Total contact cast wall load in patients with a plantar forefoot ulcer and diabetes

Mesenchymal stem cell therapy in diabetic foot ulcer: An updated comprehensive review

Background

Diabetes has evolved into a worldwide public health issue. One of the most serious complications of diabetes is diabetic foot ulcer (DFU), which frequently creates a significant financial strain on patients and lowers their quality of life. Up until now, there has been no curative therapy for DFU, only symptomatic relief or an interruption in the disease's progression. Recent studies have focused attention on mesenchymal stem cells (MSCs), which provide innovative and potential treatment candidates for several illnesses as they can differentiate into various cell types. They are mostly extracted from the placenta, adipose tissue, umbilical cord (UC), and bone marrow (BM). Regardless of their origin, they show comparable features and small deviations. Our goal is to investigate MSCs' therapeutic effects, application obstacles, and patient benefit strategies for DFU therapy.

Methodology

A comprehensive search was conducted using specific keywords relating to DFU, MSCs, and connected topics in the databases of Medline, Scopus, Web of Science, and PubMed. The main focus of the selection criteria was on English-language literature that explored the relationship between DFU, MSCs, and related factors.

Results and Discussion

Numerous studies are being conducted and have demonstrated that MSCs can induce re-epithelialization and angiogenesis, decrease inflammation, contribute to immunological modulation, and subsequently promote DFU healing, making them a promising approach to treating DFU. This review article provides a general snapshot of DFU (including clinical presentation, risk factors and etiopathogenesis, and conventional treatment) and discusses the clinical progress of MSCs in the management of DFU, taking into consideration the side effects and challenges during the application of MSCs and how to overcome these challenges to achieve maximum benefits.

Conclusion

The incorporation of MSCs in the management of DFU highlights their potential as a feasible therapeutic strategy. Establishing a comprehensive understanding of the complex relationship between DFU pathophysiology, MSC therapies, and related obstacles is essential for optimizing therapy outcomes and maximizing patient benefits.

Assessment of compression forces in a digitally modified short leg cast for pressure injury risk monitoring in healthy children

Introduction

Casting is an essential treatment for neuro-orthopedic conditions in children with cognitive, sensory, and communicational disabilities. However, a main side-effect is the development of pressure injuries resulting in additional (wound) therapies and prolongation of the hospital stay. The primary aim of our study was to investigate the potential of objective pressure measurements in casts to assess the risk for pressure injury development.

Methods

Five pediatric healthy participants were included in this study. We measured the global and the local compression force at body sites prone to pressure injury development for different body positions and the transfer in-between in a cast equipped with pressure sensors. These conditions resulted in partial or full body weight loading.

Results and discussion

The global maximum compression force was affected significantly by body postures with partial and full loading of the cast and during transfer. The local compression force significantly correlated with the global compression force at the heel and instep area. In conclusion, the integration of sensing technologies into casts bears a high potential for early recognition of critical conditions inside the cast and inducing preventive measures in the at-risk population.

Function and mechanism of mesenchymal stem cells in the healing of diabetic foot wounds

Diabetes has become a global public health problem. Diabetic foot is one of the most severe complications of diabetes, which often places a heavy economic burden on patients and seriously affects their quality of life. The current conventional treatment for the diabetic foot can only relieve the symptoms or delay the progression of the disease but cannot repair damaged blood vessels and nerves. An increasing number of studies have shown that mesenchymal stem cells (MSCs) can promote angiogenesis and re-epithelialization, participate in immune regulation, reduce inflammation, and finally repair diabetic foot ulcer (DFU), rendering it an effective means of treating diabetic foot disease. Currently, stem cells used in the treatment of diabetic foot are divided into two categories: autologous and allogeneic. They are mainly derived from the bone marrow, umbilical cord, adipose tissue, and placenta. MSCs from different sources have similar characteristics and subtle differences. Mastering their features to better select and use MSCs is the premise of improving the therapeutic effect of DFU. This article reviews the types and characteristics of MSCs and their molecular mechanisms and functions in treating DFU to provide innovative ideas for using MSCs to treat diabetic foot and promote wound healing.

