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The Journal of Foot & Ankle Surgery 57 (2018) 44–51

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The Journal of Foot & Ankle Surgery
j o u r n a l h o m e p a g e : w w w. j f a s . o r g

Does First Ray Amputation in Diabetic Patients Influence Gait and
Quality of Life?
Irene Aprile, MD, PhD 1, Marco Galli, MD 2, Dario Pitocco, MD 3, Enrica Di Sipio, MSc 4,
Chiara Simbolotti, BSc 5, Marco Germanotta, PhD 4, Corrado Bordieri, BSc 6, Luca Padua, MD, PhD 7,8,
Maurizio Ferrarin, PhD 9
Director, Rehabilitation Department, Don Carlo Gnocchi Onlus Foundation, Milan, Italy
2Orthopedic Surgeon, Institute of Clinical Orthopaedic, Catholic University, Rome, Italy
3Associate Physician, Department of Internal Medicine, Diabetes Care Unit, Catholic University, Rome, Italy
Research Engineer, Don Carlo Gnocchi Onlus Foundation, Milan, Italy
5Researcher, Don Carlo Gnocchi Onlus Foundation, Milan, Italy
6Orthopedic Technician, Protesi Ortopediche Romane, Rome, Italy
7Research Head, Don Carlo Gnocchi Onlus Foundation, Milan, Italy
Associate Professor, Department of Geriatrics, Neurosciences and Orthopaedics, Catholic University of the Sacred Heart, Rome, Italy
Research Head, Biomedical Technology Department, IRCCS Don Carlo Gnocchi Foundation, Milan, Italy


Level of Clinical Evidence: 4 It has recently been suggested that first ray amputation in diabetic patients with serious foot compli-
cations can prolong bipedal ambulatory status, and reduce morbidity and mortality. However, no data
are available on gait analysis and quality of life after this procedure. In the present case-control study
diabetes (6 amputee and 6 nonamputee diabetics, 6 healthy non-diabetic), a sample of amputee diabetic pa-
gait analysis tients were evaluated and compared with a sample of nonamputee diabetic patients and a group of age-
hallux matched healthy subjects. Gait biomechanics, quality of life, and pain were evaluated. Compared with
quality of life the other 2 groups, amputee patients displayed a lower walking speed and greater variability and lower
ankle, knee, and hip range of motion values. They also tended to have a more flexed hip profile. Pain
and lower quality of life were related to worsening biomechanical data. Our study results have shown
that gait biomechanics in diabetic patients with first ray amputation are abnormal, probably owing to
the severity of diabetes and the absence of the push-off phase provided by the hallux. Tailored orthotics
and rehabilitation programs and a specific pain management program should be considered to improve
the gait and quality of life of diabetic patients with first ray amputation.
© 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.

Diabetes is one of the most common chronic diseases in the world. diabetic foot ulcers ranges from 0.6% to 2.2% (4). It has been esti-
The incidence of diabetes has increased steadily in recent years (1). mated that diabetes and its comorbidities account for 50% of the lower
Type 2 diabetes mellitus has reached epidemic proportions, affect- extremity amputations performed worldwide (5), and an estimated
ing 56 million people in Europe (i.e., 8.5% of the adult population) (2). 85% of all diabetes-related amputations are preceded by a foot ulcer
Although the natural history of diabetic neuropathy remains unclear, (6).
the late sequelae of the disease include foot ulceration and, in the worst Neuropathy, foot ulceration and, in the worst cases, amputation,
scenario, amputation (3). According to community-based studies from lead to limited joint mobility in 30% to 40% of diabetic patients, es-
North America and European countries, the annual incidence of pecially in the ankle joint and first metatarsophalangeal joint (7). Joint
impairment can lead to functional gait variations, and their severity
depends on the extent of the neuropathy, ulcers, and level of ampu-
Financial Disclosure: None reported. tation (8–11).
Conflict of Interest: None reported. Two reviews (12,13) of gait characteristics in diabetes reported
Address correspondence to: Irene Aprile, MD, PhD, Centro Santa Maria della
Provvidenza, Fondazione Don Carlo Gnocchi ONLUS, via Casal del Marmo, Rome
(1) the presence of conservative strategies, including slower walking
401-00166, Italy. speeds, prolonged double support time, and a wider base of gait; and
E-mail address: iaprile@dongnocchi.it (I. Aprile). (2) the presence of greater step variability. All these factors lead to

1067-2516/$ - see front matter © 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.

