[Criteria for socket type prescription: indications and contraindications of a liner system]. / Verordnungskriterien für Oberschenkelschaftsysteme: Indikationen und Kontraindikationen der Linerversorgung.

BACKGROUND: The prescription of socket type for above-knee-amputees is based on clinical experience. There are no official guidelines. On the basis of treatment statistics and a patient survey, this study shows the indications and contraindications of a liner system. PATIENTS AND METHODS: Treatment statistics including data from the medical reports of 183 above-knee-amputees, who were treated in our clinic from 2003 to 2007 were analysed. 32 patients had a system change between liner- and contact-shaft accommodation and were contacted by telephone. The aim was to evaluate satisfaction with the current socket type and thus be able to compare types. RESULTS: A statistically significant relation in the treatment statistics between the quality of the stump and the socket type can be shown. A mesh graft to cover the stump, extreme volume fluctuation, low activity class and co-morbidities are the main reasons for the use of a liner system. Main reasons for a change to a liner system were the preservation of individual independence, better adhesion and skin problems. CONCLUSION: The developed clinical criteria can help physicians decide which socket type is most beneficial for each individual patient.

["Münsteraner foot- and shoe score"--objectivation of patient satisfaction after provision with orthopedic shoes]. / "Münsteraner Fuß- und Schuhfragebogen" - Objektivierung der Patientenzufriedenheit nach orthopädischer Schuhversorgung.

BACKGROUND: Means to improve patient satisfaction and their compliance are essential for the successful outcome of medical interventions, e.g. supply of orthopedic shoes or orthoses in orthopedic patients. A useful validated questionnaire to monitor the subjective opinion of the patients is still lacking. METHODS: In a randomised single blinded study we created a new questionnaire with two parts. Part one deals with ten questions on patient data and illness. Part two consists of 13 questions about pain, disabilities in activities of daily life (ADL), use of painkillers, satisfaction, history of ulceration, correction of shoes and orthoses, handling and compliance using a scale of 1-6. Questions were chosen by asking a group of experts (four experienced physicians of two universities and four shoemaker master-craftsmen). Then an items reduction was performed. The reliability was tested in a pre- and retest in 20 patients of our orthopedic clinic. Then the questionnaire was validated by comparing 40 patients of our orthopedic clinic (intervention group) with 180 subjects without orthopedic treatment (control group) chosen at random. The questionnaire was always done anonymously and without the help of the interviewer. Exclusion criteria for the control group were any kind of orthopedic treatment of the lower limb in the last 2 years, orthopedic shoes or lumbar sciatic pain. Exclusion criteria for both groups were minor or major amputations, inability to walk outdoors without help. RESULTS: We demonstrated highly significant differences for each single question and the total score between orthopedic patients and healthy probands. Additionally, we saw significantly poorer scores for patients suffering from diabetes in the control group, patients with polyneuropathy and those without polyneuropathy, as well as for women vs. men. There was a high rate of diabetics (11 %) in the control group in analogy to the current literature. DISCUSSION: The new questionnaire discriminates highly significantly between healthy and ill probands. Interindividually a screening of people at risk is possible or a comparison of different interventions. Intraindividually it could be used to monitor patient satisfaction after interventions. Objectivation of patient satisfaction is important to improve their compliance and outcome.

[Orthopedic made-to-measure shoes for diabetics. Long-term 5-year outcome]. / Orthopädische Massschuhversorgung bei Diabetikern: 5-Jahres-Outcome.

For patients with diabetes mellitus and diabetic foot syndrome customized orthopedic shoes represent the most effective treatment to avoid foot ulceration and amputation. A total of 53 patients suffering from diabetes and treated with customized orthopedic shoes for more than 5 years were included in the study. Of the patients 91% had peripheral artery occlusion disease, polyneuropathy and diabetic neuropathic osteoarthropathy (DNOAP) and in nearly 25% amputation of one limb had already been carried out. The incidence of ulcers over a time period of 5 years was assessed from the patient records and questioning the patients. Questions on the duration of wearing orthopedic shoes, the durability of the shoes and resulting pain were also included. All patients except for one had problems walking on uneven surfaces. Of the patients 89% claimed to have used their shoes always or nearly always and 25% of the shoes had to be replaced after 1 year. The incidence of ulcers was 38% after 5 years. Treatment with customized orthopedic shoes is an effective method to prevent ulcers and amputation. To be successful it is necessary to control that the shoes are made correctly. Not all shoes last as long as 2 years.

