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Kamalov Telman Tolyaganovich, Head of Diabetic Foot Department of Center for the Scientific and Clinical Study of Endocrinology, Tashkent, Uzbekistan.
E-mail: evovision@bk.ru
PECULIARITIES OF PEDOGRAPHIC PICTURE IN DIFFERENT FORMS OF DIABETIC STOP SYNDROME
Abstract: A comparative assessment of the parameters of plantar pressure between healthy individuals and patients with various forms of diabetic foot syndrome revealed a predominance of pressure in the metatarsal joints in conditions of a developing pathological condition. At the same time, the comparative disproportions in the middle foot zone revealed by us indicate the presence of plantar changes characteristic of the varus installation. In spite of the presence of an identical zone of the amputational surgery carried out (the finger zone), the data obtained have the opposite level of meanings. In other words, in the presence of a predominant level of plantar pressure in the anterior zone of the foot in patients suffering from amputation of II-V toes, amputation of only one, i.e. the toe of the foot, significantly alters the superiority of plantar pressure coordination. This, in turn, indicates the need for a differentiated approach to the decision to choose a rehabilitation option for patients depending on the type of surgical intervention performed.
Keywords. Diabetes mellitus, plantar pressure, diabetic foot.
At present, there is a significant increase in the number tions, as well as the height of the inner longitudinal arch. of patients with diabetes mellitus (DM) with a tendency to Meanwhile, pedobarography is the most reliably informative
develop severe and sometimes fatal complications [1,7].
In the 1990s, in some regions ofUzbekistan (in the Fergana, Syrdarya and Khorezm regions, and in the city of Tashkent), WHO staff conducted epidemiological studies. The analysis of the obtained data showed that the main risk factors for the development ofdiabetes are socio-psychological reasons, insufficient awareness of patients and poor control ofthe disease, peripheral sensorimotor and autonomic neuropathy, chronic arterial insufficiency of the lower extremities, etc. One of the leading factors is also the unsatisfactory organization of primary health care and monitoring of patients with diabetes mellitus [5].
To date, the need for an integrated approach to the organization of special outpatient care for diabetics is already evident - these are diabetes centers or diabetes schools. Not only the doctor - the endocrinologist should resist this disease, but also the team - kyropadists, nutritionists, surgeons, etc. [6, 7]. An important attribute in the prevention of the development of purulent-necrotic complications of the diabetic foot syndrome is the carrying out of their prediction and, accordingly, prevention. One of these methods is to assess the level of plantar pressure of the foot, allowing to make appropriate orthopedic corrections.
It is known that planography is one of the available methods for studying the foot, allowing, on the basis of a visual and graphical calculation of the various indices of the print, to indirectly judge the relative location of the foot sec-
and dynamical method of research, allowing the assessment of biomechanical changes in the foot. This method of research is being constantly improved and enriched with new software options [1, 2, 3, 4, 5, 8].
It seems to us that a comparative assessment of the change in plantar foot pressure for different variants of the diabetic foot syndrome will allow us to determine the patterns of biomechanical and structural transformations in the dynamics of the course of this disease.
Material and methods: 293 patients with various clinical and pathogenetic forms of the diabetic foot syndrome participated in the studies. Prevalent were patients with a neuropathic form of the diabetic foot syndrome (74.9%). The main contingent of patients was made by male patients (66.7%) aged 51 to 80 years. 98.1% of patients had type II diabetes mellitus.
With the presence of a full anatomical and functional state of the foot, 60% of patients were hospitalized in the center. In the remaining patients, the affected foot in the history was subjected to surgical intervention. Among them were: opening of phlegmons of foot with necrectomy (22.4%), amputation of fingers or toe (17.6%), exarticulation of finger or toes (11.5%), amputation of fingers or toe with opening of phlegmon of foot and necrectomy (24.1%), exarticulation of the toe or toes with opening of phlegmon of the foot and necrectomy (17.9%), transmetatarsal foot amputation (6.4%).
Planarography was used to determine the reference area index. The essence of the method was as follows: the plantar surface of the feet was stained with a gouache solution, or by another coloring indicator, and then the footprints were made on paper in a standing position on both legs. In the same position, the contour (projection) of the feet on the paper was simultaneously traced. Using a millimeter grid, the footprint was counted and correlated with the area of the foot projection.
Considering that the support surface of the foot has a distinct differentiation, in order to quantify the distribution of plantar pressure, we have identified 5 biomechanical zones with different functional and diagnostic criteria: A - the finger zone, B - the metatarsal zone, C and D - the zones of the median region, divided into the medial or spring (C) and lat-
eral support (D) parts, E - heel zone, which is the main axial support.
Pedobarography was performed using a F-scan (US) scanning device based on a computer evaluation of the plantar pressure measurement data. Results and its discussion: The percentage of plantar load on the foot in healthy individuals confirmed well-known data on prevailing pressure in the anterior and posterior parts of the foot [Bregovsky VB, 2005; Bregovsky VB, 2006; Gorokhov SV, 2009]. The heel, being the main axial load of the foot in total with the middle part of the foot, exceeded the front limit, which consisted of the summation of the toe and metatarsal zones of the foot.
Dispersion analysis of the distribution of the plantar pressure indices in the foot zones, we did not reveal any special deviations in the general trend (Fig. 1).
Figure 1. The nature of the distribution of peak values
Peakvalues were recorded in relation to zone E (39.7 ± 0.5%) and to zone B (29.6 ± 0.2%). Almost in the same proportions were the indices of zones A (12.5 ± 0.1%) and D (15.1 ± 0.2%). The lowest level of plantar pressure was noted by us in zone C (3.1 ± 0.1%).
