Article

Elevated peak plantar pressures in patients who have Charcot arthropathy.

Department of Orthopaedics, The University of Texas Health Science Center at San Antonio, 78284-7776, USA.
The Journal of Bone and Joint Surgery (Impact Factor: 4.31). 03/1998; 80(3):365-9.
Source: PubMed

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

2 Followers
 · 
62 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Study Design: Case reports. Background: Charcot neuroarthropathy (CN) is a progressive, non-infective, inflammatory destruction of bones and joints leading to foot deformities and plantar ulceration. Though individuals with CN typically have low areal bone mineral density (aBMD), little is known regarding changes in volumetric bone mineral density (vBMD), bone geometry, joint mal-alignment, and biomechanical loads preceding fracture. Case Description: Two females, aged 45 and 54 years at the onset of an acute non-fracture CN event, received regular physical therapy with wound care and total contact casting. Both enrolled in a larger research study that included plantar pressure assessment and quantitative computed tomography (QCT) at enrollment and 3, 6, and 12 months later. The women sustained mid-diaphyseal fifth metatarsal fracture 10–11 months after enrollment. QCT image analysis techniques were used to measure vBMD; bone geometric indices reflecting strength in compression, bending, and cortical buckling; and 3-dimensional bone-to-bone orientation angles reflecting foot deformity. Outcomes: Fifth metatarsal mid-diaphyseal vBMD decreased during off-loading treatment from 0 to 3 months, then increased to above baseline levels by 6 months. All geometric strength indices improved from baseline through 6 months. Plantar loading in the lateral midfoot increased preceding fracture, concomitant with alterations in bone orientation angles which suggest progressive development of metatarsus adductus and equinovarus foot deformity. Discussion: Fractures may occur when bone strength decreases or when biomechanical loading increases. Incipient fracture was preceded by increased loading in the lateral midfoot, but not by reductions in vBMD or geometric strength indices, suggesting that loading played a greater role in fracture. Moreover, the progression of foot deformities may be causally linked to the increased plantar loading. Level of evidence: Therapy, level 4. J Orthop Sports Phys Ther, Epub 9 September 2013. doi:10.2519/jospt.2013.4443 Keyword: diabetes, foot, fracture, plantar ulcers Read More: http://www.jospt.org/doi/abs/10.2519/jospt.2013.4443
    01/2013;
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Study Design Case report. Background Charcot neuroarthropathy is a progressive, noninfective, inflammatory destruction of bones and joints leading to foot deformities and plantar ulceration. Though individuals with Charcot neuroarthropathy typically have low areal bone mineral density, little is known regarding changes in volumetric bone mineral density (vBMD), bone geometry, joint malalignment, and biomechanical loads preceding fracture. Case Description Two women, aged 45 and 54 years at the onset of an acute, nonfracture Charcot neuroarthropathy event, received regular physical therapy with wound care and total-contact casting. Both enrolled in a larger research study that included plantar pressure assessment and quantitative computed tomography at enrollment and 3, 6, and 12 months later. The women sustained mid-diaphyseal fifth metatarsal fracture 10 to 11 months after enrollment. Quantitative computed tomography image-analysis techniques were used to measure vBMD; bone geometric indices reflecting strength in compression, bending, and cortical buckling; and 3-D bone-to-bone orientation angles reflecting foot deformity. Outcomes Fifth metatarsal mid-diaphyseal vBMD decreased during offloading treatment from 0 to 3 months, then increased to above baseline levels by 6 months. All geometric strength indices improved from baseline through 6 months. Plantar loading in the lateral midfoot increased preceding fracture, concomitant with alterations in bone orientation angles, which suggest progressive development of metatarsus adductus and equinovarus foot deformity. Discussion Fractures may occur when bone strength decreases or when biomechanical loading increases. Incipient fracture was preceded by increased loading in the lateral midfoot but not by reductions in vBMD or geometric strength indices, suggesting that loading played a greater role in fracture. Moreover, the progression of foot deformities may be causally linked to the increased plantar loading. Level of Evidence Prognosis, level 4. J Orthop Sports Phys Ther 2013;43(10):744-751. Epub 9 September 2013. doi:10.2519/jospt.2013.4443.
    10/2013; 43(10):744-751. DOI:10.2519/jospt.2013.4443
  • [Show abstract] [Hide abstract]
    ABSTRACT: The biomechanics of the diabetic foot is altered and maladaptive. We lack a thorough understanding of the functional consequences of limb salvage. We currently rely on observation and descriptive data pertaining to the biomechanics of the diabetic foot. Technology has driven our ability to objectively describe biomechanics of the diabetic foot. Dynamic, segmental, gait analysis in conjunction with peak plantar pressure measurements have provided valuable insight. The biomechanical pathogenesis of a chronic ulceration that necessitates limb salvage is difficult to capture. The subsequent changes that occur after limb salvage are even more difficult to understand. However, methodical biomechanical analysis over the past several decades have provided a deeper understanding of diabetic foot function. Ultimately, a better understanding of the biomechanics of the diabetic foot would allow us to better select the most appropriate amputation level and maximize function after limb salvage attempt.
    04/2013; 2(3):107-111. DOI:10.1089/wound.2011.0315