ID- depend on the level of the amputation. Anthropometric data were collected for each subject and reduce the patient’s morbidity and mortality (21). In contrast. Each item is quantified on a numeric scale (range 0 to 10).6 years). cadence. Billington et al (35). cognitive or visual impair. Self-reported data (using QoL and pain To assess the lower limb joint kinematics on the sagittal plane. diabetic patients with neuropathy. A study conducted by Paul et al (14). / The Journal of Foot & Ankle Surgery 57 (2018) 44–51 45 an increased risk of falls and a greater likelihood of developing a foot inclusion in the study. Higher absolute SAI and TAI values indicate greater asym- liable to cause motor gait impairment (e. consequently. ⎛ SingleSupportTime_AmputeeSide ⎞ TAI = 100 × ⎜ 1 − ⎟ (2) the healthy subject (HS) group (4 females. sal head. Italy). mean age 67. walking trials were acquired for each subject. All the participants gave written informed consent before cifically. right and left fibular head. It contains 10 specific categories of physical nondiabetic subjects (15). ID-Pain. compared with NASS. contrasting results have been re- ported. have less effect on a patient’s walking ability (15). right and left lateral femur condyle. version 7. spontaneous ongoing and paroxysmal pain. val between 2 consecutive heel contacts of the same foot. which complied with the Declaration of Helsinki. disease duration since diagnosis. Transmetatarsal amputation not only preserves ankle function and maintains a distal weightbearing surface but also ensures Gait Analysis a more energy-efficient gait (17) compared with more proximal am- putations. Eq. we calculated the standardized measures) were collected. mean 13 ± 7. 12 items: 10 that describe the different symptoms and 2 that assess the duration of putations. putations. groups of 5 trials were lationship between quantitative gait parameters and QoL in diabetic separated by a 1-minute rest. The subjects were equipped with 22 retroreflective markers. Milan. mean ± standard deviation 16 ± 6.. and step width. and ankle joint angular displacements and their range of motion (ROM). to the subjects involved Regarding the biomechanical studies on kinematic gait changes in in the study. The NPSI is a self-administered ques- the physical effort required to maintain walking ability (14). longer double and single (SF-36) and North American Spine Society (NASS) questionnaire. and the Neuropathic Pain Symptom In- were seen in the neuropathic patients compared with the diabetic and ventory (NPSI). right and left mid-thigh. abetic patients who have undergone amputation.4. which is used to analyze neurologic symptoms and lower limb function. Ten linear nerve damage (24). cardiac diseases (which could reduce safety when walking). percentage of duration of the swing and double Patients and Methods support phases.5. (without shoes for nonamputee patients and without toe filler for amputee patients) straight ahead along a level surface that was approximately 6-m long. We enrolled 6 male diabetic subjects with unilateral FRA. hip. in transfer of the primary role of power system (BTS Bioengineering. A total intensity score can be calculated Few data are available on gait analysis in patients with forefoot am. Before formal measurements were started. yields healthy subjects. The official Italian version of the SF-36 (26) consists of 36 questions that cover the general health of patients. such as transmetatarsal amputations or forefoot am. pathologic nerve conduction velocity findings. Walking limitations with the score ranging from 0 (no pain) to 10 (the worst imaginable pain) (28. Eq. the amputee ⎛ StepLength_AmputeeSide ⎞ diabetic patient (ADP) group (mean age 75. The final version of the NPSI contains foot amputations. Data were processed using 3-dimensional reconstruction software (SMARTAnalyzer. The system consists of 8 infrared cameras (sampling rate of 250 Hz) to acquire movement of the reflective spherical markers placed for walking from the ankle to the hip (5. The scores for each category range from 0 to 100. The without neuropathy. Italy) and MATLAB.e. Aprile et al.17–19). The diagno. and lower growth rates using the numeric rating scale (NRS). disease duration since SAI = 100 × ⎜ 1 − ⎟ (1) ⎝ StepLength_NoAmputeeSide ⎠ diagnosis.0. 2) were calculated for the ADP group as follows (34): Our study should be considered a pilot study conducted for exploratory data anal- ysis purposes. with higher scores Some studies have investigated the kinematic gait changes in di- indicating better health (27). 