Assessment of the effect of a total contact cast on lower limb kinematics and joint loading

BACKGROUND

Total contact casts (TCCs) are used to immobilize and unload the foot and ankle for the rehabilitation of ankle fractures and for the management of diabetic foot complications. The kinematic restrictions imposed by TCCs to the foot and ankle also change knee and hip kinematics, however, these changes have not been quantified before. High joint loading is associated with discomfort and increased risk for injuries. To assess joint loading, the effect of the muscle forces acting on each joint must also be considered. This challenge can be overcome with the help of musculoskeletal modelling.

RESEARCH QUESTION

How does a TCC affect lower extremity joint loading?

METHODS

Twelve healthy participants performed gait trials with and without a TCC. Kinematic and kinetic recordings served as input to subject-specific musculoskeletal models that enabled the computation of joint angles and loading. Cast-leg interaction was modelled by means of reaction forces between a rigid, zero-mass cast segment and the segments of the lower extremity.

RESULTS

and Significance: Reduced ankle, knee and hip range of motion was observed for the TCC condition. Statistical parametric mapping indicated decreased hip abduction and flexion moments during initial contact with the TCC. The anterior knee force was significantly decreased during the mid and terminal stance and the second peak of the compressive knee force was significantly reduced for the TCC. As expected, the TCC resulted in significantly reduced ankle loading.

SIGNIFICANCE

This study is the first to quantify the effect of a TCC on lower limb joint loading. Its results demonstrate the efficiency of a TCC in unloading the ankle joint complex without increasing the peak loads on knee and hip. Future studies should investigate whether the observed knee and hip kinematic and kinetic differences could lead to discomfort.

Comparing a non-removable total contact cast with a non-removable softcast in diabetic foot ulcers: A retrospective study of a prospective database

OBJECTIVE

Diabetic foot ulcers (DFUs) are mostly cured by an off-loading cast. Healing ratios of a non-removable Total Contact Softcast (TCS) were compared to a conventional Total Contact Cast (TCC), the latter reporting negative effects on lifestyle and transportation.

METHODS

Analysis of prospectively collected data for 2010-2017. Included were patients with a neuropathic DFU. Ischemic ulcers were excluded, as were Charcot arthropathy, non-plantar/non-forefoot ulcer location, and compliance issues. Patients with TCS were compared to TCC. Primary and secondary outcomes were healing ratio and healing time of DFU.

RESULTS

50 patients with 61 cast periods were included. Mean age was 63.7 ± 10.1 years. Overall successful ulcer healing was 71% (43/61). Except for depth of the DFUs, between-group patient characteristics were comparable; deeper DFUs were reported in the TCC group. This group reported 65% healed DFU (22/34), the TCS group 74% (20/27). Mean healing time was 8.4 weeks (95 %CI 5.9-10.8) for TCC and 5.5 weeks (95 %CI 4.2-6.9) for TCS (p = 0.052). Depth of the wound was a confounder.

CONCLUSIONS

TCS had a similar DFU healing ratio and a potentially clinically relevant effect (HR 1.47, 95 %CI 0.64-3.38) on healing time (ns). Ulcer depth is important for time to ulcer healing. A randomized study is recommended.

Pressure relieving interventions for the management of diabetes-related foot ulcers: a study from the Northern Territory of Australia

BACKGROUND

Offloading intervention is an important component in the management of diabetes-related foot ulcer (DFU). The NT population is unique with certain distinctive challenges. Potential advantages of and barriers to optimal offloading methods in our setting were investigated.

METHODS

Consecutive patients with DFU treated with offloading devices between 2003 and 2015 at the Multidisciplinary Foot Clinic (MDFC), Royal Darwin Hospital were included. The outcome measures were healing, amputation and discontinuation. Risk factors for offloading failure were studied.

RESULTS

Total contact cast (TCC) was the most common offloading used (n = 175). The other removable non-TCC devices used were therapeutic footwear (n = 74), CamWalker (n = 35), and orthotic devices (n = 43). The overall healing rate was 88.7%. Healing rates were higher (93.2% versus 83.5%, P < 0.05) and amputation rates were lower (4.0% versus 7.3%, P = 0.026) in the TCC group than in the removable non-TCC group. The mean duration of offloading was longer in the TCC group (3.6 ± 1.5 versus. 3.2 ± 1.5 months, P = 0.008). Wagner grade ≥ 2 and removable non-TCC devices were significant risk factors for offloading failure.

