ESRD patients compared to non-ESRD patients, evident by higher Graziani Class VII disease (20% vs. 4.9%, p = .03). ESRD patients also had higher rates of concurrent significant stenosis of the posterior tibial and lateral plantar arteries (70% vs. 23%, p < .0001)., Conclusion: In people with CLTI, infrapopliteal arteries are more severely affected than proximal femoropopliteal arteries. ESRD patients exhibit a pattern of arterial disease, we termed the "renal foot," that frequently involves arteries providing direct flow to the plantar arch., (Copyright © 2019. Published by Elsevier Inc.)

Background: Diabetic foot ulcers (DFUs) are a major burden to patients and to the health-care systems of many countries. To prevent or treat ulcers more effectively, predictive biomarkers are needed. We examined temperature as a biomarker and as a causative factor in ulcer development., Methods: Thirty-seven individuals with diabetes were enrolled in this observational case-control study: nine with diabetic neuropathy and ulcer history (DFU), 14 with diabetic neuropathy (DN), and 14 nonneuropathic control participants (DC). Resting barefoot plantar temperatures were recorded using an infrared thermal camera. Mean temperatures were determined in four anatomical regions-hallux and medial, central, and lateral forefoot-and separate linear models with specified contrasts among the DFU, DN, and DC groups were set to reveal mean differences for each foot region while controlling for group characteristics., Results: The mean temperature reading in each foot region was higher than 30.0°C in the DFU and DN groups and lower than 30.0°C in the DC group. Mean differences were greatest between the DFU and DC groups, ranging from 3.2°C in the medial forefoot to 4.9°C in the hallux., Conclusions: Increased plantar temperatures in individuals with a history of ulcers may include acute temperature increases from plantar stresses, chronic inflammation from prolonged stresses, and impairment in temperature regulation from autonomic neuropathy. Diabetic foot temperatures, particularly in patients with previous ulcers, may easily reach hazard thresholds indicated by previous pressure ulcer studies. The results necessitate further exploration of temperature in the diabetic foot and how it may contribute to ulceration.

Background: The total contact cast has been recognized as the "gold standard" for treatment of Charcot neuro-osteoarthropathy (CN). However, removable cast walkers (RCWs) became an alternative option especially after resolution of the acute stage. RCWs with an elevated sole construction often induce leg length discrepancy (LLD) that could significantly affects plantar pressure (PP) distribution in diabetic patients with neuropathy., Aim: To study the additional effect of walking speed on PP abnormalities induced by LLD., Method: The study included 16 patients with diabetes (59±8.8years; 8 men and 8 women), with unilateral CN offloaded by RCW. In-shoe PP distribution was measured using F-scan (Tekscan Inc.), whilst patients walked at their normal speed (53±4 steps/min), versus short slow steps (24±3/min) under the two walking conditions: (1) neglected LLD, and (2) corrected LLD., Results: The greatest reduction in PP was seen during reduction of walking speed, with corrected LLD, followed by corrected LLD with normal walking speed, followed by neglected LLD with slowing of walking speed. The highest PP was found when the patient remain on their normal walking speed and LLD was neglected., Conclusion: The contralateral foot of CN offloaded with RCW, is subjected to high pressure loads beneath the hallux, 1st, 2nd, 3rd, and 5th metatarsal heads. As such, care should be taken not only to avoid minor LLD, but to also advise the patient to practice short slow steps while walking, so that pressure overload on contralateral limb and its possible contribution to the development of bilateral Charcot, could be minimized., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: This study examined the impact of shoe closure on plantar thermal stress response (TSR), which is known to be a surrogate of shear stress and skin perfusion. It is aimed to explore potential impact of shoe closure on increasing risk factors associated with plantar ulcers in people with diabetic peripheral neuropathy (DPN)., Methods: Fifteen eligible subjects were enrolled. The left foot was used as a reference and fitted to a self-adjusted and habitual lace-tightening method by each subject. The right foot was used as a test closure and fitted into three lace closure conditions: loose, tight, and preset optimal closure (reel clutch, BOA technology). Thermal images were taken after 5 minutes of acclimatization (pre-trial) and immediately after 200 walking steps in each shoe closure condition (post-trial). TSR was calculated from the thermal images., Results: TSR was significantly higher in the test closure with loose (70.24%, P = .000) and tight (66.85%, P = .007) and lower (-206.53%, P = .000) in the preset optimal closure when compared to the reference closure. Only lace closure conditions affected TSR with no significant impact from age, BMI, and gender in our sample in a multivariable regression model., Conclusion: The results from this study suggest that shoelace closure technique can have a profound effect on TSR. It therefore stands to reason that optimal lace closure may have an impact in reducing risk of plantar ulcers in people with DPN. Interestingly, results revealed that even a self-adjusted lace closure may not be necessarily optimal and a preset closure setting like reel clutch might ultimately be recommended to minimize risk. Further study is warranted to confirm or refute these interesting results.