4 males. the SAI and TAI were computed according to Hodt- exclusion criteria were a history of previous amputation. the diabetic patient (DP) group (2 females. metry. by summing the scores of the 12 items (31). To evaluate the asymmetry and bilat- Participants eral coordination of gait. The following spatiotemporal parameters were calculated: stance. knee. However. but not in those with neuropathy. 2 scores: lumbar spine pain/disability (NASS-P) and lumbar spine neurogenic symp- toms (NASS-L). right and left lateral malleolus. The gait cycle duration was defined as the inter- these patient-oriented subjective tools and the objective gait data.29). which was explained. The markers were placed on the following ana- in patients who have undergone first ray amputation (FRA). The ethics com- ulcer. range 64 to 73 years). No studies have yet been conducted on the kinematic gait changes according to the Davis protocol (32). right and left fifth metatar- that can save the foot. and right and left heel. Natick. The NRS (range 0 to 10) measures the intensity of pain. The score for each category ranges from 0 to 100. The aim of the present study was to investigate whether diabetic Data Analysis patients with FRA adopt different walking strategies from either nonamputee diabetic patients or healthy subjects. and perfect symmetry in the spatiotemporal parameters corresponds to an SAI sis of peripheral neuropathy was defined as a neuropathy disability score >5 (25) and and a TAI of 0. right and left acromioclavicular joint. 1) and temporal asymmetry index (TAI. lower minimum vertical force. sacrum. ⎝ SingleSupportTime_NoAmputeeSide ⎠ The inclusion criteria were type 2 diabetes mellitus (with or without diabetic neu- ropathy) and the ability to walk independently without assistance or walking aids. Similarly. 6 diabetic patients without FRA.g. defined tomic landmarks: seventh cervical vertebra. the coefficient of variation was calculated as the ratio between the standard deviation and the mean value for each subject. respectively. 2 males. range 60 to 90 years. A significant worsen. (33). over anatomic landmarks. in which diabetic patients QoL and Pain Assessment with neuropathy were compared with those without neuropathy. Italy). This surgical technique was recently proposed as a procedure right and left mid-shank. Milan. Major amputations will result Pain is a 6-item self-administered questionnaire developed by Portenoy (30) to in significant functional impairment associated with the increase in discriminate neuropathic from nociceptive pain. right as amputation of the phalanxes and at least part of the metatarsus and left anterior superior iliac spine.. shorter steps. neuropathic subjects walked The QoL assessment was performed using the Short-Form 36-item Health Survey more slowly and took smaller steps). together with the aims of the research. radiculopathy and fractures). Yavuzer et al (16) found slower and emotional domains. Pain was evaluated stance times. with very gait. patients. MA). and limited knee and ankle mobility in patients low values corresponding to severe physical impairment or emotional discomfort. Milan. Both diabetic ing occurs in the QoL of diabetic patients (23) in relation to peripheral and healthy subjects were asked to walk at a comfortable self-selected speed. To avoid fatigue. mean age 68. practice sessions were performed to Abnormal gait can negatively affect quality of life (QoL) and has familiarize the participants with the procedure. mittee of the Don Carlo Gnocchi Onlus Foundation approved the experimental protocol. Pain and QoL were Three-dimensional marker trajectories were tracked using a frame-by-frame track- evaluated to analyze possible differences between amputee and ing system (Smart Tracker-BTS. range 65 to 73 years. prolong the patient’s bipedal ambulatory status. step length. Partial tionnaire designed to evaluate various symptoms of neuropathic pain. no studies have yet investigated the re. nonamputee diabetic patients and to evaluate any correlation between software (MathWorks. I. Spe- formed of all 18 subjects. BTS.6 years). de- tected differences in gait parameters (i. the spatial asymmetry index (SAI. (20). For all spatiotemporal param- eters.16. and other diseases support time. and an objective gait evaluation was per. we considered the amputated and nonamputated side for the ADP group . right and left greater trochanter. They were trained to walk barefoot been observed in a range of pathologies (22). The For the DP and HS groups. The latter result in compromised foot and ankle propulsive The gait analysis was performed using the Smart D500 stereophotogrammetric function and. using the lower and higher values of the step length and single ment. and 6 healthy subjects.