CONCLUSION

Patients treated with TCC had higher healing rates than those treated with removable non-TCC devices. The duration of offloading was longer than reported in other studies. Higher Wagner grade and removable non-TCC devices were risk factors for offloading failure. Non-removable offloading devices are the first choice in diabetes-related neuropathic ulcers.

Stress-Reducing Psychological Interventions as Adjuvant Therapies for Diabetic Chronic Wounds

BACKGROUND

Diabetic foot ulcers (DFUs) are a major complication of diabetes mellitus and a leading cause of lower limb amputation. Interventions to reduce psychological stress may have the potential to improve self-care and greatly reduce the morbidity and mortality associated with DFU. This review is focused on the consequences of psychological stress in wound healing and reflects on the effects of currently used psychological stress-reducing interventions in patients with DFU, proposing new applications for currently used stress-reduction interventions.

RESULTS

Stress is a natural and fundamental survival mechanism that becomes harmful when chronic. DFU is associated with high levels of anxiety and chronic psychological stress. Chronic stressinduced cortisol and adrenaline release impair wound healing, independently of the stressor. Psychological stress-reducing interventions, such as relaxation with guided imagery, biofeedback-assisted relaxation, mindfulness-based strategies, and hypnosis, can lead to a reduction in perceived stress and improve wound healing by reducing wound inflammation and pain while improving glycemic control. All stress reduction interventions also lead to pain relief and improved patient's quality of life.

CONCLUSION

Psychological stress-reducing interventions are promising adjuvant therapies for DFU. Their clinical application can improve self-care by tackling patient's expectations, anxieties, and fears. They can also help patients manage stress and pain while reducing wound inflammation and improving wound healing.

Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are a leading cause of the global disease burden. Most DFUs are caused, and prolonged, by high plantar tissue stress under the insensate foot of a person with peripheral neuropathy. Multiple different offloading treatments have been used to try to reduce high plantar tissue stress and heal DFUs, including bedrest, casting, offloading devices, footwear, and surgical procedures. The best offloading treatments are those that balance the benefits of maximizing reductions in high plantar tissue stress, whilst reducing the risks of poor satisfaction, high costs and potential adverse events outcomes. This review aimed to summarize the best available evidence on the effects of offloading treatments to heal people with DFUs, plus review their use in clinical practice, the common barriers and solutions to using these treatments, and discuss promising emerging solutions that may improve offloading treatments in future. Findings demonstrate that knee-high offloading devices, non-removable or removable knee-high devices worn for all weight-bearing activities, are the gold standard offloading treatments to heal most patients with DFU, as they are much more effective, and typically safer, quicker, and cheaper to use compared with other offloading treatments. The effectiveness of offloading treatments also seems to increase when increased offloading mechanical features are incorporated within treatments, including customized insoles, rocker-bottom soles, controlled ankle motion, and higher cast walls. However, in clinical practice these gold standard knee-high offloading devices have low rates of prescription by clinicians and low rates of acceptance or adherence by patients. The common barriers resulting in this low use seem to surround historical misperceptions that are mostly dispelled by contemporary evidence. Further, research is now urgently required to close the implementation gap between the high-quality of supporting evidence and the low use of knee-high devices in clinical practice to reduce the high global disease burden of DFU in future.

Is TCC-EZ a Suitable Alternative to Gold Standard Total-Contact Casting?

BACKGROUND

The total-contact cast (TCC) is the gold standard for off-loading diabetic foot ulcers (DFUs) given its nonremovable nature. However, this modality remains underused in clinical settings due to the time and experience required for appropriate application. The TCC-EZ is an alternative off-loading modality marketed as being nonremovable and having faster and easier application. This study aims to investigate the potential of the TCC-EZ to reduce foot plantar pressures.

METHODS

Twelve healthy participants (six males, six females) were fitted with a removable cast walker, TCC, TCC-EZ, and TCC-EZ with accompanying brace removed. These off-loading modalities were tested against a control. Pedar-X technology measured peak plantar pressures in each condition. Statistical analysis of four regions of the foot (rearfoot, midfoot, forefoot, and hallux) was conducted with Friedman and Wilcoxon signed rank tests. Significance was set at P < .05.

