A comparison study of plantar foot pressure in a standardized shoe, total contact cast, and prefabricated pneumatic walking brace

A Dynamic Ankle Orthosis Reduces Tibial Compressive Force and Increases Ankle Motion Compared With a Walking Boot

PURPOSE

Tibial bone stress injuries are a common overuse injury among runners and military cadets. Current treatment involves wearing an orthopedic walking boot for 3 to 12 wk, which limits ankle motion and leads to lower limb muscle atrophy. A dynamic ankle orthosis (DAO) was designed to provide a distractive force that offloads in-shoe vertical force and retains sagittal ankle motion during walking. It remains unclear how tibial compressive force is altered by the DAO. This study compared tibial compressive force and ankle motion during walking between the DAO and an orthopedic walking boot.

METHODS

Twenty young adults walked on an instrumented treadmill at 1.0 m·s -1 in two brace conditions: DAO and walking boot. Three-dimensional kinematic, ground reaction forces, and in-shoe vertical force data were collected to calculate peak tibial compressive force. Paired t -tests and Cohen's d effect sizes were used to assess mean differences between conditions.

RESULTS

Peak tibial compressive force ( P = 0.023; d = 0.5) and Achilles tendon force ( P = 0.017; d = 0.5) were moderately lower in the DAO compared with the walking boot. Sagittal ankle excursion was 54.9% greater in the DAO compared with the walking boot ( P = 0.05; d = 3.1).

CONCLUSIONS

The findings from this study indicated that the DAO moderately reduced tibial compressive force and Achilles tendon force and allowed more sagittal ankle excursion during treadmill walking compared with an orthopedic walking boot.

Methods of Investigation of Functional Disturbances After Burn Injury of the Foot

BACKGROUND

Foot burns involve a specialized area of function, and although they involve a small total body surface area (3.5%), they can cause a significant degree of morbidity.

METHODS

This study included 104 patients with burn trauma of the foot treated at the burn department of Republican Scientific Centre of Urgent Medical Aid and Inter-Regional Burn Center, Samarkand, Uzbekistan. A study of support-motor function of the foot after a burn by means of simultaneous registration of mechanograms of ankle join mobility in various terms made it possible to reveal considerable walking disturbances manifested in short-term support ability of various foot parts compared with normal.

RESULTS

Deviations in podagrams were clearly marked during the first weeks after elimination of burn wounds, especially the duration of support ability of the plantar surface in those who experienced burns.

CONCLUSIONS

The study in separate terms after elimination of burn injury showed that the function of feet begins to regenerate in 3 to 4 months in deep foot burns.

Is TCC-EZ a Suitable Alternative to Gold Standard Total-Contact Casting?

BACKGROUND

The total-contact cast (TCC) is the gold standard for off-loading diabetic foot ulcers (DFUs) given its nonremovable nature. However, this modality remains underused in clinical settings due to the time and experience required for appropriate application. The TCC-EZ is an alternative off-loading modality marketed as being nonremovable and having faster and easier application. This study aims to investigate the potential of the TCC-EZ to reduce foot plantar pressures.

METHODS

Twelve healthy participants (six males, six females) were fitted with a removable cast walker, TCC, TCC-EZ, and TCC-EZ with accompanying brace removed. These off-loading modalities were tested against a control. Pedar-X technology measured peak plantar pressures in each condition. Statistical analysis of four regions of the foot (rearfoot, midfoot, forefoot, and hallux) was conducted with Friedman and Wilcoxon signed rank tests. Significance was set at P < .05.

RESULTS

All of the off-loading conditions significantly reduced pressure compared with the control, except the TCC-EZ without the brace in the hallux region. There was no statistically significant difference between TCC-EZ and TCC peak pressure in any foot region. The TCC-EZ without the brace obtained significantly higher peak pressures than with the brace. The removable cast walker produced similar peak pressure reduction in the midfoot and forefoot but significantly higher peak pressures in the rearfoot and hallux.

CONCLUSIONS

The TCC-EZ is a viable alternative to the TCC. However, removal of the TCC-EZ brace results in minimal plantar pressure reduction, which might limit clinical applications of the TCC-EZ.

Biomechanical Comparison of a New Dynamic Ankle Orthosis to a Standard Ankle-Foot Orthosis During Walking

Patients who sustain irreversible cartilage damage or joint instability from ankle injuries are likely to develop ankle osteoarthritis (OA). A dynamic ankle orthosis (DAO) was recently designed with the intent to offload the foot and ankle using a distractive force, allowing more natural sagittal and frontal plane ankle motion during gait. To evaluate its efficacy, this study compared ankle joint kinematics and plantar pressures among the DAO, standard double upright ankle-foot orthosis (DUAFO), and a nonorthosis control (CON) condition in healthy adults during walking. Ten healthy subjects (26 ± 3.8 yr; 69.6 ± 12.7 kg; and 1.69 ± 0.07 m) walked on a treadmill at 1.4 m/s in three orthosis conditions: CON, DAO, and DUAFO. Ankle kinematics were assessed using a three-dimensional (3D) motion capture system and in-shoe plantar pressures were measured for seven areas of the foot. DAO reduced hallux peak plantar pressures (PPs) compared to CON and DUAFO. PPs under toes 2–5 were smaller in DAO than DUAFO, but greater in DUAFO compared to CON. Early stance peak plantarflexion (PF) angular velocity was smaller in DAO compared to CON and DUAFO. Eversion (EV) ROM was much smaller in DUAFO compared to CON and DAO. Early stance peak eversion angular velocity was smaller in DAO and much smaller in DUAFO compared to CON. This study demonstrates the capacity of the DAO to provide offloading during ambulation without greatly affecting kinematic parameters including frontal plane ankle motion compared to CON. Future work will assess the effectiveness of the DAO in a clinical osteoarthritic population.

Pressure distribution under the contralateral limb in Charcot arthropathy with different walking speeds

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.

Physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers: a critical review

Obesity and a sedentary lifestyle are common challenges among individuals at risk of diabetic foot ulcers. While substantial research exists on physical activity interventions in adults with diabetes, those at greatest risk for foot ulceration were often excluded or not well represented. Both at-risk patients and their clinicians may be hesitant to increase physical activity because of their perception of diabetic foot ulcer risks. Physical activity is not contraindicated for those at risk of diabetic foot ulcer, yet patients at risk present with unique barriers to initiating increases in physical activity. This review focuses upon the physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers. Offloading, diabetic peripheral neuropathy, depression, pain, self-efficacy and social support, diabetic foot ulcer risk-specific beliefs and emotions, and research to date on exercise interventions in this population are all discussed. Additionally, recommendations for implementing and researching physical activity interventions for individuals at risk for diabetic foot ulcer are provided. Copyright © 2016 John Wiley & Sons, Ltd.