[Reconstructive surgery for Charcot foot. Long-term 5-year outcome]. / Rekonstruktive Chirurgie beim Charcot-Fuss: 5-Jahres-Langzeitoutcome.

INTRODUCTION: Diabetic neuropathic osteoarthropathy (DNOAP) often leads to progressive malpositioning of the foot with subsequent ulcers and a high risk of amputation. There are very few reliable studies on long-term outcome. This study includes the largest follow- up collective ever carried out. METHODS: In a retrospective study 205 surgical procedures (195 patients) for complex malpositioning of the foot and/or chronic ulcers using a fixateur externe (188 cases) or Steinmann pins (17 cases) in patients with NOAP were included. The average follow-up time was 21 months. The goal was walking without pain in customized orthopedic shoes and avoiding amputation. RESULTS: No primary amputations were necessary. Patient activity improved by more than 1 level according to the classification for lower limb amputees following the Hofer activity score. The most common minor complication was persistence or recurrence of ulcers in 48 patients. Only 7 new recurrences of NOAP were observed. In 15 patients secondary amputation was necessary. Approximately 50% of the patients could be mobilized with the help of customized orthopedic shoes 18 months after surgery. CONCLUSION: By using a fixateur externe many amputations could be avoided and patient's activity could be improved. The interdisciplinary teamwork between an orthopedic surgeon, orthopedic shoemaker and orthopedic technician is essential for long term success.

Plantar pressure reduction in step-to gait: a biomechanical investigation and clinical feasibility study.

BACKGROUND: Protection of the foot may necessitate reduction of peak pressures in specific plantar regions. The study focuses on the unloading effects that exercising step-to gait may have. METHODS: 20 healthy volunteers were recruited and completed three pedobarographic examinations measuring peak pressures in different gait patterns: normal, half-step length, step-to gait with normal step length on the leading side and zero step length on the trailing side--all gait patterns with an individual but constant cadence. To test clinical feasibility 10 diabetic-neuropathic patients were studied in normal and step-to gait without any restrictions regarding speed or cadence. FINDINGS: Volunteers exercising step-to gait exhibit a significant (P<1%) reduction of peak pressures under the heels and central metatarsals by 9% and 67% on the leading side and of 32% and 19% on the trailing side, respectively. In the diabetic-neuropathic patients unloading effects of the same magnitude but less significant were observed. INTERPRETATION: Reduction of speed reduces peak pressures in all plantar regions. Asymmetry of step patterns reduces peak pressures in the heel and forefoot regions of that foot where heel strike and push-off are suppressed, respectively. However, pressures on the contralateral side are increased. The result is an asymmetric distribution of pressure that is reduced in all regions. Step-to gait may be an option, if pressure protection is required in selected plantar regions. This is confirmed by a feasibility study done with diabetic-neuropathic patients. Protection of the foot, however, is balanced at the cost of harmony of gait, impeding clinical application.

[Management of upper limb deformities. Treatment concepts through the years]. / Hilfsmittel bei Fehlbildungen der oberen Extremitäten. Versorgungskonzepte im Wandel der Zeit.

The provision of aids and prostheses for patients with upper limb deficiencies has to be based on comprehensive knowledge in the field of orthopaedic technology. Taking into account the patient's complete background, evaluation of the possible functional benefit is mandatory in order to achieve good acceptance of a prosthesis in the long term. The extent of extremity "loss" and the remaining function of the deficient limb have an impact on the success of prosthetic fitting. Furthermore, there is a trend towards myoelectric prostheses, which seem to improve prosthetic acceptance. Bilateral congenital deficiency of the upper limbs cannot be equated with amputations. Most people affected do not push for a prosthesis, but should be provided with one, if the need arises. Decades of overuse of the deficient limbs often take their toll in terms of decreasing function as degenerative changes occur. As a consequence, artificial upper limbs may be obligatory to prevent loss of independence.

