IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes

Recommendations - 1 To identify a person with diabetes at risk for foot ulceration, examine the feet annually to seek evidence for signs or symptoms of peripheral neuropathy and peripheral artery disease. (GRADE strength of recommendation: strong; Quality of evidence: low) - 2 In a person with diabetes who has peripheral neuropathy, screen for a history of foot ulceration or lower-extremity amputation, peripheral artery disease, foot deformity, pre-ulcerative signs on the foot, poor foot hygiene and ill-fitting or inadequate footwear. (Strong; Low) - 3 Treat any pre-ulcerative sign on the foot of a patient with diabetes. This includes removing callus, protecting blisters and draining when necessary, treating ingrown or thickened toe nails, treating haemorrhage when necessary and prescribing antifungal treatment for fungal infections. (Strong; Low) - 4 To protect their feet, instruct an at-risk patient with diabetes not to walk barefoot, in socks only, or in thin-soled standard slippers, whether at home or when outside. (Strong; Low) - 5 Instruct an at-risk patient with diabetes to daily inspect their feet and the inside of their shoes, daily wash their feet (with careful drying particularly between the toes), avoid using chemical agents or plasters to remove callus or corns, use emollients to lubricate dry skin and cut toe nails straight across. (Weak; Low) - 6 Instruct an at-risk patient with diabetes to wear properly fitting footwear to prevent a first foot ulcer, either plantar or non-plantar, or a recurrent non-plantar foot ulcer. When a foot deformity or a pre-ulcerative sign is present, consider prescribing therapeutic shoes, custom-made insoles or toe orthosis. (Strong; Low) - 7 To prevent a recurrent plantar foot ulcer in an at-risk patient with diabetes, prescribe therapeutic footwear that has a demonstrated plantar pressure-relieving effect during walking (i.e. 30% relief compared with plantar pressure in standard of care therapeutic footwear) and encourage the patient to wear this footwear. (Strong; Moderate) - 8 To prevent a first foot ulcer in an at-risk patient with diabetes, provide education aimed at improving foot care knowledge and behaviour, as well as encouraging the patient to adhere to this foot care advice. (Weak; Low) - 9 To prevent a recurrent foot ulcer in an at-risk patient with diabetes, provide integrated foot care, which includes professional foot treatment, adequate footwear and education. This should be repeated or re-evaluated once every 1 to 3 months as necessary. (Strong; Low) - 10 Instruct a high-risk patient with diabetes to monitor foot skin temperature at home to prevent a first or recurrent plantar foot ulcer. This aims at identifying the early signs of inflammation, followed by action taken by the patient and care provider to resolve the cause of inflammation. (Weak; Moderate) - 11 Consider digital flexor tenotomy to prevent a toe ulcer when conservative treatment fails in a high-risk patient with diabetes, hammertoes and either a pre-ulcerative sign or an ulcer on the distal toe. (Weak; Low) - 12 Consider Achilles tendon lengthening, joint arthroplasty, single or pan metatarsal head resection, or osteotomy to prevent a recurrent foot ulcer when conservative treatment fails in a high-risk patient with diabetes and a plantar forefoot ulcer. (Weak; Low) - 13 Do not use a nerve decompression procedure in an effort to prevent a foot ulcer in an at-risk patient with diabetes, in preference to accepted standards of good quality care. (Weak; Low)

Postoperative soft tissue defects in the ankle area : The etiology and methods of reconstruction