For generations, the use of techniques to defer skin pressure and protect the lower-extremity wound has been a cardinal goal to achieve therapeutic success and healing. Choosing the appropriate postoperative offloading device or shoe is often difficult, as it is challenging to merge optimal mechanical protection with clinical realities and patient needs. The gold standard for offloading remains the total contact cast, yet it receives minimal utilization in the clinical setting. Other devices have shown benefit, including the removable cast walker, instant total contact cast, and depth inlay shoes, for preventative measures. Ultimately, any plantar, lower-extremity wound must receive some form of external pressure reduction to reach acceptable rates of healing. Future technologies will aid these measures by providing body-worn constant monitoring systems and more effective offloading via patient-specific exoskeletons. This review is a supplemental update on the available wound offloading modalities based on logic-driven research regarding pressure relief across the diabetic neuropathic or impaired perfusion foot., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Magnetic resonance imaging (MRI) has been recognized as the most accurate imaging modality for the detection of diabetic foot osteomyelitis. However, how accurately MRI displays the extent of diabetic foot osteomyelitis in the presence of ischemia is still unclear. We retrospectively compared the preoperative MRI findings with the results of histopathologic examinations of resected bones and studied the efficacy of MRI in the diagnosis of diabetic foot osteomyelitis of different etiologies. A total 104 bones from 18 foot ulcers in 16 diabetic patients (10 men and 6 women; age range 42 to 84 years) treated by surgical intervention from 2008 to 2012 was examined. In 8 neuropathic ulcers, 29 bones were accurately diagnosed in detail using MRI, even those with severe soft tissue infection. Of 75 bones in 10 ischemic ulcers, only 7 bones evaluated by MRI after revascularization were diagnosed accurately; the other 68 could not be diagnosed because of unclear or equivocal MRI findings. On histopathologic examination, all the bones were found to be infected through the bone cortex by the surrounding infected soft tissue, not directly by articulation. Overall, preoperative MRI is effective in the diagnosis of neuropathic ulcers, but less so of ischemic ones., (Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Although the literature is replete with recommendations for people with diabetes-particularly those with neuropathy, ischemia, or both-to avoid caring for corns and calluses on their own feet, there are virtually no reports of damage associated with this care. The purpose of this article is to report on the potential perils of personal pedicures in the presence of peripheral neuropathy by using a case-based example. In this article, we report on the inappropriate use of a Ped Egg personal pedicure device that led to limb-threatening lesions in a gentleman with diabetic peripheral sensory neuropathy.

The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.

Patients with diabetes are prone to ulcerations of the lower extremities, frequently complicated by infection, and are then reliant upon their caregivers for preservation of their limbs without the dreaded outcome of amputation. The enormous tolls of foot infections in diabetes, in terms of both health-related quality of life issues and associated economic burdens, have only been fully realized within the last few decades, and it is anticipated that these burdens will only increase over time. Early and appropriate antibiotic treatment targeting the most likely etiologic pathogens is a cornerstone of management of foot infections in diabetes, but these decisions are now complicated by the emergence of resistant organisms, particularly methicillin-resistant Staphylococcus aureus and multidrug-resistant Gram-negative species. This review will examine the impact of foot infections in diabetes and the overall care and management of the diabetes patient with foot infection, including the potential value of emerging antibiotic therapies within the milieu of antibiotic resistance.

Disruption of the body's plantar fat pad can occur as a result of one of three mechanisms: simple fat pad atrophy associated with age-related degeneration, steroid use, or collagen vascular disease. Actual or relative displacement in to the underlying osseous prominences may be seen in association with structural deformity of the foot. Disease states such as diabetes may alter the normal structural integrity of soft tissues through nonenzymatic glycation leading to increased stiffness and thus reduced attenuating capacity. Fat pad atrophy, regardless of the cause, is often associated with substantial emotional, physical, productivity, and financial losses. In situations where the patient is sensate, the resultant skin on bone situation is extremely painful, especially when walking., (2010 Diabetes Technology Society.)