[Changes in shape and size of the foot during pregnancy]. / Form- und Grössenveränderungen des Fusses während der Schwangerschaft.

Many women report an increase in foot size during their pregnancy. Our objective was to verify this anecdotal evidence. In an initial survey of 21 mothers in 2 Münster nursery schools we found a tendency towards an increase in foot size during pregnancy. We therefore developed a measuring system to measure changes in foot length, width, height and volume. A total of 40 women recruited from the antenatal clinic of the University Hospital of Münster and a participating practice were seen three times during their pregnancy. The results were analysed using the Wilcoxon test. We found a statistically significant increase in foot length, width and volume, whereas foot height decreased slightly. This difference was, however, not significant. Especially in diabetic women with polyneuropathy it is important to pay attention to shoe size to prevent pressure sores.

[The influence of proprioceptive insoles (Bourdiol) on the sagittal curvature and inclination of the trunk]. / Der Einfluss neurologischer Einlagen nach Bourdiol auf die Rumpfhaltung.

Proprioceptive insoles rely on the concept of Réné-Jaques Bourdiol, a French neurologist. The aim is to modulate plantar surface sensibility and to influence posture and statics of patients: it is hypothesized that the effect of modified afferent sensory input through proprioceptive stimulation of terminal muscle chains will have either a relaxing or stimulating effect on the whole body, which may be realized by affecting the posture. Small pads with a thickness of typically 1-3 mm are embedded into the insole to provide a specific stimulation. In fitting the insoles selectively to the individual patient the effect of the insoles on the trunk posture is taken as a feedback. This study investigates the influence of proprioceptive insoles on the sagittal curve in 20 selected patients. The protocol used a repeated measures research design. The measures of the sagittal curve were obtained using raster stereography. The four different conditions were: (1) barefoot, (2) convenient shoes without the insoles, (3) the same shoes with a placebo insole, and (4) the same shoes with neurological insoles. Evaluation of raster stereographs provided the kyphotic angle between T4 and T12 and lordotic angle between T12 and S1. Statistical evaluation was performed with the t-test for paired measurements. No significant differences were found in the sagittal profile. Only trunk inclination in normal posture was found to yield a significant difference (0.38 degrees) between placebo and neurological insoles. However, no clear statement on the efficiency of neurological insoles can be made.

[Significance of microbial colonisation in materials for orthopaedic technology. New insights]. / Bedeutung der mikrobiellen Besiedlung orthopädietechnischer Materialien. Neue Erkenntnisse.

A great problem in the treatment of diabetes are infections of diabetic feet. A likely reservoir of microorganisms are contaminated orthopaedic materials. Insoles from 70 patients were examined for potential microbial colonisation. Commonly employed materials were contaminated in vitro under standardised conditions using known microorganisms. After treating with an alcoholic skin disinfectant, the organisms were counted semiquantitatively. In addition to pathogens, the surfaces showed mainly microorganisms present in the normal skin flora. In all materials tested, disinfection reduced the number of organisms by 4-5 log orders. It could be shown that simple disinfection (wiping) reduces the microorganisms present on orthopaedic materials to an acceptable number. Further studies are needed to determine whether this also reduces the incidence of diabetic skin and soft tissue infection.

[Anxiety and depression after loss of a lower limb]. / Angst und Depressionen nach einer Amputation der unteren Extremität.

A good number of psychosocial-, disease-, and disability-related variables influence the adaptation process after the loss of a lower limb. In this case psychological problems, as a result of a failed adaptation process, are common. Of the 75 patients examined who had an amputation of a lower extremity 27% showed increased depression and 25% increased anxiety scores; 18.3% showed higher than normal scores in both categories. Regression analysis showed that in addition to pain reception poor acceptance of the prosthesis is an important predictive factor for the development of psychological disorders and diseases like anxiety and depression. Therefore, measures for psychological diagnostics and care should be initiated soon after the amputation to prevent psychological abnormalities. Here interdisciplinary management and cooperation of the professions involved in the care of the patient are recommended.

