Multi-segment foot kinematics during gait in children with spastic cerebral palsy

BACKGROUND

Foot deformities (e.g. planovalgus and cavovarus) are very common in children with spastic cerebral palsy (CP), with the midfoot often being involved. Dynamic foot function can be assessed with 3D gait analysis including a multi-segment foot model. Incorporating a midfoot segment in such a model, allows quantification of separate Chopart and Lisfranc joint kinematics. Yet, midfoot kinematics have not previously been reported in CP.

RESEARCH QUESTIONS

What is the difference in multi-segment kinematics including midfoot joints between common foot deformities in CP and typically-developing feet?

METHODS

103 feet of 57 children with spastic CP and related conditions were retrospectively included and compared with 15 typically-developing children. All children underwent clinical gait analysis with the Amsterdam Foot Model marker set. Multi-segment foot kinematics were calculated for three strides per foot and averaged. A k-means cluster analysis was performed to identify foot deformity groups that were present within CP data. The deformity type represented by each cluster was based on the foot posture index. Kinematic output of the clusters was compared to typically-developing data for a static standing trial and for the range of motion and kinematic waveforms during walking, using regular and SPM independent t-tests respectively.

RESULTS

A neutral, planovalgus and varus cluster were identified. Neutral feet showed mostly similar kinematics as typically-developing data. Planovalgus feet showed increased ankle valgus and Chopart dorsiflexion, eversion and abduction. Varus feet showed increased ankle varus and Chopart inversion and adduction.

SIGNIFICANCE

This study is the first to describe Chopart and Lisfranc joint kinematics in different foot deformities of children with CP. It shows that adding a midfoot segment can provide additional clinical and kinematic information. It highlights joint angles that are more distinctive between deformities, which could be helpful to optimize the use of multi-segment foot kinematics in the clinical decision making process.

Measuring Inflammatory Foot Disease in Rheumatoid Arthritis: Development and Validation of the Rheumatoid Arthritis Foot Disease Activity Index-5

OBJECTIVE

Omission of foot joints from composite global disease activity indices may lead to underestimation of foot and overall disease in rheumatoid arthritis (RA) and under-treatment. The aim of this study was to evaluate the measurement properties of the Rheumatoid Arthritis Foot Disease Activity Index-5 (RADAI-F5), a newly developed patient-reported outcome measure for capturing foot disease activity in people with RA.

METHODS

Participants with RA self-completed the RADAI-F5, modified Rheumatoid Arthritis Disease Activity Index (mRADAI-5), Foot Function Index (FFI), and Foot Impact Scale (FIS) impairment/footwear and activity/participation subscales. The 28-joint Disease Activity Score using the erythrocyte sedimentation rate (DAS28-ESR) was also recorded. Subgroups completed the RADAI-F5 at 1 week and 6 months. Psychometric properties, including construct, content and longitudinal validity, internal consistency, 1-week reproducibility, and responsiveness over 6 months were evaluated.

RESULTS

Of 142 respondents, 103 were female, with a mean ± SD age of 55 ± 12.5 years and median RA disease duration of 10 (interquartile range 3.6-20.8) months. Theoretically consistent associations confirming construct validity were observed with mRADAI-5 (0.789 [95% confidence interval (95% CI) 0.73, 0.85]), FFI (0.713 [95% CI 0.62, 0.79]), FIS impairment/footwear (0.695 [95% CI 0.66, 0.82], P < 0.001), FIS activity/participation (0.478 [95% CI 0.37, 0.63], P < 0.001), and the DAS28-ESR (0.379 [95% CI 0.26, 0.57], P < 0.001). The RADAI-F5 demonstrated high internal consistency (Cronbach's α = 0.90) and good reproducibility (intraclass correlation coefficient = 0.868 [95% CI 0.80, 0.91], P < 0.001, smallest detectable change = 2.69). Content validity was confirmed, with 82% rating the instrument relevant and easy to understand.

CONCLUSION

The RADAI-F5 is a valid, reliable, responsive, clinically feasible patient-reported outcome measure for measuring foot disease activity in RA.

Impact of foot modeling on the quantification of the effect of total ankle replacement: A pilot study

BACKGROUND

Kinematic and kinetic foot models showed that computing ankle joint angles, moments and power with a one-segment foot modeling approach alters kinematics and tends to overestimate ankle joint power. Nevertheless, gait studies continue to implement one-segment foot models to assess the effect of total ankle replacement.

RESEARCH QUESTION

The objective of this pilot study was to investigate the effect of the foot modeling approach (one-segment versus multi-segment) on how total ankle replacement is estimated to benefit or degrade the patient's biomechanical performance.

METHODS

Ten subjects with post-traumatic ankle osteoarthritis scheduled for total ankle replacement and 10 asymptomatic subjects were recruited. A one-segment and a multi-segment foot model were used to calculate intrinsic foot joints kinematics and kinetics during gait. A linear mixed model was used to investigate the effect of the foot model on ankle joint kinematic and kinetic analysis and the effect of total ankle replacement.

RESULTS

Differences in range of motion due to the foot model effect were significant for all the gait subphases of interest except for midstance. Peak power generation was significantly overestimated when computed with the one-segment foot model. Ankle and shank-calcaneus joint dorsi-/plantarflexion range of motion did not increase post-operatively except during the loading response phase. A significant 'group' effect was found for stance and pre-swing phase range of motion, with total ankle replacement patients showing lower range of motion values than controls for dorsi/plantarflexion.

SIGNIFICANCE

The outcome of this study showed that the 'foot model' had a significant effect on estimates of range of motion and power generation. The findings in our study therefore emphasize the clinical interest of multi-segment foot modeling when assessing the outcome of a therapeutic intervention.

Foot structure and lower limb function in individuals with midfoot osteoarthritis: a systematic review

OBJECTIVE

To determine how foot structure and lower limb function differ between individuals with and without midfoot osteoarthritis (OA).

DESIGN

Electronic databases were searched from inception until May 2020. To be eligible, studies needed to (1) include participants with radiographically confirmed midfoot OA, with or without midfoot symptoms, (2) include a control group of participants without radiographic midfoot OA or without midfoot symptoms, and (3) report outcomes of foot structure, alignment, range of motion or any measures of lower limb function during walking. Screening and data extraction were performed by two independent assessors, with disagreements resolved by a third independent assessor. The methodological quality of included studies was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

RESULTS

A total of 1,550 records were screened by title and abstract and 11 met the inclusion criteria. Quantitative synthesis indicated that individuals who had midfoot OA had a more pronated foot posture, greater first ray mobility, less range of motion in the subtalar joint and first metatarsophalangeal joints, longer central metatarsals and increased peak plantar pressures, pressure time integrals and contact times in the heel and midfoot during walking. Meta-analysis could not be performed as the data were not sufficiently homogenous.

CONCLUSIONS

There are several differences in foot structure and lower limb function between individuals with and without midfoot OA. Future research with more consistent case definitions and detailed biomechanical models would further our understanding of potential mechanisms underlying the development of midfoot OA.

