Structural Changes in the Forefoot of Individuals with Diabetes and a Prior Plantar Ulcer

Robertson, Douglas D.; Mueller, Michael J.; Smith, Kirk E.; Commean, Paul K.; Pilgram, Thomas K.; Johnson, Jeffrey E.

doi:10.2106/00004623-200208000-00016

Cited by 139 publications

(72 citation statements)

References 29 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…One group developed measures of foot shape from scans of diabetic feet; they determined which forefoot structural parameters could be used to predict high plantar pressure 26 or explain past ulceration. 25 However, this group used different parameters (e.g., calcaneal inclination and metatarsal inclination) than our study, and their data were non-weightbearing, making comparison to our work difficult. Grasso and Scarfi (1993) employed transverse and coronal CT scans to study plantar arch alterations.…”

Section: Discussionmentioning

confidence: 82%

“…Others have examined plantar and coronal CT scans for differences due to foot type, but the scans were non-weightbearing, the measures were subjective, and no statistical analysis was performed. 24 Recently, CT scans have been used to demonstrate that diabetic subjects had increased metatarsophalangeal extension at the first, second, and third rays 25 and that hammertoe deformity was the strongest predictor of increased plantar pressure. 26 However, both studies employed a noload condition, their measures had a subjective component (the placement of the measurement lines), and foot type classification was not the aim.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Effect of foot shape on the three-dimensional position of foot bones

et al. 2006

View full text Add to dashboard Cite

To eliminate some of the ambiguity in describing foot shape, we developed threedimensional (3D), objective measures of foot type based on computerized tomography (CT) scans. Feet were classified via clinical examination as pes cavus (high arch), neutrally aligned (normal arch), asymptomatic pes planus (flat arch with no pain), or symptomatic pes planus (flat arch with pain). We enrolled 10 subjects of each foot type; if both feet were of the same foot type, then each foot was scanned (n ¼ 65 total). Partial weightbearing (20% body weight) CT scans were performed. We generated embedded coordinate systems for each foot bone by assuming uniform density and calculating the inertial matrix. Cardan angles were used to describe five bone-to-bone relationships, resulting in 15 angular measurements. Significant differences were found among foot types for 12 of the angles. The angles were also used to develop a classification tree analysis, which determined the correct foot type for 64 of the 65 feet. Our measure provides insight into how foot bone architecture differs between foot types. The classification tree analysis demonstrated that objective measures can be used to discriminate between feet with high, normal, and low arches. ß

show abstract

Section: Discussionmentioning

confidence: 82%

Section: Introductionmentioning

confidence: 99%

Effect of foot shape on the three-dimensional position of foot bones

et al. 2006

View full text Add to dashboard Cite

show abstract

“…The ICCs for these variables were high (Ͼ0.98), which demonstrates that these variables can be assessed in a reproducible way. Small limits of agreement are important for regression analyses or correlation coefficients computed between variables of foot structure and/or foot function (3,5,6,15,16) because the outcomes from these analyses are determined by the scatter of individual cases.…”

Section: Discussionmentioning

confidence: 99%

“…Measures of structural changes and deformity in the diabetic foot have been obtained using different in vivo imaging techniques, such as ultrasound (3,17), radiography (18), and computed tomography (CT) (6,16,19,20). Saltzman et al (21) determined the interobserver variability of radiographic foot measurements in nondiabetic subjects and found a 95% limit for the MTP joint angle of 6°, which is higher than the limit in the present study (Ͻ3.0°).…”

Section: Discussionmentioning

confidence: 99%

Reproducibility of foot structure measurements in neuropathic diabetic patients using magnetic resonance imaging

Bus

Maas

Lindeboom

2006

Magnetic Resonance Imaging

View full text Add to dashboard Cite

Purpose:To assess the intra-and interobserver agreement of commonly reported foot structure measurements in diabetic patients with neuropathy using magnetic resonance imaging (MRI). Materials and Methods:In 23 neuropathic diabetic patients and five age-matched healthy controls, sagittal-plane MR images of the forefoot were obtained to assess joint configuration and plantar fat-pad thickness on two different occasions by the same observer and once by a different observer. The degree of intrinsic muscle atrophy was scored from coronal plane images on two different occasions by two observers. Results:The intraclass correlation coefficients (ICCs) between occasions and between observers were Ͼ0.94. The mean differences (bias) and the limits of agreement (LoA ϭ mean Ϯ 2 SDs) were small for the metatarsal-phalangeal (MTP) joint angle, toe angle, and plantar fat-pad thickness (bias Յ 0.8°or 0.2 mm, LoA Յ 3.8°or 0.8 mm), but larger for interphalangeal joint angles (bias Յ 3.4°, LoA Յ 8.8°). The weighted kappa for intrinsic muscle atrophy was 0.94. Conclusion:Static foot structure data can be assessed reliably using MRI. Because changes in foot structure contribute to the development of foot ulcers in neuropathic patients, MRI may be a useful technique to assess risk of ulceration in these patients. DIABETIC FOOT ULCERATION is a frequently reported and serious complication in people with diabetes and peripheral neuropathy, and precedes the vast majority (85%) of lower-extremity amputations (1). Elevated dynamic plantar pressure has been established as a major risk factor for plantar ulceration in the diabetic foot with lack of protective sensation (2).Structural changes and deformities of the foot, such as claw/hammer toe deformity and thinning of soft tissue or fat pads underneath the metatarsal heads, are associated with increased plantar pressures in diabetic subjects (3-6). Additionally, intrinsic muscle atrophy secondary to peripheral neuropathy may significantly affect foot function and lead to altered gait biomechanics (7).Because of its multiplanar imaging capability and inherent superiority in tissue contrast, magnetic resonance imaging (MRI) is increasingly being used as a tool to assess structural pathology in the foot or lower leg of diabetic patients with peripheral neuropathy (5,7-11). These assessments are considered important for improving our understanding of the relationship between structure and function in the foot and the pathogenesis of foot ulceration.However, little is known about the reproducibility of the MRI assessments for this purpose. Therefore, the purpose of this study was to evaluate the intra-and interobserver agreement of (semi-)quantitative measurements by MRI of foot structure in neuropathic diabetic patients. MATERIALS AND METHODS SubjectsTwenty-eight subjects participated in this study and underwent MRI of the foot. The study group consisted of 23 diabetic patients with peripheral sensory neuropathy (15 men and eight women, mean age ϭ 56.8 years) and five age-matched healthy subject...

show abstract

“…9,10 Ulceration over the prominent first metatarsal head is a frequent problem. [11][12][13][14] Increased pressure under the first metatarsal head is thought to result from an imbalance of the three extrinsic muscles to the first ray, extensor hallucis longus (EHL), flexor hallucis longus (FHL) and peroneus longus and intrinsic muscle weakness. 15,16 A cadaver study 16 showed that overaction of the EHL raised the pressure under the first metatarsal head.…”

mentioning

confidence: 99%

Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing: A prospective cohort study

2009

Fuß & Sprunggelenk

View full text Add to dashboard Cite

We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed.The mean duration of chronic ulceration despite a minimum of six months' conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal.We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.

show abstract

Structural Changes in the Forefoot of Individuals with Diabetes and a Prior Plantar Ulcer

Cited by 139 publications

References 29 publications

Effect of foot shape on the three-dimensional position of foot bones

Effect of foot shape on the three-dimensional position of foot bones

Reproducibility of foot structure measurements in neuropathic diabetic patients using magnetic resonance imaging

Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing: A prospective cohort study

Contact Info

Product

Resources

About