Pt.0 ± 2.2 ± 16. step length. NA. NASS.22 NS nificant differences for most of the SF-36.47 NS A comparison of the ADP and DP groups showed statistically sig.2 187 19 NA NA No No No DP5 M 67 30. patient number.02 NS 36 role physical (p < .05).05 the 2 groups were observed in age. Tulsa. .01).61 <.8 ± 24. separately.02 1.3 ± 2. Aprile et al.01). for the DP and HS groups..01 Role emotional 33. Significant differences in mean speed were observed between Statistical Analysis the ADP and DP groups (p < .8 ± 10. QoL. NASS-L. and SF-36 height were not statistically significantly different neither between the Physical function 39.3 ± 3.01 height. quality of life. and step width) in the ADP (amputated side).20 <. SF-36. or history QoL of acute myocardial infarction.63 NS NRS 3.56 84.05). nonparametric analyses were performed.28 NS 2).8 ± 1.65 <.7 160 20 NA NA No No No DP3 M 65 26.68 NS QoL and Pain Social function 52. acute myocardial infarction.76 1.01). lower extremity arterial occlusive disease.5 ± 41.5 170 7 NA NA No No Yes DP6 F 72 26. 2. age.01 Role physical 37. 1). than for the DP group. worse pain) in Abbreviations: ADPs.6 ± 0. / The Journal of Foot & Ankle Surgery 57 (2018) 44–51 Table 1 Diabetic patients with and without first ray amputation: clinical characteristics Pt. F. the NPSI.02 0.2 ± 24. no pain.3 ± 1. In particular.44 0. percentage of double support. SF-36 physical composite score.7 ± 7. To deter. group for any of the spatiotemporal data between the amputated mine the clinical differences between the 2 patient groups.e.23 54.19 NS Vitality 45.56 <.01 General health 44..9 168 11 Left 7 Yes Yes Yes ADP6 M 72 27 172 24 Left 4 No No Yes DP1 F 67 29.9 ± 1.8 ± 20.2 158 3 NA NA No No No DP2 M 65 26.4 ± 1. SF-36 bodily pain (p < . * Higher scores are more indicative of pain with a neuropathic component. history of lower extremity arterial occlusive disease. NRS.0 ± 0.01).7 ± 1. body mass index.63 0.01).55 NS Evoked pain 3.0 NS The clinical features.3 ± 0. DP. Moreover.2 ± 12.50 49.01). The level of significance for all parameters was set at p ≤ . yielded higher scores (i.0 ± 6. disease duration. and NPSI items (Table Physical composite score 33. greater neuropathic pain) for the ADP group NS. Finally. and nonamputated sides. we only considered the data from the The Kruskal-Wallis test was used to determine differences between the groups for all amputated side. AMI.05) and between the ADP and HS groups (p < . and SF-36 physical composite score (p < .e.7 ± 12. we performed the Mann. body mass index. No. worst imaginable pain). When the test was positive. and diabetic Pressing (deep) spontaneous pain 2. pain).1 ± 0.57 <.05. of stance. diabetic patient. nor between the DP and HS groups. worse QoL) NASS than those of the DP group for SF-36 physical function (p < .21 97. score of 10..7 ± 16. amputee diabetic patient. Sex Age BMI (kg/m2) Height (cm) Time Since Amputation Time Since LEAOD AMI Neuropathy (y) Diagnosis (y) Side Amputation (y) ADP1 M 71 32. not applicable. Neuro- the ADP group than in the DP group (p < . No statistically significant differences between Paresthesia/dysesthesia 5.30 72.05).51 1.0 ± 1. male.7 ± 27.08 100 ± 0. (Fig.5 ± 23. The main spatiotemporal parameters (percentage the variables investigated. NPSI. DPs.58 55.e.88 NS Sample NPSI Burning (superficial) spontaneous pain 2. NRS. body mass index.0 ± 0. NPSI-evoked pain (p < . Because no significant differences emerged in the ADP Owing to the small sample size. female.46 I. Data presented as mean ± standard deviation. SF. and NPSI total score (p < .3 ± 3.70 51. pathic Pain Symptom Inventory (higher scores indicate greater intensity of