The risk is obvious for soft tissue complications after operative treatment of the Achilles tendon, calcaneal bone or after ankle arthroplasty. Such complications after malleolar fractures are, however, seldom seen. The reason behind these complications is that the soft tissue in this region is tight and does not allow much tension to the wound area after surgery. Furthermore the area of operation may be damaged by swelling after the injury, or can be affected by peripheral vascular disease. While complications in this area are unavoidable, they can be diminished. This study attempts to highlight the possible predisposing factors leading to complications in these operations and on the other hand, to determine the solutions to solve soft tissue problems in this region. The study consists of five papers. The first article is a reprint on the soft tissue reconstruction of 25 patients after their complicated Achilles tendon surgeries were analysed. The second study reviews a series of 126 patients after having undergone an operative treatment of calcaneal bone fractures and analyses the complications and possible reasons behind them. The third part analyses a series of corrections of 35 soft tissue complications after calcaneal fracture operations. The fourth part reviews a series of 7 patients who had undergone complicated ankle arthroplasties. The last article presents a series of post operative lateral defects of the ankle treated with a less frequently used distally based peroneus brevis muscle flap and analyses the results. What can be conducted from these studies is that in general, the results after the correction of even severe soft tissue complications in the ankle region are good. For the small defects around the Achilles tendon, the local flaps are useful, but the larger defects are best treated with a free flap. We found that a long delay from trauma to surgery and a long operating time were predisposing factors that lead to soft tissue complications after operatively treated calcaneal bone fractures. The more severe the injury, the greater the risk for wound complication. Surprisingly, the long-term results after infected calcaneal osteosyntheses were acceptable and the calcaneal bone seems to tolerate chronic infections very well if the soft tissue is reconstructed successfully. Behind the complicated ankle arthroplasties, unexpectedly high number of cases experiencing arteriosclerosis of the lower extremity was found. These complications lead to ankle fusion but can be solved with a free flap if the vascularity is intact or can be reconstructed. For this reason a vascular examination of the lower extremity arteries of the patients going to ankle arthroplasty is strongly recommended. Moreover postoperative lateral malleolar wound infections which typically create lateral ankle defects can successfully be treated with a peroneus brevis muscle flap covered with a free skin graft.

Anterior cruciate ligament reconstruction with special reference to magnetic resonance imaging of the postoperative outcome

Anterior cruciate ligament (ACL) tear is a common sports injury of the knee. Arthroscopic reconstruction using autogenous graft material is widely used for patients with ACL instability. The grafts most commonly used are the patellar and the hamstring tendons, by various fixation techniques. Although clinical evaluation and conventional radiography are routinely used in follow-up after ACL surgery, magnetic resonance imaging (MRI) plays an important role in the diagnosis of complications after ACL surgery. The aim of this thesis was to study the clinical outcome of patellar and hamstring tendon ACL reconstruction techniques. In addition, the postoperative appearance of the ACL graft was evaluated using several MRI sequences. Of the 175 patients who underwent an arthroscopically assisted ACL reconstruction, 99 patients were randomized into patellar tendon (n=51) or hamstring tendon (n=48) groups. In addition, 62 patients with hamstring graft ACL reconstruction were randomized into either cross-pin (n=31) or interference screw (n=31) fixation groups. Follow-up evaluation determined knee laxity, isokinetic muscle performance and several knee scores. Lateral and anteroposterior view radiographs were obtained. Several MRI sequences were obtained with a 1.5-T imager. The appearance and enhancement pattern of the graft and periligamentous tissue, and the location of bone tunnels were evaluated. After MRI, arthroscopy was performed on 14 symptomatic knees. The results revealed no significant differences in the 2-year outcome between the groups. In the hamstring tendon group, the average femoral and tibial bone tunnel diameter increased during 2 years follow-up by 33% and 23%, respectively. In the asymptomatic knees, the graft showed homogeneous and low signal intensity with periligamentous streaks of intermediate signal intensity on T2-weighted MR images. In the symptomatic knees, arthroscopy revealed 12 abnormal grafts and two meniscal tears, each with an intact graft. Among 3 lax grafts visible on arthroscopy, MRI showed an intact graft and improper bone tunnel placement. For diagnosing graft failure, all MRI findings combined gave a specificity of 90% and a sensitivity of 81%. In conclusion, all techniques appeared to improve patients' performance, and were therefore considered as good choices for ACL reconstruction. In follow-up, MRI permits direct evaluation of the ACL graft, the bone tunnels, and additional disorders of the knee. Bone tunnel enlargement and periligamentous tissue showing contrast enhancement were non-specific MRI findings that did not signify ACL deficiency. With an intact graft and optimal femoral bone tunnel placement, graft deficiency is unlikely, and the MRI examination should be carefully scrutinized for possible other causes for the patients symptoms.