Shorter recovery can be achieved from using walking boot after operative treatment of an ankle fracture

Background/Objective

Ankle fractures, even if treated surgically, usually take a long time to heal. For all patients with ankle fracture, immobilisation is a critical part of treatment. Short-leg walking boots (WBs) have been reported to be an effective alternative to plaster casts (PCs) that could shorten this postoperative recuperative period. The aim of this study was to compare the functional recovery of a conventional PC with that of a WB after surgery for ankle fractures.

Methods

Forty-seven patients (mean age, 53.9 ± 12 years) who had undergone surgical operation for an unstable ankle fracture from January 2008 to October 2014 were reviewed retrospectively. Either a PC or a WB was prescribed postoperatively, with 25 patients and 22 patients, respectively. The time that it took the patient to stand unipedal on the affected side after allowing full-weight bear and to walk without crutches were used for assessment of functional recovery. The prevalence of postoperative loss of reduction and nonunion was also reviewed.

Results

Both the time of being able to stand unipedal on the injured side and to walk without crutches were significantly shorter in patients using WBs (WB, 2.6 weeks; PC, 4.5 weeks, p = 0.01; WB, 1.4 weeks; PC, 3.1 weeks, p = 0.03). There were no patients with loss of reduction or nonunion.

Conclusion

Patients who used WBs showed a significantly faster recovery. WBs have an adjustable heel lift that allows users to change the ankle position slightly plantarflexed that helps walking in a postoperative swollen ankle. WBs are easy to slip on, and it is easy to adjust the ankle position in conformity with swelling so that the least painful position could be maintained during walking. WBs have good fixity to allow immediate weight-bearing postoperatively, and there were no cases with loss of reduction postoperatively. The Rocker bottom design minimises the sagittal plane motion in the specific joint of the foot, which also facilitates the course of recuperation. An ankle fracture fixed appropriately endures loading when a WB is used. The WB treatment results in faster functional recovery, allowing the patients to return to normal activity at a faster rate.

A Review of the Biomechanics of the Diabetic Foot

In general, diabetic foot ulcers result from abnormal mechanical loading of the foot, such as repetitive moderate pressure applied to the plantar aspect of the foot while walking. Diabetic peripheral neuropathy causes changes in foot structure, affecting foot function and subsequently leading to increased plantar foot pressure, which is a predictive risk factor for the development of diabetic foot ulceration. Prevention of diabetic foot ulceration is possible by early identification of the insensitive foot, therefore a foot “at risk,” and by protecting the foot from abnormal biomechanical loading. Abnormal foot pressures can be reduced using several different approaches, including callus debridement, prescription of special footwear, injection of liquid silicone, Achilles tendon lengthening, and so forth. Off-loading of the diabetic wound is a key factor in successful wound healing, as it is associated with reduced inflammatory and accelerated repair processes. Pressure relief can be achieved using various off-loading modalities including accommodative dressing, walking splints, ankle-foot orthosis, total contact cast, and removable and irremovable cast walkers.

Effective and Economic Offloading of Diabetic Foot Ulcers in India with the Bohler Iron Plaster Cast

Economic constraints are a major obstacle to the implementation of offloading casts in India. The aim of this study is to monitor the healing and activity limitations related to Bohler iron plaster cast (BIPC) when used for offloading diabetic neuropathic plantar foot ulcers. Thirty patients were cast for 1 month and evaluated for healing using the Pressure Ulcer Scale for Healing (PUSH), and for activity limitation using the Lower Extremity Functional Scale (LEFS). The change in the scores after intervention was the outcome measure. There was good healing as evidenced by a statistical difference in mean PUSH scores. The baseline PUSH score of 9.76-0.41 (T1-SEM) was greater than follow-up PUSH score of 6.32 + 0.41 (T2 + SEM) and the p value <0.0001. Improvement was seen in ulcer area, exudate, and tissue type. There was no mobility effect as there was no significant difference in LEFS. Significant negative correlation was there between PUSH and LEFS. The r value was less than -0.7 both at baseline and after intervention. The combined benefits of good healing, lack of affect on lower extremity function, the ease of application and dressing, and relative affordability make BIPC a commendable offloading modality for the management of diabetic plantar ulcers.

Total contact cast wall load in patients with a plantar forefoot ulcer and diabetes

BACKGROUND

The total contact cast (TCC) is an effective intervention to reduce plantar pressure in patients with diabetes and a plantar forefoot ulcer. The walls of the TCC have been indirectly shown to bear approximately 30 % of the plantar load. A new direct method to measure inside the TCC walls with capacitance sensors has shown that the anterodistal and posterolateral-distal regions of the lower leg bear the highest load. The objective of this study was to directly measure these two regions in patients with Diabetes and a plantar forefoot ulcer to further understand the mechanism of pressure reduction in the TCC.

METHODS

A TCC was applied to 17 patients with Diabetes and a plantar forefoot ulcer. TCC wall load (contact area, peak pressure and max force) at the anterodistal and posterolateral-distal regions of the lower leg were evaluated with two capacitance sensor strips measuring 90 cm(2) (pliance®, novel GmbH, Germany). Plantar load (contact area, peak pressure and max force) was measured with a capacitance sensor insole (pedar®, novel GmbH, Germany) placed inside the TCC. Both pedar® and pliance® collected data simultaneously at a sampling rate of 50Hz synchronised to heel strike. The magnitude of TCC wall load as a proportion of plantar load was calculated. The TCC walls were then removed to determine the differences in plantar loading between the TCC and the cut down shoe-cast for the whole foot, rearfoot, midfoot and forefoot (region of interest).

RESULTS

TCC wall load was substantial. The anterodistal lower leg recorded 48 % and the posterolateral-distal lower leg recorded 34 % of plantar contact area. The anterodistal lower leg recorded 28 % and the posterolateral-distal lower leg recorded 12 % of plantar peak pressure. The anterodistal lower leg recorded 12 % and the posterolateral-distal lower leg recorded 4 % of plantar max force. There were significant differences in plantar load between the TCC and the cut down shoe-cast for the whole foot, rearfoot, midfoot and forefoot (region of ulcer). Contact area significantly increased by 5 % beneath the whole foot, 8 % at the midfoot and 6 % at the forefoot in the shoe-cast (p < 0.05). Peak pressure significantly increased by 8 % beneath the midfoot and 13 % at the forefoot in the shoe-cast (p < 0.05). Max force significantly increased 6 % beneath the midfoot in the (shoe-cast p < 0.05).