Background: Off-loading excessive pressure is essential to healing diabetic foot ulcers. However, many patients are not compliant in using prescribed footwear or off-loading devices. We sought to validate a method of objectively measuring off-loading compliance via activity monitors., Methods: For 4 days, a single subject maintained a written compliance diary concerning use of a removable cast walker. He also wore a hip-mounted activity monitor during all waking hours. An additional activity monitor remained mounted on the cast walker at all times. At the conclusion of the 4 days, the time-stamped hip activity data were independently coded for walker compliance by the compliance diary and by using the time-stamped walker activity data., Results: An intraclass reliability of 0.93 was found between diary-coded and walker monitor-coded activity., Conclusions: These results support the use of this dual activity monitor approach for assessing off-loading compliance. An advantage of this approach versus a patient-maintained diary is that the monitors are not susceptible to incorrect patient recall or a patient's desire to please a caregiver by reporting inflated compliance. Furthermore, these results seem to lend support to existing reports in the literature using similar methods.

Background: This literature review was undertaken to evaluate the reliability and validity of the orthopedic, neurologic, and vascular examination of the foot and ankle., Methods: We searched PubMed-the US National Library of Medicine's database of biomedical citations-and abstracts for relevant publications from 1966 to 2006. We also searched the bibliographies of the retrieved articles. We identified 35 articles to review. For discussion purposes, we used reliability interpretation guidelines proposed by others. For the kappa statistic that calculates reliability for dichotomous (eg, yes or no) measures, reliability was defined as moderate (0.4-0.6), substantial (0.6-0.8), and outstanding (> 0.8). For the intraclass correlation coefficient that calculates reliability for continuous (eg, degrees of motion) measures, reliability was defined as good (> 0.75), moderate (0.5-0.75), and poor (< 0.5)., Results: Intraclass correlations, based on the various examinations performed, varied widely. The range was from 0.08 to 0.98, depending on the examination performed. Concurrent and predictive validity ranged from poor to good., Conclusions: Although hundreds of articles exist describing various methods of lower-extremity assessment, few rigorously assess the measurement properties. This information can be used both by the discerning clinician in the art of clinical examination and by the scientist in the measurement properties of reproducibility and validity.

The indications for external fixation in foot and ankle surgery are expanding and now include the use on patients with significant comorbidities. Protecting the contralateral limb from inadvertant injury is important especially in patients with diabetes where the contralateral limb is already "at risk". The authors describe a simple and inexpensive technique to protect the external fixator and the contralateral limb from potential injury.

Our objective was to determine factors associated with complications of Ilizarov external ring fixator surgery for foot and ankle disorders in persons with diabetes mellitus. We reviewed the records of patients who underwent Charcot foot reconstruction or soft tissue offloading surgery over 1 year at a single institution. We compared the association of serious pin tract infection, pin fracture, and surgical wound dehiscence with the patient age, weight, duration device was used, preoperative glucose, preoperative hemoglobin, tourniquet time, and total operating time. Fifteen patients (16 limbs) underwent reconstructive surgery. Younger age, elevated preoperative glucose, and lengthy tourniquet times were associated with complications (P = .03). These data demonstrate that 2 modifiable factors (preoperative hyperglycemia and tourniquet time) predict complications and should be mitigated to lower risk.

The etiology of neuropathic diabetic foot wounds can be summarized by the following formula: pressure x cycles of repetitive stress = ulceration. The final pathway to ulceration consists of an inflammatory response, leading to tissue breakdown. Mitigation of this response might reduce the risk of ulceration. This proof-of-concept trial evaluates whether simple cooling of the foot can safely reduce the time to thermal equilibrium after activity. After a 15-min brisk walk, the six nondiabetic volunteers enrolled were randomly assigned to receive either air cooling or a 10-min 55 degrees F cool water bath followed by air cooling. The process was then repeated with the intervention reversed, allowing subjects to serve as their own controls. There was a rise in mean +/- SD skin temperature after 15 min of activity versus preactivity levels (87.8 degrees +/- 3.9 degrees versus 79 degrees +/- 2.2 degrees F; P = .0001). Water cooling immediately brought the foot to a point cooler than preactivity levels for all subjects, whereas air cooling required an average of nearly 17 min to do so. Ten minutes of cooling required a mean +/- SD of 26.2 +/- 5.9 min to warm to preactivity levels. No adverse effects resulted from the intervention. We conclude that cooling the foot may be a safe and effective method of reducing inflammation and may serve as a prophylactic or interventional tool to reduce skin breakdown risk.