Bone Stress Injuries of the Foot and Ankle

Bone stress injuries of the foot have been known for more than 150 years. For a century, their primary diagnostic imaging tool has been radiography. However, currently the golden standard for establishing the diagnosis of stress injuries is magnetic resonance imaging (MRI). Although the injury type has been fairly well documented in the earlier literature, little information is available on the healing of stress injuries located in e.g. the talus and calcaneus. The current study retrospectively evaluated the stress injuries of the foot and ankle treated at the Central Military Hospital over a period of eight years in patients who underwent MRI for stress injury of the foot. The imaging studies of the patients were reevaluated to determine the exact nature of the stress injury. Moreover, the hospital records of the patients were reviewed to determine the healing of stress injuries of the talus and calcaneus. Patients with a stress fracture in the talus were recalled for a follow-up examination and MRI scan one to six years after the initial injury to determine if the fracture had completely healed, clinically and radiologically. The bone stress injuries of the foot were found to affect more than one bone in a majority of the cases. The talus and the calcaneus were the bones most commonly affected. In the talus, the most common site for the injuries was the head of the bone, and in the calcaneus, the posterior part of the bone. The injuries in these bones were associated with injuries in the surrounding bones. Stress injuries in the calcaneus seemed to heal well. No complications were seen in the primary healing process. The patients were, however, sometimes compelled to refrain from physical training for up to months. In the talus, minor degenerative findings of the articular surface were seen in half of the patients who participated in a follow-up MRI scan and radiographs taken one to six years after the initial injury. Half of the patients also reported minor exercise related symptoms in the follow-up. The symptoms were, however, not noticeable in everyday life.

Magnetic resonance imaging and ultrasonography in brachial plexus birth injury

Brachial plexus birth injury (BPBI) is caused by stretching, tearing or avulsion of the C5-C8 or Th1 nerve roots during delivery. Foetal-maternal disproportion is the main reason for BPBI. The goal of this study was to find out the incidence of posterior subluxation of the humeral head during first year of life in BPBI and optimal timing of the ultrasonographic screening of the glenohumeral joint. The glenohumeral congruity and posterior subluxation of the humeral head associated to muscle atrophy were assessed and surgical treatment of the shoulder girdle as well as muscle changes in elbow flexion contracture were evaluated. The prospective, population based part of the study included all neonates born in Helsinki area during years 2003-2006. Patients with BPBI sent to the Hospital for Children and Adolescents because of decreased external rotation, internal rotation contracture or deformation of the glenohumeral joint as well as patients with elbow flexion contracture were also included in this prospective study. The incidence of BPBI was calculated to be 3.1/1000 newborns in Helsinki area. About 80% of the patients with BPBI recover totally during the follow-up within the first year of life. Permanent plexus injury at the age of one year was noted in 20% of the patients (0.64/1000 newborns). Muscle imbalance resulted in sonographically detected posterior subluxation in one third of the patients with permanent BPBI. If muscle imbalance and posterior subluxation are left untreated bony deformities will develop. All patients with internal rotation contracture of the glenohumeral joint presented muscle atrophy of the rotator cuff muscles. Especially subscapular and infraspinous muscles were affected. A correlation was found particularly between greatest thickness of subscapular muscle and subluxation of the humeral head, degree of glenoid retroversion, as well as amount of internal rotation contracture. Supinator muscle atrophy was evident among all the studied patients with elbow flexion contracture. Brachial muscle pathology seemed to be an important factor for elbow flexion contracture in BPBI. Residual dysfunction of the upper extremity may require operative treatment such as tendon lengthening, tendon transfers, relocation of the humeral head or osteotomy of the humerus. Relocation of the humeral head improved the glenohumeral congruency among patients under 5 years of age. Functional improvement without remodeling of the glenohumeral joint was achieved by other reconstructive procedures. In conclusion: Shoulder screening by US should be done to all patients with permanent BPBI at the age of 3 and 6 months. Especially atrophy of the subscapular muscle correlates with glenohumeral deformity and posterior subluxation of the humeral head, which has not been reported in previous studies. Permanent muscle changes are the main reason for diminished range of motion of the elbow and forearm. Relocation of the humeral head, when needed, should be performed under the age of 5 years.