Is bodyweight affecting plantar pressure distribution in children?: An observational study

The aim of this study is twofold: firstly, to investigate the plantar pressure distribution differences in children coming from 4 different weight categories and secondly to analyze the presence of sex-related plantar pressure distribution differences.Overall, 416 children, aged 7 to 12 years old were randomly selected from 6 different local schools, and voluntarily participated in the study. Two hundred twenty six of them were men, while 190 were women (mean age: 9.93 ± 1.02 years; height: 1.39 ± 0.8 m; body mass: 37.76 ± 10.34 kg; BMI: 19.24 ± 4.02 kg/m). Based on the body mass index (BMI) the sample was grouped in the following categories: underweight (UW); normal weight (NW); overweight (OW), and obese (OB). Besides, the plantar load distribution parameters (total plantar load distribution and load distribution in forefoot and rearfoot) were assessed employing freeMed Maxi; Sensor Medica device. Shapiro-Wilk test was used to test the data distribution. Between-groups comparisons were conducted using Mann-Whitney U test, or using Kruskal-Wallis test associated with pairwise comparisons.There were significant differences in load distribution between weight categories, with (OW) and (NW) being significantly different with (O), P = .03 and P = .04, respectively. No significant differences were found on load distribution on the rearfoot and forefoot between categories. The sex effect, particularly among boys, revealed a different pattern of load distribution among (O) compared with other categories. This effect was not detected among women. Different profile of load distribution on the rearfoot and forefoot between boys and girls was found, with girls bearing significantly more weight in the right rearfoot compared with boys (P = .001).It can be concluded that the weight status of the children can affect the plantar load distribution, with obese category being different from (NW) and (OW). Additionally, the sex plays a role when it comes to the load distribution in different regions of the foot. Moreover, since the young age, due to growth and development process, is accompanied with anatomical foot changes which might be affected from numerous factors, assessing plantar pressure distribution in young children results to be a quite complicated matter.

Objectively Assessed Foot and Ankle Characteristics in Patients With Systemic Lupus Erythematosus: A Comparison With Age- and Sex-Matched Controls

OBJECTIVE

To objectively identify foot and ankle characteristics in patients with systemic lupus erythematosus (SLE) compared to age- and sex-matched controls.

METHODS

A total of 54 patients with SLE and 56 control participants attended a study visit designed to comprehensively assess the foot and ankle. Objectively assessed foot characteristics included muscle strength, joint motion, foot posture, foot problems, protective sensation, vibration perception threshold (VPT), ankle brachial index (ABI), plantar pressure, and spatiotemporal gait characteristics. Self-reported measure of foot pain and impairment were also assessed using a 100-mm foot pain visual analog scale. Data were analyzed using regression models. Plantar pressure and gait models were adjusted for walking velocity, body mass index, and foot pain.

RESULTS

Compared to controls, participants with SLE had lower muscle force for plantarflexion, dorsiflexion, inversion, and eversion (all P < 0.001), higher foot posture indices (P = 0.007), higher foot problem scores (P = 0.001), higher VPT (P = 0.001), and more frequent abnormal ABI (odds ratio [OR] 3.13, P = 0.044). Participants with SLE also had lower peak pressure and higher pressure time integrals for all foot regions (all P < 0.001), lower step and stride length, velocity, and cadence, and higher step, swing, stance, and single and double support times compared to controls (all P < 0.001). Compared to controls, participants with SLE also reported greater foot pain (P < 0.001).

CONCLUSION

Patients with SLE experience a wide range of foot symptoms. This study has provided objective evidence of foot and ankle disease in patients with SLE, including reduced muscle strength and altered gait patterns when compared to controls. This highlights the importance of foot health assessments as part of SLE management.

Following the correction of varus deformity of the knee through total knee arthroplasty, significant compensatory changes occur not only at the ankle and subtalar joint, but also at the foot

PURPOSE

This study aimed to assess radiological changes of the ankle joint, subtalar joint and foot following the correction of varus deformity of the knee with total knee arthroplasty (TKA). It was hypothesized that following the correction of varus deformity by TKA, compensatory reactions would occur at the subtalar joint in accordance with the extent of the correction.

METHODS

For this prospective study, 375 knees of patients who underwent TKA between 2011 and 2012 were enrolled. The varus angle of the knee, talar tilt of the ankle joint (TT), ground-talar dome angle of the foot (GD), anterior surface angle of the distal tibia and lateral surface angle of the distal tibia, heel alignment ratio (HR), heel alignment angle (HA), and heel alignment distance (HD) were measured on radiographs obtained pre-operatively and at post-operative 6 months.

RESULTS

The mean correction angle in varus deformity of the knee was 10.8 ± 4.1°. TT and GD changed significantly from 0.4 ± 1.9° and 6.5 ± 3.1° pre-operatively to 0.1 ± 1.8° and 0.2 ± 2.1°, respectively (p = 0.007, p < 0.001). No correlation was found between the preop-postop variance in mechanical axis of the lower extremity (MA) and TT, but there was a strong correlation between the preop-postop variance in MA and GD (r = 0.701). HR, HA and HD also changed significantly post-operatively, and the preop-postop variance in MA showed correlations with the preop-postop variances in HR, HA and HD (r = 0.206, - 0.348, and - 0.418). TT and the three indicators of hindfoot alignment all shifted to varus whereas GD was oriented in valgus.

CONCLUSION

Following the correction of varus deformity of the knee through TKA, significant compensatory changes occurred not only at the ankle and subtalar joints, but also at the foot. The findings of this study are useful in predicting the orientation of changes in the ankle and subtalar joints and the foot following TKA, and in determining the sequence of surgery when both the ankle and knee have a problem. In other words, changes in the parts of the lower extremity below the ankle joint following the correction of varus deformity of the knee must be considered when TKA is planned and performed. Patients who have problems at the ankle, subtalar, and foot joints in addition to varus deformity of the knee are recommended to undergo knee joint correction first.

LEVEL OF EVIDENCE

II.

Features of patients with rheumatoid arthritis whose debut joint is a foot or ankle joint: A 5,479-case study from the IORRA cohort

Background

Foot and ankle joint disorders are serious issues for patients with rheumatoid arthritis (RA). We compared the differences between patients with RA whose first symptom involved a foot or ankle joint (FOOT group) versus other joints (non-FOOT group) within the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort in our institute.

Patients and methods

In the IORRA survey conducted in April 2016, patients were invited to complete six questionnaires about their first symptom at RA onset, current foot or ankle symptoms, daily living activities, and mental health. Disease activity, clinical laboratory variables, functional disability, quality of life, use and ratio of anti-inflammatory and antirheumatic drugs, daily living activities and mental health were compared between the two groups.

Results

Among 5,637 Japanese patients with RA who participated in the IORRA survey on April 2016, 5,479 (97.2%) responded to the questionnaire regarding their debut joint. Of these patients, 2,402 (43.8%) reported that their first symptom of RA involved a foot or ankle joint. The FOOT group (n = 2,164) had higher disease activity, higher disabilities, lower quality of life, lower activities of daily living, and poorer mental health and used anti-inflammatory drugs at a higher rate and at higher doses compared with the non-FOOT group (n = 2,164). On the other hand, the use of medications to suppress the disease activity of RA was similar between the groups.

Conclusion

Clinicians should pay more attention to foot and ankle joints in daily practice so as not to underestimate the disease activity of RA.

Comparison of the effects of forefoot joint-preserving arthroplasty and resection-replacement arthroplasty on walking plantar pressure distribution and patient-based outcomes in patients with rheumatoid arthritis

Purpose

The purpose of this retrospective study is to clarify the difference in plantar pressure distribution during walking and related patient-based outcomes between forefoot joint-preserving arthroplasty and resection-replacement arthroplasty in patients with rheumatoid arthritis (RA).

