Die Einlagenversorgung des rheumatischen Fußes

Assessment of plantar pressure in hindfoot relief shoes of different designs

BACKGROUND

Although there are several different concepts of hindfoot relief footwear, there are no studies on the extent of pressure reduction to be achieved by this footwear. Therefore, we sought to evaluate the reduction in plantar pressure to be achieved with two different hindfoot relief shoes.

METHODS

Ten healthy volunteers performed three trials at a self-selected speed. Peak pressure values in mass-produced shoes (normal gait) were considered as 100% and were compared with measurements in two differently designed hindfoot relief shoes. Foot portions were defined as heel (0%-15% of total insole length), hindfoot (16%-30%), midfoot (31%-60%), and forefoot (61%-100%).

RESULTS

Heel and hindfoot peak pressures were significantly reduced in both shoes compared with normal gait (P < .05), but the extent of peak pressure reduction under the heel and hindfoot varied significantly between the tested shoes. Midfoot peak pressure was not significantly reduced in tested shoes compared with baseline (P > .05) but differed significantly between the two shoes. Forefoot peak pressure was significantly reduced with one of the tested shoes (to a median 73% baseline; P = .004) but not with the other (median, 88% baseline).

CONCLUSIONS

Hindfoot relief shoes leave a considerable amount of peak pressure, predominantly under the hindfoot. The extent of peak pressure reduction for the heel and the hindfoot varies between different hindfoot relief shoes. Depending on the affected foot area, the kind of hindfoot relief shoe should be carefully chosen.

How do leg press exercises comply with limited weight bearing?

OBJECTIVES

To investigate foot loadings in different leg press settings with respect to a possible graduation of weight bearing (WB).

DESIGN

Case series.

SETTINGS

Assessing plantar force values by means of dynamic pedobarography taken place in orthopaedic departments' rehab center.

PARTICIPANTS

15 healthy students (9 men and 6 women, age 23 ± 2, weight 75 ± 6 kg) were recruited as participants from the medical faculty.

MAIN OUTCOME MEASURES

Peak force values from normal gait (referred to as 100%) and single and double leg presses (SLP, DLP) with resistances of 10 kg, 20 kg and 40 kg, obtained with pedobarographic insoles.

RESULTS

Performing DLP produced foot loadings (N) of 37 ± 15 with 10 kg, 91 ± 29 with 20 kg and 203 ± 27 with 40 kg, equal to 5%, 12% and 26% of full WB. SLP result in force values of 195 ± 32 with 10 kg, 308 ± 34 with 20 kg and 516 ± 45 with 40 kg, corresponding to 25%, 40% and 67% baseline.

CONCLUSIONS

Leg press exercises can be performed in accordance with a given limitation of foot loading. Above mentioned conditions allow a graduation from 5% to 67% of full WB.

[Orthopedic shoe treatment: Inserts]

The use of inserts and orthopedic shoe adjustment represents an essential component of the conservative therapy of degenerative diseases and deformities of the musculoskeletal system. Inserts can have supportive, bedding and corrective effects and are used in particular for complaints of the feet and ankles. The combination of diverse materials allows a high level of cushioning and supporting features and corresponding longevity to be accomplished. The production is carried out on an individual basis and if necessary computer-assisted in order to achieve an optimal fit. For severe and rigid deformities the formation of pressure ulcers can be prevented by orthopedic shoe adjustment and by the use of orthopedic tailor-made shoes.

Association between arthritis score at the onset of the disease and long-term locomotor outcome in adjuvant-induced arthritis in rats

INTRODUCTION

To investigate the connection between the intensity of initial symptoms of inflammation and locomotor outcome in rheumatoid arthritis, we examined the relationship between long-term locomotor abnormalities and signs of inflammation at the onset of the disease in adjuvant-induced arthritis (AIA) in rats.

METHODS

The arthritis score and hind-paw diameter were followed from immunization to day 195 (~7 months). At this time, locomotion was recorded during forced treadmill walking using 3D motion technology before radiographic scoring of hind limb joint damage. Many locomotor parameters were analyzed including time and length parameters, limbs kinematics, lateral paw position at toe off, maximal hind-paw elevation and posture. Ankle mobility was assessed from range of motion (ROM) of the joint during locomotion. Experiments were run in AIA (n = 18) and age-matched non-AIA rats (n = 8).

RESULTS

All AIA rats exhibited signs of inflammation at day 14 with a peak of inflammatory symptoms at day 22 post-immunization. After the first episode of inflammation, 83 % of AIA rats demonstrated recurrent disease (from week 6 to week 23). The frequency of inflammatory episodes (1 to 5) was not linked to the arthritis score at day 22. At day 195 post-immunization, AIA rats showed significantly impaired locomotion and radiographic lesions as compared to control rats. Significant relationships were observed between most locomotion-related parameters and concurrent ROM of ankle, which correlated negatively with the radiographic score. ROM of ankle at day 195 correlated negatively with both the arthritis score and hind-paw diameter measured at day 14, 22 and 30 post-immunization.

