Forefoot Deformities Research Articles

A short-term result of arthroplasty by shortening osteotomy for rheumatoid forefoot deformities

A short-term result of arthroplasty by shortening osteotomy for rheumatoid forefoot deformities

Intraosseous and Extraosseous Blood Supply to the Medial Cuneiform

Osteotomies of the medial cuneiform are commonly used to correct forefoot deformity. Bone healing occurs despite periosteal stripping of the dorsal and medial surfaces of this widely articulated bone followed by osteotomy in the midsection of the bone. The objective of this study was to characterize the blood supply of the medial cuneiform. Thirty matched pairs of adult cadaver legs, 60 legs total, were amputated below the knee, and arterial casts were created with India ink and latex. Soft tissues were debrided, allowing visualization of the extraosseous blood vessels. In 53 specimens the vascular supply to the medial cuneiform was photographed and recorded. Forty-nine specimens were then cleared using a modified Spälteholz technique. The intraosseous vascularity of the medial cuneiform was successfully characterized and reviewed in 48 of these specimens. The extraosseous blood supply was similar to previous reports with a middle pedicle branch originating from the dorsalis pedis artery. The medial plantar and superficial medial plantar artery supplied the plantar aspect of the bone. Intraosseous analysis showed a dense capillary network throughout the cuneiform, with typically one central medial major and several minor nutrient arteries noted. Areas of hypovascularity were infrequent and when noted occurred at inconsistent locations. These findings support the clinical suspicion that the medial cuneiform is well vascularized from multiple sources. The plantar blood supply is likely sufficient to allow bone healing after dorsal periosteal exposure and possible injury to the middle pedicle branch of the distal medial tarsal artery. A medial cuneiform opening wedge osteotomy can be used to correct forefoot deformity. This study investigates the blood supply to that bone to better characterize the healing potential of the medial cuneiform.

The effects of sandals on postural stability in patients with rheumatoid arthritis: An exploratory study

BackgroundRheumatoid arthritis results in postural instability, pain and functional limitations. As rheumatoid arthritis progresses, localised forefoot deformities such as hallux valgus and clawing of the lesser toes occur, leading to a high proportion of people with rheumatoid arthritis wearing sandals. Sandals may affect postural stability due to poor motion control. The aim was to assess two different open-toe sandals on postural stability in people with rheumatoid arthritis. MethodsTwenty women with rheumatoid arthritis were assessed in quiet standing under four conditions: (1) open-back sandal; (2) closed-back sandal; (3) own footwear and (4) bare feet. Postural stability was assessed as postural sway in the anterior-posterior and medial-lateral directions, with eyes open and eyes closed, using a pressure mat. Repeated measures analysis of variance tested the interaction effect of the footwear and eye conditions on anterior-posterior and medial-lateral sway. FindingsIn eyes-open, there was no significant difference in anterior–posterior sway (P=.169) and medial-lateral sway (P=.325) for footwear conditions. In eyes-closed testing, compared with barefoot conditions, increased anterior–posterior sway was observed with participants' footwear (P<.0001), the open-back sandal (P=.005), and the closed-back sandal (P=.017). With eyes closed, increased anterior–posterior sway was also observed with the participants' footwear compared with the closed-back sandal (P=.041). Increased medial-lateral sway was observed with the closed-back sandal compared with bare feet (P=.014). InterpretationSandals may be detrimental to older women with well-established rheumatoid arthritis when eyes are closed. Further investigation is needed to evaluate the effect of sandals on dynamic tasks.

