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Ростовский Государственный Медицинский Университет

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Медицина общая

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Книга_2821_Библиотеки_им_академика_М_И_Перельмана

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diabetes mellitus. Patients with diabetes mellitus have two to four times higher risk of cardiovascular disease and up to three times increase in mortality than in the case of nondiabetics. The accelerated rate of atherosclerosis seen in diabetes mellitus predisposes patients to coronary artery disease and to higher rates of myocardial infarction (MI) and

death.

27–30

Peripheral arterial disease (PAD) is also a major risk factor for lower extremity amputation,especiallyinpatientswithdiabetes.Moreover,evenfortheasymptomaticpatient, PADisamarkerforsystemicvasculardiseaseinvolvingcoronary,cerebral,andrenalvessels,

leadingtoanelevatedriskofevents,suchasMI,stroke,anddeath.

Theendothelialcellliningofthearterialvasculatureisabiologicallyactiveorgan.Most patients with diabetes, including those with PAD,demonstrate abnormalities of endothelial function and vascular regulation and abnormalities of endothelial function can render the

arterialsystemsusceptibletoatherosclerosisanditsassociatedadverseoutcomes.

ThemostcommonsymptomofPADisintermittentclaudication,definedaspain,cramping, orachinginthecalves,thighs,orbuttocksthatappearsreproduciblywithwalkingexerciseand is relieved by rest. More extreme presentations of PAD include rest pain, tissue loss, or gangrene;theselimb-threateningmanifestationsofPADarecollectivelytermed critical limb

ischemia.

PADisoftenmoresubtleinitspresentationinpatientswithdiabetesthaninthosewithout diabetes.IncontrasttothefocalandproximalatheroscleroticlesionsofPADfoundtypicallyin otherhigh-riskpatients,thelesionsindiabeticpatientsaremorelikelytobemorediffuseand distal. Persons withdiabetes andlowerextremityPADhaveaveryconsistentpatternnoted anatomically:multisegmentalocclusiondistaltothe trifurcationofthepoplitealarteryatthe

leveljustdistaltotheknee.

The initial assessment of PAD in patients with diabetes should always begin with a thorough historyand physical. Ensure a completewalking historycomparing functiontoday with thatinyears past toassess functionalstatus andclaudication symptoms, whichmayor maynotbetheclassicalvariation.Inregardtophysicalexam,theabsenceofbothpedalpulses

ishighlysuggestiveofvasculardisease.

Noninvasivevascularstudiesareahelpfulscreeningtoolforperipheralvasculardisease inthepatientwithdiabetes.Theankle-brachialindex(ABI),istheratioofthesystolicblood pressureintheankledividedbythesystolicbloodpressureatthearmandisareproducible and reasonably accurate, noninvasive measurement for the detection of PAD and the

determinationofdiseaseseverity.

ThediagnosticcriteriaforPADbasedontheABIareinterpretedasfollows:

Normalif0.91to1.30 Mildobstructionif0.70to0.90 Moderateobstructionif0.40to0.69 Severeobstructionif<0.40 Poorlycompressibleif>1.30

It has been validated against angiographically confirmed disease and found to be 95%

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sensitiveandalmost100%specific.There are somelimitations,however,inusing theABI. Calcified, poorly compressible vessels inthe elderly and some patients with diabetes may give you false values. The ABI may also be falsely negative in symptomatic patients with moderateaortoiliacstenoses.Theseissuescomplicatetheevaluationofanindividualpatient, butarenotprevalentenoughtodetractfromtheusefulnessoftheABIas aneffectivetestto screenforandtodiagnosePADinpatientswithdiabetes.Indiabeticpatients,anABIwithin normal range needs to be taken in context with history and physical to ensure proper

diagnosis.

Angiograms and other invasive vascular studies are more conclusive andare generally warrantedinpatientswhoaremostlikelygoingtobenefitfrom aperipheralarterialbypass. Coordinated care withan interventional radiologist and a vascular specialist is an integral

component of the team approach.

