John H. Bowker

Impaired vibratory perception and diabetic foot ulceration

We have studied risk factors for diabetic foot ulceration by comparing diabetic patients who had active foot ulcers (n = 86) with diabetic patients who had no history of foot ulcers (n = 49). Whereas there was a strong association of diabetic foot ulceration with abnormal vibratory perception (Odds Ratio = 10.77; p < 0.001, which increased with worsening vibratory perception), there was little association with abnormality of the ankle‐pressure index (Odds Ratio = 2.84, p = n.s.). Although foot ulceration and limited joint mobility were associated (Odds Ratio = 3.57, p < 0.001), this relation was not significant when allowances for abnormal vibratory perception and diabetes duration were made. These data suggest that sensory neuropathy is of greater aetiological importance than peripheral vascular disease in the development of diabetic foot ulceration. The measurement of the vibratory perception threshold is clinically useful in identifying those diabetic patients at high risk of foot ulceration.

Use of Plaster Casts in the Management of Diabetic Neuropathic Foot Ulcers

Neuropathic foot ulceration is a major medical and economic problem among diabetic patients, and the traditional treatment involves bed rest with complete freedom from weight-bearing. We have investigated the use of walking plaster casts in the management of seven diabetic patients with longstanding, chronic plantar ulcers. Although all ulcers healed in a median time of 6 wk, this therapy was not without side effects, which are described in detail. We conclude that casting is a useful therapy for neuropathic ulcers, although several clinic visits, including cast removal and foot inspection, are necessary to avoid potential side effects caused by the casting of insensitive feet.

North American experience with knee disarticulation with use of a posterior myofasciocutaneous flap. Healing rate and functional results in seventy-seven patients.

Background: A method for closure of a knee disarticulation wound with use of the posterior calf skin and gastrocnemius muscle bellies as an integral flap, without destruction of the perforating vessels, was described by Klaes and Eigler in 1985. The purposes of the present study were to report our experience with use of this technique in a prospective series of knee disarticulations and to determine the healing rate and the functional result after use of the flap.Methods: Eighty knee disarticulations, performed with use of the flap described by Klaes and Eigler, in seventy-seven patients were evaluated in a prospective manner. The patients ranged in age from nineteen to ninety-two years (mean, sixty-four years). Thirty-one patients had diabetes mellitus with peripheral vascular disease, and twenty-nine had peripheral vascular disease alone as the primary cause of gangrene. Fourteen patients had a traumatic injury, two had a sarcoma, and one had Ollier disease.Results: Five patients died in the early postoperative period, leaving seventy-five stumps available for evaluation. A total of sixty-seven stumps (89 percent) healed; sixty-three (84 percent) of them healed primarily. Major wound dehiscence occurred in seven stumps (9 percent), requiring revision to the transfemoral level. Six of those patients had a serum albumin level of less than thirty millimoles per liter. Twenty-two (81 percent) of the twenty-seven patients who could walk before surgery were able to walk with a prosthesis after it.Conclusions: This simple technique offers reliable healing of knee disarticulation wounds in properly selected patients with a variety of conditions. It also provides comfortable end-bearing for prosthesis wearers because the distal flap is thick and mobile.

New developments in recreational prostheses and adaptive devices for the amputee.

Regardless of age, conventional prostheses and traditional rehabilitation programs no longer meet the needs and expectations of active amputees. The emphasis on fitness, the availability of stronger and lighter materials, and strong consumer demand have led to plethora of new prosthetic designs by progressive prosthetists and engineers. Prosthetic training techniques now take into account the amputees recreational and sports needs and desires, using advanced athletic training concepts to achieve superior performance in a wide variety of activities. The surgeon, as a key member of the amputee team, should be aware of these profound changes so that they may contribute his or her skill in surgically crafting an optimally functional residual limb. This will allow the amputee to reach for the maximum in cardiopulmonary fitness while achieving social reintegration after amputation. The combination of skills, concepts, and techniques of the amputation surgeon, prosthetist, and therapist/trainer has led to a unique situation, in which for the first time, amputees are able to successfully compete in sports because of their prostheses, rather than in spite of them.

Prosthetics/orthotics research for the twenty-first century: Summary of 1992 conference proceedings

&NA; This article summarizes the findings from a 1992 conference sponsored by the National Center for Medical Rehabilitation Research (NCMRR), which brought together a multidisciplinary group of scientists, clinicians and consumers from the United States and abroad. Participants reported on current prosthetic and orthotic practice and developed recommendations for research initiatives to advance the state of the art. The conferences text, Prosthetic/Orthotic Research for the Twenty‐First Century: Proceedings of an NCMRR Conference, is available from the NCMRR.

Complete replacement of the peroneus longus muscle by a ganglion with compression of the peroneal nerve: a case report.

In a 38-year-old woman, the entire muscle belly of the peroneus longus was replaced by a ganglion. Signs of peroneal nerve dysfunction resulted from direct pressure of the ganglion. Excision of the ganglion required a tenodesis of the peroneus longus tendon to provide a normal gait pattern which was maintained during a 17 month follow-up period. This entity needs careful, prompt evaluation to avoid neurological damage and to distinguish it from compartment syndrome.

Neurological Aspects of Prosthetic/Orthotic Practice

Many patients referred for orthotic or prosthetic services will have associated neurologic deficits. These must be recognized by the practitioner prior to the design and fitting of an orthosis or prosthesis to avoid costly and potentially harmful errors in design and application. Commonly seen deficits are loss of protective sensation, impaired proprioception and spasticity. Any one of these may be associated with fixed soft tissue or bony deformity. A working knowledge of sensory and motor examination, combined with careful history-taking, will greatly enhance the clinical skills of the prosthetistlorthotist in this challenging aspect of practice.