Tag Archives: diabetes

A new approach to quantifying the sustainability effects of healthcare: Applied to the diabetic foot

by Stefan Hellstrand1 and Ulla Hellstrand Tang2,3*

The Foot and Ankle Online Journal 12 (3): 5

A vital role for any society is to deliver health care considering: 1) the planetary boundaries, 2) the complexity of systems and 3) the 17 sustainable development goals (SDGs). The aim is to explore the feasibility of a method to quantify the sustainability effects in health-care services. A toolbox was explored in the prevention and care of foot complications in diabetes. People with diabetes run the risk of developing foot ulcers and undergoing amputations. Three relationships between ecosystems and human health and health-care systems were identified as: (i) The economic resources for health care have previously appropriated ecological resources in the economic process. (ii) Health-care systems consume natural resources. (iii) Ecosystems and the landscape affect human well-being. Some types of landscape support human well-being, while others do not. This category also includes the impact of emissions on human health. Diabetes is one of the non-communicable diseases with high mortality and foot complications. With health-promoting interventions, the risk of developing foot ulcers and undergoing amputations can be halved. The toolbox that was used could manage the complexity of systems. Several of the 17 SDGs can be calculated in the prevention of complications in diabetes: quality of life improves, while the costs of healthcare and the burden on the economy caused by people not being able to work decrease. The appropriation of natural resources and the wasted assimilated capacity for the same welfare level decreases, thereby offering an option to deliver health care within the planetary boundaries. 

Keywords: healthcare, sustainability, diabetes, diabetic foot, noncommunicable diseases, NCD, SDG, sustainable development goals

ISSN 1941-6806
doi: 10.3827/faoj.2018.1203.0005

1 – Nolby Ekostrategi, Tolita 8, SE-665 92 Kil, Sweden stefan@ekostrateg.se
2 – The Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
3 – The Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Gothenburg, Sweden.
* – Corresponding author: ulla.tang@vgregion.se

Achieving sustainable development from local to global level is challenging. One vital part is offering health care to patients in need. One unresolved question remains and that is how to ensure that healthcare is delivered within the planetary boundaries [1,2]. Health care should serve an increasing number of patients diagnosed with non-communicable diseases (NCD) and in need of prevention and care [3]. The intention is to minimise the negative consequences of the disease for the individual, society and the planet.

There is very little scientific research that presents approaches designed to measure the consequences of health care in the three dimensions of sustainability; ecological, economic and social. Tools such as analytical hierarchical processes have been used to manage and evaluate the complexity of the health-care system in relation to the social aspects using semi-quantitative measurements [4]. The authors Aljaberi et al encourage health-care professionals to collect data, in particular data on patient satisfaction, as a basis for further analysis of the sustainability dimension of health-care systems. However, two important dimensions, the ecological and the economic, were left out of their analysis. The definition of sustainability that the authors used was put forward in 1992 by the International Institute for Sustainable Development in conjunction with Deloitte & Touche and the World Business Council for Sustainable Development: “For the business enterprise, sustainable development means adopting business strategies and activities that meet the needs of the enterprise and its stakeholders today, while protecting, sustaining and enhancing the human and natural resources that will be needed in the future” [5]. Twenty-three years later, in 2015, the UN approved the 17 Sustainability Development Goals (SDG) to secure a life for future generations on our planet, not only limited to the business enterprise but also including all aspects of life [6]. 

A substantial percentage of Gross Domestic Product (GDP) funds health-care systems. With well-functioning health care, the benefits to the individual and to society are substantial. Dealing with sustainability means dealing with complex systems and complexity. The complexity is expressed in the 17 sustainable goals the UN approved in 2015 [6]. At national level, Sweden manages the 16 Swedish national environmental quality objectives [7]. The systems in which sustainability is an issue are typically complex. To a significant degree, their complexity stems from the fact that life, bios, is a vital system-defining element. No system of importance for ecological, economic or social sustainability is possible, if we assume life outside the borders of the system. This information is fairly general. Is it necessary? The OECD made an important contribution to the definition of sustainable development and how to achieve it [8]. Two of the main problems that were identified were the implementation gap and knowledge gap respectively. Despite knowing fairly well how policies supporting sustainable development should be designed, implementation is at a low and varying level [1]. In the 2000s, some authors [9-13] concluded that the implementation gap and the closely related knowledge gap were caused to a substantial degree by inappropriate analytical and management tools. 

With life as a crucial system element, it is clear that all processes are driven by a flux of energy by which quality is degraded. The sum of energy is constant, while the quality of energy is degraded. From an energy perspective, the system is a linear one. 

Cells, organs, individuals and ecosystems represent different system levels in biological and ecological systems. Feedback loops at each of these levels and between them are important for the efficient use of available resources [14, 15]. The linear flux of energy with quality drives loops of matter. These reinforcing loops may include a number of system levels, as well as all three sustainability dimensions. This results in systems with mutual dependence between system levels and the three sustainability dimensions. With the existence of thresholds, and the nature of interconnections, the system typically has features such as thresholds, irreversibility and resilience. The knowledge gap and demand for analytical tools that takes account of thresholds, irreversibility and resilience has been addressed by the Rockefeller Foundation-Lancet Commission on planetary health [1]. 

Within life sciences, irreversibility is easily understood. The process from living to dead cannot be reversed. Resilience is a phenomenon that requires some effort to understand. A resilient system is able to withstand stress from internal and external sources without changing its character. If the source of stress is removed, it returns to its original status. Systems that are not resilient are pushed away by internal and/or external sources from the domain of an operating balance space or point, into a phase of rapid, unpredictable change. Its system conditions then experience rapid, catastrophic changes. Some important considerations:

  1. A change in a well-defined part of a system may affect a hierarchy of sustainability goals from low to high system levels in the ecological, economic and social dimensions
  2. Instruments from mathematics, such as differential functions and linear and non-linear algebra, are of importance in analytical and management tools supporting sustainable health care. 

With a multitude of goals in different dimensions and system levels, there is a need for instruments that support the optimisation of utilised resources. With systems with reinforcing loops operating close to the borders of chaos, differential functions are tools that are able to extract order from chaos. 

As mentioned before, the OECD found that the understanding of what sustainable development is and how to achieve it was well understood [8]. In spite of this, policies for sustainable development that were in place were on a low, uneven level. The OECD expressed great concern about this and related it to two closely related obstacles they called the implementation gap and the knowledge gap. 

These gaps reflected a broken connection between 

  1. A general understanding of what sustainable development is and the policies needed to promote it, expressed in fields and policy contexts such as classic economic theory back to the 18th century, agricultural sciences as living knowledge until the Second World War, system ecology and ecological economics from around 1990, the UN Millennium Development Goals [6], the OECD [8], the Millennium Ecosystem Assessment [16] and the Economics of Ecosystems and Biodiversity [17], on the one hand, and
  2. Instruments and concepts in common practice with the aim of putting sustainable development in place, on the other hand [10]. 

Typical instruments and concepts in (2) are life cycle assessments, in accordance with the ISO 14 001 system, the Best Available Techniques (BAT) principle in the Integrated Pollution Prevention and Control Directive in the EU, the Integrated Production Policy from the EU Commission and a number of other policies from the same scientific ground, suffering from the same drawbacks [10]. As these concepts and tools are derived from engineering sciences, they do not express the competence relating to systems where life, bios, defines system characteristics. Their “default solution” when managing the complexity of life, e.g. in the understanding of the impact of the use of natural resources and the emissions in biological and ecological systems actually affected by production, is to assume that this complexity does not exist [9, 10, 12, 13].

Within agricultural and forestry science and practice, tools that are able to manage this complexity have emerged over hundreds of years of theoretical development and of trial and error in practice. A similar development has been seen in system ecology and economic theory during the last few decades. A combination of contributions from agricultural sciences, forestry sciences, system ecology, integrative assessments, applied environmental sciences and economic theory at micro and macro level offers a solution to the implementation gap by resolving the challenge, in everyday actions, of managing complex real-world systems, while being aware of and respecting their genuine complexity due to life as a defining system characteristic. A new approach to calculating the sustainability effects in health care is needed with criteria as mentioned above. An approach of this kind considers the planetary boundaries, the three dimensions of sustainability and the complexity of ecosystems. The aim of the article is to present a new approach to measuring sustainability in health care, applied to the prevention of foot complications in diabetes.


Conceptual model

Tools and methods that considered the planetary boundaries, the three dimensions of sustainability and the complexity of ecosystems were chosen. The toolbox originates from a variety of fields. For example, they supported sustainable animal production systems; sustainable industrial production systems; effective policies to minimise health hazards associated with cadmium fluxes in food systems; milk consumption and the human health impact; physical planning for sustainable attractiveness at local and regional level; sustainable local, regional and national development; the development of certification schemes such as ISO 14 001 to contribute more effectively to improving the status of ecosystems actually affected by production and consumption; the development of public procurement in favour of growth, employment and a better environment in accordance with national environmental objectives [9, 10, 12, 13, 18-26]. 

In what follows, our approach that supports the management of health-care systems in a sustainable society is presented. The accuracy of these instruments is investigated and applied to the prevention of foot complications in diabetes. The effects on the individuals living with diabetes is dramatic, with a lifetime risk of 25% that a foot ulcer will develop, a threatening reality for the 425 million people living with diabetes [27]. Every thirty minutes, an amputation takes places on the planet due to diabetes [28]. People with a lower socioeconomic status are more likely to develop complications such as cardiovascular disease and/or foot ulcers and amputations [29-31]. This means that people already struggling for their lives and surveillance will be marginalised, more vulnerable in the presence of foot ulcers and amputations. Their health-related quality of life will decrease [32-34].

The article presents a new approach that includes a conceptual model, a map, of the economic system in its ecological and social context [13]. From this map of the sustainability landscape, we are able to define different pathways by which we can improve human health and meet the demands of society. One way of estimating the impact of health care on the appropriation of natural capital, man-made capital, human capital and social capital is suggested. We use the diabetic foot as a case in this exercise. The hypothesis is that a set of these instruments developed with the aim of supporting the effective management of natural resources, with the emphasis on acreage-dependent sectors, is able to significantly improve the efficiency of health-care systems in meeting the 17 SDGs. The toolkit has five internally consistent instruments:

  1. A conceptual model of the GDP part of the economy embedded in its ecological and social contexts where stocks of natural, man-made, human and social capital are located [11].
  2. From the conceptual model, Biophysically Anchored Production Functions (BAPFs) are constructed showing how the GDP economy is dependent on nature and delivers resources for the fulfilment of human needs [13].
  3. An application based on the general features of Impredicative Loop Analysis by which the impacts in a hierarchy of sustainability sub-goals of a specific change in a specific production process can be evaluated [20].
  4. From BAPFs, ecological economic accounts (EEA) can be derived by which the sustainability performance of any system can be evaluated [10-12]. 