[The influence of the C-leg knee-shin system from the Otto Bock Company in the care of above-knee amputees. A clinical-biomechanical study to define indications]. / Einfluss des C-Leg-Kniegelenk-Passteiles der Fa. Otto Bock auf die Versorgungsqualität Oberschenkelamputierter. Eine klinisch-biomechanische Studie zur Eingrenzung von Indikationskriterien.

The C-Leg microprocessor-controlled knee-shin system for the above-knee amputees is introduced as a dramatic improvement over all other prosthetic knees. This is due to its combination of on-board microprocessor and the hydraulic controls acting both on the swing and stance phase. A more secure, natural and efficient gait is expected. Following the recommendations of Otto Bock the indications for the prescription of the C-leg are: Amputees with mobility level "able to walk outdoors without limitations" (AK3) and "able to walk outdoors without limitations plus engage in high performance activities" (AK4) if they face at least one extra obstacle as listed in the Otto Bock catalogue of indications. In this article it is aimed to critically review the indications for the C-leg. In particular the question is posed, whether a different or sophisticated indication of mobility levels might be suggested. Therefore this study does not concentrate on the 3C-100 C-Leg((R)) component but on the system patient + C-leg. So the testing is done by comparing the C-Leg against the regular knee, which is assumed to be an adequate choice for this patient and to which he is accustomed. So far 25 patients with activity levels AK 2 (5), AK 3 (13) and AK 4 (7) have participated in the study. 23 patients, i.e. all patients except one AK 2 and one AK 3 exhibit functional improvement at least according to one criterion. On the other side, only three patients (2 AK 4), fulfill all criteria of functional improvement, which have been defined for this test. It is concluded, that multi-handicapped patients of all activity levels generally experience substantial improvement due to this system. AK 2 patients may show significant functional improvement. As a prerequisite, however, they must not exhibit deficiencies regarding stump movement, muscular status or cognitive abilities. Active patients (AK 3 and AK 4) benefit in the majority of cases. However, some highly active patients of AK 4 complain about interferences between their intended movement and the microprocessor control of knee movements.

[Comorbidity of mental and internal medical disorders in inpatients treated at the clinic for technical orthopedics]. / Komorbidität psychischer und internistischer Erkrankungen bei stationär behandelten Patienten in der technischen Orthopädie.

Due to the severity of their clinical picture and their shattered sense of physical inviolability that almost always is associated with their condition as well as their changed physical appearance, inpatients being treated at the clinic for technical orthopedics frequently exhibit comorbid mental disorders. This article examines these mental health comorbidities. The proportion of adjustment disorders in this group was shown to be noticeably higher than in a comparative group of outpatients attending a psychosomatic/psychotherapeutic clinic. Furthermore, diabetes mellitus proved to be another statistically significant organic comorbidity in the patients treated at the clinic for technical orthopedics. This article discusses the extent to which the chronicity of this disease affects the psychosomatic diagnoses but also the course of the treatment in the clinic for technical orthopedics. In conclusion, this article emphasizes the need for close interdisciplinary management for this highly selected patient group because of the high rates of comorbidity.

[Radiological and clinical aspects of diabetic-neuropathic osteoarthropathy]. / Radiologische und klinische Aspekte der diabetisch-neuropathischen Osteoarthropathie.

