Effect of customized insoles on vertical plantar pressures in sites of previous neuropathic ulceration in the diabetic foot

It is well documented that people with peripheral neuropathy resulting from diabetes mellitus are at an increased risk of developing foot ulceration. Decreased sensation, in combination with high underfoot pressures, has been identified as a prime aetiological factor in the cause of plantar neuropathic ulceration. Foot orthoses are amongst the therapeutic modalities utilized by clinicians in an attempt to decrease elevated plantar pressures from focal areas of actual or potential ulceration. To investigate the effect that custom-made orthoses have on vertical plantar pressures in previously ulcerated sites, eight participants with diabetes mellitus and a history of neuropathic ulceration (four with unilateral ulceration and four with bilateral ulceration), that had been healed for a duration of two months or longer, were assessed. All participants were routinely wearing customized orthoses that had been issued after ulcer healing, with the aim of decreasing plantar pressures and maintaining the healed state. Measurements were taken with and without the customized insole using the F-Scan in-shoe pressure measurement system. Peak vertical pressure, duration of loading, rate of loading, pressure/time integral and total contact surface area were the parameters compared in the insole versus no insole situation.Data were analysed with two-tailed paired t -tests. Reductions in peak vertical pressure (P<0.01), the pressure/time integral (P<0.05) and increased total contact surface area (P<0.01) were statistically significant for the insole versus no insole comparison. Interestingly, there were large differences between participants in the amount of pressure reduction that occurred with the insole, which in some instances was negligible. The findings of this study continue to raise questions regarding the multifactorial aetiology of neuropathic ulceration and the role of vertical plantar pressures in this process.     

Factors associated with ulceration and amputation in the neuropathic foot

The purpose of this paper is to review selected literature on the relationship of neuropathy and other related factors in foot ulceration and lower extremity amputation. There is strong evidence that sensory loss and mechanical stress are the primary cause of foot ulceration and common factors in the pathway to lower extremity amputation. Foot stress results from extrinsic factors such as footwear and intrinsic factors such as deformity and limited joint mobility. Understanding the interplay of these factors is valuable in identifying persons whose feet are at risk, effectively preventing and treating foot ulcerations and ultimately preventing lower extremity amputation.     

The surgical conservation of the neuropathic foot.

Basic surgical principles applied when caring for neuropathic limbs can result in the maintenance or restoration of a useful ulcer-free limb. It is possible to help many patients with neuropathy to become ulcer-free and to remain ulcer-free and mobile, with surgical procedures. Recommended methods of management are briefly outlined. These include the débridement of the osteomyelitic, metatarsal head in order to save the adjacent toe, removal of bony irregularities that predispose to ulceration, and the use of wedge osteotomies and arthrodeses to improve the functional shape of the affected foot. The emphasis is on the removal of high pressure points from the weight-bearing surface and to increase the total area available for weight-bearing. Adequate rest and protection are essential, and include the use of splints or total contact plaster casts in all cases of ulceration of weight-bearing surfaces. All patients with reduced sensory perception should learn daily self-examination and care to reduce the chances of recurrent ulceration. Healing after surgical reconstruction will occur, and the healed tissues, if adequately cared for, will maintain their integrity for years.     

A holistic approach to the management of a neuropathic plantar ulcer

While pressure relief is a vital component of the treatment of neuropathic plantar foot ulcers, many patients are reluctant to wear offloading devices. Healing is more likely to occur if the patient is happy with its appearance and comfort.     

Wound healing: total contact cast vs. custom-made temporary footwear for patients with diabetic foot ulceration

The objective of this study was to compare the effectiveness of irremovable total-contact casts (TCC) and custom-made temporary footwear (CTF) to heal neuropathic foot ulcerations in individuals with diabetes. In this prospective clinical trial, 43 patients with plantar ulcer Grade 1 or 2 (Wagner scale) were randomized to one of two off-loading modalities: TCC or CTF. Outcomes assessed were wound surface area reduction (cm2) and time to wound healing (days) at 2, 4, 8 and 16 weeks. To evaluate safety, possible side effects were recorded at each follow-up visit. The results showed no significant difference in wound surface area reduction (adjusted for baseline wound surface) at 2, 4, 8 or 16 weeks (adjusted mean difference 0.10 cm2; 95% CI -0.92-0.72 at 16 weeks). At 16 weeks, 12 patients had a completely healed ulcer, 6 per group. The median time to healing was shorter for the patients using a cast (52 vs. 90 days, p = 0.26). Five patients with TCC and two with CTF developed device-related complications. It was concluded that: (i) the rate of wound healing is not significantly different for patients treated with CTF or TCC. The difference in wound surface area was small and not significant at any time during follow-up; and (ii) the difference in healing time (38 days) may have attained statistical significance if the numbers in these sub-groups (2 x 6) had been higher. Since there appears to be little difference in effectiveness between both off-loading modalities, further investigation into the benefits of CTF is warranted.     