35,36

 No angiographic factors were predictive of limb

salvage.37 Vascular reconstructive surgery of the impaired limb may be required prior to debridement and/or partial amputation foot surgery. Other options include endovascular surgery(i.e., stents/balloon angioplasty)forwhichlong-term yields havenot currentlybeen reported. Vasodilator medications have not been found to promote wound healing in the ischemic foot. Treatment for such patients is individualized taking into account all the contributingfactors.

MusculoskeletalComplicationsofDiabetesMellitus

Diabetes leads to changes in connective tissue by glycosylation of proteins, microvascular abnormalitieswithdamagetobloodvesselsandnerves,andcollagenaccumulationinskinand

periarticularstructures.38Musculoskeletal complicationsaremostcommonlyseeninpatients with a long-standinghistoryoftype 1 diabetes.Some havea knowndirectassociationwith

diabetes.

LimitedJointMobility

Limited joint mobility in the hands is also known as diabetic cheiroarthropathy, and is characterizedbythick,tight,waxyskinmainlyonthedorsalaspectofthehands,withflexion deformities of the metacarpophalangeal and interphalangeal joints (increased resistance to passiveextensionofthejoints).Intheearlystages,paresthesiasandslightpaindevelopfrom causesthoughttobemultifactorial,mostlikelyincreasedglycosylationofcollagenintheskin

andperiarticulartissueanddecreasedcollagendegradation.

DupuytrenDisease(Contracture)

Dupuytrendiseaseisafibroproliferativedisorderofunknownorigincausingpalmarnodules andflexion contracture of the digits. About 5% of individuals with Dupuytren disease are diabetic,withanincreasedprevalencethatisproportionaltothedurationofthediabetes.The associationwith diabetes mellitus iswell recorded, with a reportedprevalenceofbetween

3%and32%.

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CarpalTunnelSyndrome

Carpaltunnelsyndromeanddiabeticpolyneuropathyarecommonconditionsinpatientswith type1andtype2diabetes.Theprevalenceofcarpaltunnelsyndromeisthoughttobehigherin patients with diabetic polyneuropathy than inthe general population,and the treatment less

successful,41 but recent studies seem to disparage the relationship. A retrospective, casecontrol studylooked atall patients diagnosed with carpal tunnelsyndromebetweenJanuary 2011 andJuly2012and comparedthem with a controlgroupofherniatednucleuspulposus patients.Atotalof997patientswithcarpaltunnelsyndromeand594controlswereincluded. Prevalenceoftype2diabeteswas11.5%inthecarpaltunnelsyndromegroupversus7.2%in the control group (odds ratio [OR] 1.67; 95% confidence interval [CI] 1.16 to 2.41). In multivariateanalysesadjustingforgender,age,andbodymassindex,type2diabeteswasnot associatedwithcarpal tunnelsyndrome(OR0.99; 95% CI0.66 to1.47). Nodifferencesin duration of diabetes mellitus, microvascular complications, or glycemic control between

groupsweredetected.

FrozenShoulder

Oneofthemostdisablingmusculoskeletalproblemsseenindiabeticsisadhesivecapsulitis, whichis also knownas frozenshoulder,shoulder periarthritis, or obliterative bursitis. Itis characterizedbyprogressive, painfulrestrictionofshouldermovement,specificallyexternal rotation and abduction. The thickened joint capsule is closely applied and adherent to the

humeralhead,resultinginconsiderablereductioninthevolumeoftheglenohumeraljoint.

Recognizing biomechanically altered gait patterns and prescribing the appropriate offloadingis imperative if oneis toattain healing ofan ulcer anddecrease theprobability of developinganewone.

Highcompressiveandfrictionalforcesoccuraroundareasofdeformity.Thesedeformities canincludesimplefootailmentssuchasbunions,hammertoes,andprominentmetatarsals.