CONCLUSION

In patients with diabetes and a plantar forefoot ulcer, the walls of the TCC bear considerable load. Reduced plantar contact area in the TCC compared to the shoe-cast suggests that the foot is suspended by the considerable load bearing capacity of the walls of the TCC which contributes mechanically to the pressure reduction and redistribution properties of the TCC.

[Surgical treatment of the Charcot foot : long-term results and systematic review]

BACKGROUND

Because of extensive bone loss and the associated complex instability and deformity of the feet, Charcot arthropathy or neuroosteoarthropathy is a challenge for the orthopedic surgeon. Ulcerations offer entry of various bacteria; thus, infections are a frequent serious issue and complication. The careful choice of treatment is not only very important for the correct alignment of the foot and the loading capacity, but also contributes significantly to the prevention of skin irritation or the healing of existing ulcers. Above all, chronic plantar ulcerations, caused by prominent exostoses or axial malalignments are almost untreatable without surgery. Because diagnosis requires an individual approach, no strict regimen of therapy has become established.

OBJECTIVES

The major objective was to reduce the number of ulcerations and infections, and to minimize the risk of amputation. In addition, complications and comorbidities were determined. Tibio-calcaneal arthrodesis is a very frequently used surgical treatment option. Therefore, a special focus in the following article is on this method.

MATERIALS AND METHODS

In a 12-year period (1999-2011), 43 patients (46 feet) suffering from Charcot foot were treated surgically. The following were used: triple, talo-navicular, subtalar, tibio-calcaneal arthrodesis and midfoot fusion bolts. The arthrodesis related to the hindfoot and tarsus and most commonly the tibio-calcaneal arthrodesis was applied. The reduction of load on the affected foot preoperatively and postoperatively by white-cast, Aircast walker shoe or other orthesis is essential in the treatment. For a long-term satisfactory outcome, an orthopedic custom-made shoe is indispensable after surgical treatment.

RESULTS

After surgical treatment of 16 feet with ulcerations, 14 could be healed and only 2 suffered from complications, such as infections, nonunions, talus necrosis, and wound healing disorder. Revision was frequently necessary, although the majority of complications could be treated. In this population, three amputations could not be prevented.

CONCLUSION

Even with strict aseptic techniques and years of experience in Charcot arthropathy, complications can occur, which can even lead to amputation. The early detection of the Charcot foot is the most important factor and helps to reduce morbidity and further complications. Co-morbid diseases (e.g., diabetes mellitus) need special care and optimal treatment, because they are often responsible for the poor surgical outcome. Finally, the ulceration rate and related complications, such as amputation, can be reduced by timely surgical treatment. Unfortunately, the progressive course of the disease often requires follow-up operations.

Diabetes mellitus: musculoskeletal manifestations and perioperative considerations for the orthopaedic surgeon

Diabetes mellitus is a disease of uncontrolled hyperglycemia. Despite a more sophisticated understanding of the pathophysiology of diabetes mellitus and despite pharmacologic advancements that enable better glycemic control, the prevalence of this disease and its devastating sequelae continue to rise. The adverse effects of diabetes on the nervous, vascular, and immune systems render the musculoskeletal system vulnerable to considerable damage. Foot involvement has traditionally been thought of as the most severe and frequently encountered orthopaedic consequence. However, the upper extremity, spine, and muscles are also commonly affected. Orthopaedic surgeons are more involved than ever in the care of patients with diabetes mellitus, and they play a vital role in the multidisciplinary approach used to treat these patients. As a result, surgeons must have a comprehensive understanding of the musculoskeletal manifestations and perioperative considerations of diabetes in order to most effectively care for patients with diabetes mellitus.

Patellar tendon bearing brace: combined effect of heel clearance and ankle status on foot plantar pressure

BACKGROUND

Heel clearance and ankle status (free or locked) are of major determinants affecting peak plantar pressures and contact area in patellar tendon bearing brace and have been separately studied by many researchers. This study investigated the combined effect of ankle status and heel clearance on contact area and peak plantar pressure in different areas of foot (hindfoot, midfoot, and forefoot).

STUDY DESIGN

Before-after repeated measurement trial.

METHODS

Nine healthy male volunteers walked 8 m with normal shoe and four conditions of patellar tendon bearing brace wear. Repeated-measure analysis of variance test was used to compare contact area and plantar pressure changes in three areas of the foot.

RESULTS

Application of patellar tendon bearing brace significantly reduced overall plantar pressure and contact area (p < 0.01). Although both contact area and plantar pressure significantly decreased in hindfoot and midfoot, plantar pressure increased in forefoot area (p < 0.05).

CONCLUSIONS

Application of the patellar tendon bearing brace can reduce the overall peak plantar pressure in the foot but increases focal plantar pressure in forefoot. Excessive lifting of the heel seems to minimize the contact area, thus increase focal pressure in forefoot. Overall, plantar pressure seems to be more effectively off-loaded by combining maximum heel clearance and restriction of the ankle joint.

CLINICAL RELEVANCE

Although effective parameters of patellar tendon bearing brace have been separately addressed in previous studies, no study was found that investigated the combined effect of ankle status and heel clearance. This study investigates the combined effect of these parameters and provides detailed information on clinical application of the patellar tendon bearing brace.

The Correlation between Dynamic Balance Measures and Stance Sub-phase COP Displacement Time in Older Adults during Obstacle Crossing

[Purpose] This study examined the relationship between the center of pressure (COP) displacement time during the stance subphases and dynamic balance ability when elderly cross obstacles 0, 10, and 40 cm in height. [Subjects] Fifteen older adults were enrolled in this study (≥65 years of age). [Methods] An F-Scan System was used to measure the COP displacement time when subjects crossed obstacles 0, 10, and 40 cm in height, and the Dynamic Gait Index, Berg Balance Scale, and Four Square Step Test were used to measure dynamic balance ability. [Results] The Dynamic Gait Index, Berg Balance Scale, and Four Square Step Test were correlated with each other. Dynamic balance tests were correlated with the COP displacement time during the stance phase. At obstacle heights of 10 and 40 cm during loading response and at all heights during pre-swing, there were correlations with dynamic balance ability. However, dynamic balance ability did not affect the COP displacement time during mid-stance and terminal stance. [Conclusion] People with a lower dynamic balance ability show a larger COP displacement time during loading response and pre-swing. Therefore, dynamic balance ability can be predicted by measuring the COP displacement time.