In what follows, the conceptual model of the economic system in its ecological and social context is presented in some detail. This supports the understanding of health care in a broader sustainability context. The conceptual model of the economy in its ecological and social context is presented, Figure 1 [12].

The model consists of three compartments, where the first refers to nature, to ecosystems providing natural resources and taking care of emissions. The second is the traditional economy where goods and services are produced from natural resources and inputs of labour and (traditional) capital. GDP measures the size of the output. The third is the social dimensions where the economic resources that are created to meet human needs, including health care. In all parts of the economy, emissions and waste return to nature. 

With some simplification, Compartment I represents nature, the ecological dimension of the economy, Compartment II represents the economic system, in the narrower sense in which we often discuss it, and Compartment III represents the social dimension of our economy. In reality, they are three closely integrated parts of our economic system.

Compartment I defines ecological restrictions in society, Compartment II provides the means, while Compartment III contains the objective: human well-being. 

From the perspective presented in Figure 1, the challenge of health care is to use appropriated economic resources as efficiently as possible in order to improve the health of the population. It focuses on preventing and/or compensating for the functional loss of the individual. With the efficient use of economic resources, the needs of the people suffering from illnesses are met, while the economic burden on the rest of the economy is kept down. This increases the demand for goods and services from households, which stimulates the economy. At the same time, the competitiveness between enterprises is increased, while everything else is equal. The efficiency measurement referred to implicitly is the ratio between the level of health in the population as the numerator and the economic cost of providing it as the denominator. With efficient health care, the level of health in the numerator is increased, while everything else is equal, which improves the life quality of individuals, thereby improving the social capital. With improved health, the productivity of the same individuals increases and the stock of human capital is thereby also improved.

Relationships between nature and health care

There are three types of relationship between health and health care and NC (Natural Capital) and NR (Natural Resources), as shown in Figure 1. 

  1. The appropriate economic resources are produced in the GDP economy where NR are upgraded to goods and services through the input of labour and capital, while, on the output side, potentially harmful emissions are generated. Health care thus appropriates NR embedded in the economic resources that are used and indirectly cause emissions that can harm human health and ecosystem health. This is the indirect support to service sectors such as health care from nature [35, 36]. 
  2. The health-care system also directly consumes NR, by using the energy needed to build and heat/cool the buildings, fuel the equipment and transport personnel and patients to and from hospitals [35, 36].
  3. The third type of relationship relates to the way ecosystems and the landscape affect human well-being. Some landscapes support human well-being, others do not. This category also includes the impact of emissions on human health. The first two relationships are connected to the appropriation of ecological resources in the production of health. The third relationship relates to the demands on health care to the needs to be met.

Through emissions and changes in land use, the capacity and quality of the life-support system of ecosystems are affected. In maps of Europe [10, 11] the effect on (i) expected human life expectancy due to the emission of particles into the air is presented, as well as (ii) the deposits of nitrogen exceed the assimilative capacity of ecosystems. The congruence in the geography of these human health and ecosystem health impacts is profound. 

The United Nations Environment Programme (UNEP) [37], in collaboration with the World Health Organisation (WHO), estimated that, in 2012, 12.6 million deaths, or 23 per cent of the total, were due to deteriorating environmental conditions [38]. Air pollution which, according to the UNEP, kills seven million people across the world each year, dominates. Of these, 4.3 million are due to household air pollution, particularly among women and young children in developing countries. There is an uneven distribution of deaths due to environmental deterioration, with the highest proportion of deaths attributable to the environment in South-East Asia and in the Western Pacific (28 per cent and 27 per cent respectively). The percentage of deaths attributable to the environment is 23 per cent in sub-Saharan Africa, 22 per cent in the Eastern Mediterranean region, 11 percent and 15 per cent in OECD and non-OECD countries in the Americas region and 15 per cent in Europe.

In the case of the diabetic foot, the transport of personnel and patients to and from providers of health care consumes energy and causes a multitude of emissions, harming the health of ecosystems and of humans. The emissions from hospitals should be considered. Health-care services located in areas stressed by high emission rates have a greater negative impact on human health compared with health-care services localised in areas with forests and land. Forests and land assimilate emissions [10, 39]. 

Non-communicable diseases (NCDs) are a group of diseases with a substantial impact on health [3].They kill 41 million people each year. Cardiovascular diseases account for most NCD deaths, or 17.9 million people annually, followed by cancers (9.0 million) and respiratory diseases (3.9 million). Tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets all increase the risk of dying from an NCD. The facts in the UNEP [37] and the WHO [38] imply that environmental issues are a substantial category of factors causing NCDs. This is supported by Lim et al. [40].

Health care and Agenda 2030 with 17 SDGs

Society can work through three major pathways to improve human health; traditional health care when illness is present, preventing illnesses by lifestyle changes within the population and by upgrading the quality of the environment and life-support systems. Odum [15] describes in detail the life-support systems of ecosystems, providing the physiological necessities for all life. In 2015, the UN [6] approved 17 SDGs. They form the basis of Agenda 2030. The overall objective of County Administrative Boards in Sweden, the regional representation of the national government, is to support the implementation of the 17 SDGs at regional level, in each county. The first paragraph in the task assigned to them is, at regional level, to contribute to sustainable, enduring solutions. The second is to contribute to the implementation of Agenda 2030 [41]. In Sweden, there is also a system of 16 environmental quality objectives [7]. Their role is to lay the environmental foundation for economic and social development within affected ecosystems carrying capacity limits. They agree well with the 17 SDGs from the UN with their foundation in the need for ecological sustainability as a prerequisite for economic and social sustainability. The recommendation from the UNEP [37] to reduce the number of deaths due to environmental deterioration reflects the purpose of the UN’s 17 SDGs. 

The presented toolbox supports policies that improve (i) health, by lowering the environmental burden on the ecosystem and human health, and (ii) diet patterns and physical activity, for example, to benefit both ecosystem health and human health, thus lowering NCDs. 

In what follows, an approach is presented in which the capacity of the toolbox to help health-care systems to comply with the 17 SDGs and the Swedish environmental quality objectives is tested. We do this using the case of diabetes and the prevention of diabetic foot ulcers (DFU).

Costs associated with diabetes and the diabetic foot

From 1980 to 2014, the prevalence of diabetes rose by a factor of 3.9, to 422 million people in 2014 [42]. In 1980, 4.7% of adults had diabetes and, in 2014, it was 8.5%. The rate of the increase in diabetes is highest in low-income and middle-income countries. If we add up the effect of diabetes and high blood glucose, 3.8 million deaths were related to these causes in 2012 [43]. The social and economic costs of diabetes to the individual and to society are therefore significant. Lowering the prevalence of diabetes will improve social and human capital (see Figure 1) and support a number of the 17 SDGs. 

A healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use are ways to prevent or delay the onset of diabetes type 2. For patients with diabetes it is important to maintain good function in the feet and in the lower extremities. 

The cost of the treatment of DFUs is substantial. In one study with data from Sweden, the span was 993-17,519 US$ [44, 45]. Table 1 presents estimates of treatment costs for diabetic foot ulcers at regional, national and global level [46]. 

Treatment costs US$ 2015
Patients, no Per patient Total, millions
Region Västra Götaland 3,000 5500 16.5
Sweden 20,000 5500 110
Global 20,000,000 5500 110000

Table 1 Estimated regional, national and global costs for treating DFUs in 2015. The equivalent of 5,525 US$ of 2015 converted from figures from 1990 per treatment of DFUs (5000 US$) was originally provided by Apelqvist et al. (1995) and refers to Sweden. Available 2018-07-12. http://www.historicalstatistics.org/Currencyconverter.html. 

Region Västra Götaland is one of the counties in Sweden. The estimated cost relates to the treatment of DFUs not infected or in need of intervention due to artery disease. The estimate is therefore conservative. We assume the same cost at regional level in Sweden (Västra Götaland) and global level as well. The estimate agrees well with the figures from Prompers et al [47], presenting estimates at European level, suggesting that the estimate is relevant at international level as well. 

The prevalence of DFUs is set at 5% among patients with diabetes [48]. The estimate is based on a population-based annual incidence of DFUs of 1.0-7.2% [49-53]. The number of patients with diabetes in Västra Götaland, in 2015, was approximately 60,000, in Sweden 400,000 [54] and globally 400 million people [55].


By using the example of DFUs and the need for early prevention and treatment as an example, we shall now outline how the principles presented in previous parts can be considered in everyday practice in health care. We, therefore, present a proposal for ways of operationalising the UN’s 17 SDGs in health-care systems from the level of individual treatment to aggregated effects regionally, nationally and globally.

Of the population of people suffering from diabetes, it is estimated that 50% are in need of preventive foot care. This is based on the presence of the risk factor of loss of protective sensation, which can be as high as 50% in patients with diabetes [46]. Using early monitoring, patients at risk are identified, enabling intervention at an early stage [56]. Promising results show a reduction in the amputation rate of 40% to 60% [57] and DFUs of 50% [58]. Halving the presence of small DFUs leads to a reduction in ulcers that might develop into severely infected ulcers and amputations. 

One part of early treatment is the provision of insoles from a Department of Prosthetics & Orthotics (DPO) [59]. Insoles reduce the risk of pressure-induced DFUs [58, 60]. Insoles can be prefabricated or custom made or traditionally made [46]. Assume that we have custom-made insoles. Two visits to a health-care provider are needed. The costs associated with this solution are:

  • Time appropriated by
    1. The patient
    2. The staff at the health-care provider
  • Energy (with quality) consumed for
    1. Transportation to and from the health-care provider
    2. Heating of buildings and for the production of insoles 
  • Emissions from energy consumption potentially harming human and ecosystem health. 

The time appropriated by patients can be leisure time, or times when the patient would otherwise have worked, contributing to GDP.

The energy cost can be measured in both monetary and physical terms. Both are of interest. When measuring in physical terms, information is gathered that makes it possible to evaluate future risks and opportunities in relation to possible changes in the price of energy. The available amount of fossil fuels is limited. In 2015, fossil fuels provided 86% of the global energy budget [61]. 

The climate challenge calls for action which, in a fair number of decades, will eliminate the increase in greenhouse gases in the atmosphere [6, 7]. Energy consumption causes the emission of a spectrum of substances that affect the majority of the 16 environmental quality objectives in Sweden and those of the UN’s 17 SDGs that are related to emissions and their impact on ecosystems and human health. Regarding energy systems, we also have a range of aspects related to hydropower and nuclear power to consider, as well as contributions to climate change. Renewable fuels are of increasing importance for the supply of energy.