Objective: To evaluate the effectiveness of at-home infrared temperature monitoring as a preventative tool in individuals at high risk for diabetes-related lower-extremity ulceration and amputation., Research Design and Methods: Eighty-five patients who fit diabetic foot risk category 2 or 3 (neuropathy and foot deformity or previous history of ulceration or partial foot amputation) were randomized into a standard therapy group (n = 41) or an enhanced therapy group (n = 44). Standard therapy consisted of therapeutic footwear, diabetic foot education, and regular foot evaluation by a podiatrist. Enhanced therapy included the addition of a handheld infrared skin thermometer to measure temperatures on the sole of the foot in the morning and evening. Elevated temperatures (>4 degrees F compared with the opposite foot) were considered to be "at risk" of ulceration due to inflammation at the site of measurement. When foot temperatures were elevated, subjects were instructed to reduce their activity and contact the study nurse. Study subjects were followed for 6 months., Results: The enhanced therapy group had significantly fewer diabetic foot complications (enhanced therapy group 2% vs. standard therapy group 20%, P = 0.01, odds ratio 10.3, 95% CI 1.2-85.3). There were seven ulcers and two Charcot fractures among standard therapy patients and one ulcer in the enhanced therapy group., Conclusions: These results suggest that at-home patient self-monitoring with daily foot temperatures may be an effective adjunctive tool to prevent foot complications in individuals at high risk for lower-extremity ulceration and amputation.

One of the central goals of reconstructive foot and ankle surgery is restoration of or improvement in the quality of physical activity. Until recently, objective assessment of how well this goal has been attained has been elusive at best. Recent advances in activity monitoring have advanced sufficiently to help many clinicians and researchers objectively measure and potentially modulate activity. In this brief article, we describe our current experience with computerized activity monitoring. Use of modalities such as these may ultimately be able to monitor and dose levels of activity just as we do with a drug.

This prospective longitudinal study assessed whether baseline mean skin temperature measurements are useful in predicting the most common foot-related complications of diabetes mellitus. We evaluated the mean of baseline skin temperatures taken bilaterally from six plantar sites in 1,588 patients with diabetes. There was no difference in skin temperature based on neuropathy, foot laterality, or foot risk category or between people with and without foot deformity and elevated plantar foot pressure. Whereas people with Charcot's arthropathy had slightly but significantly higher mean temperatures (84.8 degrees +/- 3.5 degrees F versus 82.5 degrees +/- 4.7 degrees F), this was not true for those who developed ulcers or infections or who underwent amputations. The presence of vascular disease was not associated with lower skin temperatures. Mexican Americans (83.0 degrees +/- 4.6 degrees F) and blacks (83.6 degrees +/- 4.5 degrees F) had higher mean skin temperatures at baseline than did non-Hispanic whites (81.8 degrees +/- 4.6 degrees F). Baseline measurement of nonfocal mean skin temperatures is not an effective means of screening people for future events. Regular assessment of skin temperatures, using the contralateral site as a physiologic control, may be a better use of this technology.

Objective: To evaluate the effectiveness of dynamic plantar pressure assessment to determine patients at high risk for neuropathic ulceration. In choosing the cut point, we looked for an optimum combination of sensitivity and specificity of plantar pressure to screen for neuropathic ulceration., Research Design and Methods: A total of 1,666 consecutive individuals with diabetes (50.3% male) presenting to a large urban managed care-based outpatient clinic were enrolled in this longitudinal 2-year outcome study. Patients received a standardized medical and musculoskeletal assessment at the time of enrollment, including evaluation in an onsite gait laboratory., Results: Of the entire population, 263 patients (15.8%) either presented with or developed an ulcer during the 24-month follow-up period. As expected, baseline peak plantar pressure was significantly higher in the ulcerated group than in the group who did not ulcerate (95.5 +/- 26.4 vs. 85.1 +/- 27.3 N/cm(2), P < 0.001). There was also a trend toward increased pressure with increasing numbers of foot deformities, as well as with increasing foot risk classification (P = 0.0001). Peak pressure was not a suitable diagnostic tool by itself to identify high-risk patients. After eliminating patients without loss of protective sensation, using receiver operating characteristic (ROC) analysis, the optimal cut point, as determined by a balance of sensitivity and specificity, was 87.5 N/cm(2), yielding a sensitivity of 63.5% and a specificity of 46.3%., Conclusions: The data from this evaluation continue to support the notion that elevated foot pressure is an important risk factor for foot complications. However, the ROC analysis suggests that foot pressure is a poor tool by itself to predict foot ulcers.