The predictors of foot ulceration in patients with rheumatoid arthritis

This study was conducted to determine the predictors of foot ulceration occurring in patients with rheumatoid arthritis (RA) without diabetes. A multi-centre case control study was undertaken; participants were recruited from eight sites (UK). Cases were adults diagnosed with RA (without diabetes) and the presence of a validated foot ulcer, defined as a full thickness skin defect occurring in isolation on / below the midline of the malleoli and requiring > 14 days to heal. Controls met the same criteria but were ulcer naive. Clinical examination included loss of sensation (10g monofilament); ankle-brachial pressure index (ABPI); forefoot deformity (Platto); plantar pressures (PressureStat); RA disease activity (36 swollen/tender joint counts) and the presence of vasculitis. History taking included past ulceration/foot surgery; current medication and smoking status. Participants completed the Health Assessment Questionnaire (HAQ) and Foot Impact Scale. A total of 83 cases with 112 current ulcers and 190 ulcer naïve controls participated. Cases were significantly older (mean age 71years; 95% confidence interval [CI], 69-73 vs. 62years, 60-64) and had longer RA disease duration (mean 22years; 19-25 vs. 15, 13-17). Univariate analysis showed that risk of ulceration increases with loss of sensation; abnormality of ABPI and foot deformity. Plantar pressures and joint counts were not significant predictors. HAQ score and history of foot surgery were strongly associated with ulceration (odds ratio [OR] = 1.704, 95% CI 1.274-2.280 and OR = 2.256, 95% CI 1.294-3.932). Three cases and two controls presented with suspected cutaneous vasculitis. In logistic regression modelling, ABPI (OR = 0.04; 95% CI, 0.01-0.28) forefoot deformity (OR = 1.14; 95% CI, 1.08-1.21) and loss of sensation (OR = 1.22; 95% CI, 1.10-1.36) predicted risk of ulceration. In patients with RA, ABPI, forefoot deformity and loss of sensation predict risk of ulceration but, in contrast with diabetes, raised plantar pressures do not predict risk.

Midterm Results of Resection Arthroplasty for Forefoot Deformities in Patients with Rheumatoid Arthritis and the Risk Factors Associated with Patient Dissatisfaction

We investigated the midterm results of resection arthroplasty of all 5 metatarsal heads in patients with rheumatoid arthritis and forefoot deformity and analyzed the factors that affect patient satisfaction levels. Of 64 patients (1 male, 63 females), 107 feet were treated with resection arthroplasty for forefoot deformity at our hospital from January 1992 to December 2005. The mean follow-up period was 5.8 ± 3.1 years, with all patients having at least 1 year of follow-up. Of the 64 patients, 75% were satisfied with the surgery. The mean score for the postoperative Japanese Society for Surgery of the Foot lesser metatarsophalangeal-interphalangeal scale was 75.0 ± 15.8 points. Multivariate logistic regression analysis showed that patient-reported dissatisfaction was significantly associated with the recurrence of hammer toe deformity (odds ratio 2.66, 95% confidence interval 1.07 to 6.97), shortening of the resection arthroplasty space (odds ratio 0.85 for a 1-unit increase, 95% confidence interval 0.74 to 0.96), and the recurrence of hallux valgus (odds ratio 1.04 for a 1-unit increase, 95% confidence interval 1.00 to 1.09) during the postoperative period. From our results, interventions to prevent recurrence of hammer toe deformity, especially in toes with preoperative metatarsophalangeal joint dislocations, have been shown to be important in preventing complications and patient dissatisfaction after resection arthroplasty.

Intrinsic foot muscle deterioration is associated with metatarsophalangeal joint angle in people with diabetes and neuropathy