Taken together, the limitedness of non-renewable natural resources, fossil fuels, their dominance among energy sources in the economy from local to global level and the environmental and human health impacts of these energy sources and of hydropower and nuclear power all indicate a future, substantial transformation of the energy systems from local to global level. This transformation to future energy systems effectively supporting a sustainable society will cause a change in energy prices. 

Since 1998, there has been a substantial increase in the fixed level of global oil prices [10]. This may affect the outcome with regard to the rational localisation of future health care in the landscape. As a result, there are good economic reasons for health-care providers to be in control of their energy consumption in both economic and physical terms.

The time that each patient appropriates from the staff is time during which the staff are unable to support other groups of patients within budget restrictions. 

Figure 1 A conceptual model of the economy in its ecological and social contexts.

Assume that we have a solution where we can offer the same benefits to the patient with only one visit (the system with prefabricated insoles). If so, the above-mentioned costs can be cut by 50% per patient treated. On a regional, national and international scale, this would substantially improve the contribution to a number of ecological, economic and social sustainability goals.

So far, we have not dealt with the challenge of health-care systems that operate within affected ecosystems with capacity limits. The toolbox for sustainable development mentioned above [10] supports a solution to this challenge. It thus supports the emergence of health-care systems promoting Agenda 2030.

The production of ecosystem services from the life-support systems of ecosystems can be quantified. These systems are located in rural areas, in the so-called cultural and natural landscapes as defined within system ecology [15]. The contribution from Odum laid the scientific foundation for most of the work that has subsequently been devoted to the issue of ecosystem services and their importance for human well-being: the OECD [8], the Millennium Ecosystem Assessment [16] and the Economics of Ecosystems and Biodiversity [17].

Ecosystems are Compartment 1 in the model of the economic system in its ecological and social contexts in Figure 1. This is the ecological dimension of our economy and of our society. Using the same tools, the consumption of ecosystem services can also be quantified.

So, using the same tools deeply rooted in natural sciences, including agricultural sciences and system ecology, we are able to quantify the sustainable production of ecosystem services, as well as consumption. With this information related to the demand for and supply of ecosystem services, the human appropriation of ecosystem services can be adapted to affected ecosystems with capacity limits.

This suggests a way in which the appropriation of natural resources and the emissions related to the treatment of the diabetic foot are related to the area of ecosystems with the capacity to deliver natural resources and assimilate emissions. This suggests a methodological route to evaluate the pressure on nature from health-care systems and to adapt health-care systems and other socioeconomic systems to the carrying capacity of affected ecosystems.

Through this route, ecological and economic dependence between rural and urban areas can be visualised and policies that contribute to their mutual development in a sustainability context can be effectively implemented. 


This paper presents a framework for measuring sustainability in health-care using a toolbox supporting the effective management of natural resources. Analytical tools evaluating the sustainability performance in health care in ecological, economic and social terms are a prerequisite for the management of health-care systems, in agreement with the UN’s 17 SDGs. Using a sustainability map, three types of relationship between ecosystems and human health and health-care systems were identified. 

  1. The economic resources needed to cover the cost of health care have previously appropriated ecological resources in the economic process, at the same time as good health care may reduce future economic costs and thereby the ecological resources that are appropriated. 
  2. Health-care systems consume natural resources.
  3. Ecosystems and the landscape affect human well-being. Some types of landscape support human well-being, while others do not. This category also includes the impact of emissions on human health. 

Diabetes, one of the NCDs, has a substantial impact on the health level of societies. In Sweden, around 20,000 patients with diabetes suffer from DFUs, while the global figure is 20 million people. With preventive interventions, the prevalence can be halved, saving 50 million USD in health-care costs in Sweden and 50 billion USD globally. 

Further research should preferably present details in ecological units, economic monetary terms and social terms from a real case for the two alternatives: the supply of insoles with one visit as compared with two visits to a DPO.

Effective, preventive interventions reduce the cost of health care, as well as the burden on the economy imposed by people who are not able to work. Life quality, i.e. social sustainability, is improved. The appropriation of natural resources and the waste of assimilative capacity for the same welfare level decrease. As a result, ecological, economic and social sustainability is improved – a prerequisite for development within the planetary boundaries.


BAPF; Biophysically Anchored Production Functions, GDP; Gross Domestic Product, NC; natural capital, NCD; non-communicable diseases, NR; natural resources, SDG; Sustainable Development Goals, WHO; World Health Organisation, UNEP; United Nations Environment Programme


We are most grateful for the useful comments on the manuscript made by Professor Jon Karlsson, Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg. The Department of Prosthetics & Orthotics at Sahlgrenska University Hospital, Gothenburg, Sweden, encouraged the project. Thanks to all co-workers at the department and to graphic designer Pontus Andersson.

Availability of data and materials

Not applicable.

Authors’ contributions

S.H and U.H.T wrote the main manuscript text. S.H. prepared Figure 1. U.H.T prepared Table 1. All the authors reviewed the manuscript.


This research was supported by by Stiftelsen Promobilia, Stiftelsen Skobranschens Utvecklingsfond, the Research and Development Council of the County of Göteborg and Södra Bohuslän, the Health & Medical Care Committee of the Västra Götaland Region, Stiftelsen Felix Neubergh, Stiftelsen Gunnar Holmgrens Minne, IngaBritt & Arne Lundbergs Forskningsstiftelse, Adlerbertska forskningsstiftelsen, Diabetesfonden, the Gothenburg Diabetes Association (Inger Hultman med fleras fond and Utvecklingsfonden) and Sveriges Ortopedingenjörers Förening, Greta och Einar Askers Stiftelse and Hans Dahlbergs stiftelse för miljö och hälsa.

Competing interests

S.H. manages Nolby Ekostrategi but does not consider this to be a conflict of interest in this work. UT declares no competing interests.


  1. Whitmee S, Haines A, Beyrer C, Boltz F, Capon AG, de Souza Dias BF, et al. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health. The Lancet. 2015;386(10007):1973-2028.
  2. Wijkman A, Rockström J. Bankrupting Nature: Denying Our Planetary Boundaries: Taylor and Francis; 2013.
  3. World Health Organisation. Noncommunicable diseases. 2018.
  4. Aljaberi OA, Hussain M, Drake PR. A framework for measuring sustainability in healthcare systems. International Journal of Healthcare Management. 2017:1-10.
  5. Deloitte, Touche. Business strategy for sustainable development: Leadership and accountability for the ’90s. International Institute for Sustainable Development Winnipeg Canada: IISD, jointly with Deloitte and Touche; Business Council for Sustainable Development. West Sussex: IISD; 1992. 29- p.
  6. United Nations. Sustainable Development Goals. https://www.un.org/sustainabledevelopment/development-agenda/. 2015. Accessed 14 April 2019.
  7. Swedish Environmental Protection Agency. Swedish Environmental Objectives. https://www.miljomal.se/sv/Environmental-Objectives-Portal/ 2018. Accessed 8 Dec 2018.
  8. OECD. Policies to Enhance Sustainable Development. Meeting of the OECD Council at ministerial level. 2001.
  9. Hellstrand S. Animal production in a sustainable agriculture. Environment, Development and Sustainability. 2013;15(4):999-1036.
  10. Hellstrand S. On the value of land 2015.
  11. Hellstrand S. The challenges of measuring sustainability performance. In: Dahlquist E, Hellstrand S, editors. Natural resources available today and in the future: how to perform change management for achieving a sustainable world: Springer; 2017.
  12. Hellstrand S, Skånberg K, Drake L. The relevance of ecological and economic policies for sustainable development. Environment, Development and Sustainability. 2009;11(4):853-70.
  13. Hellstrand S, Skånberg K, Drake L. A biophysically anchored production function. Environment, Development and Sustainability. 2010;12(4):573-96.
  14. Odum E. Fundamentals of ecology. 3. ed. ed. Philadelphia: First edition 1971 USA: W. B. Saunders Company, third edition 1991 New Delhi: Natraj Publishers; 1991.
  15. Odum E. Ecology and our endangered life-support systems. 2. ed. ed. Sunderland, Mass.: Sunderland, Mass. : Sinauer Associates; 1989.
  16. Millennium Ecosystem Assessment. Overview of the Milliennium Ecosystem Assessment. http://www.millenniumassessment.org/en/About.aspx. 2005. Accessed 8 Dec 2018.
  17. TEEB. The Economics of Ecosystems and Biodiversity: Mainstreaming the Economics of Nature: A synthesis of the approach, conclusions and recommendations of TEEB. 2010.
  18. Hellstrand S. Methods for operationalizing an ecologically effective and economically profitable sustainable development [Natural Resources Management]: Stockholm University; 1998.
  19. Hellstrand S. Ecological Economic Accounts on the Regional Scale. Outcomes for one rural and one urban region in Sweden 2000. Institutionen för samhällsvetenskap Karlstads universitet; 2003.
  20. Hellstrand S. A Multi-Criteria Analysis of Sustainability Effects of Increasing Concentrate Intensity in Swedish Milk Production 1989–1999. Environment, Development and Sustainability. 2006;8(3):351-73.
  21. Hellstrand S. Värdet av den svenska skogens leverans av ekosystemtjänster. Uppdrag för LRF Skog; 2014.
  22. Hellstrand S. Inventering ekosystemtjänster Värmlands län. Uppdrag för Paper Province; 2015.
  23. Hellstrand S. Nyckeltal för styrning mot ett hållbart och attraktivt Kil. Uppdrag för Kils kommun.; 2015.
  24. Hellstrand S, Landner L, editors. Role of phosphorus in sustainable agriculture and the cadmium issue. . Proceedings of the SCOPE workshop, Belgian Academy of Sciences, Brussels, Belgium, financially supported by the Royal Academy of Sciences of Belgium, the Institute Mondial du Phosphate (IMPHOS) and the US National Institute of Environmental Health Sciences; 2001 13-16 of September; Brussels, Belgium.
  25. Hellstrand S, Yan J, editors. The potential to increase sustainable global green energy production through increased efficiency in milk and cattle production: a Swedish case. First International Conference on Applied Energy; 2009 5-7 January 2009; Hong Kong.
  26. Hellstrand S, editor Reduction of the Discharges on the Local Level not Always Sustainable: – A Swedish Example, . Pulp & Paper Conference; 1997 March 9-13, 1997; Orlando, Florida.
  27. InternationaL DIABETES FEDERATION. Clinical Practice Recommendations on the Diabetic Foot – 2017. 2017.
  29. Navarro-Peternella FM, Lopes APAT, de Arruda GO, Teston EF, Marcon SS. Differences between genders in relation to factors associated with risk of diabetic foot in elderly persons: A cross-sectional trial. Journal of Clinical & Translational Endocrinology.6:30-6.
  30. Nather A, Siok Bee C, Keng Lin W, Qi Odelia KS, Yiong Huak C, Xinyi L, et al. Socioeconomic profile of diabetic patients with and without foot problems. Diabetic Foot & Ankle. 2010;1:10.3402/dfa.v1i0.5523.
  31. Rawshani A, Svensson A-M, Rosengren A, Eliasson B, Gudbjörnsdottir S. Impact of Socioeconomic Status on Cardiovascular Disease and Mortality in 24,947 Individuals With Type 1 Diabetes. Diabetes Care. 2015;38(8):1518-27.
  32. Raspovic KM, Wukich DK. Self-Reported Quality of Life and Diabetic Foot Infections. The Journal of Foot and Ankle Surgery. 2014;53(6):716-9.
  33. Ribu L, Hanestad BR, Moum T, Birkeland K, Rustoen T. Health-related quality of life among patients with diabetes and foot ulcers: association with demographic and clinical characteristics. J Diabetes Complications. 2007;21(4):227-36.
  34. Ragnarson Tennvall G, Apelqvist J. Health-related quality of life in patients with diabetes mellitus and foot ulcers. J Diabetes Complications. 2000;14:235-41.
  35. Odum HT. Self-organization, transformity, and information. Science (New York, NY). 1988;242(4882):1132.
  36. Odum HT. Environmental accounting : EMERGY and environmental decision making. New York: New York : Wiley; 1996.
  38. World Health Organisation. Preventing disease through healthy environments. 2016.
  39. Viglizzo EF, Ricard MF, Taboada MA, Vázquez-Amábile G. Reassessing the role of grazing lands in carbon-balance estimations: Meta-analysis and review. Sci Total Environ. 2019;661:531-42.
  40. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224-60.
  41. The Swedish Government. Regleringsbrev för budgetåret 2017 avseende länsstyrelserna. In: Finansdepartementet, editor. 2016.
  42. World Health Organisation. Global report on diabetes. 2016.
  43. World Health Organisation. Diabetes fact sheet. 2018.
  44. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719-24.
  45. Ragnarson Tennvall G, Apelqvist J. Health-Economic Consequences of Diabetic Foot Lesions. Clin Infect Dis. 2004;39(S2):132-9.
  46. Hellstrand Tang U. The Diabetic Foot – assessment and assistive devices. Gothenburg: University of Gothenburg; 2017.
  47. Prompers L, Huijberts M, Schaper N, Apelqvist J, Bakker K, Edmonds M, et al. Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study. Diabetologia. 2008;51(10):1826-34.
  48. Boulton A, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al. Comprehensive Foot Examination and Risk Assessment: A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008;31(8):1679-85.
  49. Abbott CA, Vileikyte L, Williamson S, Carrington AL, Boulton AJ. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care. 1998;21(7):1071-5.
  50. Reiber GE. The epidemiology of diabetic foot problems. Diabetic medicine : a journal of the British Diabetic Association. 1996;13 Suppl 1:6.
  51. Lavery L, Armstrong D, Wunderlich R, Tredwell J, Boulton A. Diabetic foot syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans and non-Hispanic whites from a diabetes disease management cohort. Diabetes Care. 2003;26:1435 – 8.
  52. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217-28.
  53. Henriksson F, Agardh CD, Berne C, Bolinder J, Lönnqvist F, Stenström P, et al. Direct medical costs for patients with type 2 diabetes in Sweden. J Intern Med. 2000;248(5):387-96.
  54. Nationella Diabetes Registret. Årsrapport 2016.
  56. Socialstyrelsen. Nationella riktlinjer för diabetesvård 2015.
  57. Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, et al. Lower extremity amputations — a review of global variability in incidence. Diabet Med. 2011;28(10):1144-53.
  58. Bakker K, Apelqvist J, Schaper NC, on behalf of the International Working Group on the Diabetic Foot Editorial Board. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev. 2012;28(1):225-31.
  59. World Health Organization. Priority Assistive Products List. 2016.
  60. van Netten JJ, Price PE, Lavery LA, Monteiro-Soares M, Rasmussen A, Jubiz Y, et al. Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev. 2016;32 Suppl 1:84-98.
  61. 61. BP. BP Statistical Review of World Energy June 2016. 2016.

