Frykberg R G, Lavery L A, Pham H, Harvey C, Harkless L, Veves A
Deaconess-Joslin Foot Center, Beth Israel Deaconess Medical Center, Division of Podiatry, Harvard Medical School, Boston, Massachusetts 02215, USA.
Diabetes Care. 1998 Oct;21(10):1714-9. doi: 10.2337/diacare.21.10.1714.
High plantar foot pressures in association with peripheral neuropathy have been ascertained to be important risk factors for ulceration in the diabetic foot. Most studies investigating these parameters have been limited by their size and the homogeneity of study subjects. The objective of this study was therefore to ascertain the risk of ulceration associated with high foot pressures and peripheral neuropathy in a large and diverse diabetic population.
We studied a cross-sectional group of 251 diabetic patients of Caucasian (group C) (n=121), black (group B) (n=36), and Hispanic (group H) (n=94) racial origins with an overall age of 58.5+/-12.5 years (range 20-83). There was an equal distribution of men and women across the entire study population. All patients underwent a complete medical history and lower extremity evaluation for neuropathy and foot pressures. Neuropathic parameters were dichotomized (0/1) into two high-risk variables: patients with a vibration perception threshold (VPT) > or =25 V were categorized as HiVPT (n=132) and those with Semmes-Weinstein monofilament tests > or =5.07 were classified as HiSWF (n=190). The mean dynamic foot pressures of three footsteps were measured using the F-scan mat system with patients walking without shoes. Maximum plantar pressures were dichotomized into a high-pressure variable (Pmax6) indicating those subjects with pressures > or =6 kg/cm2 (n=96). A total of 99 patients had a current or prior history of ulceration at baseline.
Joint mobility was significantly greater in the Hispanic cohort compared with the other groups at the first metatarsal-phalangeal joint (C 67+/-23 degrees, B 69+/-23 degrees, H 82+/-23 degrees, P=0.000), while the subtalar joint mobility was reduced in the Caucasian group (C 21+/-8 degrees, B 26+/-7 degrees, H 27+/-11 degrees, P=0.000). Maximum plantar foot pressures were significantly higher in the Caucasian group (C 6.7+/-2.9 kg/cm2, B 5.7+/-2.8 kg/cm2, H 4.4+/-1.9 kg/cm2, P=0.000). Univariate logistic regression for Pmax6 on the history of ulceration yielded an odds ratio (OR) of 3.9 (P=0.000). For HiVPT, the OR was 11.7 (P=0.000), and for HiSWF the OR was 9.6 (P=0.000). Controlling for age, diabetes duration, sex, and race (all P < 0.05), multivariate logistic regression yielded the following significant associations with ulceration: Pmax6 (OR=2.1, P=0.002), HiVPT (OR=4.4, P=0.000), and HiSWF (OR=4.1, P=0.000).
We conclude that both high foot pressures (> or =6 kg/cm2) and neuropathy are independently associated with ulceration in a diverse diabetic population, with the latter having the greater magnitude of effect. In black and Hispanic diabetic patients especially, joint mobility and plantar pressures are less predictive of ulceration than in Caucasians.
已确定高足底压力与周围神经病变是糖尿病足溃疡形成的重要危险因素。大多数研究这些参数的研究都受到样本量和研究对象同质性的限制。因此，本研究的目的是在一个大型且多样化的糖尿病患者群体中确定与高足压和周围神经病变相关的溃疡形成风险。
我们研究了一个横断面的251例糖尿病患者群体，他们分别来自白种人（C组）（n = 121）、黑人（B组）（n = 36）和西班牙裔（H组）（n = 94）种族，总体年龄为58.5±12.5岁（范围20 - 83岁）。整个研究人群中男女分布均衡。所有患者均接受了完整的病史询问以及针对神经病变和足压的下肢评估。神经病变参数被二分类（0/1）为两个高危变量：振动觉阈值（VPT）≥25 V的患者被归类为高VPT（n = 132），Semmes - Weinstein单丝试验≥5.07的患者被归类为高SWF（n = 190）。使用F - scan垫系统在患者不穿鞋行走时测量三步的平均动态足压。最大足底压力被二分类为一个高压变量（Pmax6），表示压力≥6 kg/cm²的受试者（n = 96）。共有99例患者在基线时有当前或既往溃疡病史。
与其他组相比，西班牙裔队列在第一跖趾关节处的关节活动度显著更大（C组67±23度，B组69±23度，H组82±23度，P = 0.000），而白种人组的距下关节活动度降低（C组21±8度，B组26±7度，H组27±11度，P = 0.000）。白种人组的最大足底压力显著更高（C组6.7±2.9 kg/cm²，B组5.7±2.8 kg/cm²，H组4.4±1.9 kg/cm²，P = 0.000）。关于溃疡病史的Pmax6单因素逻辑回归得出优势比（OR）为3.9（P = 0.000）。对于高VPT，OR为11.7（P = 0.000），对于高SWF，OR为9.6（P = 0.000）。在控制年龄、糖尿病病程、性别和种族（所有P < 0.05）后，多因素逻辑回归得出与溃疡形成的以下显著关联：Pmax6（OR = 2.1，P = 0.002），高VPT（OR = 4.4，P = 0.000），高SWF（OR = 4.1，P = 0.000）。
我们得出结论，在一个多样化的糖尿病患者群体中，高足压（≥6 kg/cm²）和神经病变均与溃疡形成独立相关，其中后者的影响程度更大。特别是在黑人和西班牙裔糖尿病患者中，关节活动度和足底压力对溃疡形成的预测性低于白种人。