The authors undertook a study to evaluate the prevalence of ankle equinus and its potential relationship to high plantar pressure in a large, urban population with diabetes mellitus. The first 1,666 consecutive people with diabetes (50.3% male; mean [+/-SD] age, 69.1 +/- 11.1 years) presenting to a large, urban, managed-care outpatient clinic were enrolled in this longitudinal, 2-year outcomes study. Patients received a standardized medical and musculoskeletal assessment at the time of enrollment, including evaluation at an onsite gait laboratory. Equinus was defined as less than 0 degrees of dorsiflexion at the ankle. The overall prevalence of equinus in this population was 10.3%. Patients with equinus had significantly higher peak plantar pressures than those without the deformity and were at nearly three times greater risk for presenting with elevated plantar pressures. There were no significant differences in age, weight, or sex between the two groups. However, patients with equinus had a significantly longer duration of diabetes than those without equinus. Having a high index of suspicion for this deformity and subsequently addressing it through conservative or surgical means may help to reduce the risk of foot ulceration and amputation.

Objective: To report the efficacy of injected liquid silicone (ILS) in the foot at 2 years after administration., Design: Randomized controlled trial., Setting: Diabetic foot clinic in the United Kingdom., Participants: Twenty-eight diabetic neuropathic patients, randomized into an active treatment group (n=14) and a placebo group (n=14)., Intervention: Participants were given either 6 injections of 0.2mL of liquid silicone (silicone group) or equal volumes of saline (placebo group) under metatarsal head sites with callus., Main Outcome Measures: Plantar tissue thickness and plantar pressures were measured at 3, 6, 12, and 24 months postinjection., Results: At 12 months, the plantar tissue thickness in the silicone group had increased by a mean 1.6+/-0.9mm (P=.001), and remained increased at 24 months (1.1+/-0.7mm, P=.003). Peak plantar pressure in the silicone group was reduced at 12 months (-165.0+/-253.5kPa, P=.03), but not at 24 months. There was no change in tissue thickness or peak plantar pressure in the placebo group at 12 and 24 months. The reduction in the pressure time integral (PTI) in the silicone group did not reach significance at 12 months (-.71+/-1.17kPa/s, P=.055). Although PTI returned to baseline at 24 months for the silicone group, it was significantly increased in the placebo group (.64+/-.37kPa/s, P=.043), suggesting that silicone may still exhibit some pressure-reducing properties after 24 months., Conclusions: The results indicate that at 24 months postinjection the cushioning properties of ILS have reduced, suggesting that booster injections may be required in certain patients., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of physical Medicine and Rehabilitation)

Background: The purpose of this study was to determine the degree to which pressure on the plantar aspect of the forefoot is reduced following percutaneous lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot., Methods: Ten diabetic patients who had a history of neuropathic plantar ulceration of the forefoot were enrolled in a laboratory gait trial. A repeated-measures design and a computer analysis of force-plate data were used to examine dynamic pressures on the forefoot, with the patient walking barefoot, immediately before percutaneous lengthening of the Achilles tendon and at eight weeks afterward. Although the wound in each patient had healed at least one month before the operation, we considered the patients to be at high risk for ulceration because they had had an ulcer previously., Results: The mean peak pressure (and standard deviation) on the plantar aspect of the forefoot decreased significantly from 86+/-9.4 newtons per square centimeter preoperatively to 63+/-13.2 newtons per square centimeter at eight weeks postoperatively (p<0.001). Commensurately, the mean dorsiflexion of the ankle joint increased significantly from 0+/-3.1 degrees preoperatively to 9+/-2.3 degrees at eight weeks post-operatively (p<0.001)., Conclusions: The results of this study suggest that peak pressures on the plantar aspect of the forefoot are significantly reduced following percutaneous lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. We are unaware of any other reports in the medical literature that describe such findings. These data may lend support to studies that have indicated that this procedure should be used as an adjunctive therapeutic or prophylactic measure to reduce the risk of neuropathic ulceration.