BackgroundMetatarsophalangeal joint deformity is associated with skin breakdown and amputation. The aims of this study were to compare intrinsic foot muscle deterioration ratios (ratio of adipose to muscle volume), and physical performance in subjects with diabetic neuropathy to controls, and determine their associations with 1) metatarsophalangeal joint angle and 2) history of foot ulcer. Methods23 diabetic, neuropathic subjects [59 (SD 10) years] and 12 age-matched controls [57 (SD 14) years] were studied. Radiographs and MRI were used to measure metatarsophalangeal joint angle and intrinsic foot muscle deterioration through tissue segmentation by image signal intensity. The Foot and Ankle Ability Measure evaluated physical performance. FindingsThe diabetic, neuropathic group had a higher muscle deterioration ratio [1.6 (SD 1.2) vs. 0.3 (SD 0.2), P<0.001], and lower Foot and Ankle Ability Measure scores [65.1 (SD 24.4) vs. 98.3 (SD 3.3) %, P<0.01]. The correlation between muscle deterioration ratio and metatarsophalangeal joint angle was r=−0.51 (P=0.01) for all diabetic, neuropathic subjects, but increased to r=−0.81 (P<0.01) when only subjects with muscle deterioration ratios >1.0 were included. Muscle deterioration ratios in individuals with diabetic neuropathy were higher for those with a history of ulcers. InterpretationIndividuals with diabetic neuropathy had increased intrinsic foot muscle deterioration, which was associated with second metatarsophalangeal joint angle and history of ulceration. Additional research is required to understand how foot muscle deterioration interacts with other impairments leading to forefoot deformity and skin breakdown.

Proximal rotational closing-wedge osteotomy of the first metatarsal in rheumatoid arthritis: clinical and radiographic evaluation of a continuous series of 35 cases

Objectives The introduction of powerful antirheumatic drugs has dramatically improved the treatment of rheumatoid arthritis (RA), leading clinicians to reconsider the benefits of joint preservation for rheumatoid forefoot deformities. We have employed joint-preserving forefoot surgeries, including rotational closing-wedge osteotomy of the first metatarsal. The aim of our study is to assess the short-term results of this procedure.Methods From January 2011 through December 2011, 35 feet were treated with this procedure. Subjective, functional, and radiographic outcomes were surveyed.Results The mean Japanese Society for Surgery of the Foot improved from a preoperative level of 52.6 to 68.7 postoperatively. The average hallux valgus and intermetatarsal angles improved from 47.3° preoperatively to 17.5° postoperatively, and from 16.7° preoperatively to 9.0° postoperatively, respectively. To assess the repositioning of pronation deformities of the first metatarsal, the position of the medial sesamoid was also surveyed according to the measurement system proposed by Hardy and Clapham. All feet except two were classified as grade V or higher preoperatively; 25 of these were grade IV or lower at the latest follow-up.Conclusions Rotational closing-wedge osteotomy of the first metatarsal was beneficial for correcting forefoot deformities in RA over the short term.

Influence of Common Associated Forefoot Disorders on Preoperative Quality of Life in Patients With Hallux Valgus

Hallux valgus (HV) is frequently associated with other forefoot disorders, but its influence on preoperative quality of life (QOL) has not been well characterized. The main purpose of this study was to assess the influence of common associated forefoot disorders (metatarsalgia and lesser toe deformities) on preoperative QOL in patients with HV. Preoperative QOL assessed through the Short Form-36 (SF-36, version 2) was obtained from 94 patients with HV from a database. Patients were classified according to their condition: HV alone, HV and metatarsalgia, HV and lesser toe deformities, and HV and both metatarsalgia and lesser toe deformities. Values of each domain were compared among groups. In addition, a correlational study between SF-36 and radiographic severity of HV was performed. The mean age of the 94 patients was 62.6 ± 12.3 years. There were 42.6% patients with HV alone, 30.8% with HV and metatarsalgia, 16% with HV and lesser toe deformities, and 10.6% with HV and both metatarsalgia and lesser toe deformities. Patients with HV and associated metatarsalgia and lesser toe deformities had significantly worse physical function (P = .029), role-physical (P = .017), bodily pain (P = .045), role-emotional (P = .016), mental health (P = .001), and mental component summary (P = .003) compared to patients with HV alone. There were no significant correlations between radiographic HV and intermetatarsal angles and any of the domains or summaries of the SF-36. Patients with HV and both metatarsalgia and lesser toe deformities have significantly worse QOL compared to patients with HV alone. The presence of associated forefoot deformities may be a discriminating factor for the prioritization of surgical treatment of HV. Level III, cross-sectional study.

Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options.