neuropathic pressing (deep) spontaneous pain (p < .6 171 13 Right 11 No No No ADP4 M 90 22.01 comorbidities in the ADP and DP groups are listed in Table 1.01 Mental composite score 40. Bodily pain 35. we averaged the data between the right and left Gait Analysis: Spatiotemporal Parameters sides. DP.64 94. SF-36 mental compos- ite score.1 162 11 Left 5 No No No ADP5 M 86 25.05 of the DPs had ulcers.4 ± 3. OK) package.7 ± 3.3 166 19 NA NA No No No DP4 M 73 23.45 79.3 ± 3.0 <.86 <.14 1.1 ± 2. although not between the DP and HS groups Statistical analysis was performed using the StatSoft (Statistica.. LEAOD. Lumbar spine neurogenic symptoms 67.0 165 7 NA NA No No No Abbreviations: ADP. BMI.05).5 ± 13. Whitney U test to determine exactly where the differences between groups lay. No.93 <. Moreover.1 165 12 Right 8 Yes Yes Yes ADP3 M 63 26. NPSI.13 <.66 0.5 170 25 Right 1 Yes Yes No ADP2 M 71 33. the gait spatiotemporal parameters and joint ROMs and the results from the ID-Pain.00 <. diabetic patients. All the tests should be considered exploratory because no previous Table 2 power calculation or subsequent corrections for multiple testing were applied. the NASS-P scores were significantly lower (i.8 ± 4. Short-Form 36-item Health Survey (lower scores indicate NPSI-paresthesia/dysesthesia (p < . Pain and quality of life assessment questionnaire scores Variable ADPs (n = 6) DPs (n = 6) p Value Results Pain ID-PAIN* 1. amputee diabetic patients. and NASS-P questionnaires. over.8 ± 19. More. NASS.01 function (p < . and we used Spearman’s rank correlation coefficient test to evaluate the correlations between HS (mean value between lower limbs) groups are shown in Fig.05 ADP and HS groups. percentage of swing. the ADP group yielded lower values (i.8 ± 14. the Mann-Whitney U test was used for continuous variables and the Fisher exact test for categorical variables. North American Spine Society (higher scores indicate better health). anthropometric aspects. None Paroxysmal pain 1.69 91. Total score 15.0 ± 0. numeric rating scale (score of 0. M.3 ± 51. Mental health 52. SF-36 social Lumbar spine pain/disability 61. not statistically significant.01) low QoL).5 ± 28.05 94. SF-36 bodily pain. cadence.

5 box lengths from the box. DP. with no significant difference in hip ROM detected between the DP p < . diabetic patient (n = 6). HS. I. A significantly greater coefficient of variation was observed for the ADP group than for the DP group in the duration of the swing phase (p < . 5.01). DP. and hip joints. ADP.01. sion peak (p < .05).01) and between the ADP and HS groups (step length. healthy subject (n = 6). The reduction detected in the ADP group compared with the DP and HS groups. Gait Analysis: Joint Kinematics The peak value of the angular displacement. The knee flexion peak in the swing phase was lower step width.01). p < . Box plot showing the comparison in spatiotemporal parameters among the groups. p < . The hip joint extension profile was remarkably indicates the median. the range of observations. 5). healthy subject (n = 6). and HS groups. the DP and HS groups. In the ADP group. amputee diabetic patient (n = 6). and ankle joint kinematics for the 3 groups are Fig.01. with a shorter step length and larger step width in the ADP group than in the other 2 groups (Fig. p < . step width.01 for both ADP versus DP and ADP versus HS).05) and difference in the knee flexion peak contrast. ROM for the ankle. . knee. we only considered data from the amputated side. no statistically significant differences were found between (p < . the range of observations excluding outliers (circles). diabetic patient which was confirmed by the significant reduction in the hip exten- (n = 6). knee. and statistical analysis results are listed in Table 3. and the vertical bars. between the ADP and DP groups (step length. 