Multipletechniquesareavailabletooff-loadareasofincreasedpeakpressure.Useofsimple feltorplastazoteinsolesforredistributionofweight-bearingforcesiscommoninthetreatment

ofthe acute ulcer.45 Recently, some removable walking casts have beenshown to be very effectiveandstatisticallyasefficaciousasthetotalcontactcast.46However,thetotalcontact

castisstill consideredthegoldstandardforoff-loadingsinceitisacustom-moldeddevice andappliedonaweeklybasistoallowforregularwoundcaretothesite.

47,48

Oncehealed,

long-term managementofthepatientmay incorporate useof custom-molded orthosesand/or specializedsupportivefootweartodecreasetheprobabilityofredevelopinganulcer.

DermatologicManifestationsofDiabetesMellitus

Theskinofalldiabeticpatientsisaffectedinsomeformoranother,andcutaneousdiseasecan appearasthefirstsignofdiabetesormaydevelopatanytimeinthecourseofthedisease.The manifestationsaresecondarytolong-termeffectsofdiabetesonthemicrocirculationandskin

collagen.50Ithasbeensuggestedthatincreasedcross-linkingofcollagenindiabeticpatientsis responsibleforthefactthattheirskinisgenerallythickerthanthatofnondiabetics.Advanced

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glycosylationendproductsareprobablyresponsibleforyellowingofskinandnails,increased viscosityofbloodresultingfromstiffRBCmembranes,andengorgementofthepostcapillary venulesinthepapillarydermis.Itissuggestedthattheseskinchangesmayeventuallybeused

as a reflection of the patient’s current as well as past metabolic status.51 Whereas type 2 diabeticsmoreoftenhaveskininfection,type1diabeticshavemoreautoimmune-relatedskin lesions. Skin manifestations of diabetes may also serve as ports of entry for secondary

infection.

Specificcutaneousmarkersfordiabetesareasfollows:

Necrobiosislipoidica

Generalizedgranulomaannulare

Diabeticbullae

Scleredemadiabeticorum

Acanthosisnigricans

Eruptivexanthomatosis

Diabeticdermopathy

Nonspecificconditionassociatedwithdiabetes:

Acrochordons

Yellowskin/nails

Pruritus

Thickskin

Rubeosisfaciei

Palmarerythema

Pigmentedpurpuricdermatosis

Conditionsthataremorecommonindiabetics:

Perforatingdermatosis

Vitiligo

Lichenplanus

Eruptivexanthomas

Kaposisarcoma

Bullouspemphigoid

Psoriasis

Dermatitisherpetiformis

52,53

Oneofthemoredevastatingdermatologiccomplicationsfromdiabetesisafootwound.54The lifetime risk for foot ulceration in a person with diabetes is estimated at 15%. Most foot

ulcerationsareplantarlesionsthatresultfromneuropathyinthefaceofincreasedpressure.

55,56

The pivotal events that cause skin breakdown, and ultimately foot ulceration, can be identifiedinthreemaincategories57:

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1.

2.

3.

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Low pressure over prolonged periods oftime, that is, pressure sores from bed rest.It takes ~2 lb per in2 to cause blanching of the skin. This amount of pressure over 15

minutesaffectsmicrocirculationandtissueoxygenation.Commonanatomicsitesforthese ulcerstopresentaretheheel andthesacrum.Thesearealsoknownaspressureulcers, bedsores,ordecubitusulcerations. Highpressureoverashortperiodoftime,thatis,puncturewoundsfromaforeignobject.