The role of tinea pedis and onychomycosis prevention in diabetic education: A literature review

by Ebony Love DPM1, Tracey Vlahovic DPM1*, Lauren Christie DPM1

The Foot and Ankle Online Journal 12 (3): 2

The prevalence of individuals with diabetes has steadily been increasing, creating both a health and economic crisis world-wide.  Previous studies have suggested that foot fungal infections, including onychomycosis and tinea pedis, increase the risk of developing a diabetic foot ulcer. Through a thorough PubMed search, this article aims to review relevant literature relating to superficial fungal infections and patients with diabetes.  

Keywords: Tinea pedis, diabetes, onychomycosis, patient education

ISSN 1941-6806
doi: 10.3827/faoj.2018.1203.0002

1 – Temple University School of Podiatric Medicine, Philadelphia, PA
* – Corresponding author: traceyvlahovicdpm@yahoo.com

The prevalence of individuals with diabetes has steadily been increasing, creating both a health and economic crisis world-wide [1,2]. Diabetic foot infections, one of the major complications associated with diabetes, have significantly contributed to both an increase in mortality and financial burden in the diabetic population. The incidence of diabetic foot ulceration has been reported in up to 19% of the diabetic population, which has been associated with lower limb amputation and mortality [3,4]. In the efforts to prevent these complications from occurring, patients with diabetic foot infections tend to have more frequent outpatient visits, increase frequency of visits to the emergency room, increased frequency and duration of hospital stays, and an increased need for home health care; further increasing the economic crisis of this disease [2].

Previous studies have suggested that foot fungal infections, including onychomycosis and tinea pedis, increase the risk of developing a diabetic foot ulcer [5,6,7]. Diabetics are 2.77 times more likely to develop onychomycosis compared to non-diabetics, negatively impacting their physical and physiological health [8,9]. If left untreated, onychomycosis and tinea pedis can lead to cutaneous injury and ulceration due to dystrophic, brittle nails penetrating the skin and/or interdigital or moccasin skin fissuring, especially in patients with neuropathy or peripheral vascular disease (PVD) [10].

Patient education is critical in diabetic foot care to help manage and prevent diabetic foot infections, other comorbidities, and mortality. The objective of this review is to assess the current literature on foot fungal infections in patients with diabetes as it relates to diabetic foot care education.


A PubMed review of literature with keywords of tinea pedis and onychomycosis in patients with type II diabetes was reviewed.


The frequency of foot fungal infections is significantly higher in diabetics compared to non-diabetics. In a 2016 study, Oz et al., found that while elderly males are at an increased risk of developing onychomycosis regardless of whether they have diabetes, 14% of those in the diabetic group versus 5.9% of those in the control group had tinea pedis and/or onychomycosis [11]. According to Papini et al., in 2013, 69.3% of diabetics with a foot complication present with a foot fungal infection. Dermatophytes were the most common fungal species present, but non-dermatophytes, such as Candida albicans were also noted. Additionally, they found that diabetics with a previous toe amputation were significantly more likely to present with both tinea pedis and onychomycosis concomitantly. They concluded that specific treatment of the fungus involved is necessary for mycological cure to prevent diabetic foot complications, such as ulceration, loss of limb, and loss of life [12].

Another study by Gulcan et al., in 2014, found 25.3% of diabetic subjects mycologically had mycotic nails, out of the 161/321 diabetic patients who clinically presented with mycotic nails. Additionally, there was a significant association between onychomycosis and family history of the disease, BMI, longer duration of being diabetic, neuropathy, and retinopathy. They suggested that diabetic patients who have any of the risk factors found to be associated with onychomycosis in this study, should be properly educated diabetic and fungal infection education, to prevent the development of secondary lesions [13].

In addition to being more prevalent in the diabetic population, fungal foot infections occur in diabetics at a significantly earlier age compared to non-diabetics. In 2008, Legge et al., obtained scrapings from interdigital maceration of 40 diabetics and 40 non-diabetics. Of the 40% of samples collected that tested positive for fungal infection, patients in the diabetic group were on average 6.3 years younger than the non-diabetic group. They concluded that patients with diabetes may be more susceptible to developing tinea pedis at a younger age [14].

In 2017, Takehara et al., analyzed 30 patients with diabetes, 16 of which had tinea pedis, and found the number of times scrubbing between toes while washing with soap was significantly lower in subjects with tinea pedis compared to those who did not have tinea pedis. The number of times subjects scrubbed between toes with soap was also significantly lower in those who had difficulty reaching their feet. The authors suggested that each web space should be scrubbed 4-5 times for tinea pedis prevention and that proper education and intervention should be given to patients who have difficulty reaching their feet on more convenient foot washing positions [15].

It has well been known that foot fungal reinfection can occur from contaminated socks and sneakers. Broughton in 1955 found that individuals who wore cotton or wool socks were particularly susceptible to reinfection in hot, moist conditions, even after six wash cycles [16]. To reduce the risk of relapse, they suggested modifications and materials used to make socks and footwear and improved hygiene could potentially help.

Modifications to cotton socks have been found to have antifungal properties for diabetic patients. In 2012, Tarbuk et al., found modified cotton socks worn by diabetic subjects with active carbon, natural mineral, or zeolite had antimicrobial properties against Candida albicans after 15 washing cycles, unlike the pure cotton control. Modified cotton socks with zeolite additionally had antimicrobial properties to S. aureus. The authors concluded that the active carbon and mineral particles found in the modified cotton socks did not directly prevent microbial infection, but through creating a drier environment for the foot by absorbing more moisture, were able to prevent microbial growth in patients with diabetes [17].

Another treatment that has been shown to be beneficial in reducing fungal load is ultraviolet treatment of shoes of those infected with dermatophytes. Ghannoum et al., in 2012, found that ultraviolet treatment of shoes infected with dermatophytes was significantly effective in reducing fungal load in shoes. There was a 76.28% mean reduction of colony-forming units/ml of Trichophyton rubrum after 3 cycles of UV C radiation treatment. They suggested that by sanitizing shoes, it can stop the cycle of reinfection while being treated for fungal infection by other means and it can help prevent relapse [18].