2. The hip joint ROM was also reduced in the ADP group compared with the DP and HS groups (although without reaching statistical signifi- Significant differences were observed in step length and step width cance). ADP.01) and step length (p < . The box shows the interquartile range (25th to 75th percentile). The coefficient of variation of the spatiotemporal although not between the ADP group and the DP group. therefore. A greater Fig. 4). 1. 5) in the ADP group than in either the DP or HS group. Finally. **Statistically significant difference (p < .01). Outliers are observations >1.05) and step length (p < . nificant difference (p < . A significantly greater coefficient of variation was also observed for the ADP group compared with the HS group in the duration of the swing phase (p < . Aprile et al.05) was significant between the ADP group and the HS group. Hip joint kinematic behavior in the DP group was normal. Box plot showing the comparison in walking speed among the groups. amputee diabetic patient (n = 6). The box shows the interquartile range (25th to 75th percentile). and the vertical bars. / The Journal of Foot & Ankle Surgery 57 (2018) 44–51 47 parameters is shown in Fig. The mean hip. the horizontal line box shown in Fig.05). no significant differences emerged for any of the kinematic data between the amputated and nonamputated sides. *Statistically sig. HS. shorter (Fig. the horizontal line indicates the median. no significant differences among the 3 groups were observed in the SAI and TAI (Fig. 3. In observed in ROM (p < .

with the HS group.05) in the ADP group compared (r = 0. p < .67.01).01). / The Journal of Foot & Ankle Surgery 57 (2018) 44–51 Fig. the horizontal line indicates the median. A qualitative analysis of the plot (Fig. **Statistically significant difference at p < . p < . Aprile et al. . which was confirmed by the vealed that the NPSI scores correlated positively with step width significantly lower ankle ROM (p < . ADP. diabetic patient (n = 6).48 I. extremes are >3 box lengths from the box. with the ADP group displaying Correlations Between Pain and QoL and Biomechanical Parameters lower levels of dorsiflexion and plantarflexion. HS. and the vertical bars.01. knee ROM (r = −0. 5) revealed a marked reduction in plantarflexion The correlation analysis between the gait parameters and pain re- during push-off in the ADP group. DP. the range of observations excluding outliers (circles) and extremes (stars).64. ADP. diabetic patient (n = 6). Outliers are observations >1. difference emerged in the ankle joint.5 box lengths from the box.05). DP. p < . ankle ROM (r = −0. the horizontal line indicates the median. amputee diabetic patient (n = 6).78. The box shows the interquartile range (25th to 75th percentile). p < . and the vertical bars. 3. amputee diabetic patient (n = 6).05. *Statistically significant difference at p < .05) and negatively with step length (r = −0. the range of observations excluding outliers (circles) and extremes (stars). Box plot showing the comparison in coefficient of variation (CV) of spatiotemporal parameters among the groups. The box shows the interquartile range (25th to 75th percentile). 4. healthy subject (n = 6). and knee Fig. HS. Outliers are obser- vations >1. Box plot showing the comparison in spatial asymmetry index (SAI) and temporal asymmetry index (TAI) among the groups.5 box lengths from the box. healthy subject (n = 6).77. extremes are >3 box lengths from the box.