Methods

Four groups of patients were recruited. Group1 included 22 feet of 11 healthy controls (age 48.6 years), Group2 included 36 feet of 28 RA patients with deformed non-operated feet (age 64.8 years, Disease activity score assessing 28 joints with CRP [DAS28-CRP] 2.3), Group3 included 27 feet of 20 RA patients with metatarsal head resection-replacement arthroplasty (age 60.7 years, post-operative duration 5.6 years, DAS28-CRP 2.4), and Group4 included 34 feet of 29 RA patients with metatarsophalangeal (MTP) joint-preserving arthroplasty (age 64.6 years, post-operative duration 3.2 years, DAS28-CRP 2.3). Patients were cross-sectionally examined by F-SCAN II to evaluate walking plantar pressure, and the self-administered foot evaluation questionnaire (SAFE-Q). Twenty joint-preserving arthroplasty feet were longitudinally examined at both pre- and post-operation.

Results

In the 1^st MTP joint, Group4 showed higher pressure distribution (13.7%) than Group2 (8.0%) and Group3 (6.7%) (P<0.001). In the 2^nd-3^rd MTP joint, Group4 showed lower pressure distribution (9.0%) than Group2 (14.5%) (P<0.001) and Group3 (11.5%) (P<0.05). On longitudinal analysis, Group4 showed increased 1^st MTP joint pressure (8.5% vs. 14.7%; P<0.001) and decreased 2^nd-3^rd MTP joint pressure (15.2% vs. 10.7%; P<0.01) distribution. In the SAFE-Q subscale scores, Group4 showed higher scores than Group3 in pain and pain-related scores (84.1 vs. 71.7; P<0.01) and in shoe-related scores (62.5 vs. 43.1; P<0.01).

Conclusions

Joint-preserving arthroplasty resulted in higher 1^st MTP joint and lower 2^nd-3^rd MTP joint pressures than resection-replacement arthroplasty, which were associated with better patient-based outcomes.

Characteristics of patients with fibromyalgia

BACKGROUND

Fibromyalgia is characterised by generalized pain. A search of the available literature found no previous reports describing the specific characteristics of patients with fibromyalgia.

OBJECTIVES

To describe characteristics of patients with fibromyalgia.

MATERIAL AND METHODS

Case-control study including 50 patients with fibromyalgia and 50 gender and age-matched controls. After obtaining written informed consent for the study, demographic data were collected and pain in the leg, ankle and foot area was measured using a visual analogue scale (VAS). A general physical examination to test mobility and rigidity of the foot joints was also performed. Patients were also asked about their shoe utilisation habits.

RESULTS

The results confirm that patients with fibromyalgia experience significantly more pain in the whole leg, ankle and foot areas than the control subjects. For this reason they use significantly more pain-killing drugs than the control subjects. However, this increase in pain is not associated with stiffness or mobility abnormalities in this series. In addition, patients with fibromyalgia show no increase in the rate of hyperkeratosis or other foot lesions.

CONCLUSIONS

Patients with fibromyalgia do not seem to show a higher rate of foot lesions or a peculiar pattern of foot involvement compared to age and gender-matched controls.

Ultrasound of the osteoarthritic joint

Ultrasound (US) has acquired an increasing role in the assessment of joint and periarticular abnormalities in osteoarthritis (OA). It is able to image a large set of abnormalities in this disease which include both inflammatory and structural changes at different peripheral joint sites and it is helpful in guiding local procedures that can be easily and safely performed with optimal patient's tolerance. US is a feasible imaging modality that has become a bedside procedure in the rheumatology clinical practice, thus filling the gap between clinical and radiographic evaluations of patients with OA. The present review focuses and summarises the currently available data on the applications of US in OA.

Extension and grading of osteomyelitis are not related to limb salvage in Charcot neuropathic osteoarthropathy: A cohort prospective study

AIMS

Charcot neuropathic osteoarthropathy (CN) represents a complication for diabetic patients which involves a progressive alteration of the osteoarticular apparatus with high risk of amputation. The aim of the study was to assess whether the localization of CN and the extent or grading of the osteomyelitis have an influence on the rate of limb salvage and the time to recovery.

METHODS

We treated a diabetic population affected by CN complicated by ulceration and widespread osteomyelitic involvement. All patients were treated surgically to eliminate infected tissues, stabilize and correct the bone deformities. Histopathological and microbiological analyses were carried out on the bone specimens.

RESULTS

Thirty-three patients affected by CN complicated by large osteomyelitic involvement of midfoot and/or ankle were treated between January 2010 and May 2014. The mean follow-up was 409,35 ± 154,06 days. Thirty patients had complete recovery (90.91%) at the end of follow-up. No difference in limb salvage rate and time to recovery was observed when stratifying the population according to CN localization, extent and grading of osteomyelitis.

CONCLUSIONS

In this cohort prospective study we observed a high percentage of limb salvage in patients affected by CN complicated by diffuse midfoot/hindfoot osteomyelitis. The localization of Charcot deformity and the extent/stage of osteomyelitis did not change the rate of limb salvage.

Effect of Rhythmic Auditory Stimulation on Hemiplegic Gait Patterns

PURPOSE

The purpose of our study was to investigate the effect of gait training with rhythmic auditory stimulation (RAS) on both kinematic and temporospatial gait patterns in patients with hemiplegia.

MATERIALS AND METHODS

Eighteen hemiplegic patients diagnosed with either cerebral palsy or stroke participated in this study. All participants underwent the 4-week gait training with RAS. The treatment was performed for 30 minutes per each session, three sessions per week. RAS was provided with rhythmic beats using a chord progression on a keyboard. Kinematic and temporospatial data were collected and analyzed using a three-dimensional motion analysis system.

RESULTS

Gait training with RAS significantly improved both proximal and distal joint kinematic patterns in hip adduction, knee flexion, and ankle plantar flexion, enhancing the gait deviation index (GDI) as well as ameliorating temporal asymmetry of the stance and swing phases in patients with hemiplegia. Stroke patients with previous walking experience demonstrated significant kinematic improvement in knee flexion in mid-swing and ankle dorsiflexion in terminal stance. Among stroke patients, subacute patients showed a significantly increased GDI score compared with chronic patients. In addition, household ambulators showed a significant effect on reducing anterior tilt of the pelvis with an enhanced GDI score, while community ambulators significantly increased knee flexion in mid-swing phase and ankle dorsiflexion in terminal stance phase.

CONCLUSION

Gait training with RAS has beneficial effects on both kinematic and temporospatial patterns in patients with hemiplegia, providing not only clinical implications of locomotor rehabilitation with goal-oriented external feedback using RAS but also differential effects according to ambulatory function.

[Patient-reported SEFAS: Questionnaire good evaluation method in foot and ankle disorders]

There is need for structured evaluation of disability before and after surgery. The patients' subjective aspects of their symptoms should be one part of this evaluation, preferably captured by patient-reported outcome measures (PROMs). There are several PROMs, either generic or region-specific questionnaires, but no » gold standard « for foot or ankle evaluation. We translated the Self-reported Foot and Ankle Score (SEFAS) and evaluated the psychometric properties of the score in terms of reliability, validity and responsiveness in patients with a variety of foot and ankle disorders. In this report we recommend a validation process for PROMs and report that SEFAS shows good results when doing this. As SEFAS is a PROM, the instrument seems suitable for use in national registers.

A comparison of two podiatric protocols for metatarsalgia in patients with rheumatoid arthritis and osteoarthritis

OBJECTIVES

In rheumatoid arthritis (RA) and osteoarthritis (OA) forefoot involvement causes disability and metatarsalgia. Our objective was to evaluate, in RA and OA patients, the efficacy of two protocols combining insoles in polypropylene terephtalate (PPT) and custom silicone orthoses for toes on disability and metatarsalgia.