RESULTS

All of the off-loading conditions significantly reduced pressure compared with the control, except the TCC-EZ without the brace in the hallux region. There was no statistically significant difference between TCC-EZ and TCC peak pressure in any foot region. The TCC-EZ without the brace obtained significantly higher peak pressures than with the brace. The removable cast walker produced similar peak pressure reduction in the midfoot and forefoot but significantly higher peak pressures in the rearfoot and hallux.

CONCLUSIONS

The TCC-EZ is a viable alternative to the TCC. However, removal of the TCC-EZ brace results in minimal plantar pressure reduction, which might limit clinical applications of the TCC-EZ.

Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices?

Physical activity is an essential part of general health and diabetes management. However, recommending weight-bearing physical activity for people with plantar diabetic foot ulcers is controversial, even when gold standard offloading devices are used, as it is commonly thought to delay healing. We aimed to narratively review relevant studies investigating the relationship between plantar diabetic foot ulcer healing and weight-bearing activity, plantar pressure and device adherence. We defined relevant studies as those from two systematic reviews, along with those identified since using a similar updated Pubmed search strategy. We identified six studies. One study found that more daily steps were associated with worse ulcer healing, three found no significant association between steps and ulcer healing, and in two others the association was unclear. Thus, there is weak evidence for an inverse relationship between weight-bearing physical activity and plantar ulcer healing while utilizing offloading devices. We propose a Diabetic foot Offloading and Activity framework to guide future research to find the optimal balance between the positive and negative effects of weight-bearing activity in the context of foot ulcers. We hope such future studies will shed more conclusive light on the impact of weight-bearing activity on healing of plantar diabetic foot ulcers.

Systematic review of techniques to monitor remission of acute Charcot neuroarthropathy in people with diabetes

AIM

The management of acute Charcot neuroarthropathy relies on off-loading which is costly and time-consuming. Published studies have used monitoring techniques with unknown diagnostic precision to detect remission. We performed a systematic review of techniques for monitoring response to offloading in acute Charcot neuroarthropathy.

MATERIALS AND METHODS

We included studies of off-loading which evaluated or described monitoring techniques in acute Charcot neuroarthropathy. PubMed, EMBASE, CINAHL and Cochrane databases were searched (January1993-July 2018). We extracted data from papers including study design, setting, population, monitoring techniques and treatment outcomes. We also extracted information on the cost, clinical applicability, sensitivity and specificity, safety and participant acceptability of the monitoring techniques.

RESULTS

We screened 1205 titles, 140 abstracts and 45 full-texts, and included 29 studies. All studies were of low quality and at high risk of bias. In seven studies, the primary aim was to evaluate monitoring techniques: three evaluated magnetic resonance imaging, two thermography monitoring, one three-phase bone scanning and one Doppler spectrum analysis. The remaining 22 observational studies reported treatment outcomes and described the monitoring techniques used to assess the Charcot neuroarthropathy. Heterogeneity prevented the pooling of data. Very few studies included data on cost, clinical applicability, sensitivity and specificity, safety and patient acceptability of the monitoring techniques used.

CONCLUSION

Multiple techniques have been used to evaluate remission in acute Charcot neuroathropathy but uncertainty remains about their effectiveness. We recommend further research into the influences of different monitoring techniques on treatment outcomes.

Smart Socks and In-Shoe Systems: State-of-the-Art for Two Popular Technologies for Foot Motion Analysis, Sports, and Medical Applications

The present paper reviews, for the first time, to the best of our knowledge, the most recent advances in research concerning two popular devices used for foot motion analysis and health monitoring: smart socks and in-shoe systems. The first one is representative of textile-based systems, whereas the second one is one of the most used pressure sensitive insole (PSI) systems that is used as an alternative to smart socks. The proposed methods are reviewed for smart sock use in special medical applications, for gait and foot pressure analysis. The Pedar system is also shown, together with studies of validation and repeatability for Pedar and other in-shoe systems. Then, the applications of Pedar are presented, mainly in medicine and sports. Our purpose was to offer the researchers in this field a useful means to overview and select relevant information. Moreover, our review can be a starting point for new, relevant research towards improving the design and functionality of the systems, as well as extending the research towards other areas of applications using sensors in smart textiles and in-shoe systems.