Impact of strut height on offloading capacity of removable cast walkers

BACKGROUND

Reducing weight-bearing stress to diabetic foot ulcers is critical to healing and commonly called offloading. Removable cast walkers are frequently used for offloading; however, patient compliance is often poor. Walkers commonly extend to the knee. Patients complain about walkers' weight and diminished balance with their use. This study compared the offloading capacity of walkers that varied by height. Heights included: knee, ankle, and shoe levels. To ensure a fair comparison the outsole and insole were standardized across the devices.

METHODS

Eleven diabetic subjects with moderate to high risk of ulceration were recruited. Subjects completed four 20 m walking trials. Subjects performed one trial with each walker and one trial with an athletic shoe. Primary outcomes focused on plantar loading and were measured by pressure insoles. Secondary outcomes were associated with gait kinematics as collected by body worn sensors.

FINDINGS

Significant differences were found for the peak pressure and pressure time integrals of the different footwear. All walkers performed better than the athletic shoe. The ankle and knee-high devices performed best. Center of mass rotation data showed a trend of the ankle walker yielding a smaller range of motion (18% medial/lateral and 22% anterior/posterior) than the knee level.

INTERPRETATION

The ankle-high walker was able to provide similar offloading capacities as the knee-high walker. The diminished weight, along with potentially improved stability, may result in improved compliance with ankle-high walkers. A study comparing the use of the two devices for treating ulcers is now suggested.

The effects of safety handrails and the heights of scaffolds on the subjective and objective evaluation of postural stability and cardiovascular stress in novice and expert construction workers

Work performed on scaffolds carries the risk of falling that disproportionately threatens the safety and health of novice construction workers. Hence, objective measures of the postural stability, cardiovascular stress, and subjective difficulty in maintaining postural balance were evaluated for four expert and four novice construction workers performing a manual task in a standing posture on a scaffold with and without safety handrails at two different elevation heights. Based on a multivariate analysis of variance, the experience, scaffold height, and presence of a handrail were found to significantly affect measures of the postural stability and cardiovascular stress. At a lower level of worker experience, a higher scaffold height, and in the absence of a handrail (which may correspond to higher risk of a fall), postural stability was significantly reduced, while cardiovascular stress and subjective difficulties in maintaining postural balance increased. We emphasize the importance of training and handrails for fall prevention at construction sites.

Pedographic classification and ulcer detection in the diabetic foot

BACKGROUND

Plantar pressure is a cause of foot ulceration in diabetes. Attempts to determine a pressure threshold have failed. The aim of this study was to determine a pedographic classification to identify patients at risk for a foot ulcer.

METHODS

210 diabetics and controls categorized into 4 groups with deformities of the forefoot were analyzed. For the pedographic measurement peak pressure, force and their integrals were analyzed using a percentage and an anatomic mask. A multivariant logistic regression analysis was performed.

RESULTS

Logistic regression analysis using pedographic variables of a percentage mask revealed a combination of 4 variables (pressure time integral forefoot, peak pressure midfoot, pressure time integral heel, and peak pressure heel) identifying the foot ulcer with a sensitivity of 73% and a specificity of 87%. The analysis using an anatomic mask identified 8 variables (pressure time integral mask 4 (metatarsal 2), force mask 9 (2. toe), force time integral mask 8 (great toe), peak pressure mask 6 (metatarsal 4), pressure time integral mask 6 (metatarsal 4), peak pressure mask 8 (great toe), peak pressure mask 7 (metatarsal 5), and force mask 6 (metatarsal 4)) that characterized a pedal ulcer with a sensitivity of 95% and a specificity of 90%.

CONCLUSION

This screening method identifies diabetics who are at risk for a foot ulcer.

Role of dynamic MRI in the follow-up of acute Charcot foot in patients with diabetes mellitus

PURPOSE

To evaluate the usefulness of magnetic resonance imaging (MRI) in assessing the level of activity of acute Charcot foot, monitoring treatment response and predicting healing time.

MATERIALS AND METHODS

Forty diabetic patients with acute Charcot foot were prospectively enrolled. Patients underwent limb immobilization and were followed every 3 months by clinical examination (skin temperature and circumferences) and MRI. MR protocol included T1-weighted and fast spin echo inversion recovery (FSE-IR) sequences, and a dynamic study (fast spoiled gradient echo), after gadolinium administration (0.1 ml/kg). The contrast medium uptake rate at D-MRI and the signal intensity (SI) ratio on the FSE-IR sequence were measured.

RESULTS

At baseline, mean contrast medium uptake rate was 136 ± 49.7% and the mean SI ratio was 5 ± 3. A high intra- and inter-observer agreement was found for the contrast medium uptake rate, whereas a low agreement was observed for the SI ratio. At 3 months' follow-up, reduction of the contrast medium uptake rate was observed in all patients with improved clinical findings (n = 34), whereas the SI ratio was reduced in 15/34 (44.1%) patients. Mean healing time was significantly related to the baseline contrast medium uptake rate (P=0.005); it was 5.3 ± 2.7 months in patients with contrast medium uptake rate ≤ 100%, compared with 9.1 ± 2.5 months in the remaining patients (P=0.0003).

CONCLUSIONS

Contrast medium uptake rate obtained at D-MRI represents a reproducible parameter that is reliable for predicting and monitoring treatment outcome in acute Charcot foot.

A prospective study comparing attempted weight bearing in fiberglass below-knee casts and prefabricated pneumatic braces

Partial weight bearing is commonly advised after fracture of the lower extremity. Research has determined this to be inaccurate both in its instruction and its reproducibility. Many trauma departments are commonly using alternatives to plaster in the splintage of fractures, such as fiberglass and the prefabricated pneumatic braces. This study's null hypothesis is that there is no difference between partial weight bearing through a fiberglass cast as compared with a pneumatic walker. A prospective study was conducted in our department including all patients who had metatarsal or ankle fractures and could partially weight bear. Patients were excluded if they were not allowed to bear weight, had received operative fixation of their fracture, or were younger than age 16 years. The patients' total weight was measured first, and then they were trained to place 50% of their weight through the splinted limb. Three measurements were taken of their attempted weight bearing at 50%, and they were blinded to the results. Over a 16-month period, 117 patients were enrolled for this study: 72 in the pneumatic walker group and 45 in the fiberglass group. There was no significant difference in sex, age, or fracture type. There was a significant difference in percentage of weight placed through the splinted limb, with the pneumatic brace group placing much greater force than the fiberglass group. This may have been caused by altered proprioception from the walker. It is important to realize this when prescribing partial weight bearing in a particular splint as this may result in avoidable complications.

The efficacy of a removable vacuum-cushioned cast replacement system in reducing plantar forefoot pressures in diabetic patients

BACKGROUND

The purpose of this study was to determine the plantar forefoot offloading efficacy of a new prefabricated vacuum-cushioned cast replacement system designed for foot ulcer treatment in neuropathic diabetic patients.