METHODS

Twenty-four women (13 with OA, 11 with RA) with metatarsalgia were treated with two protocols: group A (protocol A) wore PPT insoles (T1) for 30 days and for another 30 days silicone orthosis for toes were added (T2). Group B (protocol B) wore PPT insoles and silicone orthosis (T1) for 30 days and in the following 30 days only insoles (T2). At T0, T1 and T2, pain, disability and function (Foot Function Index - FFI), pressure (KPA) and plantar contact areas (cm2) (baropodometer), and gait spatial-temporal parameters (GAITRite®) were assessed.

RESULTS

At T0 versus T2, both protocols reduced FFI-pain, -disability and -functional limitation (p<0.05), with better results of protocol A than protocol B (p<0.05) for FFI-pain and -disability. Both protocols reduced baropodometer foot plantar pressures (p<0.001), with better results for protocol A for right foot pressures (p<0.05) and increased foot contact areas (p<0.05), with no difference between them (p=NS). Gait parameters were not significantly changed by both protocols (p=NS).

CONCLUSIONS

In patients with RA and OA with metatarsalgia, the synergic action of silicone toe orthosis and PPT insoles improves FFI, reduces foot plantar pressures and increases foot plantar contact areas. Protocol A, using firstly insoles and then adding silicone toe orthoses, is the more efficacious.

[Peripheral arthritis in polymyalgia rheumatica]

Polymyalgia rheumatica is characterized by aching and stiffness of the shoulder, the pelvic girdles and the neck. Peripheral joint involvement is less recognized by the medical community as a sign of the disease. In this article we present two patients whose disease was manifested by peripheral symptoms. The frequency, manifestations and the pathogenesis of the disorder are discussed and the importance of recognition of these symptoms and signs of the disease is stressed.

Multi-segment foot mobility in a hinged ankle-foot orthosis: the effect of rotation axis position

Hinged ankle-foot orthoses are prescribed routinely for the treatment of ankle joint deficits, despite the conflicting outcomes and the little evidence on their functional efficacy. In particular, the axis of rotation of the hinge is positioned disregarding the physiological position and orientation. A multi-segment model was utilized to assess in vivo the effect of different positions for this axis on the kinematics of foot joints. A special custom-made hinged orthosis was manufactured via standard procedures for a young healthy volunteer. Four locations for the mechanical axis were obtained by a number of holes where two nuts and bolts were inserted to form the hinge: a standard position well above the malleoli, at the level of the medial malleolus, at the level of the lateral malleolus, and the physiological between the two malleoli. The shank and foot were instrumented with 15 reflective markers according to a standard protocol, and level walking was collected barefoot and with the orthosis in the four mechanical conditions. The spatio-temporal parameters observed in the physiological axis condition were the closest to normal barefoot walking. As expected, ankle joint rotation was limited to the sagittal plane. When the physiological axis was in place, rotations of the ankle out-of-sagittal planes, and of all other foot joints in the three anatomical planes, were found to be those most similar to the natural barefoot condition. These preliminary measures of intersegmental kinematics in a foot within an ankle-foot orthosis showed that only a physiological location for the ankle mechanical hinge can result in natural motion at the remaining joints and planes.

The relationship between clinical measurements and gait analysis data in children with cerebral palsy

Spasticity is a common impairment that interferes with motor function (particularly gait pattern) in children with cerebral palsy (CP). Gait analysis and clinical measurements are equally important in evaluating and treating gait disorders in children with CP. This study aimed to explore the relationship between the spasticity of lower extremity muscles and deviations from the normal gait pattern in children with CP. Thirty-six children with spastic CP (18 with spastic hemiplegia [HS] and 18 with spastic diplegia [DS]), ranging in age from 7 to 12 years, participated in the study. The children were classified as level I (n=24) or level II (n=12) according to the Gross Motor Function Classification System. Spasticity levels were evaluated with the Dynamic Evaluation of Range of Motion (DAROM) using the accelerometer-based system, and gait patterns were evaluated with a three dimensional gait analysis using the Zebris system (Isny, Germany). The Gillette Gait Index (GGI) was calculated from the gait data. The results show that gait pathology in children with CP does not depend on the static and dynamic contractures of hip and knee flexors. Although significant correlations were observed for a few clinical measures with the gait data (GGI), the correlation coefficients were low. Only the spasticity of rectus femoris showed a fair to moderate correlation with GGI. In conclusion, the results indicate the independence of the clinical evaluation and gait pattern and support the view that both factors provide important information about the functional problems of children with CP.

Lisfranc injuries: an update

Lisfranc injuries are a spectrum of injuries to the tarsometatarsal joint complex of the midfoot. These range from subtle ligamentous sprains, often seen in athletes, to fracture dislocations seen in high-energy injuries. Accurate and early diagnosis is important to optimise treatment and minimise long-term disability, but unfortunately, this is a frequently missed injury. Undisplaced injuries have excellent outcomes with non-operative treatment. Displaced injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome. Although evidence to date supports the use of screw fixation, plate fixation may avoid further articular joint damage and may have benefits. Recent evidence supports the use of limited arthrodesis in more complex injuries.

The importance of clinical biomechanical assessment of foot deformity and joint mobility in people living with type-2 diabetes within a primary care setting

AIMS

The aim of the study was to assess foot morphology and document foot deformities and joint mobility in a cohort of subjects living with type-2 diabetes mellitus in Malta in a Primary Care setting.

METHODS

A retrospective observational study was conducted on 243 subjects who participated in a local pilot diabetes foot screening project. Assessments included hammer/claw toes, hallux valgus, hallux limitus, prominent metatarsal heads, bony prominences, Charcot deformity, plantar callus, foot type and ankle and hallux mobility. The clinical assessments used during this screening program were based on validated and previously published tools.

RESULTS

Upon clinical examination 38% of the sample was found to have developed some form of corns or callosities in their feet. Hallux valgus deformity was present in 49.4% of the sample, whilst 39% of the sample had hammer toes. Prominent metatarsal heads (24%), other bony prominences (44%) and limited joint mobility were also reported. Furthermore, 56% of the sample presented with unsuitable footwear and upon clinical biomechanical examination a further 28% of the sample required prescription orthosis.

CONCLUSIONS/INTERPRETATION

A significant proportion of participants living with type-2 diabetes presented with foot deformities which are known to be predictive of foot ulceration in this high risk population. This research conducted in a primary care setting highlights the importance of increased vigilance coupled with strengthening of existing screening structures and introducing clinical guidelines with regards to biomechanical assessment of the feet in a primary care setting in order to reduce the incidence of diabetes foot complications.

[The most common entities of localised extraarticular rheumatism]

Extra-articular rheumatism includes inflammatory and degenerative disorders of soft-tissues, most commonly tendons, enthesis and bursae. Although prevalent, this form of rheumatism is often a diagnostic problem. Exact and early diagnosis is based on history and clinical examination, with a help of diagnostic methods, especially diagnostic ultrasound. In this article are presented the most important entitites of localized extra-articular rheumatism.

Asymmetrical attenuation of vibration sensation in unilateral diabetic Charcot foot neuroarthropathy

AIMS

To further characterize the distal sensory neuropathy in subjects with unilateral diabetic Charcot foot neuroarthropathy.

METHODS

A retrospective cohort study to assess the level to which the sensory modalities of pinprick, light touch, vibration, joint position and temperature were attenuated in the affected and unaffected limbs in subjects with unilateral Charcot. The level to which the sensory modality was attenuated in each limb was assigned a score. The Wilcoxon signed rank test was used to compare the scores in the affected and unaffected limbs and also to compare the scores of the different sensory modalities in the affected and unaffected limbs.