Despite recent advances in pharmacological management of rheumatoid arthritis, forefoot deformity, with its symptoms, remains a common problem, often requiring operative treatment. Typical deformities in these patients comprise hallux valgus and deformity of the lesser metatarsophalangeal (MTP) joints and toes. With regard to the lesser rays the standard operative procedure, advocated for the disabling forefoot pain in these patients, remains metatarsal head resection. It should be considered that with increasing success of pharmacological treatment the degree of forefoot deformity in these patients is becoming less and that resection of the lesser MTP joints is becoming more and more superfluous. This supports a trend towards metatarsal head-preserving surgery. The optimal treatment of the hallux deformity remains unclear. Fusion of the first MTP joint is, generally, recommended. This article will discuss the current surgical options in rheumatoid forefoot pathology.

Plantarflexory Osteotomy for a Plantar Flexed First Ray? A Cross-sectional Study of the Relationship between Frontal Plane Forefoot Deformity and Lateral Intermetatarsal Angle in 190 Patients

Many surgeons consider performing plantarflexory osteotomy when a lateral weightbearing radiograph shows an elevated first metatarsal. In our study, we clinically evaluated the first metatarsal position in terms of the forefoot-to-rearfoot relationship and radiographically evaluated the lateral intermetatarsal angle in 190 patients. We divided the subjects into forefoot varus, valgus, and neutral groups and compared their mean lateral intermetatarsal angle. The mean lateral intermetatarsal angle for those with forefoot varus, valgus, and neutral was 1.4° ± 3.10°, 1.3° ± 3.30°, and 0.4° ± 2.67°, respectively. Neither analysis of variance nor post hoc tests showed any significant difference among the groups. We hypothesized that the ground reacting force alters the first ray position on the weightbearing radiographs; thus, it would not be advisable to rely solely on this angular measurement for surgical decision-making.

High Heels as a Cause

In women it is not only narrow shoes that cause hallux valgus but also higher heels. These result in more weight placed on the forefoot, with overstretching of the toes and resultant splayfoot development, which in turn triggers metatarsus primus varus deformity. As the sesamoid bones embedded within the tendons of the flexor hallucis brevis muscle are laterally connected with the second metatarsal bone through the intermetatarsal ligament, the muscle’s direction of movement changes and it slowly turns into an adductor muscle, like the flexor hallucis longus muscle, and therefore functionally “draws the bow” of the proximal phalanx of the great toe, which increasingly deviates laterally. The abductor hallucis muscle is not equal to this overload, shifts in a plantar direction and thus causes pronation of the proximal phalanx. Wearing tight shoes is usually an agreeable sensation because they compress the forefoot and subjective provide greater stability; they functionally counteract splayfoot formation, so to speak. “Hammer toe” and “claw toe” deformities are by no means sequelae of the great toe’s lateral deviation but defined as a hyperextension position in the proximal metatarsophalangeal joint with simultaneous flexion contracture of the medial interphalangeal joint; claw toe deformity also shows contracture of the distal interphalangeal joint. Such toe deformities can occur independently of hallux valgus, which can also lead to digitus superductus deformity of the neighboring toe. Night splints are entirely pointless, as are redressing special sandals and the recommended toe straighteners and toe pads. The latter are supported by the much stronger great toe and therefore force the much weaker neighboring toe in a lateral direction. The often comorbid rheumatic forefoot deformity with pronounced hallux valgus and often grotesque axial deviations of the other toes is not only not a contraindication to hallux valgus surgery but on the contrary, a much harder indication than in non-rheumatic hallux valgus. Unfortunately, orthopedic specialists without an additional rheumatological qualification encounter only rarely those patients with toe deformities and axial deviations who also have severe splayfoot deformity accompanied by extremely painful synovitis and arthritis of the proximal joints, accompanied by sometimes complete destruction, owing to the inflammatory activity of the underlying disorder.

First metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe to treatment forefoot deformities caused by rheumatoid arthritis

Objective To explore the effect of the treatment of forefoot deformities caused by rheumatoid arthritis by the method of the first metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe.Methods The data of 19 patients with forefoot deformities caused by rheumatoid arthritis was retrospectively studied after receiving the treatment by the method of the first metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe from June 2007 to October 2010.There were 17 females (31 feet) and 2 males (4 feet) with an average age of 56 years (range,33-73 years).The American Orthopaedic Foot and Ankle Society (AOFAS),visual analogue scale (VAS) were applied.Hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured to investigate the changes in forefoot deformity preoperatively and postoperatively respectively.Results In 17 cases,the appearances of forefoot were improved in different degrees.The metatarsalgia disappeared completely in 29 feet.In other 3 feet,the fifth metatarsal metastatic metatarsalgia appeared and the pain was relieved after the forefoot decompression pad treatment.The distal end of hallux was excised due to necrosis.Forming joint have different degrees of anchylosis.The AOFAS improved from 46.82±6.13 preoperative to 84.25±2.87 postoperative,while the VAS,HVA,IMA decreased from 9.03±1.82,38.96°±10.13° and 15.87°±3.43° to 2.12±0.67,15.84°±5.12° and 10.35°±1.67° respectively.Conclusion The effect of the treatment for forefoot deformities caused by rheumatoid arthritis by the first metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe is excellent. Key words: Arthritis, rheumatoid; Foot deformities, acquired; Metatarsophalangeal joint; Arthrodesis

Efficacy of the first metatarsophalangeal joint arthrodesis versus resection arthroplasty for rheumatoid forefoot deformity :a systematic review

Objective To evaluate the efficacy of the first metatarsophalangeal joint arthrodesis versus resection arthroplasty for rheumatoid forefoot deformity.Methods Randomized controlled studies in the first metatarsophalangeal joint arthrodesis versus resection arthroplasty for rheumatoid forefoot deformity were collected in data bases like Cochrane library (Issue 3,2011),OVID (from January 1996 to June 2012),PubMed (from January 1990 to June 2012),CNKI (from January 1990 to June 2012),CBM,EMBASE (from January 1966 to June 2012) and Wanfang (from January 1990 to June 2012).Software RevMan 5.1 was used to analyze the trials included in terms of patient satisfaction,hallux area weight-bearing,AOFAS score,FFI score,HAV angle,IMA angle,operative time and complications.Results The totals of 5 RCTs were included in the study which involved 285 patients.The results of meta-analysis showed that the efficacy of the arthrodesis group was superior to that of the arthroplasty group in footwear (MD=-0.88,95％CI [-1.55,-0.22],P=0.010)and alignment (MD=-5.04,95％CI [-8.94,-1.14],P=0.01) significantly.The arthrodesis group also has an advantage of IMA and HAV angle correction (MD=1.43,95％CI [0.37,2.48],P=0.008; MD=13.27,95％CI [11.44,15.09],P＜ 0.00001).Significant difference was found between the two groups in the rate of complications.The rate of complication in the arthrodesis group was lower than that of the arthroplasty group (OR=2.32,95％CI [1.06,5.05],P=0.03).No significant difference was found between the two groups in patient satisfaction and FFI score.Conclusion Compared with resection arthroplasty,first metatarsophalangeal joint arthrodesis could be a better choice.It alleviates the pain effectively,improves the appearance and functions of the foot,and has a lower rate of postoperative complications. Key words: Arthritis, rheumatoid; Metatarsophalangeal joint; Arthrodesis; Arthroplasty; Meta-analysis

Sagittal Alignment of the First Metatarsophalangeal Joint after Arthrodesis for Rheumatoid Forefoot Deformity

