Abstract
Diabetic foot syndrome refers to heterogeneous clinical and biomechanical profiles, which render predictive models unsatisfactory. A valuable contribution may derive from identification and descriptive analysis of well-defined subgroups of patients. Clinics, biology, function, gait analysis, and plantar pressure variables were assessed in 78 patients with diabetes. In 15 of them, the 3D architecture of the foot bones was characterized by using weight-bearing CT. Patients were grouped by diabetes type (T1, T2), presence (DN) or absence (DNN) of neuropathy, and obesity. Glycated hemoglobin (HbA1c) and plantar lesions were monitored during a 48-month follow-up. Statistical analysis showed significant differences between the groups for at least one clinical (combined neuropathy score, disease duration, HbA1c), biological (age, BMI), functional (joint mobility, foot alignment), or biomechanical (regional peak pressure, pressure-time integral, cadence, velocity) variable. Twelve patients ulcerated during follow-up (22 lesions in total), distributed in all groups but not in the DNN T2 non-obese group. These showed biomechanical alterations, not always occurring at the site of lesion, and HbA1c and neuropathy scores higher than the expected range. Three of them, who also had weight-bearing CT analysis, showed >40% of architecture parameters outside the 95%CI. Appropriate grouping and profiling of patients based on multi-instrumental clinical and biomechanical analysis may help improve prediction modelling and management of diabetic foot syndrome.
Highlights
Altered plantar pressure patterns are largely debated when investigating diabetic foot syndrome
The following information were collected via the clinical and podiatric screening: biological data (age, gender, body mass index (BMI), and obesity grade [13]), clinical data (type of diabetes, years of disease (YOD), glycated hemoglobin (HbA1c) level, peripheral neuropathy grade based on the Michigan Neuropathy Screening Instrument [14] and the Vibration Perception Threshold (VPT) measurement, the presence of peripheral artery disease or of other relevant comorbidities), and functional and orthopedic data (passive ankle joint mobility [15], hindfoot alignment, hallux mobility and alignment [15], pain via the visual analogue scale (VAS) and the Manchester Oxford Foot Questionnaire (MoX) [16])
No statistically significant differences were found between the entire group of patients and the group of patients with lesions (Figure 1)
Summary
Altered plantar pressure patterns are largely debated when investigating diabetic foot syndrome. The most recent guidelines of the International Working Group on Diabetic Foot (IWGDF) [1] stated that “high plantar pressures are a significant independent risk factor for foot ulceration and should be avoided” [2,3]. Despite this evidence, predictive models of risky plantar pressure patterns still have to reach general validity and agreement. The model showed moderate-to-good sensitivity and specificity to predict foot ulceration, but it was only validated for type 2 diabetes
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