RESULTS

Fifty subjects with unilateral Charcot foot neuroarthropathy were assessed. Mean age was 45 ± SD 6 years for the 17 subjects with Type 1 diabetes and 62 ± 10 years for the 33 subjects with Type 2 diabetes. Duration of diabetes was 21 ± 13 years, HbA(1c) was 70 ± 19 mmol/mol [8.6 ± 1.8 %] and 15 subjects (30%) required renal replacement therapy. The level of attenuation of vibration sensation was more proximal in the affected compared with the unaffected limbs (P = 0.002). Pinprick, light touch, joint position and temperature sensations were not different. Joint position sensation was less attenuated bilaterally than the other sensory modalities.

CONCLUSIONS

Asymmetrical attenuation of vibration sensation may predict the side that will develop a Charcot joint and may suggest a more important role for vibration sense loss than loss of other sensory modalities in the pathophysiology of Charcot.

Nutcracker fracture of the cuboid: management and results

Nutcracker fractures of the cuboid are rare and often missed at an initial visit. They can be difficult to manage and convey a high risk of long-term pain in the foot. During the last six years, 6 recent cuboid fractures in 6 patients were treated at our hospital by open reduction, allogeneic bone grafting (where necessary) and internal fixation. Shortening of the lateral column of the foot existed in all these fractures. At the time of follow-up the results concerning pain and function were good in 2 and fair in 4 patients. We recommend open treatment for cuboid fractures with shortening of the lateral column of the foot or articular displacement of more than 1 mm.

Charcot foot: skin temperature as a good clinical parameter for predicting disease outcome

Twenty-eight diabetics presenting with acute Charcot foot were immobilized and the temperature difference between limbs measured at each month. All patients had monthly follow-up visits for a year and the relapse rate was zero. We found that skin temperature is a good parameter to ensure safe immobilization withdrawal.

The population prevalence of foot and ankle pain in middle and old age: a systematic review

A systematic review and meta-analysis of population-based epidemiological studies was undertaken to determine the prevalence of foot and ankle pain in middle and old age. Searches were conducted in the following electronic databases from inception to October 2010: PubMed, EMBASE, AMED, CINAHL, Cochrane, PEDro, and SportDiscus. Full-text English language articles were included if they used population sample frames, cross-sectional design or analysis, and reported prevalence estimates for foot and/or ankle pain in adults aged 45 years and over. Thirty-four articles from 31 studies involving 75,505 participants provided 529 prevalence estimates based on different case definitions and population strata. Random-effects meta-analyses of studies with comparable case definitions provided pooled prevalence estimates, for frequent foot pain of 24% (95% confidence interval 22-25%; n=3; I(2)=46%) and for frequent ankle pain of 15% (95% confidence interval 13-16%; n=2; I(2)=0). Small sample sizes and low response rates in some studies, together with heterogeneous case definitions, limit confident conclusions on the distribution, subtypes, and impact of foot/ankle pain. Narrative synthesis of evidence from existing studies suggested preponderance in females, an age-related increase in prevalence in women but not men, that the toes/forefoot were the most common anatomical sites of pain, and that moderate disability in an aspect of daily life was reported by two-thirds of cases. This review provides estimates of the community burden of foot and ankle pain in middle and old age. By outlining the scale of this clinical problem, these findings can be used to inform health care planning and provision.

[Functional metabolic characteristics of sodium hyaluronate in mammal organism]

In the review data concerning functional metabolic characteristics of sodium hyaluronate in mammal organism, as well as autologous results concerning the study of its intraarticular action on metabolism of conjunctive tissue in the conditions of experimental arthritis in rabbits are given.

Strong relationships between disease activity, foot-related impairments, activity limitations and participation restrictions in children with juvenile idiopathic arthritis

OBJECTIVES

To assess possible relationships between disease activity, foot-related impairments, activity limitations and participation restrictions in children with juvenile idiopathic arthritis (JIA).

METHODS

Thirty-four children were studied. Disease activity was assessed with the Juvenile Arthritis Disease Activity Score in 71 joints (JADAS-71). Foot-related impairments, activity limitations and participation restrictions were measured with the Juvenile Arthritis Foot Disability Index (JAFI), the Childhood Health Assessment Questionnaire (CHAQ), self-reported or parent-reported and doctor-reported VAS scales. Relationships were quantified with Spearman's correlation coefficient.

RESULTS

The mean age was 12.4±3.7 years, the median disease duration 1.5 years (interquartile range (IQR) 1.0-4.0), 88% were girls, and 76% had polyarticular disease course. The median JADAS-71 score (range 0-101) was 6 (IQR 1-13). On the JAFI sub-scores (range 0-4) 88% of the children reported some foot-related impairments (median 1.1, IQR 0.4-2.0); 82% reported some foot-related activity limitations (median 0.9, IQR 0.3-2.0), and 65% reported some foot-related participation restrictions (median 0.6, IQR 0-2.1). The median CHAQ score was 0.9 (IQR 0.1-1.8). The JADAS-71 correlated with all impairment, activity limitation and participation restriction variables (r=0.48-0.81, p<0.01). Most of the impairment variables correlated with activity limitation (r=0.39, p<0.05 to r=0.92, p<0.01) and participation restriction variables (r=0.44, p<0.05 to r=0.81, p<0.01). All activity limitation variables correlated with participation restriction variables (r=0.62-0.84, p<0.01).

CONCLUSIONS

We observed strong relationships between disease activity, foot-related impairments, activity limitations and participation restrictions in children with JIA, and therefore suggest that standard screening for foot problems should be included in follow-up care for JIA patients.

Patients with inflammatory arthropathies undergo feet surgery later in the disease course than hand surgery

OBJECTIVES

Inflammatory arthropathies often results in functional impairment and joint damage and deformity. Hand and foot are frequent locations for surgical interventions. Our objective is to compare disease duration, patient reported health status measures and use of medication in patients with inflammatory arthropathies referred for hand or foot surgery.

METHODS

Patients referred for hand or foot surgery at the Diakonhjemmet Hospital responded to mail surveys preoperatively, including AIMS2, HAQ, SF-36, EQ-5, and visual analogue scales addressing patient global assessment of disease activity, fatigue, general pain and pain in the actual joint. Data on disease duration, surgical treatment and medication were collected from the hospital records.

RESULTS

116 patients (mean (SD) age 57 (13) years, 76% female) with inflammatory arthropathies underwent hand (n=52, mean (SD) age 55 (13) years) or foot (n=64, mean (SD) age 58 (13) years) surgery. Disease duration at the time of surgery was significantly longer for patients referred for foot vs. hand surgery (19 (13) vs. 13 (10) years, p=0.04). Patients undergoing foot surgery used more frequently biological or conventional disease-modifying antirheumatic drug at the time of surgery than patients having hand surgery (50% vs. 71%, respectively, p=0.02). Baseline values for the patient-reported health status measures were mainly similar for the two patient groups.

CONCLUSIONS

Patients undergoing surgical procedures in the foot had significantly longer disease duration and were more frequently on potent medication at the time of surgery than patients undergoing hand surgery. The observation may indicate that the impact of foot damage in inflammatory arthropathies is underestimated.

[Treatment of tarsometatarsal joint injury combined with metatarsal fracture by open reduction and internal fixation]

OBJECTIVE

To evaluate the therapy and the key points of the tarsometatarsal joint injury combined with metatarsal fracture.