METHODS

Fifteen diabetic subjects with peripheral neuropathy underwent in-shoe plantar pressure assessment while walking in five different footwear types: a standard vacuum-cushioned system with instantly moldable vacuum cushion and roller outsole, two modified vacuum-cushioned systems, one with flat surface vacuum cushion and one with flat outsole, a forefoot offloading shoe, and a control shoe. Regional peak pressures, pressure-time integrals, and inter-regional load transfers were calculated to determine the mechanical action of the footwear. Perceived walking comfort was tested using a 10-point visual analogue scale.

FINDINGS

Forefoot peak pressures and pressure-time integrals were significantly lower (by 41-56%) in the vacuum-cushioned system compared to control. Compared to the forefoot offloading shoe, the vacuum-cushioned system showed significantly higher metatarsal head peak pressures, similar metatarsal head pressure-time integrals, and significantly lower hallux peak pressures and pressure-time integrals. A major transfer of forefoot load to the midfoot explained the offloading efficacy of the vacuum-cushioned system. Few significant differences were present between the modified and standard vacuum-cushioned systems. Perceived walking comfort was significantly higher in the vacuum-cushioned system (score 6.6) than in the forefoot offloading shoe (score 3.4).

INTERPRETATION

The results showed that the vacuum-cushioned cast replacement system was effective in offloading the plantar forefoot of diabetic patients at risk for ulceration, although the contribution of the instantly moldable vacuum cushion and roller outsole were relatively small. The combined peak pressure, pressure-time integral and walking comfort results indicate that the vacuum-cushioned system may be a useful alternative for the forefoot offloading shoe in offloading the plantar diabetic forefoot.

Treatment of Charcot foot and ankle with a prefabricated removable walker brace and custom insole

BACKGROUND

Removable walker braces have been used successfully to treat acute and chronic foot and ankle conditions including diabetic foot ulcers. We hypothesized that a removable walker brace may be successfully used in the management of the Charcot foot and ankle.

METHODS

Twenty-five feet and ankles with Charcot arthropathy in 21 patients (bilateral in 4 patients) were treated with a prefabricated, pneumatic removable walker brace fitted with a custom orthotic insole. Follow-up data were collected from patient interview, examination, and radiography.

RESULTS

Brace fitting was accomplished usually with a single visit to the prosthetist or pedorthist/orthotist. At the most recent evaluation, 17 (68%) feet and ankles had consolidation (stage III) of the Charcot arthropathy (average duration of brace use, 29+/-19 weeks) and were subsequently treated with rocker sole shoes, insoles, and ankle foot orthoses; 8 (32%) feet and ankles had ongoing brace treatment. Three feet developed new deformity during brace treatment, but average radiographic parameters of hindfoot to forefoot alignment had minimal change between initial and final radiographs at an average of 36+/-24 weeks after initial radiographic evaluation.

CONCLUSIONS

The prefabricated, pneumatic removable walker brace fitted with a custom insole was successful in the management of the Charcot foot and ankle and had a high satisfaction rate and safety profile despite frequent, albeit usually minor, complications.

The football: an intuitive dressing for offloading neuropathic plantar forefoot ulcerations

A reproducible, affordable, efficacious and safe modality for offloading neuropathic plantar foot ulcerations was previously presented in a pilot study. A follow-up retrospective multicentre analysis of the football dressing is now presented. Wound healing rates are compared with published data on the total contact cast (TCC) and instant total contact cast (iTCC). Overall wound healing rates for University of Texas Health Science Center class 1A, 1B, 1C, 1D, 2A, 2B, 2C and 3B plantar forefoot ulcerations is 2.91 weeks with a 95% confidence interval of 2.36-3.47 weeks for complete wound epithelialisation. The cost associated with this dressing technique is a fraction of that associated with the TCC and iTCC. The ease of application coupled with reliable healing rates and affordable materials makes the football dressing a worthy partner against the sequelae of plantar forefoot ulcerations.

Physical management of the Charcot foot

Charcot arthropathy places individuals at risk of developing diabetic foot ulcers and potentially subsequent limb amputation by means of altering the anatomy of the foot and ankle. Physical trauma is an important component to the etiology of the condition. The physical management of the Charcot foot is concerned with minimizing the stress applied to the affected foot and ankle skeletal structure. The most appropriate device is temporally dependent on the progression of the disease. At the initiation of Charcot arthropathy, care by total contact cast is recommended. As the affected bones begin to heal, use of a removable cast walker may be implemented. When the bones reach a fixed state, appropriate footwear is dictated by the degree of deformity.

The diabetic foot

Diabetic foot problems are common throughout the world, resulting in major medical, social and economic consequences for the patients, their families, and society. Foot ulcers are more likely to be of neuropathic origin, and therefore eminently preventable. People at greatest risk of ulceration can easily be identified by careful clinical examination of the feet: education and frequent follow-up is indicated for these patients. When infection complicates a foot ulcer, the combination can be limb or life-threatening. Infection is defined clinically, but wound cultures assist in identifying the causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and although such therapy may cure the infection, it does not heal the wound. Alleviation of the mechanical load on ulcers (offloading) should always be a part of treatment. Plantar neuropathic ulcers typically heal in 6 weeks with irremovable casting, because pressure at the ulcer site is mitigated and compliance is enforced. The success of other approaches to offloading similarly depends on the patients' adherence to the effectiveness of pressure relief.

Alterations in plantar pressure with different walking boot designs

BACKGROUND

Specialized walking devices, such as total contact casts and removable walking boots, have been shown to be effective noninvasive treatment options for plantar ulcers. Attempts at improving patient compliance frequently lead to new boot designs; however, the effect of the design modifications on plantar pressures or on the contralateral limb often is unknown. The purpose of this study was to determine the effect of different walking-boot calf heights and rocker sole designs on regional plantar pressures, as well as, on contralateral limb loading during walking.

METHODS

Twenty-six subjects, 20 to 54 years of age, without foot pathology were tested using four different configurations: high calf, rocker sole (HCR); low calf, rocker sole (LCR); low calf, modified rocker sole (LCMR), and shoe. Peak pressures, pressure-time integrals, and contact areas were measured using the Novel Pedar-X insole pressure measurement system. Average peak force was calculated for the contralateral limb.

RESULTS

Greatest forefoot peak pressure reduction was found in the HCR group (37.3% reduction compared to shoe condition), followed by 31.6% and 19.8% in the LCR and LCMR groups, respectively (p<0.0001). Forefoot pressure-time integrals were reduced for HCR and LCR (22.1% and 21.5%, respectively) compared to the LCMR (13.0%) (p<0.0001).