AIMS: The clinical and radiological observation of patients with neuroarthropathy was carried out with the aim of determining the most significant factors and risk factors involved. METHODS AND MATERIALS: From January 1998 to December 2000, 53 patients between 29 and 79 years of age were treated in the Clinic for Technical Orthopedics for diabetic-neuropathic osteoarthropathy (DNOAP) of the foot. A comparison was made between the retrospective data for conservative and surgical treatments. RESULTS: Almost 90% of the effected patients were of working age, which is an indication of the socioeconomic consequences of DNOAP. The mean age of the diabetics was 30.3 years for diabetes mellitus type 1 and 14.6 years for type 2. Overweight was a possible risk factor for the development of orthoarthropathic lesions, in particular at the rear of the foot. An additional risk factor was the presence of claw toes. Taking the radiological data into consideration, DNOAP of the foot can be seen as a dynamic illness that is not adequately dealt with in the commonly used Sanders' classification. In the case of proximal lesions, the number of additional DNOAP changes on the same foot was more than for distal lesions. A possible explanation is the microtrauma of neighbouring bones due to changes in the statics and biomechanics of the foot. Our results indicate that type 1 diabetes plays a particularly important role. Contrary to the other forms of DNOAP, Sanders type 1 is associated with atrophic-destructive changes to the bone. In our cohort, pAVK and ulcers were common with Sanders type 1 diabetes, and overweight appeared to be insignificant. CONCLUSIONS: Our results are a plea for an early, consequent and stage specific treatment of DNOAP in order to prevent the advance of bone destruction. The clinical and radiological course show that a lasting clearance of ulcers, the removal of necrosis and the repositioning of luxations by suitable stabilisation promote healing in DNOAP.

[Reconstructive foot surgery in cases of diabetic-neuropathic osteoarthropathy]. / Rekonstruktive Fusschirurgie bei diabetisch-neuropathischer Osteoarthropathie.

QUESTION: Neurogenic osteoarthropathy often results in a debilitating deformity of the foot which can not be handled conservatively. Indications for surgery are recurrent ulcers, deep tissue infection and decompensated statics with progressing deformity. External fixation as a possible method of correction has to show its efficiency and methods. METHODS: Between 1997 and 2003, 65 feet which could be examined retrospectively, were operated for neuroarthropathy in 21 women and 43 men. A diabetic polyneuropathy was present in 56 patients. In 59 cases, an external fixation was used while in nine cases Steinmann pins were used. Follow-up treatment consisted of mobilisation in a ankle-foot-orthosis (AFO) for up to a year. RESULTS: For diabetics, the mean duration of illness was 24.8 years (Type 1) and 13.7 years (Type 2). All feet were Levin stage 3 or 4 and for the classification types II-V. In five cases there was only luxation, another nine had a combination of luxation and osseous changes. Surgical revision was necessary in seven cases, sometimes more than once. Additional operations as the illness progressed were necessary 13 times, in six cases due to loss of correction. The application of a prosthesis was necessary in three cases following amputations in two patients after an average of 752 days. Pin infections and disturbances in healing wound were common but could be successfully treated conservatively and were independent of previous ulceration or infection. Within the first year after operation, 13.9% of the feet developed an ulcer. All of the patients could be mobilised with the help of an orthosis (47 cases) or orthopedic shoes (15 cases) CONCLUSIONS: External fixation is a suitable and variable method for correcting malalignment of the foot in cases of neuroarthropathy. It has a low complication rate and can be used for rapidly developing as well as non-progressing osteoarthropathies. In general, a fibrous ankylosis is the result of treatment, which allows pain free mobilisation under full weight bearing. In suitable cases, with a good alignment of the foot and good patient cooperation, the use of the AFO can be changed to orthopedic shoes after about 12 months.

[Reduction of plantar peak pressure by limiting stride length in diabetic patients]. / Verringerung des plantaren Spitzendrucks beim Diabetiker durch Verkürzung der Schrittlänge.

Plantar peak pressure is a diagnostically significant parameter for the evaluation of the risk of foot ulceration in patients with diabetic neuropathy. The prophylaxis and therapy of the diabetic foot therefore is to a large extent oriented on peak pressure, and is aimed at an extensive reduction in this parameter. This is mainly accomplished with protective footwear including shoe modifications and cushioning. In comparison, other approaches affecting the loading and motion pattern of the patient are of minor importance--as for example control of gait pattern. In this study we examined shortening of stride length as a possible measure in reducing plantar peak pressure during gait. In 17 diabetic patients without acute foot ulcerations, stride length was reduced to 33% of leg length using an elastic hobble. This led to a reduction in stride length of 23%. At the same time, the walking speed was significantly reduced by 27% and the cadence by 5.7%. As a consequence, the peak pressure was reduced in nearly all regions of the foot--except the small toes. In the metatarsal region peak pressure is reduced by 14.5%. Thus, a reduction in stride length offers the possibility of reducing plantar peak pressure as a supplementary measure in addition to orthopaedic footwear. However, at present clinical feasibility has not yet been established.