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.

Registry number: IPGRP-2020cn124

Comparative study of the strength characteristics of a novel wood-plastic composite and commonly used synthetic casting materials

BACKGROUND

Woodcast® is a wood-plastic composite casting material that becomes pliable and self-adhesive when heated to 65 °C and returns to being weightbearing as it cools down. The present study aims to test whether this novel non-toxic casting material is strong enough for clinical use by comparing its strength against materials that are already used in weightbearing casting applications such as total contact casts.

METHODS

The strength of Woodcast® samples was compared against the strength of two commonly used synthetic casting materials (Delta-Cast®, OrthoTape). The effect of environmental factors such as cooling, prolonged heating and exposure to water was also assessed.

FINDINGS

The results of this study indicated that Woodcast® is stronger than the synthetic casting materials in compression but weaker in tension. The flexural strength of Woodcast® was 14.24 MPa (±1.25 MPa) while the respective strength of Delta-Cast® and OrthoTape was 18.96 MPa (±7.46 MPa) and 12.93 MPa (±1.93 MPa). Independent samples t-test indicated that the difference between Woodcast® and the other two materials was not statistically significant (P > .05). Woodcast® recovered 90% and 78% of its tensile or flexural strength respectively after 15 min of cooling at ambient temperature and its strength was not reduced by prolonged heating. On average, exposure to water reduced the flexural strength of Delta-Cast® by 6% and of OrthoTape by 44%. The strength of Woodcast® was not affected by exposure to water.

INTERPRETATION

The comparison between Woodcast® and commonly used synthetic casting materials indicated that Woodcast® is indeed strong enough to be safely used in weightbearing casting applications.

Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review

BACKGROUND

Offloading interventions are commonly used in clinical practice to heal foot ulcers. The aim of this updated systematic review is to investigate the effectiveness of offloading interventions to heal diabetic foot ulcers.

METHODS

We updated our previous systematic review search of PubMed, EMBASE, and Cochrane databases to also include original studies published between July 29, 2014 and August 13, 2018 relating to four offloading intervention categories in populations with diabetic foot ulcers: (a) offloading devices, (b) footwear, (c) other offloading techniques, and (d) surgical offloading techniques. Outcomes included ulcer healing, plantar pressure, ambulatory activity, adherence, adverse events, patient-reported measures, and cost-effectiveness. Included controlled studies were assessed for methodological quality and had key data extracted into evidence and risk of bias tables. Included non-controlled studies were summarised on a narrative basis.

RESULTS

We identified 41 studies from our updated search for a total of 165 included studies. Six included studies were meta-analyses, 26 randomised controlled trials (RCTs), 13 other controlled studies, and 120 non-controlled studies. Five meta-analyses and 12 RCTs provided high-quality evidence for non-removable knee-high offloading devices being more effective than removable offloading devices and therapeutic footwear for healing plantar forefoot and midfoot ulcers. Total contact casts (TCCs) and non-removable knee-high walkers were shown to be equally effective. Moderate-quality evidence exists for removable knee-high and ankle-high offloading devices being equally effective in healing, but knee-high devices have a larger effect on reducing plantar pressure and ambulatory activity. Low-quality evidence exists for the use of felted foam and surgical offloading to promote healing of plantar forefoot and midfoot ulcers. Very limited evidence exists for the efficacy of any offloading intervention for healing plantar heel ulcers, non-plantar ulcers, and neuropathic ulcers with infection or ischemia.

CONCLUSION

Strong evidence supports the use of non-removable knee-high offloading devices (either TCC or non-removable walker) as the first-choice offloading intervention for healing plantar neuropathic forefoot and midfoot ulcers. Removable offloading devices, either knee-high or ankle-high, are preferred as second choice over other offloading interventions. The evidence bases to support any other offloading intervention is still weak and more high-quality controlled studies are needed in these areas.

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.