CONCLUSIONS

Isolated modifications in walking boot designs resulted in plantar pressure modifications. LCR and LCMR designs favorably altered plantar pressures, but of a lesser magnitude than the HCR design. If lower calf, lower sole walking boot designs are recommended because of anticipated improvement in patient compliance, healing times may be prolonged.

Ground reaction force and 3D biomechanical characteristics of walking in short-leg walkers

Short-leg walking boots offer several advantages over traditional casts. However, their effects on ground reaction forces (GRF) and three-dimensional (3D) biomechanics are not fully understood. The purpose of the study was to examine 3D lower extremity kinematics and joint dynamics during walking in two different short-leg walking boots. Eleven (five females and six males) healthy subjects performed five level walking trials in each of three conditions: two testing boot conditions, Gait Walker (DeRoyal Industries, Inc.) and Equalizer (Royce Medical Co.), and one pair of laboratory shoes (Noveto, Adidas). A force platform and a 6-camera Vicon motion analysis system were used to collect GRFs and 3D kinematic data during the testing session. A one-way repeated measures analysis of variance (ANOVA) was used to evaluate selected kinematic, GRF, and joint kinetic variables (p<0.05). The results revealed that both short-leg walking boots were effective in minimizing ankle eversion and hip adduction. Neither walker increased the bimodal vertical GRF peaks typically observed in normal walking. However, they did impose a small initial peak (<1BW) earlier in the stance phase. The Gait Walker also exhibited a slightly increased vertical GRF during midstance. These characteristics may be related to the sole materials/design, the restriction of ankle movements, and/or the elevated heel heights of the tested walkers. Both walkers appeared to increase the demand on the knee extensors while they decreased the demand of the knee and hip abductors based on the joint kinetic results.

Outcomes of allogenic acellular matrix therapy in treatment of diabetic foot wounds: an initial experience

The purpose of this study was to evaluate outcomes of persons with UT grade 2A neuropathic diabetic foot wounds treated with an acellular matrix. Data were abstracted for 17 consecutive patients with diabetes--76.5% males, aged 61.5 +/- 8.5 years with a mean glycated haemoglobin of 9.2 +/- 2.2% presenting for care at a large, multidisciplinary wound care centre. All patients received surgical debridement for their diabetic foot wounds and were placed on therapy consisting of a single application of an acellular matrix graft (GraftJacket; Wright Medical Technologies, Arlington, TN, USA) with dressing changes taking place weekly. Outcomes evaluated included time to complete wound closure and proportion of patients achieving wound closure in 20 weeks. Acellular matrix therapy was used as initial therapy and was sutured or stapled in place under a silicone-based non adherent dressing. Therapy was then followed by a moisture-retentive dressing until complete epithelialisation. In total, 82.4% of wounds measuring a mean 4.6 +/- 3.2 cm(2) healed in the 20-week evaluation period. For those that healed in this period, healing took place in a mean 8.9 +/- 2.7 weeks. We conclude that a regimen consisting of moist wound healing using an acellular matrix dressing may be a useful adjunct to appropriate diabetic foot ulcer care for deep, non-infected, non-ischaemic wounds. We await the completion of further trials in this area to confirm or refute this initial assessment.

The Role of Activity, Adherence, and Off-Loading on the Healing of Diabetic Foot Wounds

The etiology of diabetic foot ulcerations is commonly associated with the presence of peripheral neuropathy and repetitive trauma due to normal walking activities to areas of the foot exposed to moderate or high pressure. The goal of any treatment plan should include as a central tenet the mitigation or modulation of this activity and/or pressure. While numerous studies have detailed the potential pressure off-loading properties of various treatment modalities, subsequent studies have suggested that, if easily removable, these therapies will likely not be used for the majority of steps taken each day. This serves to explain at least in part the often disappointing results of both these pressure off-loading technologies and advanced wound-healing therapies. This article reviews these data and suggests that an amalgam of effective pressure relief coupled with strategies to reduce nonadherence to this therapy could yield a potentially favorable clinical result.

The pivotal role of offloading in the management of neuropathic foot ulceration

Lower extremity amputations among persons with diabetes are generally preceded by neuropathic foot ulcerations. Healing of diabetic ulcerations in a timely manner is of central importance in any plan for amputation prevention. With sufficient vascular supply, appropriate débridement, and infection control, the primary mode of healing a diabetic neuropathic foot ulcer is pressure dispersion. The total contact cast has been deemed by many to be the gold standard in offloading; however, modification of a standard removable cast walker to ensure patient compliance may be as efficacious in healing diabetic foot ulcers as the total contact cast. Combining an effective, easy to use offloading device that ensures patient compliance with advanced wound healing modalities may form a formidable team in healing ulcers and potentially averting lower limb amputations.

Treatment for diabetic foot ulcers

People with diabetes develop foot ulcers because of neuropathy (sensory, motor, and autonomic deficits), ischaemia, or both. The initiating injury may be from acute mechanical or thermal trauma or from repetitively or continuously applied mechanical stress. Patients with clinically significant limb ischaemia should be assessed by a vascular surgeon to determine the need for angioplasty, stenting, or femorodistal bypass. When infection complicates a foot ulcer, the combination can be limb or life-threatening. Infection is defined clinically, but wound cultures reveal the causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and should aim to cure the infection, not to heal the wound. Alleviation of the mechanical load on ulcers (off-loading) should always be a part of treatment. Neuropathic ulcers typically heal in 6 weeks with total contact casting, because it effectively relieves pressure at the ulcer site and enforces patient compliance. The success of other approaches to off-loading similarly depends on the patients' adherence to the effectiveness of pressure relief. Surgery to heal ulcers and prevent recurrence can include tenotomy, tendon lengthening, reconstruction, or removal of bony prominences. However, these procedures may result in secondary ulceration and other complications. Ulcer recurrence rates are high, but appropriate education for patients, the provision of posthealing footwear, and regular foot care can reduce rates of re-ulceration.