CONCLUSION

Decreased ankle mobility can be considered a driver of locomotion impairment in AIA. In this model, the severity of the initial inflammatory symptoms had a good prognostic value for long-term locomotor outcome.

Incompliance of total hip arthroplasty (THA) patients to limited weight bearing

INTRODUCTION

Limited weight bearing of the lower extremity is a commonly applied procedure in orthopedic rehabilitation following trauma surgery and joint replacement. The compliance of patients with limited weight bearing after cementless total hip arthroplasty has not yet been surveyed using sensor-loaded insoles. The objective of this study was to investigate foot loadings in patients after THA under the assumption of limited weight bearing.

METHODS

Peak pressures for the hindfoot, midfoot and forefoot were obtained from 14 patients (10 women, 4 men, age 63 ± 12 years, height 172 ± 9 cm, weight 92 ± 20 kg, BMI 31 ± 6 kg/m(2)) by means of dynamic pedobarography, with full weight bearing preoperatively (baseline) and at 8-10 days after cementless total hip arthroplasty, walking again on even floor, and also walking upstairs and downstairs with a restriction of weight bearing to 10 % body weight, taught by an experienced physiotherapist with a bathroom scale.

RESULTS

Foot loadings with limited weight bearing on even floor remained up to 88 % from full weight bearing preoperatively. Walking upstairs and downstairs under the same condition was approximately equal to a bisection of peak pressures from full weight bearing.

CONCLUSIONS

Patients following cementless do not comply with limited weight bearing when they are trained by the use of a bathroom scale.

[Rheumatic forefoot deformities]

The frequency and extent of rheumatic forefoot deformities have been greatly reduced since the introduction of disease-modifying antirheumatic drugs (DMARD). The accompanying reduction in arthritic destruction of joints opens up new treatment options whereby priority is given to joint preservation. This is true for the first middle foot ray as well as for the small toe rays. Whereas resection arthroplasty of the metatarsophalangeal joints II-V was previously considered the gold standard treatment, joint-preserving operative procedures (e.g. metatarsal osteotomy and periarticular soft tissue interventions) are now being increasingly more propagated. Resection arthroplasty of the first midfoot ray has major biomechanical disadvantages so that it is not surprising that reconstructive procedures are given priority. In patients with severe arthritic destruction of the first metatarsophalangeal joint, arthrodesis has substantial biomechanical advantages compared to resection arthroplasty. Nevertheless, it has not yet been confirmed that fusion leads to superior clinical results.

[Technological orthopedic treatment of feet destroyed by rheumatism. Update]

BACKGROUND

The course of rheumatoid arthritis often leads to afflictions of the feet with typical deformities and complaints. In addition to the basis medication, physical therapy, physiotherapy and local infiltration techniques, technological orthopedic shoe treatment is an important component of conservative therapy.

MATERIAL AND METHODS

This review article presents the foundations of the pathomechanics of rheumatic feet and the principles of treatment.

RESULTS AND CONCLUSION

Through a sensible implementation of a foot disorder orthosis it is possible to mitigate deformities due to rheumatoid arthritis and also positively influence the further course. The aim of a foot disorder orthosis is ultimately to delay or even avoid surgical measures for rheumatic feet and also to stabilize the results after surgical interventions.

Gait analysis in orthopedic foot and ankle surgery--topical review, part 1: principles and uses of gait analysis

Gait analysis, the systematic study of human walking, is a field that has been studied for well over 100 years. With the technological and scientific advancements of the last several decades, there has been substantial improvement in our understanding of the mechanics of human walking. Particularly important has been the advancement in understanding of the differences between normal and pathological gait. The purpose of this paper is to review the principles of gait analysis, with a particular focus on the underlying methods and science. This will assist orthopedic foot and ankle surgeons in better understanding the methods and meaning of gait research and the publications that commonly appear in the orthopedic foot and ankle surgery literature.

LEVEL OF EVIDENCE

Level V, expert opinion.

[Presurgical and postsurgical orthotic management of the rheumatoid foot]

Foot complaints remain frequent in patients with rheumatoid arthritis (RA) even in the era of biological anti-rheumatic drugs. Orthotic management of rheumatoid foot disorders is able to improve mobility and thus the quality of life in RA patients. This article highlights the preoperative and postoperative orthotic management of the rheumatoid arthritic foot.

Custom foot orthoses for rheumatoid arthritis: A systematic review

OBJECTIVE

To identify and critically appraise the evidence for the effectiveness of custom orthoses for the foot and ankle in rheumatoid arthritis.