Ankle Motion and Offloading in Short Leg Cast and Low and High Fracture Boots

BACKGROUND

Short leg casts (SLCs) and fracture boots are used to treat foot and ankle injuries, but the decision to use one device over the other is often subjective. This study compared the impact of SLCs and low and high fracture boots on ankle motion and offloading.

METHODS

Twenty healthy adults were prospectively studied. High-speed dynamic radiography was utilized to determine tibiotalar range of motion in the sagittal plane during nonweightbearing (NWB) and weightbearing (WB) gait in a shoe (control), SLC, and low and high fracture boots. Sensors captured peak plantar surface forces to determine ankle offloading.

RESULTS

In NWB, the low fracture boot (2.2 ± 2.0 degrees), high fracture boot (2.3 ± 1.6 degrees), and SLC (2.3 ± 1.5 degrees) had significantly less motion compared with the control (3.6 ± 2.1 degrees; P ≤ .026). During WB, the SLC (3.4 ± 1.4 degrees) and high fracture boot (4.8 ± 2.0 degrees) had less motion compared with the low fracture boot (7.8 ± 3.4 degrees; P < .001). Finally, the SLC (172.6% ± 48.3% body weight [BW]) and low fracture (165.1% ± 36.2% BW) and high fracture (154.5% ± 32.9% BW) boots were associated with less peak plantar surface force compared with the control (195.0% ± 43.8% BW; P ≤ .087).

CONCLUSION

The SLC and high fracture boot immobilized the ankle in NWB and offloaded and immobilized the ankle in WB. The low fracture boot also immobilized the ankle in NWB, but in WB, the low fracture boot only offloaded the ankle and did not immobilize it.

CLINICAL RELEVANCE

The low fracture boot may be more suited for NWB or possibly immobilizing the foot in WB.

Use of 3D-Printed Heel Support Insoles Based on Arch Lift Improves Foot Pressure Distribution in Healthy People

Background

3D-printed insoles are widely used. This study was conducted to test a customized three-dimensional (3D)-printed heel support insole based on arch lift and to investigate whether the pressure distribution on the sole was improved while maintaining foot function.

Material/Methods

The design was based on a 3D plantar contour scanning modeling technique. Thirty healthy male participants walked along a 10-m track under 3 self-controlled interventions. A customized 3D-printed heel support insole based on arch lift was inserted into the socks for the experimental condition A. For condition B, a customized 3D-printed heel-supporting insole was inserted into the socks, and a standardized pre-made heel-supporting insole was inserted into the socks as a control (condition C). We used the Footscan^® pressure plate to measure the plantar parameters in the forefoot contact and foot flange phases in each condition.

Results

Compared with condition B and the control condition, the peak pressure under the heel was significantly lower in condition A (P<0.05), and the peak pressure in the midfoot region was not significantly increased (P>0.05).

Conclusions

The biomechanical properties of the customized 3D-printed heel support are better than those of the traditional heel support insole, especially when there is a need for an additional increase in heel height. Patients do not decrease midfoot motion function while using this customized insole.

Does Flexible Flatfoot Require Treatment?: Plantar Pressure Effects of Wearing Over-the-Counter Insoles when Walking on a Level Surface and Up and Down Stairs in Adults with Flexible Flatfoot

BACKGROUND

Orthotic insole is a popular physiotherapy for flatfoot. However, the effects and whether flexible flatfoot needs orthotic insole treatment are not clear, and how the plantar pressure changes while walking up and down stairs has not been studied. Therefore, this study observed the plantar pressures of different walking conditions to find the answers.

METHODS

Fifteen adults with flexible flatfoot and 15 adults with normal foot were examined while walking on a level surface and while walking up and down 10- and 20-cm stairs before treatment. The maximum force and the arch index were acquired with a force plate system. Participants with flexible flatfoot were instructed to wear the orthotic insoles for 3 months, and plantar pressures were measured again after treatment. The repeated measure was performed to analyze the data.

RESULTS

The maximum force and the arch index of flatfoot after treatment were significantly decreased under different walking conditions (P < .01). When walking down 10- and 20-cm stairs, the plantar data of normal foot and flatfoot were significantly increased (P < .05).