Plantar pressure in off-loading devices used in diabetic ulcer treatment

Four off-loading devices used for the treatment of diabetic forefoot ulcers were compared: a custom-molded insole shoe, a cast MABAL shoe, a prefabricated pneumatic walking brace, and a bivalved total contact cast (BTCC). It was anticipated that all devices would significantly reduce forefoot plantar pressure compared with a control shoe. Sixteen healthy volunteers participated. Plantar pressures were evaluated using the Pedar system, while walking speed was determined using an optoelectric timer. Peak pressure (PP) of ten plantar areas and pressure-time integral for the first metatarsal area were analyzed statistically using a repeated measures analysis of variance. Forefoot pressures were significantly reduced compared with the control shoe for all devices (p<0.001). PP was most reduced (by 65.8%) for the BTCC, and pressure-time integral was most reduced for the BTCC and cast MABAL shoe. Small but significant differences between devices in walking speed (p<0.05) could not explain the substantial PP differences between the different devices. Although all off-loading devices resulted in a significant reduction of forefoot plantar pressure, devices differed significantly in the magnitude of pressure reduction. Further research will have to reveal the level of off-loading sufficient for effective treatment of diabetic ulcers.

An analysis of iatrogenic complications from the total contact cast

BACKGROUND

Many physicians continue to fear iatrogenic complications of the total contact cast, and use of this modality has remained restricted to a segment of the orthopaedic and podiatric communities. I examined the actual rate of complications and the factors associated with them in a large consecutive series of total contact casts drawn from the practice of a single surgeon to determine whether this modality is safe for multiple conditions in the neuropathic foot and ankle.

METHOD

A consecutive series of 398 total contact casts spanning a 28-month period from the practice of a single physician were analyzed. All casts were placed by the same team of orthotists. This study comprised 70 patients with severe peripheral neuropathy; an average of 5.69 sequential casts per patient were placed. Three-hundred and sixty-seven casts were placed in diabetic patients, and 31 in patients with idiopathic peripheral neuropathy. By protocol, the initial cast was changed at an interval of no more than 1 week. On occasion, subsequent casts were left on longer, but on average casts were left in place for 7.69 days. Logistic regression analysis was used to analyze the contribution of patient factors to the chance of ulceration.

RESULTS

Complications occurred in 22 casts, including six new pretibial ulcers, six new midfoot ulcers, four forefoot or toe ulcers, five hindfoot ulcers, and one malleolar ulcer. In no case was a preexisting ulcer made worse. This corresponds to an overall complication rate of 5.52% per cast. Overall, 30% of patients suffered one complication during the course of their treatment. With one exception, all new ulcers healed with simple modalities within 3 weeks, often with continued total contact casting. A single cast led to a proximal interphalangeal ulceration that exposed the joint and eventually required toe amputation. The rate of permanent sequelae from cast-related injuries was therefore 0.25%. In no case were the resultant odds ratios statistically different from 1.0, but several trends were observed. Charcot arthropathy represented the highest risk (odds ratio 1.46), while the presence of neuropathic ulceration was surprisingly benign (odds ratio 0.69). The presence of diabetes as opposed to other causes of neuropathy was associated with increased risk (odds ratio 1.34). The use of a cast after deformity-correcting surgery in a neuropathic patient was remarkably safe (odds ratio 0.44), as were casts in which the patient was instructed to remain nonweightbearing (odds ratio 0.27). Patient age was not a factor (odds ratio 1.03). The length of time the cast was left on was not statistically important (odds ratio 0.99), although strict protocols for cast changing likely altered this data.

CONCLUSION

A frequently changed total contact cast is a safe modality for the offloading and immobilization of the neuropathic foot, albeit with an expected constant rate of minor, reversible complications. Patients should be informed of these complications and risks before cast application.

Neuroartropatía diabética en fase aguda: un dilema diagnóstico. A propósito de dos casos y revisión de la bibliografía

INTRODUCTION

Charcot's neuroarthropathy is a progressive deterioration of bones and joints, mainly the ankle and foot of the diabetic patients suffering severe neuropathy. Its pathogeny is not well known, although mechanical, vascular and neurological factors are thought to be involved, generally with a precipitating minor traumatic even. Charcot's foot acute phase is inflammatory, and it is often confused with other diseases such as arthritis, cellulitis and deep venous thrombosis (DVT). This leads to delays or errors in the diagnosis, the patient coming to the hospital too late with severe foot deformation.

OBJECTIVE

Thus, it must always be posed as differential diagnosis in a diabetic patient who comes with a warm and inflamed foot, generally without fever, even more if he has a severe autonomic or somatic neuropathy. In the acute onset, the only treatment has been complete and long term off-loading with a total contact cast that should be initiated immediately after diagnosis. More recent studies show promising results with biphosphonates to decrease bone turnover in acute phase.

CONCLUSION

We present two cases of acute Charcot's foot and we briefly review the bibliography.

Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a removable cast walker (RCW) and an "instant" total contact cast (iTCC) in healing neuropathic diabetic foot ulcerations.

RESEARCH DESIGN AND METHODS

We randomly assigned 50 patients with University of Texas grade 1A diabetic foot ulcerations into one of two off-loading treatment groups: an RCW or the same RCW wrapped with a cohesive bandage (iTCC) so patients could not easily remove the device. Subjects were evaluated weekly for 12 weeks or until wound healing.

RESULTS

An intent-to-treat analysis showed that a higher proportion of patients had ulcers that were healed at 12 weeks in the iTCC group than in the RCW group (82.6 vs. 51.9%, P = 0.02, odds ratio 1.8 [95% CI 1.1-2.9]). Of the patients with ulcers that healed, those treated with an iTCC healed significantly sooner (41.6 +/- 18.7 vs. 58.0 +/- 15.2 days, P = 0.02).

CONCLUSIONS

Modification of a standard RCW to increase patient adherence to pressure off-loading may increase both the proportion of ulcers that heal and the rate of healing of diabetic neuropathic wounds.

Current topics review: Charcot neuroarthropathy of the foot and ankle

Charcot arthropathy is a destructive process, most commonly affecting joints of the foot and ankle in diabetics with peripheral neuropathy. Affected individuals present with swelling, warmth, and erythema, often without history of trauma. Bony fragmentation, fracture, and dislocation progress to foot deformity, bony prominence, and instability. This often causes ulceration and deep infection that may necessitate amputation. Instability or deformity may limit the ability to use standard footwear. Treatment is focused on providing a stable and plantigrade foot for functional ambulation with accommodative footwear and orthoses. Historically, treatment had included nonweightbearing immobilization for the acute phase, and surgery had been reserved only for infection, unresolved skin ulceration, or deformity that precluded the use of therapeutic footwear. Current controversies include weightbearing in the acute or reparative phases and early surgical stabilization. Foot-specific patient education and continued periodic monitoring may reduce the morbidity and associated expense of treating the complications of this disorder and may improve the quality of life in this complex patient population.