Prophylactic application of topical antifungals in diabetic patients has also been suggested, given the potential complications that onychomycosis can cause in diabetics and the high reinfection relapse [19]. A study by Sigurgeirsson et al., in 2010, found that patients previously cured from onychomycosis who were prophylactically treated with amorolfine twice a week statistically benefited from prophylaxis up to 12 months after cure. Although relapse rates at 12 months of those treated prophylactically was 8.3% compared to 31.8% of those who were not prophylactically, there were insignificant differences in relapse rates between study groups at 36 months post-cure. While it is unknown if increasing the frequency of dosing would create a better protection against onychomycosis, it is still unclear whether prophylactic application of antifungal medications help prevent onychomycosis in diabetic patients [20].


Onychomycosis and tinea pedis have been attributed to increasing the risk of diabetic foot ulceration and infections, especially in the elderly male population, individuals having diabetes for a longer duration, and diabetics with neuropathy and/or PVD. Based on this review, preventative measures for foot fungal infections including foot washing hygiene, wearing modified socks, shoe wear sanitation, potentially using prophylactic topical antifungal medication on nails, and stressing the importance of attending routine diabetic foot risk assessment appointments in accordance to the Lavery-Armstrong guidelines should be considered during diabetic foot care education [21].


  1. Wild S, Roglic G, Green A, Sicree R, and King H. Global Prevalence of Diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care. 27: 1047-1053, 2004.
  2. Rice JB, Desai U, Cummings AKG, Birnbaum HG, Skornicki M, and Parsons NB. Burden of Diabetic Foot Ulcers for Medicare and Private Insurers. Diabetes Care. 37: 651-658, 2014.
  3. Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, and Veves A. Screening Techniques to Identify People at High Risk for Diabetic Foot Ulceration. Diabetes Care. 23: 606-611, 2000.
  4. Johannesson A, Larsson GU, Ramstrand N, Turkiewicz A, Wiréhn AB, and Atroshi I. Incidence of Lower-Limb Amputation in the Diabetic and Nondiabetic General Population. Diabetes Care. 32: 275-280, 2009.
  5. Boyko EJ, Ahroni JH, Cohen V, Nelson KM, and Heagerty PJ. Prediction of Diabetic Foot Ulcer Occurrence Using Commonly Available Clinical Information: The Seattle Diabetic Foot Study. Diabetes Care. 29: 1202-1207, 2006
  6. Zhong A, Li G, Wang D, Sun Y, Zou X, and Li B. The risks and external effects of diabetic foot ulcer on diabetic patients: A hospital-based survey in Wuhan area, China. Wound Repair and Regeneration. 25: 858-863, 2017.
  7. Gupta AK, Gupta MA, Summerbell RC, Cooper EA, Konnikov N, Albreski D, et al. The epidemiology of onychomycosis: possible role of smoking and peripheral arterial disease. J Eur Acad Dermatol Venereol. 14: 466–469, 2000.
  8. Gupta AK, Konnikov N, MacDonald P, Rich P, Rodger NW, Edmonds MW, et al. Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey. Br J Dermatol. 139:665-671, 1998.
  9. Drake LA, Scher RK, Smith EB, Faich GA, Smith SL, Hong JJ, et al. Effect of onychomycosis on quality of life. Journal of the American Academy of Dermatology. 38: 702-704. 1998
  10. Rich P, and Hare A. Onychomycosis in a special patient population: focus on the diabetic. Int J of Dermatol. 38: 17-19, 1999.
  11. Oz Y, Qoraan I, Oz A, and Balta I. Prevalence and epidemiology of tinea pedis and toenail onychomycosis and antifungal susceptibility of the causative agents in patients with type 2 diabetes in Turkey. International Journal of Dermatology. 56: 68-74, 2017. 
  12. Papini M, Cicoletti M, Fabrizi V, and Landucci P. Skin and nail mycoses in patients with diabetic foot. G Ital Dermatol Venereol. 148: 603-608, 2013
  13. Gulcan A, Gulcan E, Oksuz S, Sahin I, Kaya D. Prevalence of Toenail Onychomycosis in Patients with Type 2 Diabetes Mellitus and Evaluation of Risk Factors. JAPMA. 101: 49-54, 2011.
  14. Legge BS, Grady JF, and Lacey AM. The Incidence of Tinea Pedis in Diabetic versus Nondiabetic Patients with Interdigital Macerations. JAPMA. 98: 353-356, 2008.
  15. Takehara K, Amemiya A, Mugita Y, Tsunemi Y, Seko Y, Ohashi Y, et al. The Association between Tinea Pedis and Feet-Washing Behavior in Patients with Diabetes: A Cross-sectional Study. Adv Skin Wound Care. 11: 510-516, 2017.
  16. Broughton RH. Reinfection from socks and shoes in tinea pedis. Br J Dermatol. 67: 249-254, 1995.
  17. Tarbuk A, Grancarić AM, and Magaš S. Modified Cotton Socks- Possibility to Protect from Diabetic Foot Infection. Coll Antropol. 39: 177-183, 2015. 
  18. Ghannoum MA, Isham N, and Long L. Optimization of an infected shoe model for the evaluation of an ultraviolet shoe sanitizer device. JAPMA. 102: 309-313, 2012.
  19. Vlahovic TC. Onychomycosis: Evaluation, Treatment Options, Managing Recurrence, and Patient Outcomes. Clin Podiatr Med Surg. 33: 305-318, 2016.
  20. Sigurgeirsson B, Olafsson JH, Steinsson JT, Kerrouche N, and Sidou F. Efficacy of amorolfine nail lacquer for the prophylaxis of onychomycosis over 3 years. JEADV. 24: 910-915, 2010.
  21. Boulton AJ, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al. Comprehensive Foot Examination and Risk Assessment. Endocrine Practice. 14: 576-583, 2008.

Staged correction of equinovarus in a diabetic patient: A case report

by Amanda Kamery DPM1*, Byron Hutchinson DPM FACFAS2

The Foot and Ankle Online Journal 12 (2): 1

A rigid equinovarus deformity in the diabetic patient is a challenge for many surgeons. The utilization of a single stage, acute correction of the deformity can lead to soft tissue compromise and neurovascular complications. Using gradual correction by means of external fixation, with subsequent internal fixation for arthrodesis, provides a viable option for limb salvage in this difficult patient cohort.

Keywords: Reconstructive surgery, diabetes, external fixation, lower extremity 

ISSN 1941-6806
doi: 10.3827/faoj.2018.1202.0001

1 – Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA PGY-3
2 – Research Director, Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA
* – Corresponding author- akamery@kent.edu

The diabetic patient with a rigid equinovarus deformity subsequent to soft tissue contracture is a unique and challenging patient [1]. Limb salvage options for this patient population are limited and complex. The utilization of gradual correction with external fixation proves to be an adequate treatment option that has less complications and leads to a stable and functional foot in this at risk group [1]. Single stage acute correction is another viable option, however, this can lead to limb length discrepancy due to significant bone resection or neurovascular compromise [2,3]. Longstanding soft tissue contracture of the medial ankle can lead to a rigid equinovarus deformity, in this setting acute correction is not a viable option due to the risk of neurovascular compromise and the delicate soft tissue envelope [4].

Case Report

A 59 year-old female presented to the clinic with a rigid equinovarus deformity secondary to multiple medial malleolar wound debridement. The patient developed this deformity over several months of wound care, which resulted in soft tissue contracture to the medial ankle. She presented to our service non-ambulatory and unbraceable due to progression of the deformity (Figure 1). She subsequently developed a wound on the lateral malleolus. 

Staged surgical correction was planned due to severe contracture and questionable medial neurovascular and soft tissue compromise. It was felt that a single stage correction would not be ideal in this particular patient. A dynamic circular frame was placed for gradual correction (Figure 2). Five days post initial procedure, the patient was educated on how to perform distraction with a total of 2 degrees of angular correction daily. The patient was non-weight bearing during the correction process. 

After 42 days, approximately 84 degrees of correction was obtained (Figure 3). At this point, a clinical decision was made to proceed with a Tibio-talo-calcaneal (TCC) fusion. 

Figure 1 Pre-operative AP foot radiograph showing severe equinovarus deformity.

Figure 2 Intra-operative clinical picture.  

Figure 3 Clinical picture after 42 days of correction.

It was determined that enough correction had occurred to relax the medial soft tissue envelope. The patient was returned to the operating room for the secondary procedure. This included external fixator removal and TCC arthrodesis with an intramedullary nail.  The patient remained non-weight bearing for 6 weeks until bony consolidation was seen on x-ray (Figure 4). 

The patient was then transitioned to protected weight bearing for 2 weeks in a controlled ankle motion (CAM) boot. The patient eventually successfully transitioned into a Charcot restraint orthotic walker (CROW) (Figure 5). The patient has remained ambulatory in a CROW for 6 months.

Figure 4 Six-week post secondary procedure. 

Figure 5 Clinical picture six weeks post secondary procedure.


The diabetic patient with a severe lower extremity deformity and soft tissue compromise presents a challenging case for foot and ankle surgeons. Staged correction of these deformities utilizing gradual correction by external fixation and subsequent internal fixation with arthrodesis proves to be a viable option to help with limb preservation in these patients. Our case presentation demonstrates the efficacy of staged correction in these challenging patients and that limb salvage and return to ambulation in a CROW can be obtained and maintained. 


  1. Cuttica DJ, Decarbo WT, Philbin TM. Correction of rigid equinovarus deformity using a multiplanar external fixator. Foot Ankle Int. 2011;32(5):S533-9.
  2. Mirzayan R, Early SD, Matthys GA, Thordarson DB. Single-stage talectomy and tibiocalcaneal arthrodesis as a salvage of severe, rigid equinovarus deformity. Foot Ankle Int. 2001;22(3):209-13.
  3. Paley, D., Herzenberg, JE. Ankle and Foot Considerations In: Principles of Deformity Correction. 2002. 571-646.
  4. Bellamy JL, Holland CA, Hsiao M, Hsu JR. Staged correction of an equinovarus deformity due to pyoderma gangrenosum using a Taylor spatial frame and tibiotalar calcaneal fusion with an intramedullary device. Strategies Trauma Limb Reconstr. 2011;6(3):173-6.

Initial experiences with clinical assessment of plantar tissue hardness in diabetes: A brief case series

by Joshua Young BSc.(Hons), MBAPO1,2*

The Foot and Ankle Online Journal 12 (1): 2

Plantar tissue assessment is important in the management of diabetic foot problems. As clinical assessment of plantar tissue hardness typically relies on palpation and observation only, durometer assessment is a potentially useful and feasible addition. This brief case series reports on initial experiences with the use of plantar tissue hardness measurement in 5 patients, together with plantar pressure measurement data. The results suggest some relationship between tissue hardness and peak plantar pressures (PPPs) at the forefoot. The data may suggest cut-off values, with forefoot tissue hardness <40 predicting safe PPPs and tissue hardness 60+ predicting dangerous PPP. However further research would be required to clarify these initial findings. Use of a durometer was found to be feasible within a clinical setting, and some initial data for comparison is provided. While assessment of plantar tissue hardness alone is unlikely to be a singular value which can guide treatment, it may offer a helpful addition to existing clinical assessments.