Pressure >100 lb per in2 (70 N per cm2) will puncture the skin. This is seen most commonlyontheplantarsurfacesofthefootfrompuncturewoundscausedbyametallic orwoodenobject.Thesegenerallypresentasacuteinfectionsandcanhaveahighriskfor amputationbecauseofthepossibleinoculationfromapenetratingobject. Moderatepressureinarepetitivesetting,thatis,neuropathiculcersfromweightbearing. This is theprimarycausative factorinplantarfootulcer development.Multiple studies have attempted to quantify this pressure, but no clear pressure threshold has been demonstrated.However,peakplantarpressuresanalyzedwithcomputerizedgaitanalysis

systemshavedemonstrated70Npercm2(100psi)asafocalpoint.Pressuresinexcess ofthishaveahighriskforneuropathiculceration(sensitivityof70.0%andspecificityof

65.1%).

58,59

WoundClassifications

Woundassessmentcallsfortheuseofacommonlanguagethatcanbeeasilyinterpretedfrom one practitioner to the next. Wounds should be described by location,size (such as crosssectional measurements), depth and/or level of tissue involved, color and type of wound surface (i.e., red granulation tissue, fibrous or necrotic), exudate, odor, sinus track,and/or tunneling.Adescriptionofthesurroundingtissueshouldnotesuchfactorsascellulitis,edema,

and/orcallustissue.60Classificationswere developedtobringthesedescriptionstogether to helpsimplifyandhelpstandardizechartingsoastobereproduciblefromcliniciantoclinician.

Basisforclassification,including:

Staging Predictingoutcome Identifyingmanagementstrategy

OneofthefirstandmostoftenusedclassificationsystemsistheMeggitt/WagnerClassification 0to5,where61:

0—Skinintact

1—Superficialulcerwithoutpenetratingtothedeeplayers

2—Deepertissuesinvolvedandthereisabscess

3—Deepinvolvementwithosteomyelitis

4—Gangrene,localized

5—Gangrene,generalized

Thebasicstructureofthisclassificationis:

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■

Table5-1.

0to2:Graduationbasedondepth

3:Deepandinfected

4to5:Gangrene(i.e.,criticalischemia)

Aproblemwiththistypeofwoundclassificationsystemisthatonecannotcombinedifferent categories of pathology in order to accurately identify and define the multiple processes occurring concurrently. For example, aninfectedwoundiseasilyclassifiedaccording tothe Meggitt/Wagner system, but an infected/ischemic wound is difficult to properly assess and

describewiththislimitedsystem.

AwoundclassificationsystemfordiabeticfootwoundswasdevelopedattheUniversityof Texas (UT) Health Science Center at SanAntonio, Texas. The UT classificationsystem is basedondepthofwoundandstateofwound(i.e.,ischemic,infected)(seeTable5-1).

TheUTWound ClassificationSystemtakesintoaccountonlytheknownriskfactorsthat ultimatelyinfluence the prognosis of a givenwound site (depth, infection, ischemia). Many factors(i.e.,woundsize,drainage,quality)arenottakenintodirectaccountbecausethesehave notbeendemonstratedtodirectlydeterminetheoutcomesofthewoundsite(Table5-2).

NATURALHISTORY

TreatmentOptions

Theessentialtherapeuticobjectivesforthemanagementofanyplantarulcerinclude36:

Establishingthelevelofarterialsupply Eradicating/protectingagainstinfectionviaappropriatedebridement Maintainingamoistwoundenvironment Off-loadingtheareasofgreatestpressure Maintainingmetaboliccontrolandnutritionalstatus Frequentlyevaluatingwithresponse-directedtreatment Patienteducationandcompliance

UniversityofTexasClassificationSystemforDiabeticFoot Wounds

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Table5-2.

FromArmstrongDG,LaveryLA,HarklessLB.Validationofadiabeticwoundclassificationsystem.Thecontribution ofdepth,infection,andischemiatoriskofamputation.DiabetesCare.1998;21:855–859;LaveryLA,ArmstrongDG, HarklessLB.Classificationofdiabeticfootwounds.JFootAnkleSurg.1996;35:528–531.

