John G. Fleischli

Reducing Plantar Pressure in the Neuropathic Foot: A comparison of footwear

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.

Avascular necrosis of the hallucial sesamoids.

The authors present a literature review and systematic approach to the diagnosis and treatment of avascular necrosis of the sesamoids of the flexor hallucis brevis tendon. Renander, in 1924, was one of the earliest authors to call attention to this condition. Since that time, many other authors have written about this entity, some even questioning its existence. Many different treatment regimes have been postulated, encompassing both the conservative and surgical modalities. Most literature advocates attempted conservative treatment followed by surgical excision, only if conservative methods fail.

Electrical stimulation in wound healing

The authors present a review of the current literature regarding electrical stimulation with special focus on the merits of its uses in wound healing. Literature from a basic science, animal studies and clinical investigations are reviewed. The literature seems to suggest that electrical stimulation can effect wound healing, but the method of delivery remains uncertain.

Effects of diabetes mellitus on the biomechanical properties of human ankle cartilage

Metabolic changes attributable to diabetes mellitus affect numerous organ systems in the body. For example, patients with diabetes have an increased number of musculoskeletal injuries and afflictions compared with patients without diabetes and experience more morbidity associated with injury and treatment. Although diabetes also may afflict articular cartilage, no studies have shown a conclusive link between diabetes and cartilage structural integrity. The objective of this study was to obtain and compare the intrinsic material properties of human ankle articular cartilage from patients with diabetes and those without diabetes. These biomechanical properties (aggregate modulus, Poissons ratio, shear modulus, and permeability) were found to differ significantly between specimens from patients with diabetes and patients without diabetes. Specifically, cartilage from patients with diabetes was significantly softer and more permeable than cartilage from control subjects. For example, in the central portion of the talus, cartilage from patients with diabetes had a 38% smaller aggregate modulus, 37% smaller shear modulus, and 111% larger permeability than did tissue from patients without diabetes. These results provide evidence that joint pathologic processes in patients with diabetes may be associated with compromised structural integrity of articular cartilage.

Reproducibility of gait analysis variables: One-step versus three-step method of data acquisition

The purpose of the study was to evaluate the preciseness and repeatability of EMED-SF platform data collection using two different protocols. Gait variables of five healthy women and five men, with an average age of 27.3 +/- 3.2 years, weighing 67.5 +/- 13.3 kg, were evaluated. With a one-step and a three-step approach of data collection, peak pressure, pressure-time integral, and contact time were measured. Peak pressures were not significantly different between both methods. Significant differences were found between both methods in total contact time and pressure-time integral. Both methods were comparable in peak pressures (error between methods = 7.0), while the one-step protocol was more repeatable (intraclass correlation coefficient = 0.59) than the three-step protocol (intraclass correlation coefficient = 0.36). The error between methods for total contact time and pressure-time integral were 143.3 and 50.1, respectively, suggesting that the two protocols lead to different results. The one-step protocol (intraclass correlation coefficient = 0.40) had a higher repeatability than the three-step protocol (intraclass correlation coefficient = 0.31). The one-step protocol has some advantages over the three-step protocol as far as repeatability, simplicity, convenience, and time conservation are concerned. For measuring total contact time and pressure-time integrals, both methods have comparable repeatability, although the protocols lead to different outcomes.

Effect of diabetes mellitus on the material properties of the distal tibia

This investigation evaluates the effects of diabetes on the mechanical properties of human bone, specifically, the tibia. Seven diabetic and seven nondiabetic human (male) cadaveric distal tibiae were used in this study. The average age of the diabetic cadaveric samples was 51 years (range, 46-61 years), and the average age of the nondiabetic cadaveric samples was 75 years (range, 67-85 years). Three-point bending tests for strength and stiffness were performed on a small sample of each distal tibia. Each specimen was loaded at a constant rate until failure. From the recorded curve of load versus displacement, the ultimate and yield strength of bone and the bending modulus of bone were calculated. The diabetic samples were generally weaker than the older, nondiabetic samples, but no statistically significant differences were found in the elastic modulus (P = .29), yield strength (P = .90), ultimate strength (P = .46), and fracture toughness (P = .78), leading to speculation that diabetes has an effect similar to that of aging on the musculoskeletal system.

Psoriasis and elective foot surgery

The authors present a brief overview of the dermatologic condition, psoriasis. Special attention is given to a review of the literature as it addresses surgery and the psoriatic patient. The authors conclude that psoriatic patients are somewhat more susceptible to postoperative infection, but with proper precautions, complications can be avoided. Therefore, the condition of psoriasis is not an absolute contraindication to elective foot surgery.

Equine Pericardium Collagen Wound Dressing in the Treatment of the Neuropathic Diabetic Foot Wound A Pilot Study

BACKGROUND Treatment of diabetic foot wounds remains a major health-care issue, with diabetic foot ulcers representing the most common causal pathway to lower-extremity amputation. Although several investigations have examined topical collagen-based dressings, none have specifically looked at equine pericardium. We, therefore, evaluated the effect of the equine pericardium dressing on neuropathic foot wounds. METHODS Twenty-three consecutive patients with 34 neuropathic foot wounds were evaluated as part of a pilot study. An equine pericardium dressing was applied in a standard manner, and the patients followed a standard postapplication treatment protocol. Changes in wound size were recorded when the equine dressing was removed and 4 and 12 weeks after application. Patients underwent dressing changes every 3 to 4 days until healed or for 12 weeks. RESULTS Thirty-two wounds in 22 patients were prospectively available for evaluation. On enrollment, the median wound size was 299 mm2. When the equine material was removed (mean, 2.9 weeks), 30 of the wounds (94%) had improved, with a median size of 115 mm2 and an average reduction in size of 44.3% (P<.0001). At 4 weeks, the average decrease in wound size was 52.3% (P<.0001). At 12 weeks, 15 wounds (47%) had healed. CONCLUSIONS This first report of equine pericardium used to treat neuropathic foot ulcerations demonstrates that the equine pericardium dressing is a safe and beneficial treatment for neuropathic wounds.

Identification and treatment of the diabetic neuropathic foot

The authors discuss neuropathic osteoarthropathy in the diabetic foot, often associated with Charcot joints. Identification of this malady as well as indications for treatment are reviewed. Representative cases are illustrated.

Relationship Between Diabetes And Age In Human Metatarsal Bones

Introduction Diabetes mellitus is one of the most complicated diseases faced by both patients and physicians. Much is known and studied about the disease. and its progression. Several studies performed have shown that diabetes has a demineralizing effect on bone, impairs wound and fracture healing, and increases collagen cross-linking. Nonetheless, not enough studies have been performed testing the effect of diabetes on the mechanical properties of bone and its relation to age. Therefore, the purpose of this study is to evaluate the effects of diabetes and age on the mechanical properties of human bones, specifically the metatarsal bones.