Keywords: diabetes, tissue hardness, durometer, tissue assessment, pressure

ISSN 1941-6806
doi: 10.3827/faoj.2018.1201.0002

1 – Roehampton Rehabilitation Centre, Queen Mary’s Hospital. St George’s University Hospitals NHS Foundation Trust
2 – Orthotist, Opcare, Oxfordshire, UK.
* – Corresponding author: joshua.young1@nhs.net

Foot ulcers are a major source of morbidity in diabetes [1]⁠. Risk factors for the development of foot ulcers include peripheral arterial disease, neuropathy and foot deformity [2,3]. Limited joint mobility⁠ and altered plantar tissue characteristics have also been shown to increase risk of ulceration [3, 4]. Plantar tissues in diabetes may become thinner, stiffer⁠ and harder [5, 6, 4]⁠.

Plantar tissue hardness can be measured relatively easily using a durometer and this has been explored in experimental studies, including studies of people with diabetes [4,7,8]⁠. Given that clinical assessment of plantar tissues typically relies on palpation, observation and subjective judgement only, the addition of durometer assessment is potentially helpful. This brief case series reports on initial experiences with the clinical use of plantar tissue hardness measurement, together with plantar pressure measurement data.


Skin hardness was measured with a durometer using the Shore O scale. The patient was positioned in supine and the durometer was applied perpendicularly to the foot for 3 seconds before taking the reading. Selected peak plantar pressures (PPP) were also recorded as part of the assessment, using the Pressure Guardian system (Tillges technologies, USA). Plantar pressures were recorded during walking at self-selected pace, with the subject wearing their usual shoes with a 3.2mm grey poron 4000 polyurethane inlay (Algeos, UK) only inside the shoe, in line with the department’s protocol. Recorded PPP were compared to the 200kPa threshold, which has been tentatively proposed as a dangerous level of pressure [9]⁠. Patients gave written informed consent for use of the information in this article.

Case 1

Subject 1 is a 60-year old male with type 2 diabetes and a left sided trans-tibial amputation. The remaining right foot has a history of ulceration at the interphalangeal joint of the hallux only, and the foot has been intact for over 1 year. The plantar tissues appeared in good condition except a small area of discolouration at the 1st metatarsal-phalangeal joint (MPJ), representing a small ‘blood blister’. Plantar tissue hardness was tested at the heel and all MPJs (Figure 1) and ranged between 28 – 41 shore O. PPP were measured at MPJs 1 and 3 in addition to the heel. Only the heel exceeded 200kPa (Table 1).

Figure 1 View of plantar tissues with shore hardness values (peak plantar pressures exceeding 200kPa indicated by ‘*’) – Subject 1.

Location Hardness (Shore O) of skin – Right foot [kPa  with 3mm poron]
1st MPJ 191 [191.26]
3rd MPJ 80 [80.19]
Heel 236* [235.73]

Table 1 Plantar tissue hardness and peak plantar pressures – subject 1.

Case 2

Subject 1 is a 70-year old male with type 2 diabetes and a right amputation through the first metatarsal. There is a history of ulceration at the right 2nd MPJ and distal aspect of the left 3rd toe and the right 2nd MPJ ulcer has been open within the prior 3 months . The plantar tissues appeared thin and dry, with reduced padding under the MPJs. Callus was visible particularly at the right 2nd MPJ and left 1st and 2nd MPJ. Plantar tissue hardness was tested at the heel, all MPJs and the cut end of the right 1st metatarsal (Figure 2) and ranged between 20 – 70 shore O. PPP were measured at MPJs 1 (cut end of metatarsal on right), 2 and 5 in addition to the heel. The right 2nd MPJ and left MPJs 1-2 exceeded 200kPa (Table 2).

Figure 2 View of plantar tissues with shore hardness values (peak plantar pressures exceeding 200kPa indicated by ‘*’) – Subject 2.

Location Hardness (Shore O) of skin – Right foot (1st ray amputation) Hardness (Shore O) of skin – Left foot
1st MPJ 20 (cut end of 1st metatarsal)  [118.52] 50* [423.34]
2nd MPJ 70* [563.99] 40* [254.62]
3rd MPJ 45 35
4th MPJ 55 40
5th MPJ 45 [78.74] 45 [74.46]
Heel 30 [108.11] 30 [123.35]

Table 2 Plantar tissue hardness and peak plantar pressures – Subject 2 (*location which exceeds 200kPa when walking on 3mm grey poron. Note sites tested for pressure = 1st MPJ, 2nd MPJ, 5th MPJ, heel).

Case 3

Subject 3 is a 70-year old male with type 2 diabetes. He has an amputation through the right first metatarsal in addition to removal of the right second toe. There is a history of ulceration at the left 1st MPJ and distal aspect of the right 4th toe but the feet have been ulcer free for over 12 months. The plantar tissues appeared generally good, with reasonable padding under most of the MPJs, but callus present at the left 1st MPJ and distal aspect of the right 4th toe. Plantar tissue hardness was tested at the heel, all MPJs, the cut end of the right 1st metatarsal and medial/lateral aspects of the plantar midfoot (Figure 3) and ranged between 28 – 60 shore O. PPPs were measured at MPJs 1 (cut end of metatarsal on right), 2 and 5 in addition to the heel. The right cut end of 1st metatarsal and left 1st MPJs exceeded 200kPa (Table 3).

Figure 3 View of plantar tissues with shore hardness values (peak plantar pressures exceeding 200kPa indicated by ‘*’) – Subject 3.

Location Hardness (Shore O) of skin – Right foot (1st ray amputation) [peak plantar pressure on 3mm poron / custom foot orthosis – kPa] Hardness (Shore O) of skin – Left foot [peak plantar pressure on 3mm poron / custom foot orthosis – kPa]
1st MPJ 55 (cut end of 1st metatarsal)* [234/177] 60* [330/306]
2nd MPJ 45 [157/55] 45 [25/132]
3rd MPJ 40 30
4th MPJ 50 40
5th MPJ 40 [113/39] 55 [18/26]
Medial arch 59 36
Lateral arch 40 41
Heel 30 [138/165] 28* [221/136]

Table 3 Plantar tissue hardness and peak plantar pressures – Subject 3 (*location which exceeds 200kPa when walking on 3mm grey poron. Note sites tested for pressure= 1st MPJ, 2nd MPJ, 5th MPJ, heel).

Case 4

Subject 4 is a 60-year old female with type 2 diabetes. She has a right trans-tibial amputation and a history of Charcot foot on the left in addition to removal of the left 5th toe. There is a history of ulceration, most recently at the dorsal hallux but the feet have been ulcer free for over 12 months. The plantar tissues appear in generally good condition, with reduced padding under the MPJs, and a very prominent lateral plantar midfoot. Plantar tissue hardness was tested at the heel, MPJs 1,3 and 5, medial arch, lateral plantar Charcot midfoot prominence and the skin adjacent to the midfoot prominence (Figure 4) and ranged between 30-70 Shore O. PPPs were only measured at the lateral plantar Charcot midfoot prominence, and exceeded 200kPa (Table 4).

Figure 4 View of plantar tissues with shore hardness values – Subject 4.

Location Hardness (Shore O) of skin
1st MPJ 30
2nd MPJ 32
3rd MPJ 32
4th MPJ 33
5th MPJ 70
Medial arch 32
Lateral midfoot Charcot prominence under cuboid region 70* [509kPa]
Tissue adjacent to Charcot prominence 40
Heel 45

Table 4 Plantar tissue hardness and peak plantar pressures – Subject 4. (*location which exceeds 200kPa when walking on 3mm grey poron. Note site tested for pressure = Lateral midfoot Charcot prominence under cuboid region).

Case 5

Subject 5 is a 75-year old male with type 2 diabetes. He has a history of Charcot foot on the right side, causing medial collapse around the talonavicular joint. There is a history of ulceration, and at the most recent assessment there were active ulcers at the right medial navicular/cuneiform region and right 5th toe.  The plantar tissues appear dry, with reduced padding under the MPJs, and callus under the 1st and 2nd MPJs bilaterally (Figure 5). Plantar tissue hardness was tested at the heel, MPJs 1,2 and 3, and ranged between 40-78 Shore O. PPPs were measured at the heel, MPJs 1,2 and 3, and exceeded 200kPa at the 1st and 2nd MPJs bilaterally (Table 5).

Figure 5 View of plantar tissues with shore hardness values (peak plantar pressures exceeding 200kPa indicated by ‘*’) – Subject 5.

Location Hardness (Shore O) of skin – Right (Charcot side) [peak plantar pressure on 3mm poron / custom foot orthosis – kPa] Hardness (Shore O) of skin – Left [peak plantar pressure on 3mm poron / custom foot orthosis – kPa]
1st MPJ 60* [307 / 91] 73* [291 / 94]
2nd MPJ 78* [257 / 65] 50* [360 / 136]
3rd MPJ 40 [32 / 27] 42 [152 / 71]
Heel 45 [61 / 26] 45 [169 / 111]

Table 5 Plantar tissue hardness and peak plantar pressures – Subject 5 (*location which exceeds 200kPa when walking on 3mm grey poron).


A wide range of tissue hardness values were recorded, ranging between 20-78 Shore O. PPP also varied widely, between 18-564kPa. Considering the plantar heel, a smaller range of hardness values was recorded, between 28-45 Shore O. This is similar to the 35-50 (Shore A) reported in a diabetic group by another author [8]. Two heels exceeded 200kPa when tested – their hardness values were 28 and 41 Shore O (mean 35). The remaining heels with both durometer and pressure data (n=5) had a mean hardness of 36 Shore O. This, combined with the fact that the two hardest heels (45 Shore O) did not exceed the pressure threshold, does not seem to show an obvious prediction of high pressures by testing tissue hardness at the heel. The forefoot included higher hardness values, ranging between 28-78 Shore O. This is a wider range than the 45-50 Shore A reported by Martinez Santos [8]. Eight MPJs tested exceeded 200kPa; the average tissue hardness of these sites was 60 Shore O. In comparison, the remaining MPJs with both durometer and pressure data (n=18) had a mean tissue hardness of 42 Shore O. Forefoot hardness values of 60 Shore O or higher always predicted PPPs exceeding 200kPa. However of 11 sites exceeding 200kPA, five (45%) had tissue hardness values below 60 Shore O. Forefoot hardness values below 40 were never associated with PPP exceeding 200kPa. While these observations seem to show some relationship between forefoot tissue hardness and dynamic PPP, which has been observed elsewhere ⁠, it would appear that other factors also influence PPP [10]. The data may suggest cut-off values, with all tissue hardness <40 predicting safe PPPs and all tissue hardness 60+ predicting dangerous PPP. This could suggest that durometer testing of forefoot tissues offers an alternative to instrumented pressure measurement, in contexts where this technology is unavailable. However further research would be required to clarify these initial findings.