UniversityofTexasRiskClassificationSystemforDiabetic FootWounds

Category0:No Neuropathy

Category1:Neuropathy, NoDeformity

Category2:Neuropathy, withDeformity

Category3:Historyof Pathology

PatientdiagnosedwithDM Protectivesensationintact ABI>0.80andtoesystolic

pressure>45mmHg

Footdeformitymaybe

present Nohistoryofulceration TREATMENT: Possibleshoe

accommodations Patienteducation Follow-upevery6–12mo

Protectivesensationabsent ABI>0.80andtoesystolic

pressure>45mmHg Nohistoryofulceration Nohistoryof

neuroarthropathy Nofootdeformity TREATMENT: Possibleshoe

accommodations Patienteducation Visitsevery3–4mo

Protectivesensationabsent ABI>0.80toesystolic

pressure>45mmHg historyofulceration Nohistoryof

neuroarthropathy Footdeformitypresent TREATMENT: Custom-molded,extra

depthshoes Possibleprophylactic

surgery Patienteducation Follow-upevery2–3mo

Protectivesensationabsent ABI>0.80andtoesystolic

pressure>45mmHg

Historyofulceration,

amputation,or

neuroarthropathy Footdeformitypresent TREATMENT: Custom-molded,extra

depthshoes Possibleprophylactic

surgery Patienteducation Follow-upevery1–2mo

Category4A: NeuropathicWound

Category4B:Acute CharcotJoint (Neuroarthropathy)

Category5:Infected DiabeticFoot

Category6:Ischemic Limb

AllUTstageAwounds

protectivesensation absent

ABI>0.80andtoesystolic

pressure>45mmHg Footdeformitypresent Noacuteneuroarthropathy TREATMENT: Woundcareregimen Pressurereduction

program

Protectivesensationabsent ABI>0.80andtoesystolic

pressure>45mmHg

Noninfectedneuropathic

ulcerationmaybe present

Diabeticneuroarthropathy

present TREATMENT: Woundcareregimenif

ulcerpresent

AllUTstageBwounds Protectivesensationmay

bepresent Infectedwound Neuroarthropathymaybe

present TREATMENT: Debridementofinfected,

nonviabletissueand/or

boneasindicated Possiblehospitalization,

AllUTstageC,Dwounds Protectivesensationmay

bepresent

ABI<0.80ortoesystolic

pressure<45mmHgor pedaltranscutaneous oxygentension<40mm

Hg Ulcerationmaybepresent TREATMENT: Vascularconsultation,

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Possiblesurgical

intervention Patienteducation Frequentfollow-upvisits

Pressurereduction

program

Thermometricand

radiographicmonitoring Patienteducation Frequentfollow-upvisits

antibiotictreatment regimen

Medicalmanagementof

diabetes

possible revascularization

Ifinfectionpresent,

treatmentsameasfor category5

FromArmstrongDG,LaveryLA,HarklessLB.Treatment-basedclassificationsystemforassessmentandcareof diabeticfeet.JAmPodiatrMedAssoc.1996;86:311–316;ArmstrongDG,LaveryLA,HarklessLB.Whoisatriskfor diabeticfootulceration?ClinPodiatrMedSurg.1998;15(1):11–19;LaveryLA,ArmstrongDG,VelaSA,etal. Practicalcriteriaforscreeningpatientsathighriskfordiabeticfootulceration.ArchInternMed.1998;158(2):157–

162.

Managementofthediabeticfootulcershouldbeinitiatedwithan assessment ofitsetiology. Thisincorporatesacarefulmedicalhistoryandphysicalexaminationwithappropriateuseof noninvasivestudies.Acompleteexaminationinvolvesassessingmanyfactors,suchas:serum glucose levels including glycosylated hemoglobin (HbA1c), complete blood count with differential, hepatic and renal profiles with electrolyte balance, nutritional status, the peripheralvascularstatus,neuropathyandsensorydeficiency,limitedjointmobility,andsigns

thatmaysuggestthepresenceofsofttissueinfectionorosteomyelitis.