Light therapy and advanced wound care for a neuropathic plantar ulcer on a Charcot foot

Light therapy is a relatively novel modality in wound care. I used a light-emitting diode (LED) and superluminous diode (SLD) to deliver low-intensity laser light as an adjunctive treatment to a patient with a chronic diabetic foot ulcer. Standard treatment of conservative sharp debridement, off-loading, bioburden management, and advanced dressings was delivered in a WOC clinic setting. This combination of therapies resulted in closure of the neuropathic plantar ulcer within 8 weeks.     

The management of neuropathic ulcers of the foot in diabetes by shock wave therapy

Background  

Diabetes is becoming one of the most common chronic diseases, and ulcers are its most serious complication. Beginning with neuropathy, the subsequent foot wounds frequently lead to lower extremity amputation, even in the absence of critical limb ischemia. In recent years, some researchers have studied external shock wave therapy (ESWT) as a new approach to soft tissue wound healing. The rationale of this study was to evaluate if ESWT is effective in the management of neuropathic diabetic foot ulcers.     

Keller procedure for the treatment of resistant plantar ulceration of the hallux

A retrospective chart review was performed on 11 patients (13 feet) who underwent a modified Keller procedure for the treatment of recalcitrant neuropathic diabetic ulcers to the plantar aspect of the hallux between 1994 and 1998 to evaluate the postoperative results and complications. Diabetic patients with hallux rigidus, adequate vascular status, documented peripheral neuropathy, and at least 6 months of conservative care for treatment of a Wagner grade I and II ulceration were included in the study. Patients with active soft tissue infections or osteomyelitis were excluded. All primary ulcers healed within 6 months postoperatively. After 1-year of follow-up, 8 feet remained completely free of ulcers and 5 transfer ulcers occurred. Four infections developed; 3 from the surgical wound and 1 from a transfer ulcer. Based on these findings, the modified Keller procedure may be an appropriate intervention for hallux ulcerations provided the surgeon and the patient are aware of its limitations and possible outcomes.     

Lengthening the Achilles tendon for the treatment of diabetic plantar forefoot ulceration

The accepted hallmarks of care for plantar forefoot ulceration are meticulous wound care, nutrition, management of infection, and non-weight bearing of the ulcerative area. Tendo-Achilles lengthening is crucial in healing these ulcerations when it is determined that the Achilles tendon is one of the main biomechanical stresses that led to the ulceration. The Silfverskiold test helps determine whether a percutaneous lengthening or gastrocnemius recession is called for. A gastrocnemius recession is the safer operation because it does not carry the postoperative risk of overlengthening or rupture, calcaneal gait, and subsequent plantar heel ulceration, but gastrocnemius recession carries a higher late recurrence rate of late plantar forefoot reulceration (16%). A more permanent result can be achieved with percutaneous tendo-Achilles lengthening, although one assumes the associated risk of overlengthening the tendo-Achilles, calcaneal gait, and the difficult-to-treat plantar calcaneal ulceration. It is crucial to address other biomechanical abnormalities that may have contributed to the specific plantar ulceration, such as hammer toe, prominent plantar metatarsal head, prominent sesamoids, and long metatarsal. In addition, the patient should be placed in proper footwear, which at the minimum includes orthoses but may include specialized accommodative shoe wear. Failure to include these adjunctive procedures to Achilles tendon lengthening may prevent healing or hasten ulcer recurrence. Future studies will be directed toward determining the roles of prophylactic Achilles tendon lengthening preventing equinovarus deformities, possible plantar foot ulceration, and Charcot collapse.     

The neuropathic ulcer and loads on the foot in diabetic patients.

Normal subjects and diabetic patients with and without food ulcers have been studied using an apparatus which measures the loads on the foot during walking. Diabetic patients have alterations in loading which show as a lateral shift of the highest maximum load on the forefoot and a decrease in the load carried by the toes. There is a significant progression of these changes between normal subjects, diabetic patients with deformity of the foot but no ulcer, and diabetic patients with foot ulcers. All the patients with ulcers exerted maximum loads at the site of the ulcer.     

Soft tissue reconstruction for the heel and plantar foot

Soft tissue resurfacing after the ravages of injury or disease continues to be a formidable problem. A thorough understanding of the biomechanics of ambulation and the way in which weight is distributed over the sole of the foot is key to successful outcomes. Soft tissue repair has evolved from the simple filling of holes to a much more sophisticated approach. A plantar-grade foot that distributes the patient's weight in a uniform manner should be the goal. If this can be done without increasing the energy expenditure of ambulation, then surgeons certainly have done our patients an excellent service. Surgeons must not overlook the tendon imbalances and bony deformities that can accompany the effects of disease or trauma. The more complex soft tissue repair may not always be in the patient's best interests. Surgeons should use the simplest approach that can restore the limb to as close to its preinjury level of function as possible. A coordinated approach with plastic surgery, orthopedic surgery, vascular surgery, and podiatric surgery should be the standard of care for patients requiring plantar soft tissue repair.     

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.