CONCLUSIONS

Orthotic insoles could effectively improve the plantar pressure of flatfoot under different walking conditions. In addition, the arches of normal foot and flatfoot were obviously influenced when walking down stairs. It is, therefore, necessary to wear orthotic insoles for flexible flatfoot to prevent further deformation.

Effect of different casting design characteristics on offloading the diabetic foot

BACKGROUND

Non-removable knee-high devices, such as a total contact cast (TCC), are recommended for offloading diabetic plantar forefoot ulcers. However, it is insufficiently known how each of the different design characteristics of these devices contribute to offloading the diabetic foot.

RESEARCH QUESTION

What is the offloading effect of the different design characteristics that make up a non-removable knee-high cast for people with diabetes and active or previous plantar forefoot ulcers?

METHODS

Sixteen persons with diabetes, peripheral neuropathy and a healed or active plantar forefoot ulcer had their plantar pressures measured during walking in a non-removable knee-high device (TCC), in that device made removable (BTCC), in that device made below-ankle (cast shoe), in that cast shoe worn with a different walking sole and in a newly made cast shoe without a custom-moulded foot-device interface. Peak pressures, force-time integral, and perceived walking comfort were assessed.

RESULTS

Compared with the BTCC, peak pressures in the TCC were 47% (P = 0.028), 26% (P = 0.003) and 15% (P = 0.050) lower at the hallux, midfoot and (previous) ulcer location, respectively. Compared to the cast shoe, peak pressures in the BTCC were 39-43% and 47% (both P < 0.001) lower in the forefoot regions and (previous) ulcer location, respectively. The total force-time integral was 21% and 11% (P < 0.007) lower in the TCC and BTCC compared to the cast shoe. Perceived walking comfort was 5.6 in the TCC and 6.5 in the BTCC (P = 0.037). Effects of the other design characteristics (i.e. walking sole and plantar moulding) were non-significant.

SIGNIFICANCE

The TCC gives superior offloading, mostly because of being a knee-high and non-removable device, providing an optimal 'shaft effect'. The TCC does, however, negatively affect walking comfort. These results aid decision-making in offloading diabetic plantar forefoot ulcers.

A Narrative Review of the Benefits and Risks of Total Contact Casts in the Management of Diabetic Foot Ulcers

Total contact casts are recognized as the gold standard treatment for neuropathic plantar diabetic foot ulceration, endorsed by all national and international consensus papers. Despite this, research has shown that there is a dichotomy between the existing evidence which supports the use of total contact casts in the management of diabetic foot ulcers and its use in clinical practice. This article aims to highlight the benefits, risks, and barriers associated with total contact cast use in the management of diabetic foot ulcers in the clinical setting, with an emphasis on existing research carried out in this field to encourage change in clinical practice and utilization of this effective treatment modality.

Evaluation of Pressure Capacitive Sensors for Application in Grasping and Manipulation Analysis

The analysis of the human grasping and manipulation capabilities is paramount for investigating human sensory-motor control and developing prosthetic and robotic hands resembling the human ones. A viable solution to perform this analysis is to develop instrumented objects measuring the interaction forces with the hand. In this context, the performance of the sensors embedded in the objects is crucial. This paper focuses on the experimental characterization of a class of capacitive pressure sensors suitable for biomechanical analysis. The analysis was performed in three loading conditions (Distributed load, 9 Tips load, and Wave-shaped load, thanks to three different inter-elements) via a traction/compression testing machine. Sensor assessment was also carried out under human- like grasping condition by placing a silicon material with the same properties of prosthetic cosmetic gloves in between the sensor and the inter-element in order to simulate the human skin. Data show that the input-output relationship of the analyzed, sensor is strongly influenced by both the loading condition (i.e., type of inter-element) and the grasping condition (with or without the silicon material). This needs to be taken into account to avoid significant measurement error. To go over this hurdle, the sensors have to be calibrated under each specific condition in order to apply suitable corrections to the sensor output and significantly improve the measurement accuracy.