METHODS

From Jan. 2006 to Jul. 2008,19 patients with tarsometatarsal joint injury combined with metatarsal fracture were treated with opened reduction and internal fixation of Kirschner wire or screws, included 13 males and 6 females with an average age of 38.1 years ranging from 21 to 56 years. The classification of tarsometatarsal joint injury showed that there were 2 cases of inner column injury, 5 cases of inner and medial column injury, 3 cases of lateral and medial column injury, 9 cases of tri-column injury. There were 8 cases of shaft fracture, 7 of neck fracture, 19 of foundation fracture.

RESULTS

All the incisions were first stage healed without skin necrosis. The healing time of fracture was 11.2 weeks on average. All the patients were followed-up for 6 to 17 months with an average of 12.8 months. According to the standard of AOFAS, the average score was (84.500 +/- 8.553), the results were excellent in 4 cases, good in 9 cases, fair in 3, and poor in 3. The regular daily life was recovered after 6.4 months, 3 patients suffer from mild osteoarthritis.

CONCLUSION

No matter which fixed mode was used, the anatomical reduction was the most important to rebuild arches of the foot and recover medial longitudinal and lateral arch. Rebuilding arches of the foot guaranteed the integrity of the stress point scaffold and avoided the pain and limp. The anatomical reduction of tarsometatarsal joint and metatarsal was also important to rebuild the function of foot.

An update on inflammatory arthropathies including pharmacologic management and preoperative considerations

This article provides an update and overview to the clinical presentations of inflammatory arthropathies. Subtleties to clinical presentations are discussed. Clues are presented which helps the reader arrive at more precise diagnostic labeling. Additionally, pharmacotherapy will be discussed, including precautions in considering the best therapy for the patient with suspected inflammatory, autoimmune, degenerative or neuropathic pain conditions. Finally, preoperative evaluations, management and risks of this patient population are reviewed. Emphasis will be on whether "cardiac clearance" should be requested based on an easy to use algorithm of cardiac risk factors. Finally recommendations based on recent literature of whether immunosuppressants should be withheld preoperatively.

Disability and health‐related quality of life among patients with rheumatoid arthritis: association with radiographic joint damage, disease activity, pain, and depressive symptoms

OBJECTIVE

To study the associations between disability and health-related quality of life (HRQoL), respectively, and radiographic joint damage, disease activity, pain, and depressive symptoms among patients with rheumatoid arthritis (RA).

METHODS

Data were collected through questionnaires and clinical examinations at baseline (1997) and at 2 years' follow-up among patients with RA (n = 307). Disability was measured with a validated Dutch questionnaire, derived from the Health Assessment Questionnaire (HAQ), and HRQoL with a validated Dutch version of the RAND-36, using physical (PCS) and mental (MCS) component summary scales. Multivariate linear regression analyses were performed to assess the relationship between disability or HRQoL and radiographic damage, disease activity, pain, and depressive symptoms.

RESULTS

Pain, with respect to disability and PCS, and depressive symptoms, with respect to MCS, were more important predictors than radiographic damage and disease activity.

CONCLUSIONS

Daily RA practice needs to be broadened by regular assessment of disease burden from the patients' perspectives. Patient-reported measures, such as disability or HRQoL, should be incorporated for monitoring health outcomes of individual patients and for initiating and evaluating therapy.

Impact of involvement of individual joint groups on subdimensions of functional ability scales in juvenile idiopathic arthritis

OBJECTIVE

To investigate the influence of arthritis in individual joint groups on subdimensions of functional ability questionnaires in children with juvenile idiopathic arthritis (JIA).

METHODS

206 patients were included who had the Childhood Health Assessment Questionnaire (C-HAQ) and the Juvenile Arthritis Functionality Scale (JAFS) completed simultaneously by a parent and received a detailed joint assessment. In each patient, joint involvement (defined as presence of swelling, pain on motion/tenderness and/or restricted motion) was classified in 3 topographic patterns: Pattern 1 (hip, knee, ankle, subtalar and foot joints); Pattern 2 (wrist and hand joints); Pattern 3 (elbow, shoulder, cervical spine and temporomandibular joints). Frequency of reported disability in each instrument subdimension was evaluated for each joint pattern, present either isolatedly or in mixed form.

RESULTS

Among patients with Pattern 1, the JAFS revealed the greatest ability to capture and discriminate functional limitation, whereas impairment in the C-HAQ was more diluted across several subdimensions. Both C-HAQ and JAFS appeared to be less reliable in detecting functional impairment in the hand and wrist (Pattern 2) than in other body areas. Overall, the JAFS revealed a superior ability to discriminate the relative functional impact of impairment in individual joint groups among patients with mixed joint patterns.

CONCLUSION

In children with JIA, a functional measure focused to assess the function of individual joint groups (the JAFS) may detect with greater precision the functional impact of arthritis in specific body areas than does a standard questionnaire based on the assessment of activities of daily living (the C-HAQ).

Rheumatoid arthritis patients' experiences of wearing therapeutic footwear - a qualitative investigation

BACKGROUND

Specialist 'therapeutic' footwear is recommended for patients with diseases such as rheumatoid arthritis (RA) as a beneficial intervention for reducing foot pain, improving foot health, and increasing general mobility. However, many patients choose not to wear this footwear. Recommendations from previous studies have been implemented but have had little impact in improving this situation. The aim of this study was to explore RA patients' experiences of this footwear to ascertain the factors which influence their choice to wear it or not.

METHOD

Ten females and three males with RA and experience of wearing specialist footwear were recruited from four National Health Service orthotic services. Semi-structured interviews were carried out in the participants own homes. A hermeneutic phenomenological analysis of the transcripts was carried out to identify themes.

RESULTS

The analysis revealed two main themes from both the female and male groups. These were the participants' feelings about their footwear and their experiences of the practitioner/s involved in providing the footwear. In addition, further themes were revealed from the female participants. These were feelings about their feet, behaviour associated with the footwear, and their feelings about what would have improved their experience.

CONCLUSION

Unlike any other intervention specialist therapeutic footwear replaces something that is normally worn and is part of an individual's body image. It has much more of a negative impact on the female patients' emotions and activities than previously acknowledged and this influences their behaviour with it. The patients' consultations with the referring and dispensing practitioners are pivotal moments within the patient/practitioner relationship that have the potential to influence whether patients choose to wear the footwear or not.

Varied Presentations of Enthesopathy

BACKGROUND

The concept of "enthesis organ" allows a new look at the nature of enthesis involvement in some rheumatic and nonrheumatic systemic disorders.

OBJECTIVES

To describe the various presentations of enthesopathy in the course of systemic medical disorders using the available literature data.

METHODS

Review of relevant articles from 1996 to 2006 retrieved by a Medline search utilizing the index terms "enthesis," "enthesitis," and "tendonitis." The list of articles reviewed herein is not exhaustive, with preference given, where possible, to studies and surveys over case reports as well as the most recent literature reflecting new developments on the subject.

RESULTS

Enthesis is defined as the site of insertion of a tendon, ligament, fascia, or articular capsule into bone. Pain originating in the free nerve endings enriched entheses (enthesalgia) may represent a potential cause of chronic musculoskeletal pain in some individuals. Enthesis involvement in the disease process is well appreciated in spondyloarthropathies and in rheumatoid arthritis, though overshadowed by synovitis in the latter. Calcium deposition diseases may constitute the most significant articular cause of enthesopathies in the general population. New data may shed light on the possible pathophysiologic role of enthesopathy in the development of osteoarthritis. Various metabolic and endocrine conditions may manifest with enthesopathy features. The pathogenic mechanisms of enthesis involvement are not uniform and differ in the diverse disorders.