Members ofa team approachmayinclude: podiatry, vascular surgery, internal medicine,

infectious disease, endocrinology, cardiology, radiology, orthopedics, orthotist/prosthetist, nursing, and a certified diabetic educator.64 Depending on the degree of severity and the

contributingfactors,additionalspecialistsmayneedtobeconsulted.Patientcomplianceand knowledgeoftheirdiseasehasbeenidentifiedasasignificantfactorintheexpectedprognosis

andtheprevalenceofbothulcerationandlimbloss.

DEBRIDEMENT

The removal of necrotic tissue is an integral component in the treatment of ulcerative wounds.66 The types ofdebridementavailable include: surgical, mechanical, autolytic, and

enzymatic.Autolyticdebridementoccursnaturallyinamoistwoundenvironmentwhenarterial perfusion and venous drainage are maintained. The use of enzymatic debridement and its

efficacy has been questioned in the literature and seems to have limited indications.

Mechanicaldebridement,however,hasbeendemonstratedtobeofdirectbenefittothewound sitebyriddingthesiteofnecrotictissue,allowingcellactivationthroughactivebleedingand

throughstimulationofthehealingpathways.68Wet-to-drydressingswerepreviouslyusedasa common means of mechanically debriding the wound site, but debridement is now done primarily with surgical instrumentation in the form of sharp debridement and rapid tissue

demarcation.69Irrigationisanotherformofmechanicaldebridementandiscommonlyutilized atthetimeofsurgeryaswellasduringdressingchanges.Flushirrigationunderpressure(>8 psi)appears tobemore effectivein reducing thebacterialcount than low-pressureflushor scrubbing with a saline-soaked sponge. In addition, pulse lavage systems can be very efficacious in removing foreign debris. An 18-gauge needle or a 19-gauge angiocath is an alternativemeasureforprovidingpressureirrigationwhenpulselavageisnotavailableinthe

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1.

2.

3.

4.

5.

operatingroomornotpracticalfordailydressingchanges.

INFECTION

Surgicaldebridementisakeycomponentinthemanagementofnecroticwoundsandincludes theremovalofallnonviabletissuefromthesurgicalwoundaswellasthesurroundingcallus tissue.Necrotictissueremovedonaregularbasiscanexpeditetherateatwhichawoundheals andhasbeenshownina recent study toincrease theprobability ofattaining full secondary closure. Osteomyelitis may or may not require bone and possible joint resection or partial

amputationofthefoot.71Withrespecttotheassessmentofinfection, itisindeedtheoverall clinicalimpressionthatisofprimaryimportance;cultureresultsareviewedasoneaspectof thepatient’stotalpresentation.

Medical therapy should be guided, based on culture and sensitivity. For non–limbthreatening infections, treatment should be aimed at Staph and Strep. Most diabetic foot infectionsarepolymicrobialandthusrequirebroadspectrumand/ormixedantibioticcoverage initiatedempirically.Themedicationsutilizedaremodifiedprimarilyonthebasisofclinical response;cultureresults;and,whenneeded,repeatedcultures, whichare alsoconsideredin

theoveralltherapeuticmanagementofthediabeticfootinfection.

WOUNDCARE

Generally, a moist wound environment has been showntofacilitate the healingprocess. In addition,thebandageappliedshouldprovideprotectionfromtraumaandlocalcontamination, allowgaseousexchange,thermallyinsulatethewound,absorbexcessexudate,andprovidefor removalwithouttraumatizingthewoundsurface.Thetypeofdressingusedvariesaccordingto thesizeanddepthofthedefect,itslocationonthefoot,andthequalityofthewoundsurface. Normal sterile saline method ofwound managementmayrequire frequent reassessment and dressing changes up to several times daily to balance the wound between maceration and desiccation. Selection of the type of product to use varies between different degrees of absorbent dressings for exudative wounds versus those that encourage moisture for dry

nonexudativedefects.