The present study assessed the midterm results of reconstruction for rheumatoid forefoot deformity with arthrodesis of the first metatarsophalangeal (MTP) joint, scarf osteotomy, resection arthroplasty of the metatarsal head of the lesser toes, and surgical repair of hammertoe deformity (arthrodesis of the proximal interphalangeal joint). Special focus was placed on the sagittal alignment of the first metatarsophalangeal joint after arthrodesis. We retrospectively evaluated the postoperative clinical outcomes and radiographic findings for 16 consecutive female patients (20 feet) with symptomatic rheumatoid forefoot deformities. The mean duration of follow-up was 7.9 (range 4 to 13) years. All first MTP joints and first metatarsal bones were fused successfully. The mean value of the American Orthopaedic Foot and Ankle Society and Japanese Society for Foot Surgery clinical scores significantly improved overall, except for 2 patients (10%), who complained of first toe pain at the final follow-up visit owing to sagittal misalignment of the fused first MTP joint. Sagittal alignment of the first metatarsal varies greatly because of the rheumatoid midfoot and hindfoot deformities. Therefore, inclination of the first metatarsal should be considered when determining the first MTP joint sagittal fusion angle.

Involvement of valgus hindfoot deformity in hallux valgus deformity in rheumatoid arthritis.

The involvement of valgus hindfoot deformity in hallux valgus deformity was confirmed in a rheumatoid arthritis case with a destructive valgus hindfoot deformity. Correction of severe valgus, calcaneal lateral offset, and pronated foot deformity instantly normalized hallux valgus deformities postoperatively. Thus, careful hindfoot status evaluation is important when assessing forefoot deformity, including hallux valgus, in rheumatoid arthritis cases.

Relationship of Limited Joint Mobility and Foot Deformities with Neurological Examination in Patients with Diabetes

The aim is to define the association of forefoot deformity and limited joint mobility in the ankle and hallux joints in patients with diabetes mellitus subject to different diagnostic tests for diabetic neuropathy. Prospective study with 118 type 2 diabetic patients (68 men, mean age of 65.6±9.9 years) enrolled consecutively from the Diabetic Foot Unit of the Complutense University of Madrid subject to evaluation of plantar surface sensitivity by 10-g Semmes-Weinstein Monofilament, vibratory threshold by biothesiometer, and sudomotor dysfunction by Neuropad®. The patients presented with limited joint mobility of the ankle and the first metatarsophalangeal joints, and forefoot deformities were registered. Statistical analysis was done through a univariate model to test the association between neurological and biomechanical alteration. There was an association of abnormal Monofilament (p=0.01; OR=3.9) and biothesiometer tests (p=0.01; OR=2.6) with the presence of forefoot deformity. Furthermore, a relation was found between abnormal Monofilament (p=0.02; OR=4.8) and biothesiometer (p<0.00; OR=12.8) tests with limited mobility of the first metatarsophalangeal joint both in loading and off-loading. Abnormal sudomotor function test was related with limited joint mobility of the ankle joint with the knee flexed (p=0.04; OR=2.8). The results of this study show discordance between biomechanical abnormalities and neuropathy depending on the diagnostic test used. Tests that assess large myelinated nerve fibers are associated with the presence of deformities. Abnormal sudomotor function test is associated with limited joint mobility and this test has a greater capacity for selecting patients at risk.

Potentialities of Percutaneous Technique in Revision Surgery of Forefoot Static Deformities

Results of the analysis of repeated surgical interventions (34 patients, 43 feet) after previously performed surgeries for forefoot static deformities are presented. In all cases various percutaneous techniques were used. Mean follow up was 6 months (3 months — 4 years). Surgical results were assessed using patient satisfaction criterion. Satisfaction with treatment results was recorded in 95% ofpatients. It was shown that potentialities ofpercutaneous technique enabled to solve the majority offorefoot static deformityrevision surgery problems. The conclusion was made that strict order of patient management after reconstructive foot operations enabled to perform early reoperations before severe complications development.