CONCLUSIONS

The concept of enthesopathy as a variety of syndromes in the course of many rheumatic, metabolic, and endocrine disorders should be appreciated. Exercise of a high level of suspicion toward enthesopathic involvement, and greater knowledge of enthesopathy's characteristic patterns and diagnostic possibilities, may allow better management of many patients in rheumatology practice.

Clinico-radiological assessment and their correlation in clubfeet treated with postero-medial soft-tissue release

The controversy regarding the radiographic parameter which best represents the various deformities of clubfoot continues. The aim of our study was to clear up this controversy. Fifty surgically treated (soft-tissue release) congenital clubfeet were studied clinically using Laaveg and Ponseti score and radiologically using twelve different radiographic parameters in weight-bearing AP and lateral views. The talo-calcaneal angle (TCA) in AP and lateral view showed statistically significant correlation with the functional rating, but significant variation in the dimension of the angles among the different functional groups was found with AP angle only. The talo-first metatarsal angle in AP and lateral view averaged 10 degrees and 19 degrees respectively, and showed significant correlation with the functional rating. The talo-navicular subluxation in AP, the calcaneo-fifth metatarsal angle and the first-fifth metatarsal angle in lateral view did not show any significant correlation with function. Talo-calcaneal index averaged 44 degrees in the clubfeet and showed significant correlation. The wide range of parameters representing each of the deformities gives a better radiological assessment of the clubfoot than any single parameter.

Cigarette smoking and radiographic progression in rheumatoid arthritis

BACKGROUND

Smoking is a well-established environmental risk factor for the development of rheumatoid arthritis (RA). However, it remains unclear whether smoking influences RA disease progression and whether smokers have more radiographic damage progression than non-smokers over time.

OBJECTIVE

To compare the rates of radiographic damage progression in current smokers and non-smokers in a large prospective RA cohort.

METHODS

The SCQM-RA is a population-based registry monitoring disease activity, radiographic damage and symptoms at regular intervals. All patients in the SCQM-RA database with sequential plain radiographs were included. Joint erosions were assessed in 38 hand and foot joints with a validated scoring method. The rate of erosion progression was analysed using multivariate longitudinal regression models and adjusted for potential confounders.

RESULTS

2004 RA patients with a mean of 3.6 sequential radiographs and 3.1 years of follow-up were included. The 545 (27%) current smokers smoked on average 16 cigarettes per day and had a mean past smoking exposure of 20.6 pack-years. Radiographic joint damage progressed at a similar rate in current smokers and non-smokers (p = 0.26). However, smoking intensity was associated with a significant inverse dose-response; heavy smokers (>1 pack-day) progressed significantly less than non-smokers or moderate smokers (p<0.001).

CONCLUSION

Radiographic joint damage progressed at an equivalent rate in smokers and non-smokers. Furthermore, a significant trend was observed for reduced radiographic progression and generally more favourable functional scores among heavy smokers, suggesting that cigarette smoke does not accelerate RA disease progression.

Stage IV posterior tibial tendon rupture

Adult acquired flatfoot deformity progresses through well defined stages as set out by Johnson and Strom. Myerson modified this classification system with the addition of a fourth, more advanced stage of the disease. This stage describes the involvement of the tibiotalar joint in addition to the hindfoot malalignment seen in stages II and III. This most advanced stage is comprised of a hindfoot valgus deformity, resulting from degeneration of the posterior tibial tendon, with associated valgus tilting of the talus within the mortise. The deformity at the tibiotalar joint may or may not be rigid. Although rigid deformities are still best treated with fusions of the ankle and hindfoot, supple tibiotalar deformity may be treated with joint sparing procedures involving reconstructive procedures of the foot and deltoid ligaments.

Peak pressure curve: an effective parameter for early detection of foot functional impairments in diabetic patients

A clinical investigation was conducted on 61 diabetic patients and 22 healthy volunteers. Joint mobility, muscular function of the foot-ankle complex and plantar pressure measurements were characterised. A clustering algorithm was applied to obtain patient classification based on the shape and amplitude of the time curve of the instantaneous maximum pressure the foot experienced during gait. Results indicate that a screening test based on the peak pressure curve might be an effective way to detect diabetic patients at risk of foot ulceration.

Forefoot joint damage, pain and disability in rheumatoid arthritis patients with foot complaints: the role of plantar pressure and gait characteristics

OBJECTIVE

To assess (i) the relationship between forefoot joint damage and foot function (expressed as gait and pressure parameters), (ii) the relationship between foot function and pain, and (iii) the relationship between foot function and disability in patients with foot complaints secondary to rheumatoid arthritis (RA).

METHODS

Sixty-two patients with RA-related foot complaints were included. Measurements of joint damage, gait characteristics, plantar pressure, pain and disability were obtained. Data were analysed using descriptive and correlational techniques.

RESULT

s. Joint damage on radiographs of the forefoot correlated significantly with forefoot pressure (r = 0.296, P = 0.020). Further investigation of the metatarsophalangeal joints (MTPs) showed joint damage to correlate significantly with peak pressure and pressure-time integral (PTI) of MTP1 and MTP4. A significant correlation between PTI under the forefoot and barefoot pain was found (r = 0.290, P = 0.022). Gait parameters (total contact time and the duration of heel loading) and disability, measured with the Foot Function Index, were significantly correlated (r = 0.315, P = 0.013 and r = 0.266, P = 0.037, respectively).

CONCLUSION

Forefoot joint damage in the rheumatoid foot is related to increased pressure under the forefoot, especially pressure under the first and fourth MTP joints. High forefoot pressure is associated with pain during barefoot walking. A prolonged stance phase and delayed heel lift are related to disability in daily activities.

Realignment arthrodesis of the rearfoot and ankle: a comprehensive evaluation

Ankle and tibiotalocalcaneal arthrodeses are performed for the treatment of painful, arthritic, unstable, and deformed rearfoot and ankle joints. Surgical complications are not uncommon (approximately 30%); some can be attributed to poor preoperative planning and inadequate intraoperative position. Several authors have attempted to define the optimal position for ankle arthrodesis without objective multiplanar radiographic analysis and consistent reference points. This investigation explored the effects of ankle and tibiotalocalcaneal realignment arthrodeses on static lower-extremity position in 20 patients. The most common preoperative diagnosis was severe degenerative joint disease following ankle fractures and ankle instability. Seven tibiotalocalcaneal arthrodeses and 13 isolated ankle arthrodeses were performed (mean follow-up, 22 months). Average time to radiographic osseous union of the isolated ankle and tibiotalocalcaneal arthrodeses was 11 and 7 weeks, respectively. Medical complications occurred in 2 patients (10%). There were no statistically significant differences between preoperative and postoperative angular relationships. This study objectively quantifies multiplanar foot-to-leg realignment and defines the optimal clinical and radiographic positions for ankle and tibiotalocalcaneal realignment arthrodeses.

Biomechanics of the first ray part V: The effect of equinus deformity. A 3-dimensional kinematic study on a cadaver model

The positional change of the medial column of the foot in closed kinetic chain with variable Achilles tendon tension was investigated in seven fresh frozen cadaver specimens using a 3-dimensional radio wave tracking system. The distal tibia and fibula and the intact ankle and foot and were mounted on a non-metallic loading frame. The frame allowed positioning of the foot to simulate midstance phase of gait while the tibia and fibula were axially loaded to 400 N. To record osseous motion, receiving transducers were attached to the first metatarsal, medial cuneiform, navicular, and talus. Movements of these bones in 3-dimensional space were measured as specimens were axially loaded and midstance motor function was simulated using pneumatic actuators. To simulate a progressive equinus influence, force was applied to the Achilles tendon at tensile loads of 0%, 30%, and 60% of predicted maximum strength during each test trial. Osseous positions and orientations were collected and analyzed in all three cardinal planes utilizing data recorded. As Achilles load increased, the position of the first metatarsal became significantly more inverted ( P < .05). Although not statistically significant, remarkable trends of arch flattening motion were detected in the distal segments of the medial column with varied Achilles load. Increased Achilles load reduced the influence of peroneus longus on the medial column.