海洋平台张力腿非线性动力响应

采用非线性梁模型,充分考虑张力腿轴向与流向的耦合效应及平台运动对张力腿的作用,运用Galerkin法进行分析求解,研究不同的长径比(L/D)情况下,弯曲刚度和非线性耦合效应的影响,以期得到更适用于实际的张力腿简化模型.

线性张力腿模型与非线性模型的比较研究

平台运动对张力腿的非线性动力响应具有显著的影响.提出了新的更加符合实际的边界条件,分别采用线性的 Euler-Bernoulli梁和非线性梁模型,分析了在不同的张力腿长度和平台激励条件下,线性张力腿模型与非线性模型在预测其动力响应时所得结果的差异.为了保证数值计算的正确性和可靠性,运用了两种不同的计算方法;Galerkin法,有限差分法进行数值求解.结果表明:非线性模型所得的张力腿流向响应幅值要比线性模型的小,且随着张力腿长度以及平台纵荡幅值的增加,非线性模型与线性模型的预测结果之间的差异会变得越来越显著.

深水张力腿平台与系泊系统的耦合动力响应

把张力腿简化为非线性梁结构,运用Hamilton原理,推导出平面情况下平台本体与张力腿系泊系统的耦合运动方程及边界条件;分析了不同流场条件下,两种不同张力腿模型(非线性梁和无质量弹簧模型)对平台动力响应预测结果的影响;分析结果表明:随着流场条件的不同,采用不同的张力腿简化模型得到的平台动力响应预测结果具有明显的不同.阐明了两种模型所得结果产生差异的原因.

Efeitos do uso de antiinflamatório e do exercício aeróbico sobre a regeneração tecidual e perfil biomecânico do tendão calcâneo de ratos após ruptura completa

Ruptura do tendão calcâneo é uma das lesões tendíneas mais frequentes. Embora a maioria dos trabalhos sugira que o exercício seja benéfico na cicatrização tendínea, não há consenso sobre o efeito do antiinflamatório neste contexto. Trabalhos experimentais tentam reproduzir lesão aguda deste tendão, em diferentes espécies animais. Neste estudo, descrevemos uma técnica de tenotomia completa do tendão calcâneo direito em ratos e, em seguida, avaliamos os efeitos do uso do antiinflamatório e do exercício aeróbico, isoladamente e em combinação, sobre a proliferação celular e o perfil biomecânico do tendão calcâneo, durante o processo de cicatrização após tenotomia. Estudo experimental com 156 ratos machos adultos, da raça Wistar, com idade média de 3 meses e peso médio de 300g. Após anestesia com tiopental e com auxílio da microscopia de luz, foi realizada incisão longitudinal posterior de cinco milímetros, em direção proximal, a partir da tuberosidade posterior do calcâneo da pata direita do rato. Foi feito corte transversal do tendão calcâneo, a sete milímetros da tuberosidade do calcâneo, com preservação do tendão plantar. Utilizamos as técnicas de Hematoxilina e Eosina, Picrosirius-red e Resorcina-fucsina de Weigert para avaliação da cicatrização tendínea e das fibras dos sistemas colágeno e elástico. Após a tenotomia, metade dos animais receberam tenoxicam intramuscular por 7 dias e no 8o dia iniciou-se protocolo de exercício em esteira na metade de cada grupo. Os ratos foram divididos aleatoriamente em 4 grupos de tratamento: A sem antiinflamatório E sem exercício (controle); B com antiinflamatório E com exercício; C sem antiinflamatório E com exercício; D com antiinflamatório E sem exercício. Os animais foram eutanasiados com 1, 2, 4 e 8 semanas após a tenotomia, para avaliação histológica pelo PCNA, e biomecânica através do teste de resistência à tração e da medida do ciclo locomotor. Foram realizados análise de variância, teste de Kruskal-Wallis e o método de Bonferroni, no programa R Project, versão 2.11.1. O tempo cirúrgico médio foi de 1 minuto e 24 segundos, sem complicações observadas até a 8a semana pós-operatória. Observamos proliferação celular e fibrilogênese com duas semanas, e diminuição da celularidade e das fibras elásticas na 8a semana, além de mudanças na organização estrutural do sistema colágeno. Encontramos pico da imunomarcação com PCNA na 2a semana em todos os grupos, exceto no grupo A, cujo pico aconteceu com 1 semana da tenotomia. Evidenciamos resistência à tração significativamente maior (p=0,02) nos ratos submetidos ao exercício, 8 semanas após ruptura. Nos grupos com antiinflamatório, observamos um ciclo locomotor mais estável durante todo o tempo avaliado. Consideramos a técnica cirúrgica experimental de tenotomia completa do tendão calcâneo, realizada com auxílio da microscopia de luz e preservação do tendão plantar, simples, rápida, com sinais de cicatrização tendínea normal e de fácil reprodução em ratos. O exercício aeróbico, iniciado precocemente após tenotomia completa do tendão calcâneo, é significativamente benéfico na sua recuperação biomecânica e o uso combinado com antiinflamatório confere maior estabilidade na marcha, o que pode proteger contra rerruptura tendínea em ratos