The efficacy of removable devices to offload and heal neuropathic plantar forefoot ulcers in people with diabetes: a single-blinded multicentre randomised controlled trial

Non-removable offloading is the 'gold standard' treatment for neuropathic diabetic plantar forefoot ulcers. However, removable offloading is the common 'standard of care'. We compared three removable offloading devices for ulcer healing efficacy. In this multicentre, randomised controlled trial, 60 persons with neuropathic diabetic plantar forefoot ulcers were randomly assigned to wear a custom-made knee-high cast [BTCC (bivalved TCC)], custom-made ankle-high cast shoe or a prefabricated ankle-high forefoot-offloading shoe (FOS). Primary outcome was healing at 12 weeks. Dynamic plantar pressures, daily stride count and treatment adherence were assessed on a randomly selected subset (n = 35). According to intention-to-treat analysis, 58% of patients healed with BTCC [OR 0·77 (95% CI 0·41-1·45) versus FOS], 60% with cast shoe [OR 0·81 (95% CI 0·44-1·49) versus FOS] and 70% with FOS (P = 0·70). Mean ± SD peak pressure in kPa at the ulcer site was 81 ± 55 for BTCC, 176 ± 80 for cast shoe and 107 ± 52 for FOS (P = 0·005); stride count was 4150 ± 1626, 3514 ± 1380 and 4447 ± 3190, respectively (P = 0·71); percentage of 2-week intervals that patients wore the device <50% of time was 17·3%, 5·2% and 4·9%, respectively. Non-significant differences in healing efficacy between the three devices suggest that, when non-removable offloading is contraindicated or not available, each can be used for plantar forefoot ulcer offloading. Efficacy is lower than previously found for non-removable offloading maybe because suboptimal adherence and high stride count expose the patient to high repetitive stresses. These factors should be carefully considered in decision making regarding ulcer treatment.

The Role of Pressure Offloading on Diabetic Foot Ulcer Healing and Prevention of Recurrence

BACKGROUND

An increased plantar pressure is a causative factor in the development of plantar foot ulcers in people with diabetes mellitus, and ulcers are a precursor of lower extremity amputation.

METHODS

In this article, the evidence is reviewed that relieving areas of increased plantar pressure (ie, offloading) can heal plantar foot ulcers and prevent their recurrence.

RESULTS

Noninfected, nonischemic neuropathic plantar forefoot ulcers should heal in 6 to 8 weeks with adequate offloading. Recent meta-analyses and systematic reviews show that nonremovable knee-high devices are most effective. This is probably because they eliminate the problem of nonadherence with the use of a removable device. Studies show a large discrepancy between evidence-based recommendations on offloading and what is used in clinical practice. Many clinics continue to use methods that are less effective or have not been proven to be effective, while ignoring evidence-based methods. Strategies are proposed to address this issue, notably the adoption and implementation of recent international guidelines by professional societies and a stronger focus of clinicians on expedited healing. For the prevention of plantar foot ulcer recurrence in high-risk patients, 2 recent trials have shown that the incidence of recurrence can be significantly reduced with custom-made footwear that has a demonstrated pressure-relieving effect through guidance by plantar pressure measurements, under the condition that the footwear is worn.

CONCLUSION

This review helps to inform clinicians about effective offloading treatment for healing plantar foot ulcers and preventing their recurrence.

Plantar pressure differences among adults with mild flexible flatfoot, severe flexible flatfoot and normal foot when walking on level surface, walking upstairs and downstairs

[Purpose] This study observed the plantar pressure between flexible flatfoot and normal foot on different walking conditions to find out if flexible flatfoot needs the treatment and how the plantar pressure change while walking upstairs and downstairs. [Subjects and Methods] Fifteen adults with mild flexible flatfoot, fifteen adults with severe flexible flatfoot and fifteen adults with normal foot were examined while walking on a level surface, walking up and down 10 cm and 20 cm stairs. The max force and the arch index were acquired using the RSscan system. The repeated measures ANOVA was performed to analyze the data. [Results] Compared with normal foot, both max force and arch index of severe flatfoot were significantly increased on different walking conditions. When walking down 10 cm and 20 cm stairs, the plantar data of both normal foot and flatfoot were significantly increased. [Conclusion] The plantar pressure of severe flexible flatfoot were significantly larger than that of normal foot on different walking conditions. In addition, the arches of both normal foot and flatfoot were obviously deformed when walking downstairs. It is therefore necessary to be treated for severe flexible flatfoot to prevent further deformation.