Categoriesofwounddressingsincludethefollowing74:

Hydrocolloids,alginates,orfoams:absorbentdressingsforexudativewounds Films or hydrocolloids: occlusive or semiocclusive dressings for dry nonexudative wounds Hydrogels:addmoisturetodrywounds Impregnateddressings:decreasedrying,preventdressingadherence,andreducebacterial contentwithinthewound(i.e.,AdapticorXeroform) Topicalmedicationssuchasantibioticsandantiseptics

Chronic wounds are those inwhichhealing has terminated or is not occurring in a timely

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fashion.Thelengthoftimeawoundmustexistwithoutsignsofappreciablehealinguntilitis consideredchronicisnotwelldefined.Regularreassessmentofanulcer’sresponsetoagiven treatment programis necessary to avoid continuingineffective interventions and to prevent overutilizationofhealthcareresources.Onceithasbeenestablishedthataparticulartreatment is ineffective, a systematic evaluation of the basic etiologic factors usually provides the

informationnecessarytoaltertheplanofcareandreestablishthehealingprocess.

Theprimarygoalintreatingthechroniculceristoconvertitintoanacutewoundthatwill thencontaintheactivematrixneededforhealing.Thebasicprinciplesoftreatmentdiscussed for the acute ulcer apply here and include: providing the required arterial perfusion, offloading the involved area, resolving any infective processes, surgically debriding necrotic

tissue,andassessingpriorpatientcompliance.76Overallsystemicmanagementisimperative. Suchfactorsaschronichyperglycemiawithserumlevelsof180to200orhigher(HbA1c>9)

caninterferewithwoundhealing.77Thus,reassessmentrequiresanalysisofallaspectsofthe patients’careand,asmentionedpreviously,amultidisciplinaryapproachismostefficacious towardachievingthatend.

Whenalloftheabovehavebeenaddressedandactivesignsofhealinghavenotdeveloped, specifically50%areareductionover4weeks,thenengineeredwoundcareproducts,suchas endogenous or exogenous growth factors or cultured skin replacement, may be helpful to

resolvethechronicwound.

78,79

These agentshavebeenshowntoprovideanoptimal wound environmentandencouragechemotaxisand mitogenesisofplatelets,neutrophils, fibroblasts, monocytes,aswellasothercomponentsthatformthecellularbasisforgoodwoundhealing.

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Pedorthics is concerned with the design, manufacture, fit, and modification of shoes and relatedfootappliancesasprescribedforthereductionofpainfulordisablingconditionsofthe footorlimb.Pedorthicshelpreduceshear,shock,andtransferfromsensitiveorpainfulareas. Theycancorrectorsupportflexibledeformitiesoraccommodatefixeddeformities.Theyalso controlorlimitmotionofjoints.

Manymodificationscanbemadetoshoestoenabletreatmentofsymptoms.Someofthese

modificationscanbemadetotheflareoftheshoe,whereasrockersolescanalsobeusedto treatulcersandCharcot.

Extended steel shank modifications can be used for amputations of the forefoot and metatarsalulcers.Cushionheelmodificationscanbeusedtoabsorbimpact,reducestresson heel andankle.Onecandiminishthemomentofforce thatbendsthekneeaswellasreduce

demandforankleplantarflexion.

Totalcontactorthosesareusedtohelprelieveoreliminatepressureandsupport/control jointmotion.82Therearemanymaterialsthatareavailabletohelpwiththeproperfunctionof

theorthosesincludingtrilaminarmaterialtomakeanorthoticaccommodative.Rigidmaterial can be used to make an orthotic functional. There are many moldable and nonmoldable

coverings,andallthesematerialscanbeusedincombination.

Custom-molded shoes can be used for those with a severe deformity that will not be

https://t.me/medicina_free

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