Effects of solution exposure on the combined axial-shear behaviour of unidirectional CFRP rods

In fibre reinforced polymer (FRP) prestressed concrete applications, an FRP tendon must sustain high axial tensile stresses and, if cracks occur, additional dowel forces. The tendon may also be exposed to solutions and so the combined axial-shear stress performance after long-term environmental exposure is important. Experiments were conducted to investigate the combined axial-shear stress failure envelope for unidirectional carbon FRP tendons which had been exposed to either water, salt water or concrete pore solution at 60 °C for approximately 18 months. The underlying load resisting mechanisms were found to depend on the loading configuration, restraint effects and the initial stress state. When saturated, CFRP tendons are likely to exhibit a reduced shear stiffness. However, the ultimate limit state appeared to be fibre-dominated and was therefore less susceptible to reductions due to solution uptake effects. © 2012 Elsevier Ltd. All rights reserved.

Award Winner in the Young Investigator Category, 2014 Society for Biomaterials Annual Meeting and Exposition, Denver, Colorado, April 16-19, 2014: Periodically perforated core-shell collagen biomaterials balance cell infiltration, bioactivity, and mechanical properties.

Orthopedic tissue engineering requires biomaterials with robust mechanics as well as adequate porosity and permeability to support cell motility, proliferation, and new extracellular matrix (ECM) synthesis. While collagen-glycosaminoglycan (CG) scaffolds have been developed for a range of tissue engineering applications, they exhibit poor mechanical properties. Building on previous work in our lab that described composite CG biomaterials containing a porous scaffold core and nonporous CG membrane shell inspired by mechanically efficient core-shell composites in nature, this study explores an approach to improve cellular infiltration and metabolic health within these core-shell composites. We use indentation analyses to demonstrate that CG membranes, while less permeable than porous CG scaffolds, show similar permeability to dense materials such as small intestine submucosa (SIS). We also describe a simple method to fabricate CG membranes with organized arrays of microscale perforations. We demonstrate that perforated membranes support improved tenocyte migration into CG scaffolds, and that migration is enhanced by platelet-derived growth factor BB-mediated chemotaxis. CG core-shell composites fabricated with perforated membranes display scaffold-membrane integration with significantly improved tensile properties compared to scaffolds without membrane shells. Finally, we show that perforated membrane-scaffold composites support sustained tenocyte metabolic activity as well as improved cell infiltration and reduced expression of hypoxia-inducible factor 1α compared to composites with nonperforated membranes. These results will guide the design of improved biomaterials for tendon repair that are mechanically competent while also supporting infiltration of exogenous cells and other extrinsic mediators of wound healing.

Bipedal walking and running with spring-like biarticular muscles.