The obtained data testified to the lack of any deviations in the parameters of the plankography from the healthy individuals surveyed by us.
Analysis ofthe level ofplantar pressure in patients with diabetic foot syndrome not subjected to any surgical interventions in this area of the limb revealed its increase. In particular, in the front zone, an increase was observed on average by 5.95 ± 0.05%, and in the middle zone by 0.85 ± 0.04%. Despite the integrity of the foot, as in patients with neuropathic and neuroischemic forms of the diabetic foot syndrome, the pedogeographical studies we conducted showed a decrease in the level of plantar pressure in the heel of the foot (by 6.8 ± 0.1%).
of plantar pressure in the examined healthy individuals
A separate analysis of the studied parameters among patients with neuropathic and with neuroischemic forms of the diabetic foot syndrome revealed the absence of any reliably significant comparative values. Almost identical values were revealed by us in zones B, C and D. As for the remaining zones of the foot, it should be noted that in patients with a neuropathic form of the diabetic foot syndrome (in comparison with the neuroischemic form), the pressure level in zone A exceeded by 1.3% ± 0.08%, and in Zone E was lower by 1.4 ± 0.01%.
A study of the characteristics of the distribution of plantar pressure obtained during pedogra- phy showed that, in comparison with healthy persons, the maximum load in patients with various forms of diabetic foot syndrome falls on the forefoot (Figure 2.).
Figure 2. Comparative distribution of peak values of plantar pressure in healthy individuals and in patients with various forms of diabetic foot syndrome
Figure 3. Comparative character of the distribution of peak values of plantar pressure in patients who underwent amputation of 1st finger and in patients who underwent II—V finger amputation in the anamnesis
This was expressed in large values of peak pressures in this department, with the greatest burden on the B zone (32.25 ± 1.5%), which indicates a tendency to varus installation of the foot in patients with neuropathy. The increase in plantar pressure in zone C (by 2.0 ± ± 0.04%) was accompanied by a decrease in plant pressure in zone D (by 1.2 ± 0.03%), which also confirms the conclusions drawn above. The load in zone E also decreased in patients with various forms of diabetic foot syndrome (up to 32.9 ± 1.1%, respectively), while in healthy individuals it
was prevalent (39.7 ± 1.7%). Plantar pressure in patients with various forms of diabetic foot syndrome in a history of amputation of the first finger was characterized by the prevalence of values in the posterior zones of the foot. The peak value was noted by us in the zone E (41.7 ± 2.4%) which exceeded its value in comparison with patients with a complete foot (9.5 ± 0.89%). Almost at the same level were the values of zones B (26.4 ± 0.88%) and zones D (25.2 ± 0.71%). Almost 3 times the plantar pressure in zone A was reduced, which, apparently, was associated with the transferred type
of surgical intervention. The lowest level of plantar pressure was noted by us in zone C (2.1 ± 0.07%).
In contrast to the case described above, in patients who underwent an amputation of 2-5 toes of the foot, plantar pressure prevailed in the anterior part of the foot due to zones A and B (Figure 3.).
The total value of this indicator in zone A and B was 48.8 ± ± 2.5%. In this case, if in zone A the level of plantar pressure was 12.4 ± 0.85%, in zone B it was almost 3 times greater than in the region of the fingers(36.4 ± 2.12%). An increase in the index of plantar pressure in zone C (by 2.5 times), compared to patients who had amputation of the 1st finger, was accompanied by a 2-fold decrease in zone D (from 25.2 ± 0.71% to 12, 2 ± 0.55%, respectively). A decrease in the level of plantar pressure in the E zone was also detected (by 7.9 ± 0.58%).
In the study of the level of plantar pressure in patients who underwent amputation (exarticulation) of all toes in the anamnesis, changes were found that were not characteristic of previous cases. In particular, the level of plantar pressure in these patients was identical in all parts of the foot and ranged from 31.3 ± 3.47% (in the metatarsal zone) to 34.5 ± 2.87% (in the heel zone). Another distinguishing feature of this change in the foot was the presence of high plantar pressure in the middle zone of the foot (34.2 ± 2.4%). This increase was significant in relation to all the subgroups studied.
The lion's share of its composite was characterized by zone D (24.7 ± 1.1%). At the same time, the level of plantar pressure
in zone C was also higher than in the other surveyed subgroups (9.5 ± 0.24%). This circumstance indicates specific transformations in the plantar structure of the limb support function under conditions of metatarsal amputation of the foot.
Сonclusions: Comparative analysis of the parameters of plantar pressure between patients with various forms of the diabetic foot syndrome revealed no significant deviations, which, accordingly, makes it possible to consider them in the summation.
A comparative assessment of the parameters of plantar pressure between healthy individuals and patients with various forms of diabetic foot syndrome revealed a predominance of pressure in the metatarsal joints in conditions of a developing pathological condition. At the same time, the comparative disproportions in the middle foot zone revealed by us indicate the presence of plantar changes characteristic of the varus installation.
In spite of the presence of an identical zone of the amputa-tional surgery carried out (the finger zone), the data obtained have the opposite level of meanings. In other words, in the presence of a predominant level of plantar pressure in the anterior zone of the foot in patients suffering from amputation of II-V toes, amputation of only one, i.e. the toe ofthe foot, significantly alters the superiority of plantar pressure coordination. This, in turn, indicates the need for a differentiated approach to the decision to choose a rehabilitation option for patients depending on the type of surgical intervention performed.
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