METHODS

Studies were identified in appropriate electronic databases (from 1950 to March 2011). The search term "rheumatoid arthritis" with "foot" and "ankle" and related terms were used in conjunction with "orthoses" and synonyms. Included studies were quantitative longitudinal studies and included randomized controlled trials (RCTs), case-control trials, cohort studies, and case series studies. All outcome measures were investigated. Quality assessment was conducted using the Cochrane Collaboration criteria with additional criteria for sample population representativeness, quality of statistical analysis, and compliant intervention use and presence of cointerventions. Meta-analyses were conducted for outcome domains with multiple RCTs. Qualitative data synthesis was conducted for the remaining outcome domains. Levels of evidence were then assigned to each outcome measure.

RESULTS

The inclusion criteria were met by 17 studies. Two studies had high quality for internal validity and 3 studies had high quality for external validity. No study had high quality for both internal and external validity. Six outcome domains were identified. There was weak evidence for custom orthoses reducing pain and forefoot plantar pressures. Evidence was inconclusive for foot function, walking speed, gait parameters, and reducing hallux abductovalgus angle progression.

CONCLUSION

Custom orthoses may be beneficial in reducing pain and elevated forefoot plantar pressures in the rheumatoid foot and ankle. However, more definitive research is needed in this area.

Foot loading with an ankle-foot orthosis: the accuracy of an integrated physical strain trainer

PURPOSE

To investigate the value of a built-in physical strain trainer for the monitoring of partial weight bearing with an ankle-foot orthosis.

METHODS

12 healthy volunteers were asked to perform three trials. Plantar peak pressure values from normal gait (trial one) were defined as 100% (baseline). The following trials were performed with the Vacoped® dynamic vacuum ankle orthosis worn in a neutral position with full weight bearing (trial two) and a restriction to 10% body weight (BW) (trial three), as monitored with an integrated physical strain trainer. Peak plantar pressure values were obtained using the pedar® X system.

RESULTS

Peak pressure values were statistically significantly reduced wearing the Vacoped® shoe with full weight bearing for the hindfoot to 68% of the baseline (normal gait) and for the midfoot and forefoot to 83% and 60%, respectively. Limited weight bearing with 10% BW as controlled by physical strain trainer further reduced plantar peak pressure values for the hindfoot to 19%, for the midfoot to 43% of the baseline and the forefoot to 22% of the baseline.

CONCLUSIONS

The Vacoped® vacuum ankle orthosis significantly reduces plantar peak pressure. The integrated physical strain trainer seems unsuitable to monitor a limitation to 10% BW adequately for the total foot. The concept of controlling partial weight bearing with the hindfoot-addressing device within the orthosis seems debatable but may be useful when the hindfoot in particular must be off-loaded.

[Insufficiency fractures of the feet and lower limbs in rheumatoid arthritis]

BACKGROUND

Insufficiency fractures are generally a rare event, especially of the hindfoot. These are often overlooked in the initial stage, however, they must be regarded as a differential diagnosis in the range of possible causes in patients with rheumatoid arthritis and unclear complaints.

MATERIAL AND METHODS

Outpatients in an arthritis care unit from 2009-2011 were analyzed for fractures of the hindfoot and distal tibia.

RESULTS

A total of six patients with seven fractures without adequate trauma were found in the cohort. All patients had received disease modifying therapy and corticosteroids. All fractures could be successfully treated without surgery.

CONCLUSION

Insufficiency fractures in patients with rheumatoid arthritis are a typical finding after several years of the disease. They are directly related to the disease and medication and can usually be successfully treated conservatively.

Inaccuracy of a physical strain trainer for the monitoring of partial weight bearing

OBJECTIVE

To investigate the use of a physical strain trainer for the monitoring of partial weight bearing.

DESIGN

Case series with healthy volunteers.

SETTING

Orthopedic clinic.

PARTICIPANTS

Healthy volunteers (N=10) with no history of foot complaints.

INTERVENTIONS

Volunteers were taught to limit weight bearing to 10% body weight (BW) and 50% BW, monitored by a physical strain trainer.

MAIN OUTCOME MEASURES

The parameters peak pressure, maximum force, force-time integral, and pressure-time integral were assessed by dynamic pedobarography when volunteers walked with full BW (condition 1), 50% BW (condition 2), and 10% BW (condition 3).

RESULTS

With 10% BW (condition 3), forces with normative gait (condition 1) were statistically significantly reduced under the hindfoot where the physical strain trainer is placed. All pedobarographic parameters were, however, exceeded when the total foot was measured. A limitation to 10% BW with the physical strain trainer (condition 3) was equal to a bisection of peak pressure and maximum force for the total foot with normative gait (condition 1). Halved BW (condition 2) left a remaining mean 82% of peak pressure and mean 59% of maximum force from full BW (condition 1).

CONCLUSIONS

The concept of controlling partial weight bearing with the hindfoot-addressing device does not represent complete foot loading. Such devices may be preferably applied in cases when the hindfoot in particular must be off-loaded. Other training devices (eg, biofeedback soles) that monitor forces of the total foot have to be used to control partial weight bearing of the lower limb accurately.