[Diabetic neuropathic osteoarthropathy of the knee joint. A rare but increasing complication--case report]. / Diabetisch-neuropathische Osteoarthropathie des Kniegelenks. Eine seltene, aber zunehmende Komplikation--ein Fallbericht.

Since the clinical entity of diabetic neuropathic osteoarthropathy has become known as a possible complication of the diabetic foot syndrome, the number of cases reported in the literature has increased. Up to 50 cases worldwide have been described since 1970 although the number of unknown cases is likely much higher. This dreaded complication poses a difficult challenge for the orthopedic surgeon. Reports on long-term results seem to show that surgical intervention is a relative indication. This contribution describes a case of acute neuro-osteoarthropathy of the knee joint and subsequent successful conservative management after an unsuccessful osteosynthesis. In addition, the literature published since 1970 dealing with this rare complication is examined and critically discussed.

[Lower limb orthosis to relieve stress forces on the foot and its use in patients with diabetic neuropathic osteoarthropathy: Case examples]. / Die fussentlastende Unterschenkelorthese und ihre klinische Anwendung bei Patienten mit diabetisch-neuropathischer Osteoarthropathie. Fallbeispiele.

In the daily routine of treating patients with diabetic neuropathic osteoarthropathy (DNOAP), their history often reveals a prolonged course of therapy caused in part by incorrect diagnosis but also by inadequate provision of orthopedic devices. A "classic" case is that of undetected osteoarthropathy, which is erroneously interpreted as osteomyelitis. Thus, subsequent to frustrating attempts at therapy and persistence of the clinical symptoms, patients are not infrequently "offered" the option of amputation, which is performed quite proximal to the osseous lesion to "ensure treatment success." The fact that major amputations lead to a statistically significant decrease of the patient's life span is usually not taken into consideration during the decision making process for amputation. Orthopedic surgical procedures to preserve the leg should be given precedence for the sake of maintaining quality of life just as orthopedic devices and orthopedic shoes should be preferred to retain mobility before amputation is indicated in patients with DNOAP. The cases reports presented here should encourage others to implement treatment concepts with the aim of avoiding unnecessary amputations.

[Effect of weight load and carrying conditions on plantar peak]. / Der Einfluss von getragener Last und Tragetechnik auf den plantaren Spitzendruck.

Knowledge is limited regarding the effects exerted by carrying a load on the distribution of plantar peak pressures. It is unknown whether a special technique might exist which keeps peak pressures low when carrying a load. This question is important to diabetic neuropathic patients at risk for tissue damage and pressure ulcerations and therefore with a need for minimized plantar peak pressures. The study included 19 healthy volunteers (14 M, 5 F, mean age: 34.2+/-15.2 years). They walked three times each along a 7-m walkway with an EMED pressure measurement platform under five different carrying conditions. The conditions were: carrying no load (reference), carrying a load of 20 kg in a backpack, carrying a load of 20 kg in a waistcoat, and carrying 20 kg in two bags. A fifth condition, carrying a waistcoat with a load of 10 kg only,was used to check the linearity of peak pressure and weight. Velocity and step length were measured to check the gait parameters. Peak pressures were determined in six regions: large toe, small toes,metatarsals, lateral and medial midfoot, and heel. In agreement with the literature, the reference measurements showed peak pressure to be widely independent of body weight. On the other hand, a significant increase of peak pressure was observed in a single person when a carried load was added. In the regions of the large toe,metatarsals, and heel the peak pressure increased linearly with the carried weight and amounted to 0.54, 0.76, and 0.38 N/cm(2) per kg additional load, respectively. No significant difference between the various techniques of carrying was detected. The plantar peak pressure increases with weight load,however, this is independent of the way the load is carried. No specific recommendation on the technique of carrying a load can be given in order to take care of diabetic feet.