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Zhang X, Teng Z, Geng X, Ma X, Chen WM. A fluoroscopic imaging-guided computational analyses to inform internal tissue loads within fat pad of the diabetic foot during gait. J Biomech 2023; 157:111744. [PMID: 37535986 DOI: 10.1016/j.jbiomech.2023.111744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/05/2023]
Abstract
To accurately predict internal tissue loads for early diagnostics of diabetic foot ulcerations, a novel data-driven computational analysis was conducted. A dedicated dual fluoroscopic system was combined with a pressure mat to simultaneously characterize foot motions and soft tissue's material properties during gait. Finite element (FE) models of the heel pad of a diabetic patient were constructed with 3D trajectories of the calcaneus applied as boundary conditions to simulate gait events. The tensile and compressive stresses occurring in the plantar tissue were computed. Predictions of the layered tissue FE model with anatomically-accurate heel pad structures (i.e., fat and skin) were compared with those of the traditional lumped tissue (i.e., homogeneous) models. The influence of different material properties (patient-specific versus generic) on internal tissue stresses was also investigated. The results showed the peak tensile stresses in the layered tissue model were predominantly found in the skin and distributed towards the circumferential regions of the heel, while peak compressive stresses in the fat tissue-bone interface were up to 51.4% lower than those seen in the lumped models. Performing FE analyses at four different phases of walking revealed that ignorance of layered tissue structures resulted in an unphysiological increase of peak-to-peak value of stress fluctuation in the fat and skin tissue components. Thus, to produce more clinical-relevant predictions, foot FE models are suggested to include layered tissue structures of the plantar tissue for an improved estimation of internal stresses in the diabetic foot in gait.
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Affiliation(s)
- Xingyu Zhang
- Institute of Biomedical Engineering and Technology, Academy for Engineering and Technology, Fudan University, 220 Handan Road, Shanghai, China
| | - Zhaolin Teng
- Department of Orthopaedics, Huashan Hospital affiliated to Fudan University, 12 Middle Wulumuqi Road, Shanghai, China
| | - Xiang Geng
- Department of Orthopaedics, Huashan Hospital affiliated to Fudan University, 12 Middle Wulumuqi Road, Shanghai, China
| | - Xin Ma
- Department of Orthopaedics, Huashan Hospital affiliated to Fudan University, 12 Middle Wulumuqi Road, Shanghai, China
| | - Wen-Ming Chen
- Institute of Biomedical Engineering and Technology, Academy for Engineering and Technology, Fudan University, 220 Handan Road, Shanghai, China.
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Yang XG, Teng ZL, Zhang ZM, Wang K, Huang R, Chen WM, Wang C, Chen L, Zhang C, Huang JZ, Wang X, Ma X, Geng X. Comparison of material properties of heel pad between adults with and without type 2 diabetes history: An in-vivo investigation during gait. Front Endocrinol (Lausanne) 2022; 13:894383. [PMID: 36060939 PMCID: PMC9428762 DOI: 10.3389/fendo.2022.894383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study was aimed to compare the material properties of heel pad between diabetes patients and healthy adults, and investigate the impact of compressive loading history and length of diabetes course on the material properties of heel pad. METHODS The dual fluoroscopic imaging system (DFIS) and dynamic foot-ground contact pressure-test plate were used for measuring the material properties, including primary thickness, peak strain, peak stress, stiffness, viscous modulus and energy dissipation ratio (EDR), both at time zero and following continuous loading. Material properties between healthy adults and DM patients were compared both at time zero and following continuous weight bearing. After then, comparison between time-zero material properties and properties following continuous loading was performed to identify the loading history-dependent biomechanical behaviour of heel pad. Subgroup-based sensitivity analysis was then conducted to investigate the diabetes course (<10 years vs. ≥10 years) on the material properties of heel pad. RESULTS Ten type II DM subjects (20 legs), aged from 59 to 73 (average: 67.8 ± 4.9), and 10 age-matched healthy adults (20 legs), aged from 59 to 72 (average: 64.4 ± 3.4), were enrolled. Diabetes history was demonstrated to be associated with significantly lower primary thickness (t=3.18, p=0.003**), higher peak strain (t=2.41, p=0.021*), lower stiffness (w=283, p=0.024*) and lower viscous modulus (w=331, p<0.001***) at time zero, and significantly lower primary thickness (t=3.30, p=0.002**), higher peak strain (w=120, p=0.031*) and lower viscous modulus (t=3.42, p=0.002**) following continuous loading. The continuous loading was found to be associated with significantly lower primary thickness (paired-w=204, p<0.001***) and viscous modulus (paired-t=5.45, p<0.001***) in healthy adults, and significantly lower primary thickness (paired-w=206, p<0.001***) and viscous modulus (paired-t=7.47, p<0.001***) in diabetes group. No any significant difference was found when conducting the subgroup analysis based on length of diabetes course (<10 years vs. ≥10 years), but the regression analysis showed that the length of diabetes history was positively associated with the peak strain, at time zero (r=0.506, p<0.050) and following continuous loading (r=0.584, p<0.010). CONCLUSIONS Diabetes patients were found to be associated with decreased primary thickness and viscous modulus, and increased peak strain, which may contribute to the vulnerability of heel pad to injury and ulceration. Pre-compression history-dependent behaviour is observable in soft tissue of heel pad, with lowered primary thickness and viscous modulus.
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Affiliation(s)
- Xiong-gang Yang
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhao-lin Teng
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhen-ming Zhang
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Kan Wang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Ran Huang
- Academy for Engineering & Technology, Fudan University, Shanghai, China
| | - Wen-ming Chen
- Academy for Engineering & Technology, Fudan University, Shanghai, China
| | - Chen Wang
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Li Chen
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Chao Zhang
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jia-zhang Huang
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Wang
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Ma
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
- *Correspondence: Xiang Geng, ; Xin Ma,
| | - Xiang Geng
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
- *Correspondence: Xiang Geng, ; Xin Ma,
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