The diabetic foot: from art to science. The 18th Camillo Golgi lecture

Diabetic foot ulceration represents a major medical, social and economic problem all over the world. While more than 5% of diabetic patients have a history of foot ulceration, the cumulative lifetime incidence may be as high as 15%. Ethnic differences exist in both ulcer and amputation incidences, with both being less common in patients of Indian subcontinent origin living in the UK. Foot ulceration results from the interaction of several contributory factors, the most important of which is neuropathy. With respect to the management of acute Charcot neuroarthropathy in diabetes, recent studies suggest that bisphosphonates reduce disease activity as judged not only by differences in skin temperature, but also by assessing markers of bone turnover. The use of the total-contact cast is demonstrated in the treatment of acute Charcot feet and of plantar neuropathic ulcers. Histological evidence suggests that pressure relief results in chronic foot ulcers changing their morphological appearance by displaying some features of an acute wound. Thus, repetitive stresses on the insensate foot appear to play a major role in maintaining ulcer chronicity. It is hoped that increasing research activity in foot disease will ultimately result in fewer ulcers and less amputation in diabetes.

The efficacy of two methods of ankle immobilization in reducing gastrocnemius, soleus, and peroneal muscle activity during stance phase of gait

BACKGROUND

Immobilization to limit muscle activity is a common therapeutic and posttreatment event. There are potential time and resource savings if a prefabricated boot can replace a custom applied cast. The purpose of this study was to determine if muscle activity reduction is similar using a fiberglass cast versus a prefabricated (Aircast FoamWalker) boot.

METHODS

Surface EMG data were recorded from the gastrocnemius, soleus, and peroneals of 12 normal adults while walking barefoot, in a fiberglass cast with a cast shoe (cast), and while wearing an Aircast FoamWalker (boot). Subjects walked at their self-selected speed for 10 trials in each condition, and the order of barefoot, cast, and boot was randomly assigned. The data were rectified, integrated across stance phase and normalized to a percent of each subject's barefoot mean integrated EMG (iEMG) value. For each muscle, a linear mixed-effects statistical model (subject by trial by condition) was utilized to determine if iEMG activity levels were reduced by immobilization compared to barefoot walking.

RESULTS

Activity for all muscles was significantly lower in the boot compared with barefoot (p <.05). The cast iEMG levels were significantly different from barefoot for the soleus and peroneals (p <.05). Gastrocnemius activity was significantly decreased in the boot when compared with the cast (p <.0001). The greater reduction in iEMG levels for the boot indicates that it is superior to a fiberglass cast in reducing gastrocnemius muscle activity during the stance phase of gait.

CONCLUSIONS

The data show that a prefabricated boot is as effective as a custom applied cast in reducing soleus and peroneal muscle iEMG during stance phase. The boot was more effective in reducing gastrocnemius activity when compared to the cast.

CLINICAL RELEVANCE

This study suggests that a prefabricated boot may be used in place of a custom cast when the goal of treatment is to limit muscle activity of the leg.

The effect of ankle position on plantar pressure in a short leg walking boot

Short leg walking boots have been shown to be an effective alternative to total contact casting for the reduction of plantar pressure. Conventional theory indicates that placing the ankle in different positions may affect the plantar pressure and ultimately the healing time for a plantar ulcer. This study attempted to determine the changes in plantar pressures due to alterations in the position of the ankle angle in a walking boot. Thirteen healthy subjects were recruited and tested with an insole pressure measurement system. The result demonstrated that small changes in ankle position in dorsiflexion or plantarflexion have a significant impact on resulting forefoot and hindfoot plantar pressures while walking in a prefabricated boot.

The effects of total contact casting materials on plantar pressures

The plaster-based total contact cast (TCC) is effective at reducing high plantar pressures associated with foot ulceration in the patient with diabetes. However, the weight and the lengthy drying time which require nonweightbearing create an inconvenience for the patient. Fiberglass has been commonly used as a substitute for plaster due to the quicker drying time, although little is known about the effects of fiberglass on plantar pressures. The purpose of the study was to compare a plaster-based TCC (PB-TCC) and an all-fiberglass TCC (AF-TCC) using selected plantar pressure parameters for commonly ulcerated regions of the foot. Using a repeated measures design, 10 healthy subjects consented to walk, for four consecutive trials, along a 25-m corridor while wearing a running shoe, PB-TCC, and AF-TCC. For each of the footwear conditions, parameters of peak pressure, pressure-time integral, and contact time for the forefoot, lateral midfoot, and heel regions were recorded using the Pedar trade mark system of plantar pressure measurement. Both the PB-TCC and AF-TCC produced similar peak plantar pressures that were significantly lower (p =.001) than the running shoe. Pressure-time integrals were similar for all footwear conditions and contact time was not altered with footwear type. In summary, the AF-TCC appears to be an effective alternative to the PB-TCC for plantar pressure reduction in the management of neuropathic foot ulceration.

Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen

OBJECTIVE

To evaluate the activity of patients with diabetic foot ulcerations and their adherence to their pressure off-loading device.

RESEARCH DESIGN AND METHODS

We enrolled 20 subjects treated for neuropathic diabetic foot wounds corresponding to University of Texas grade 1 stage A. All were off-loaded using a removable cast walker (RCW). We recorded the total activity (measured in activity steps per day) taken on a waist-worn computerized accelerometer. We subsequently correlated this to activity recorded on an RCW-mounted accelerometer, which was not readily accessible to the patient.

RESULTS

There were a mean 1219.1 +/- 821.2 activity units (steps) taken per patient per day. Patients logged significantly more daily activity units with the protective RCW off than with it on (873.7 +/- 828.0 vs. 345.3 +/- 219.1, P = 0.01). This amounts to only 28% of total daily activity recorded while patients were wearing their RCW. Although a total of 30% of the patients in the study recorded more daily activity units while wearing the device, this subset most adherent to their off-loading regimen still only wore the device for a total of 60% of their total daily activity.

CONCLUSIONS

Subjects with diabetic foot ulcerations appear to wear their off-loading devices for only a minority of steps taken each day. This may partially explain the poor results reported from many trials of agents designed to help speed the healing of these wounds. Control of this important aspect of care with less easily removable devices may increase the prevalence of healing.

Plantar pressures in fiberglass total contact casts vs. a new diabetic walking boot

The objective of this study was to determine in healthy individuals whether the Bledsoe Diabetic Conformer Boot reduces plantar pressures as well as a fiberglass total contact cast. Eighteen normal subjects, without any prior foot or ankle problems, were recruited for this study. Plantar pressures were measured using the Novel Pedar in-shoe pressure measurement system. The results of this study demonstrate that in individuals without foot deformities, the Bledsoe Diabetic Conformer Boot performs as well as, and in many parameters, even better than a fiberglass total contact cast with respect to reducing the forces and pressures on the plantar surface of the foot.