Use of a durometer was found to be feasible within a clinical setting, and some initial data for comparison is provided. Hardness testing offers quantification of more subjective assessment methods such as palpation. While plantar tissue hardness alone is unlikely to be a singular value which can guide treatment, it may offer a helpful addition to existing clinical assessments.


This work was completed while affiliated with the above organisations, however, at the time of publication the author is affiliated with: John Florence Limited, Paediatric Orthotic Centre, Foundry Lane, Lewes, East Sussex, BN7 2AS, UK


  1. Vileikyte L. Diabetic foot ulcers: a quality of life issue. Diabetes Metab Res Rev. 2001 Jul 1;17(4):246–9.
  2. Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes Care. 1999 Jul 1;22(7):1036–42.
  3. Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000 May 1;23(5):606–11.
  4. Thomas VJ, Patil KM, Radhakrishnan S, Narayanamurthy VB, Parivalavan R. The role of skin hardness, thickness, and sensory loss on standing foot power in the development of plantar ulcers in patients with diabetes mellitus–a preliminary study. Int J Low Extrem Wounds. 2003;2(3):132-9.
  5. Chao CYL, Zheng Y-P, Cheing GLY. Epidermal Thickness and Biomechanical Properties of Plantar Tissues in Diabetic Foot. Ultrasound Med Biol. 2011 Jul 1;37(7):1029–38.
  6. Klaesner JW, Hastings MK, Zou D, Lewis C, Mueller MJ. Plantar tissue stiffness in patients with diabetes mellitus and peripheral neuropathy. Arch Phys Med Rehabil. 2002 Dec 1;83(12):1796–801.
  7. Piaggesi A, Romanelli M, Schipani E, et al. Hardness of Plantar Skin in Diabetic Neuropathic Feet. J Diabetes Complications. 1999 May 1;13(3):129–34.
  8. Martínez Santos A. An investigation into the effect of customised insoles on plantar pressures in people with diabetes [thesis]. University of Salford; 2016. Available from: http://usir.salford.ac.uk/41408/1/Ana Martinez Santos Thesis.pdf
  9. Bus SA, Ulbrecht JS, Cavanagh PR. Pressure relief and load redistribution by custom-made insoles in diabetic patients with neuropathy and foot deformity. Clin Biomech. 2004 Jul 1;19(6):629–38.
  10. Menz HB, Zammit G V., Munteanu SE. Plantar pressures are higher under callused regions of the foot in older people. Clin Exp Dermatol. 2007 Jul 1;32(4):375–80.

Ilizarov method of fixation for the management of pilon and distal tibial fractures in the compromised diabetic patient: A technique guide.

by Edgardo Rodriguez, DPM1, Michael Bowen, DPM2, Alexander Cherkashin, MD3, Mikhail Samchukov, MD4, Stephen Frania, DPM FACFAS5, Paul Dayton, DPM FACFAS6, Patrick Nelson, DPM7pdflrg

The Foot and Ankle Online Journal 7 (2): 6

The purpose of this technique guide is to provide the foot and ankle surgeon with a comprehensive guide for reducing pilon and distal tibial fractures when dealing with the co-morbid patient and/or a soft tissue envelope that does not lend itself to ORIF. The senior author presents a relatively low complication rate (13% in the pilon group and 23% in the distal tibial group), with a low number of amputations (five out of 59 patients).

Key words: Pilon fracture, distal tibial fracture, diabetes, Ilizarov external fixation.

ISSN 1941-6806
doi: 10.3827/faoj.2014.0702.0006

Address correspondence to: Edgardo Rodriguez, DPM
875 North Dearborn Street Suite 400N, Chicago, Illinois USA 60610. Telephone: 312.335.3939, Facsimile: 312.335.5469. Email: egodpm@gmail.com

1. Director, Chicago Foot and Ankle Deformity Correction Center: 875 North Dearborn Street Suite 400N, Chicago, Illinois USA 60610.
– Director, Reconstructive Foot & Ankle Fellowship Program Saint Anthony Hospital: 2875 W. 19th St, Chicago, IL 60623.
– Center for Excellence in Limb Lengthening and Reconstruction, Department of Pediatrics.
2. PGY-2, Foot and Ankle Residency Program, St. Vincent Charity Medical Center: 2351 E. 22nd St., Cleveland, OH 44115. mbowen@alumni.ocpm.edu
3,4. Orthopedics, Texas Scottish Rite Children Hospital: 2222 Welborn Street Dallas, Texas USA 75219.
5. Foot and Ankle Specialists of Ohio: 7062 Wayside Dr., Mentor, OH USA 44060.
6. Director, Podiatric Surgical Residency, Trinity Regional Medical Center, Trimark Physicians Group, Fort Dodge IA 50501
7. PGY-3, PGY-2, Foot and Ankle Residency Program, St. Vincent Charity Medical Center: 2351 E. 22nd St., Cleveland, OH 44115.

The principles of external fixation have gone far beyond the mere use of stabilizing an injury. External fixation allows for the stabilization of a traumatic injury to further stage the procedure, as with an open fracture, and allows the surgeon anatomical correction along with careful observation of the soft tissue envelope. External fixation has afforded greater surgical options when dealing with the ever increasing diabetic population which has significant manifestations in the lower extremity.

High complication rates related to open reduction and internal fixation in co-morbid patients have been well documented. Blotter et al in 1990 did a retrospective review of 21 patients who had diabetes and 46 randomly selected patients who did not have diabetes. The complication rate of patients with diabetes was 43% undergoing ORIF ankle fracture versus 16% complication rate without diabetes. Complications were more severe in diabetic population, including below knee amputation [1]. Also, McCormack and Leith’s 1998 review of 26 diabetic patients with displaced malleolar fractures and a cohort group, overall complication rate of 42% in the diabetic patients compared with no complications in the cohort group treated non-invasively. Six of the 19 patients treated surgically developed a deep infection, and 2 patients eventually required an amputation at an unspecified level [2]. Wukich and Kline in 2008 did a current concept review for the management of ankle fractures in patients with diabetes and they showed that there is currently insufficient literature (grade-I recommendation) to support the use of supplemental fixation including multiple syndesmotic screws, transarticular fixation and external fixation [3].

Figure 1

Figure 1 a. Pre-op AP radiographs (OTA 43-C2.2), b. Proper positioning of the patient with anatomical landmarks marked with skin marker. c. Distal third ring (c: floating ring) at the level of the fracture (a: proximal tibial ring, b: distal tibial ring, c: floating ring, d: foot support).

figure 2

Figure 2 a, b Placement of smooth wire with 20-25lbs hung to allow the fracture to distract.

figure 3

Figure 3 Completion of the External Fixation device (tibial block, floating ring, and foot plate).

One could make the argument that any incisions made on these already fragile soft tissue envelopes puts the patient at greater risk from the start of the surgery. This technique presents a no incisional approach and only if absolutely necessary the placement of percutaneous k-wires for additional support. The advantage of external fixation affords the patient earlier weight bearing which decreases the complications associated with the patient being bed bound and non-weight bearing.


Patient preparation: Three standard x-ray views, which include the tibia and foot, should be available for planning prior to the procedure. CT scans with 3D reconstructions are very helpful to orient the surgical team to the positions of the fracture fragments. The patient is prepared for general or spinal anesthesia. Generally a tourniquet is not needed during the procedure.

Patient positioning: The patient is placed on the operating table in the supine position with the affected extremity elevated above the contralateral limb using radiolucent materials (blankets will suffice) and the foot hanging about 2 – 3 inches over edge of table (Figure 1). The extremity is then scrubbed and draped up to the level of the knee. Using fluoroscopy the fracture, the ankle, and the tibia are mapped for proper frame placement and for planning of ring size and rod lengths. The bottom ring of the tibial block should be placed just above the most proximal extent of the fracture.

Axial traction: Axial traction is an important component of this treatment method. Sustained gentle axial traction provides relaxation of contracted soft tissues and aids in reduction through ligamentotaxis. A smooth pin is driven lateral to medial through tuber of calcaneus parallel to that of the foot (Figure 2a,b). The pin should enter inferior to the peroneal tendons and exit inferior to the tarsal tunnel in a safe zone and a weight consisting of approximately 20-25lbs is then hung from the smooth wire to aid in reducing the fracture.

Frame construction: While the ankle is being distracted by the traction construct, the static circular external fixator should be built. The fixator will consist of a long double ring proximal tibial block, a floating ring at the level of the ankle joint (All nuts securing the floating ring to the threaded rods are loosened so the ring can be pushed up or down), and a foot plate (Figure 3). The frame is then checked in the frontal and sagittal planes (Figure 4).

figure 4

Figure 4 Proper position and alignment of the frame on the leg in both the sagittal and frontal planes.

Figure 5

Figure 5 Placement of tibial block during axial traction by means of a smooth wire.

Figure 6

Figure 6 Reduction of fracture fragments via axial traction and ligamentotaxis and stabilized with temporary k-wire fixation.

Recommended wire placement technique: At least two wires per ring with wire angle between 30 and 60 degrees to augment anterior-posterior stability. One wire should be above the ring and one wire below and the wires twin tensioned. This step is then repeated at 60 degree angles from the first wires on each respective ring. The tibial block wires should be tightened and tensioned at this time. Wires exiting posteriorly should be tightened with the supplied wrench and anterior wires should be finger tightened and dual tension to 130kg.

Figure 7

Figure 7 a: A smooth wire is inserted from lateral to medial on the proximal tibial ring. b: The next wire is then inserted in the same fashion, parallel to the first wire on the distal tibial ring.

Figure 8

Figure 8 a: Placement of calcaneal smooth wires, b: Placement of midfoot olive wires.

The calcaneal wires will be dual tensioned to 90kg and then the forefoot wires will be dual tensioned to 90kg if smooth wires are used. If an olive wire across the midfoot is used, tension the opposite end of the wire (lateral) to 110kg. The foot plate is then connected to the tibial ring, bypassing the floating ring and is connected with two threaded rods (Figure 9).

Note that no wires will be attached to the floating ring at the ankle joint at this time.

Next, two smooth wires will then be placed through the posterior tuber of the calcaneus from medial to lateral at approximately 60 degrees from one another (Figure 8a). It is important not to compromise the tarsal tunnel or the peroneal tendons with these wires. Two smooth wires will then be placed across the forefoot, one from medial to lateral and the other from lateral to medial trying to grab the 1st and 5th rays with these wires. This can also be accomplished using an olive wire from medial to lateral with the olive being placed medial or across the midfoot (Figure 8b).