Compliant elements in the leg musculoskeletal system appear to be important not only for running but also for walking in human locomotion as shown in the energetics and kinematics studies of spring-mass model. While the spring-mass model assumes a whole leg as a linear spring, it is still not clear how the compliant elements of muscle-tendon systems behave in a human-like segmented leg structure. This study presents a minimalistic model of compliant leg structure that exploits dynamics of biarticular tension springs. In the proposed bipedal model, each leg consists of three leg segments with passive knee and ankle joints that are constrained by four linear tension springs. We found that biarticular arrangements of the springs that correspond to rectus femoris, biceps femoris and gastrocnemius in human legs provide self-stabilizing characteristics for both walking and running gaits. Through the experiments in simulation and a real-world robotic platform, we show how behavioral characteristics of the proposed model agree with basic patterns of human locomotion including joint kinematics and ground reaction force, which could not be explained in the previous models.

Learning legged locomotion

Legged locomotion of biological systems can be viewed as a self-organizing process of highly complex system-environment interactions. Walking behavior is, for example, generated from the interactions between many mechanical components (e.g., physical interactions between feet and ground, skeletons and muscle-tendon systems), and distributed informational processes (e.g., sensory information processing, sensory-motor control in central nervous system, and reflexes) [21]. An interesting aspect of legged locomotion study lies in the fact that there are multiple levels of self-organization processes (at the levels of mechanical dynamics, sensory-motor control, and learning). Previously, the self-organization of mechanical dynamics was nicely demonstrated by the so-called Passive Dynamic Walkers (PDWs; [18]). The PDW is a purely mechanical structure consisting of body, thigh, and shank limbs that are connected by passive joints. When placed on a shallow slope, it exhibits natural bipedal walking dynamics by converting potential to kinetic energy without any actuation. An important contribution of these case studies is that, if designed properly, mechanical dynamics can generate a relatively complex locomotion dynamics, on the one hand, and the mechanical dynamics induces self-stability against small disturbances without any explicit control of motors, on the other. The basic principle of the mechanical self-stability appears to be fairly general that there are several different physics models that exhibit similar characteristics in different kinds of behaviors (e.g., hopping, running, and swimming; [2, 4, 9, 16, 19]), and a number of robotic platforms have been developed based on them [1, 8, 13, 22]. © 2009 Springer London.

Analysis of structural health monitoring data from hammersmith flyover

There has recently been considerable research published on the applicability of monitoring systems for improving civil infrastructure management decisions. Less research has been published on the challenges in interpreting the collected data to provide useful information for engineering decision makers. This paper describes some installed monitoring systems on the Hammersmith Flyover, a major bridge located in central London (United Kingdom). The original goals of the deployments were to evaluate the performance of systems for monitoring prestressing tendon wire breaks and to assess the performance of the bearings supporting the bridge piers because visual inspections had indicated evidence of deterioration in both. This paper aims to show that value can be derived from detailed analysis of measurements from a number of different sensors, including acoustic emission monitors, strain, temperature and displacement gauges. Two structural monitoring systems are described, a wired system installed by a commercial contractor on behalf of the client and a research wireless deployment installed by the University of Cambridge. Careful interpretation of the displacement and temperature gauge data enabled bearings that were not functioning as designed to be identified. The acoustic emission monitoring indicated locations at which rapid deterioration was likely to be occurring; however, it was not possible to verify these results using any of the other sensors installed and hence the only method for confirming these results was by visual inspection. Recommendations for future bridge monitoring projects are made in light of the lessons learned from this monitoring case study. © 2014 This work is made available under the terms of the Creative Commons Attribution 4.0 International license,.

Dexterous Robotic Hands: Kinematics and Control

This report presents issues relating to the kinematics and control of dexterous robotic hands using the Utah-MIT hand as an illustrative example. The emphasis throughout is on the actual implementation and testing of the theoretical concepts presented. The kinematics of such hands is interesting and complicated owing to the large number of degrees of freedom involved. The implementation of position and force control algorithms on such tendon driven hands has previously suffered from inefficient formulations and a lack of sophisticated computer hardware. Both these problems are addressed in this report. A multiprocessor architecture has been built with high performance microcomputers on which real-time algorithms can be efficiently implemented. A large software library has also been built to facilitate flexible software development on this architecture. The position and force control algorithms described herein have been implemented and tested on this hardware.