The Treatment of Hallux Valgus

Hallux valgus is the commonest forefoot deformity, with an estimated prevalence of 23% to 35%. It causes symptoms on the medial edge of the foot, the sole, and the small toes. Non-operative treatment may alleviate symptoms but does not correct the deformity of the big toe. Surgery is indicated if the pain persists. The correct operation must be selected from a wide variety of available techniques. In this article, we selectively review the pertinent literature, including the recommendations of medical societies in Germany and abroad, in the light of our own clinical experience. There have been many clinical trials of various treatments for hallux valgus, but very few of these were randomized, and the case numbers were generally small. Mild deformities are best treated by distal first metatarsal osteotomies, e.g. the Chevron osteotomy. Severe deformities require a soft-tissue procedure at the first metatarsophalangeal joint and a proximal first metatarsal osteotomy. In case of osteoarthritis, and in elderly patients, a resection arthroplasty is preferred; arthrodesis is performed in physically active patients. After correction of hallux valgus, patients can usually bear their full weight on the treated foot while wearing a flat surgical shoe. Proper surgical treatment results in a good or very good outcome in 85% of patients and a satisfactory result in a further 10%. The clinical outcome of present treatments seems to be good in most cases, but large-scale randomized trials are still needed to verify the efficacy of the wide variety of operations and fixation techniques that are currently being offered.

Offloading effect of therapeutic footwear in patients with diabetic neuropathy at high risk for plantar foot ulceration

Custom-made therapeutic footwear is often prescribed to patients with diabetic neuropathy, foot deformity and a healed plantar foot ulcer. Offloading these feet is important to prevent ulcer recurrence. The aim was to evaluate the offloading effect of custom-made footwear in these patients. In 171 patients with diabetic neuropathy (336 feet) with foot deformity and a recently healed plantar foot ulcer, plantar pressures walking barefoot and inside new custom-made footwear were measured. At the previous ulcer location and at locations of highest barefoot pressure attributable to the deformity, in-shoe pressures were compared with non-deformed feet. The footwear was considered effective in offloading when in-shoe peak pressure at these locations was < 200 kPa. Mean in-shoe peak pressures ranged between 211 and 308 kPa in feet with forefoot deformity (vs. 191-222 kPa in non-deformed feet) and between 140 and 187 kPa in feet with midfoot deformity (vs. 112 kPa in non-deformed feet). Offloading was effective in 61% of all feet with deformity, 81% of feet with midfoot deformity, 44% of feet with forefoot deformity and 62% of previous ulcer locations. Inter-subject variability in measured in-shoe plantar pressure was large. Offloading in custom-made footwear is often not sufficiently achieved in high-risk diabetic feet with deformity. Highest offloading success rates were seen at known high-risk locations such as previous ulcer locations and Charcot feet, the lowest success rates in forefoot deformities. Together with the large inter-subject variability in pressure outcomes, this emphasizes the need for evidence-based prescription and evaluation procedures to assure adequate offloading.

Foot function is well preserved in children and adolescents with juvenile idiopathic arthritis who are optimally managed

PurposeThe objective of this study was to compare disease activity, impairments, disability, foot function and gait characteristics between a well described cohort of juvenile idiopathic arthritis (JIA) patients and normal healthy controls using a 7-segment foot model and three-dimensional gait analysis. MethodsFourteen patients with JIA (mean (standard deviation) age of 12.4 years (3.2)) and a history of foot disease and 10 healthy children (mean (standard deviation) age of 12.5 years (3.4)) underwent three-dimensional gait analysis and plantar pressure analysis to measure biomechanical foot function. Localised disease impact and foot-specific disease activity were determined using the juvenile arthritis foot disability index, rear- and forefoot deformity scores, and clinical and musculoskeletal ultrasound examinations respectively. Mean differences between groups with associated 95% confidence intervals were calculated using the t distribution. ResultsMild-to-moderate foot impairments and disability but low levels of disease activity were detected in the JIA group. In comparison with healthy subjects, minor trends towards increased midfoot dorsiflexion and reduced lateral forefoot abduction within a 3–5° range were observed in patients with JIA. The magnitude and timing of remaining kinematic, kinetic and plantar pressure distribution variables during the stance phase were similar for both groups. ConclusionIn children and adolescents with JIA, foot function as determined by a multi-segment foot model did not differ from that of normal age- and gender-matched subjects despite moderate foot impairments and disability scores. These findings may indicate that tight control of active foot disease may prevent joint destruction and associated structural and functional impairments.