For several decades, Chopart's amputation has met with some skepticism owing to reports of significant equinus deformity developing soon after the procedure is performed. However, with appropriate tendon balancing, which generally includes anterior tibial tendon transfer and tendo Achillis lengthening, this level of amputation is often more functional than slightly more distal amputations, such as Lisfranc or short transmetatarsal amputations. The authors offer a rationale for this observation, which includes a discussion of the longitudinal and transverse arch concept of the foot. This concept dictates that the shorter the midfoot-level amputation, the more likely the patient is to develop an equinovarus deformity, thus exposing the fifth metatarsal base and cuboid to weightbearing stress and a high risk of ulceration. Chopart's amputation, in eliminating the cuboid, often obviates the potential varus deformity and thus can have a more acceptable long-term result.

The purpose of this study was to determine if increased weight contributes to increased mean peak plantar foot pressures when foot function, deformity, and structure are controlled. Ten male and nine female volunteers without sensory neuropathy or other systemic disease were evaluated in the study. Using a repeated measures design, peak plantar foot pressures were compared using the Novel Pedar in-shoe pressure measurement system under three conditions. Baseline measurements were made while volunteers wore the standard test footwear, a thin-soled rubber oxford sneaker. The second and third test conditions involved pressure measurements with an additional 9.1 kg (20 lb) and 18.2 kg (40 lb), respectively, of weight evenly distributed in pockets on the front and back of a workout vest. There was a significant increase in mean peak plantar foot pressures under the metatarsal heads, heel, and midfoot for each incremental increase of weight (baseline vs. 9.1 kg, p < .05; 9.1 kg vs. 18.2 kg, p < .05). The authors conclude that increases in weight increased plantar foot pressures for the first metatarsal, lesser metatarsal, midfoot, and heel regions in both men and women.

The purpose of this study was to evaluate the effect of galvanic electrical stimulation on vascular perfusion in diabetic patients. Nineteen subjects with diabetes were enrolled. Eleven subjects (57.9%) were diagnosed with impaired peripheral perfusion based upon their initial transcutaneous oximetry values (< 40 mm Hg). The subjects were studied over a 2-day period. On the 1st day, one foot was electrically stimulated for four 60-minute periods by an external electrical stimulation device. Vascular perfusion of both feet was assessed before and after the sessions of electrical stimulation. On the 2nd day, no electrical stimulation was applied and noninvasive vascular measurements were repeated. For the 1st hour, transcutaneous oxygen pressure was measured continuously during stimulation at the lateral aspect of the leg. Subsequently, perfusion between the periods of stimulation was measured on the dorsum of the foot with both transcutaneous oximetry and laser Doppler flowmetry after each stimulation period. In the group with impaired peripheral perfusion, a significant rise in tissue oxygenation as compared to the control measurements was measured during the first 5 minutes of stimulation (p < .040). For those without vascular disease (TcpO2 > 40 mm Hg) however, there was not a significant increase compared to baseline (p = .280). After the periods of stimulation, the stimulated feet did not show any higher perfusion levels than the control feet. Patterns in perfusion during the day, as measured by laser Doppler flowmetry, were similar in the tested feet and in the controls. These data suggest that external subsensory electrical stimulation induces a transient rise in skin perfusion in persons with diabetes and impaired peripheral perfusion.

Although diabetes and peripheral neuropathy are perhaps the most important risk factors for neuropathic osteoarthropathy, we hypothesized that peak plantar pressures may also be higher in patients who have this condition. We are unaware of any reports in the medical literature that have specifically addressed this hypothesis. We obtained data from the medical records of 164 diabetic patients who had been managed in a multidisciplinary tertiary-care diabetic foot-specialty clinic. We then divided the patients into four groups: those who had acute Charcot arthropathy, those who had neuropathic ulceration, those who had neuropathy without ulceration, and those who had neither neuropathy nor ulceration. The peak plantar pressures were significantly higher in the patients who had acute Charcot arthropathy and those who had a neuropathic ulcer (p < 0.001 for both) compared with the pressures in those who had no history of arthropathy and those who had neuropathy without ulceration. With the numbers available, we could not detect a significant difference in the peak pressure between the affected and the unaffected foot in the patients who had Charcot arthropathy (mean [and standard deviation], 100+/-8.5 compared with 101+/-9.6 newtons per square centimeter; p > 0.05). However, the mean peak pressure was significantly higher on the ulcerated side than on the contralateral side in the patients who had a neuropathic ulcer (90+/-18.8 compared with 86+/-20.7 newtons per square centimeter; p < 0.02). Although the midfoot was the site of maximum involvement in all patients who had Charcot arthropathy, the peak plantar pressure was on the forefoot, suggesting that the forefoot may function as a lever, forcing collapse in the midfoot.