Figure 9

Figure 9 Attachment of the foot plate to the tibial ring. Note that the floating ring is bypassed.

Once the static circular external fixator is securely applied the weights and smooth wire can be removed from the calcaneus. The ankle is then distracted and the fracture reduction is held in place via ligamentotaxis. To maintain distraction, the nuts are tightened to secure tibial block to the foot plate (Figure 10).

Figure 10

Figure 10 Distraction of the ankle joint is held into position by tightening of the anterior and posterior threaded rods.

Figure 11

Figure 11 Adjustment of the floating ring. Position approximately 10mm above the ankle joint.

Next the medial tibial pilon reduction wire is inserted. Drive an olive wire from medial to lateral on the floating ring (the olive on the medial side of the tibia) approximately 1-2 cm superior to the ankle joint. Connection posts will be needed for the lateral side. This will allow stabilization of the largest tibial pilon fragment (Figure 12a). Tension the opposite end of the wire to 110kg.

Figure 12a

Figure 12a Reduction of medial tibial pilon fragment with olive wire placement.

Next the medial malleolar fragment is reduced. An olive wire is driven from distal medial at the tip of the medial malleolus to proximal lateral through the tibia. The wire is cut flush at the olive/wire interface and buried under the skin as to reduce the fragment (Figure 12b). This wire is then attached to the distal tibia ring (normally requiring post to reach the wire) and tensioned from the lateral side to 90kg.

Figure 12b

Figure 12b Reduction olive wire for medial malleolar fracture fragment.

Next the lateral tibial pilon fragment is reduced. An olive wire is driven from distal lateral to proximal medial through the fibula and tibia (again the olive remains on the lateral side) approximately 1-2 cm superior to the ankle joint. The distal end of the wire is then connected to the floating ring and tensioned to 110kg (Figure 12c).

Figure 12c

Figure 12c Reduction of the lateral tibial fragment.

The final reduction is then checked under fluoroscopy. The ankle joint distraction is then released, by loosening the proximal nuts on the anterior connection rods and the distal nuts on the two posterior threaded rods (Figure 13).

Figure 13

Figure 13 Decreasing the ankle joint distraction.

The distal floating ring is then attached to the double-ring block with two anterior 115mm threaded rods. The foot support can then be re-inverted to allow immediate weight bearing post operatively. We choose to use smooth wires instead of threaded half pins on the tibial block (Figure 14).

Figure 14

Figure 14 Final frame construct. Half pins in the tibial block are substituted for smooth wires as indicated in the initial steps.

The leg/foot and fixator are then cleansed with hydrogen peroxide. If need be, negative pressure wound therapy can be applied or any other wound products as you deem appropriate. If there no open wounds in the skin then all wires are dressed with gauze sponges soaked in 70% isopropyl alcohol. Kerlix fluffs are packed around the fixator. The fixator is then wrapped in three 6-inch ace wraps.

Adjunct procedure: To help aid in post-op analgesia a popliteal block can be performed either before induction of general anesthesia or immediately post-op while the patient is still on the operating table.

Tips and Pearls: It is imperative to release the ankle joint distraction at the end of the case as to not cause tibial nerve neuropraxia. Avoid the use of half pins in metaphyseal or cancellous bone.

To prevent burning of the skin, the wires should always be moist before entry into the skin (wet gauze with isopropyl alcohol can be used for this) and the drill should be pulsed during insertion of the wire.


Weight-Bearing Status:
• Patients are normally allowed to WB 20-30% on the limb with the external fixation device. This is actually encouraged as this promotes callus formation and bone healing.
• Patients are normally discharged with either crutches or a walker for assistance with ambulation. Walkers are preferred.
• Patient needs to be seen by physical therapy prior or discharge for gait training and use of assistances devices. Patients should not be discharged prior to completing all physical therapy requirements.

• Original dressing not to be changed for 12-14 days
• Ex-Fix to be sprayed with alcohol, pins cleaned, and sterile 4×4’s placed around each wire at initial bandage change by resident/doctor.
• After initial bandage change then patient can start daily cleaning of frame themselves. This will consist of spraying frame/wires daily with alcohol. Patients are instructed to not touch wires or remove scabs/crust. 4×4’s no longer need to be placed around wires unless the patient is diabetic, the wire has discharge, or if an animal is present in home.
• Once all wires are dry and stable the patient can start cleaning frame at about every 3 days.
• Once all wires are dry and stable the patient is allowed to shower/bath, whirlpool, swimming pool with spray application of alcohol immediately after.
• Frame needs to be covered at all times (except when in water) with ACE wraps or cloth bag that can be tied at the top.
• Roll of Kerlix to be placed between frame and leg in areas of swelling or when the frame is nearing the skin.
• Foot pad can be made with blue towels or ABD pads and incorporated into dressing for WB assistance
• Entire frame to be wrapped in ACE Bandage (Normally takes three rolls of 6 inch ACE)

Warning Signs:
• If the patient is concerned about pin tract infection (redness, swelling, pain, discharge) give them a prescription for oral antibiotics and see them in the office within 24 hours. Also, it is okay to give a patient a prescription for an antibiotic ahead of time and tell them to begin taking the medication if the above signs/symptoms occur and to contact office within 24 hours to make appointment.
• Superficial erythema and drainage around a wire is normally due to a loose or unstable wire (not due to infection) this can be resolved by tightening the wire with the “Russian Technique”. This technique involves applying a wrench to the top part of the bolt (the one in which the wire is passing through) and applying a wrench to the nut below this bolt. Next, tighten the bottom nut. While holding the bottom wrench in place, tighten the top bolt between a quarter and half a turn, depending on how lose the wire is.
• Painful wires are normally a sign of loose unstable wire or because of high tension on the skin. This can be resolved by tightening the wire and by releasing the skin around the wire with a # 11 blade. This is performed quickly and normally does not require anesthesia
• Granulomas are common around wires and after the ex-fix are removed. These can be resolved with a silver nitrate stick.
• Superficial infections are normally cared for with oral antibiotics; however, deep or un-resolving infections should be admitted for IV antibiotics to prevent osteomyelitis.
• Augmentin 875 mg 1 tab PO BID x 14 days (broad spectrum, commonly used)
• Cipro 500 mg 1 tab PO BID/Clindamycin 300 mg 1 tab PO QID Combo (for PNC allergy)
• Zyvox 600 mg 1 tab PO q12h

Post-Op Pain:
• Outpatients and patients at discharge should be placed on Tylenol # 3 1-2 tabs PO q4-6h
• While in the hospital it is okay to use whatever is needed for post-op pain relief however upon discharge they should be switched to Tylenol # 3. Normally post-ops that get admitted will be placed on PCA per anesthesia with either Norco 10/325 or Vicodin ES. Titrated off PCA then titrated down to Tylenol #3 then discharged. Post-ops are normally discharged on post-op day # 2.
• Never use Toradol, this inhibits bone healing. Ask the anesthesiologist to not use Toradol at the end of cases, if orthopedic work was performed.

Removal of Ex-Fix:
• Removal of circular external fixator is determined by a CT scan to confirm fusion or bone regeneration.

Cleaning Solution:
• Daily/Home/Clinic cleaning – 70% Isopropyl alcohol.
• O.R. Scrub Spray – Mixture of the following:
– 50% Hibiclens 4% (Chlorhexidine)
– 45% Isopropyl Alcohol 70%
– 5% Hydrogen Peroxide


This is a case of a 55-year-old female with a past medical history of non-insulin diabetes, peripheral arterial disease and asthma presented one hour after being involved in an MVA. Radiographs were obtained of the left ankle (Figure 15). There was an intra-articular fracture of the tibial plafond with impaction of the articular cartilage as well as comminution of the tibial dia-metaphyseal region (OTA classification 43-C1).

Treatment Stage 1: Patient underwent closed reduction with application of posterior splint (Figure 15).

Figure 15

Figure 15 Closed, displaced, intra-articular tibial plafond fracture left ankle.

Physical examination revealed isolated trauma to the left lower extremity. Brisk CFT to digits, with significant edema and ecchymosis to left ankle. No open fracture visualized, no tenting of the skin.

Treatment Stage 2: Patient underwent the previous discussed surgical technique with application of external fixator (Figures 16, 17).

Figure 16

Figure 16 a. Application of smooth wire and half ring about the calcaneus. b. Intra-op fluroscopy pictures of the reduction via ligamentotaxis, revealing anatomic alignment of the tibial plafond.

Figure 17

Figure 17 Final frame construct.

The external fixator was kept in place for 12 weeks. There were no severe complications during the post-op course, only a minor pin site redness which resolved with localized wound care. Patient was non-weight bearing for 8 weeks following fixator removal and has been in an AFO since that time. Final weight bearing films were taken at 10 months post-operatively (Figure 18).

Figure 18

Figure 18 Final lateral (a) and AP (b), weight bearing radiographs at 10 months post-operatively.


Traditional approaches to fixation for pilon and distal tibial involve large ancillary incisions putting the already fragile soft tissue envelope at even more risk of complications. According the senior author (ER), the following data has been compiled retrospectively for both pilon fractures as well as distal tibial fractures using this surgical technique. In the pilon fracture series (n= 37, mean age 57, m= 17; f= 40), mean follow-up was 42 months and an average AOFAS score of 85.04. Combined complication rate was 13% (infection, metal breakage, wound dehiscence) and two patients requiring below the knee amputations. In the Distal tibial fracture series (n= 22, mean age 62, m= 22;f= 40), with mean follow-up of 28 months and an average AOFAS score of 92.13. Combined complication rate of 23% (Infection, metal breakage, wound dehiscence) and three patients requiring below the knee amputation.


The use of circular external fixation alone in a single staged procedure might help to decrease the risk of morbidity and even mortality for these patients as shown in the data presented by the senior author. Single stage approach using external fixation allows the patient to have more mobility by allowing partial weight bearing starting on post-operative day one. As with any surgical technique, the individual patient must be fully evaluated and this technique is not proposing that it be used on every pilon fracture.


  1. Blotter RH, Connolly E, Wasan A et-al. Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int. 1999;20 (11): 687-94. – Pubmed
  2. McCormack RG, Leith JM. Ankle fractures in diabetics. Complications of surgical management. J Bone Joint Surg Br. 1998;80 (4): 689-92. – Pubmed
  3. Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. J Bone Joint Surg Am. 2008;90 (7): 1570-8. – Pubmed


Drs. Rodriguez, Cherkashin, and Samchukov are consultants for Orthofix.