Orthotic and Brace Use in the Athlete with Degenerative Joint Disease with Angular Deformity

Over the past several decades, research has shown the successful use of simple wedges, custom orthotics, and unloader braces in the treatment of athletes with DJD/angular deformity. This article reviews the use of these simple biomechanical devices in the treatment of these individuals.

Use of a Torque-Range-of-Motion device for objective differentiation of diabetic from normal feet in adults

BACKGROUND

The ability of the foot and ankle complex to act as an energy absorber is reflected in its viscoelastic properties. The Torque-Range-of-Motion (TROM) device was designed to provide an effective objective assessment of foot and ankle passive mechanical function. The hypothesis of this study was that mechanical parameters derived from passive TROM curves of otherwise normal feet of adults with diabetes would be significantly different from those of adults without diabetes.

METHODS

The TROM device is a single-degree-of-freedom hinge transducer system that is manually rotated through plantarflexion and dorsiflexion. The device was rotated manually with the muscles relaxed during a 50-second data acquisition period. A strain gauge provided the torque signal and a precision single-turn potentiometer provided plantarflexion-dorsiflexion angle to a two-channel portable data acquisition system. With the TROM device connected to a computer, input for instantaneous torque and range of motion was acquired and displayed as angle (degrees) versus torque (Newton-meters) on an output screen. The period provided sufficient data to average 16 to 20 cycles of motion. The study included 41 feet in adults without diabetes and 42 age-matched feet in adults with diabetes but no known foot problems.

RESULTS

For a probability level of.0001 there were significant differences in hysteresis area (normal: 91.1 +/- 46.9 Nm-deg and diabetic: 161.7 +/- 65.7 Nm-deg) and both dorsiflexion (normal: 0.4 +/- 0.1 Nm/deg and diabetic: 0.9 +/- 0.3 Nm/deg) and plantarflexion stiffness (normal: 0.3 +/- 0.1 Nm/deg and diabetic: 0.7 +/- 0.3 Nm/deg).

CONCLUSIONS

The feet of adults with diabetes absorb more energy during cyclic motion (thus must dissipate more energy per cycle) and are stiffer in the terminal regions (where muscle-tendon-ligament properties prevail) than are the feet of adults without diabetes. These results suggest that this passive TROM method may be a sensitive, objective measurement of the viscoelastic properties of the foot and ankle, which may be an early indicator of diabetic patients who are at risk for the development of foot problems.

The role of limited joint mobility in diabetic patients with an at-risk foot

OBJECTIVE

To assess the role of limited joint mobility (LJM) in causing abnormal high plantar pressures in the forefoot of diabetic patients with an at-risk foot.

RESEARCH DESIGN AND METHODS

A total of 70 type 1 or type 2 diabetic patients and 30 control subjects participated in this cross-sectional study. Thirty-five diabetic patients with an at-risk foot, defined as a foot with neuropathy but without ulceration or previous ulceration, and 35 diabetic control subjects without neuropathy were selected for the subgroups. Joint mobility was assessed in the foot at the ankle and metatarsophalangeal I (first MTP) joints. Using the FastScan plantar pressure analyzer, the pressure-time integrals (PTIs) as dynamic variables were measured in each foot. The clinical assessment included standard measures of peripheral neuropathy.

RESULTS

The mobility at the ankle and first MTP joint were significantly reduced in the foot-at-risk group compared with the diabetic control group and the control subjects (P < 0.0001). The PTIs were significantly higher in the foot-at-risk group compared with the two other groups (P < 0.0001). There was a strong inverse correlation between the mobility of the ankle or first MTP joint and the PTI of the diabetic patients (r = -0.67, P < 0.0001, and r = -0.71, P < 0.0001, respectively). The vibration perception threshold was positively correlated with the PTI of the diabetic patients (r = 0.44, P = 0.0001).

CONCLUSIONS

Diabetic patients with an at-risk foot have reduced joint mobility and elevated PTIs on the plantar forefoot, placing them at risk for subsequent ulceration. Therefore, LJM may be a possible factor in causing high plantar pressures and may contribute to foot ulceration in the susceptible neuropathic at-risk foot.

Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics?

BACKGROUND

If conservative therapy fails, the standard treatment for chronic ankle instability is surgical reconstruction of the lateral ligaments. For the last seventy years, the tenodesis principles have been used for reconstruction. Recently however, surgical reconstructions--respecting the intact joint anatomy--have been developed, thus called "anatomical reconstruction principles".

METHODS

This study focused on the investigation of the range of motion of the ankle and the subtalar joint following anatomical reconstruction surgery. Three different types of anatomical reconstruction procedures were compared: Direct ligament repair, tendon graft and carbon-fiber implant.

RESULTS

All procedures restored the original range of motion of the subtalar joint, except for the plantarflexed/dorsiflexed positions. As for the talocrural joint, the tendon graft and the carbon fiber implant left a small laxity for movements of inversion/eversion and internal/external rotation. The direct repair procedure achieved a more accurate result and restored the physiologic kinematics almost completely. During each procedure the insertion points and the direction of the original ligaments were maintained. However, the different results for the procedure of direct ligament repair compared to the other two anatomical reconstruction procedures showed that this condition alone is not sufficient to perfectly restore the kinematics of the talocrural and subtalar joints. It is important to note that none of the procedures caused a restriction of the range of motion.

CONCLUSIONS

The maintenance of the range of hindfoot motion decreases the risk of osteoarthritis as well as chronic pain or problems for the patient to walk on uneven surface. Therefore, we believe that standard therapy for chronic instability of the ankle should include direct surgical reconstruction of the ligaments. If this direct procedure cannot be performed because of poor quality of the ligaments an alternative anatomical reconstruction procedure should be considered.

The prevalence of symptomatic knee and distal interphalangeal joint osteoarthritis in the urban population of Antalya, Turkey

The aim of this cross-sectional study was to estimate the prevalence and risk factors of symptomatic knee and distal interphalangeal (DIP) joint osteoarthritis (OA) in the elderly (> or =50 years of age) urban population of Antalya, Turkey. According to the 1997 national census, Antalya's population was 508,840. By random cluster sampling, 655 individuals aged 50 years or more were interviewed face-to-face and subjected to structured interviews regarding knee pain, worsening pain on exertion, and the gelling phenomenon. They were also asked about performing namaz (a fundamental act of worship in Islam performed five times a day), smoking, type of residence, type of toilet, work style, and duration of walking per day. They were also questioned about swelling in DIP joints. In the case of suspicion of knee OA, the individuals were invited to the hospital for further evaluation by physical examination and direct roentgenogram. The diagnosis of knee OA was based on clinical or clinical and radiographic findings. The prevalence of symptomatic knee OA was determined as 14.8% in the population aged 50 years or over. Advanced age, female sex, namaz, and type of residence were found to be associated with knee OA. The rate of symptomatic knee OA was significantly lower in smokers and those walking more than 2 h per day. Female sex was also strongly associated with OA DIP joints. OA of DIP joints was found significantly associated with symptomatic knee OA. The latter is a major health problem in the elderly population, especially in about one fourth of women aged 50 years or over. These data suggest that advanced age, female sex, and type of residence are risk factors.