The purpose of this study was to compare peak plantar pressure in diabetic patients with and without foot-level amputation. This project was conducted as a case-control study. We enrolled 27 cases and 150 controls diagnosed with diabetes mellitus. Cases were defined as patients with a history of forefoot-level amputation (digit or ray amputations distal to the tarsometatarsal joint) secondary to an infected forefoot wound. Controls were defined as subjects that had never had a foot ulceration. We used a pressure platform system to evaluate dynamic barefoot pressure on the sole of the foot. There was no significant difference in vascular perfusion or body mass index between the case and control groups. Patients with a foot-level amputation were nearly ten times more likely to present with limited joint mobility or a rigid foot deformity than those without amputation (92.6% vs. 44.0%, p < 0.0001, X2 = 13.0, Odds Ratio = 9.8 CI = 2.2 to 43.0). Peak plantar pressure was significantly higher for patients with amputations compared to controls (80.0 +/- 31.1 N/cm2, vs, 62.5 +/- 21.0 N/cm2, p < 0.001). Peak pressure and limited joint mobility have long been associated with ulceration. We conclude that increased pressure and contractures associated with biomechanical compensation following a partial foot amputation further increase plantar pressure, placing an already high-risk limb at further risk for tissue breakdown and reamputation.

The purpose of this article is to describe the progression of ulcer healing using total contact casts (TCC) and to examine explanatory variables that may influence ulcer healing. We prospectively studied 25 diabetics with grade I (Meggitt-Wagner) plantar ulcers. All subjects received weekly contact cast changes with wound assessment. Following healing, all subjects were fitted with prescription shoe gear. Mean duration of casting until healing was 38.8 +/- 21.3 days. Individuals with pressures over 99 N/cm2 took longer to heal (33.1 +/- 13.0 vs. 53.4 +/- 31.4 days, P = 0.05) and had longer ulcer duration prior to treatment (52.7 +/- 37.2 vs. 180.7 +/- 145.0 days, P = 0.02). Subjects with wound size greater than 8 cm2 took longer to heal (50.2 +/- 26.2 vs. 29.9 +/- 10.6 days, P = 0.02). We conclude that subjects with high plantar pressures and wounds greater than 8 cm2 took significantly longer to heal when uniformly treated with TCC.

Objective: To compare the effectiveness of therapeutic, comfort, and athletic shoes with and without viscoelastic insoles., Research Design and Methods: We compared pressure reduction at ulcer sites under the hallux (n = 10), first metatarsal (n = 10), and lesser metatarsals (n = 12), using extra-depth, athletic, and comfort shoes with and without viscoelastic insoles. A rubber-soled canvas oxford was used to establish baseline pressure values., Results: When used in conjunction with a viscoelastic insole, all shoe types reduced mean peak plantar pressure better than their non-insoled counterparts (P < 0.05). Consistently, comfort shoes reduced pressure significantly better than both the cross trainers and extra-depth shoes for ulcers under the first and lesser metatarsals (P < 0.05). For each shoe type, the addition of the viscoelastic insole provided a significant reduction in mean peak pressure (P < 0.05). Compared with stock insoles, viscoelastic insoles reduced pressures an additional 5.4-20.1% at ulcer sites. The same trend was also observed at regions of the foot not associated with an ulceration., Conclusions: When used in conjunction with a viscoelastic insole, both the comfort and athletic cross-trainer shoes studied were as, if not more, effective than commonly prescribed therapeutic shoes in reducing mean peak first and lesser metatarsal pressures. Furthermore, comfort shoes were as effective as therapeutic shoes in reducing pressure under the great toe. Both of these shoe types may be viable options to prevent the development or recurrence of foot ulcers.