01) and nega. which be tailored to the patient.59 NS NS NS Ankle plantarflexion peak −7.96 ± 5.01).77. an alternative explanation might be that the effects of neu- shorter step length. and HS group.00 ± 10.86 15.71.01) and positively with step width (r = 0.49 ± 6. p < . Abbreviations: ADPs. It is noteworthy that no differences were detected in the ADP group Discussion for any of the spatiotemporal data between the amputated and nonamputated sides. p < .44 NS NS NS Knee ROM 38. p < . lished studies have reported that patients who undergo partial FRA nificant differences were found between the ADP and HS groups for often progress to requiring a more proximal repeat amputation (37). They hypothesized that step length (r = 0.02 NS <.60.. were 2 and even 3 times greater than those for either the DP or HS hallux rigidus seems to be a predisposing factor for reamputation group (Table 3). their hip flexor muscles (17). Re. p < .72. The joint angular trajectories of the DP group were the factors leading to the development of plantar foot ulcers. not statistically significant.69. abnormal plantar pressure is one of and DP groups. the pain measures we adopted showed . prevailed over those of the monolateral than either the DP or HS group. p < . no differences were found among In the present study. Yet another possible explanation is that the ADP group variability in step length and duration of the swing phase. according to Oliver et al (42).51 ± 10. To gain a more thorough related with the lower level of amputation. p < .85 ± 2.46 13. and knee flexion peak (r = 0.12 ± 4. For the QoL and peak power at the ankle and the ROM at the hip were lower in measures. and a slower walking speed ropathy.49 57.48 ± 5.63 ± 4. Thus.01). as expected. knee ROM because those who undergo transmetatarsal amputation have a (r = 0.63 NS NS NS Hip extension peak 14.33 ± 11. proximal amputation owing to the better weightbearing with the not only between the ADP and HS groups. suggesting intersubject variability within the ADP group.81 ± 6.58 ± 15. / The Journal of Foot & Ankle Surgery 57 (2018) 44–51 49 Table 3 Kinematic parameters Parameter ADPs (n = 6) DPs (n = 6) HSs (n = 6) p Value ADPs vs DPs ADPs vs HSs DPs vs HSs Hip ROM 33.21 ± 3. our biomechanical data were ob- ROM (r = 0.70.87 4. knee results from Mueller et al (17).03 ± 6.05 NS Knee extension peak 4.70.31 39.61.05) and knee flexion involvement of the knee joint. sig. a larger step width.65. knee. a total contact insole) to reduce the likelihood of reamputation (40). the 3 groups in the SAI and TAI parameters.68. Pain measured using the SF-36 bodily When Mueller et al (17) compared transmetatarsal amputee sub- pain subscale also correlated negatively with step length (r = −0. not differ from that of the nonamputated side (Fig.01). ROM.27 41.25 27. Aprile et al. pub- the ADP and DP groups was in the hip extension peak. resulting in a new ampu- However. I.26 5. at least with respect to asymmetry of the gait.75.01) amputees.50 ± 2.70.08 ± 4.05). the SF-36 physical composite score correlated positively with the amputee subjects than in the controls. flexion peak (r = −0. p < . The ADP group also displayed a greater amputation.03 ± 10. p < .45 61.72.02 NS <. p < .70 ± 5.32 ± 15. and always within the range of healthy subjects. and knee flexion tained from subjects who walked barefoot (without shoes or. p < .05). we also significant abnormalities were symmetrically present in the ADP group evaluated pain and QoL using validated tools.g. as Regarding QoL and pain.60 ± 15.99 ± 5.05). The joint kinematic pattern of the amputated side did after FRA.01 <. 5). p < . amputee diabetic patients.69 NS NS NS Ankle ROM 15. ankle ROM (r = 0.41 ± 8. hip ROM (r = 0.59. jects with a control group. The kinematic parameters at the hip tively with the ankle dorsiflexion peak (r = 0.05) and negatively with step width (r = −0. our results have shown that the QoL con- confirmed by the very similar kinematic values for both sides cerning physical aspects and pain was worse in the ADP group than (Table 3). in peak (r = 0. However. p < . healthy subjects.05). the only significant difference between amputation. p < .72 ± 8. We did not adopted a compensatory strategy on the intact side to limit the asym- observe any significant differences in walking speed between the DP metries arising on the amputated side. The SF-36 mental composite score correlated posi. This finding might be cor- nematics in patients with diabetes and FRA.01) and hip extension peak (r = rely more heavily on “pulling” their leg forward from the hip using −0. 5) in the ADPs. as demonstrated by the that the choice between the latter or other minor amputations should standard deviation of the kinematic parameters of that group.93 43.98 ± 4.01 NS Knee flexion peak 42. In patients with diabetes. In particular. but those of the ADP group ulcers are a precursor to amputation (38. NS.74.76.39). we investigated 3-dimensional lower limb ki.15 57.05).61 <. peak moments.05 NS Hip flexion peak 47. which is bilateral. p < .74 ± 5. reduced ability to generate plantarflexor power at the ankle. because understanding of the biomechanical data from such patients.54 NS NS NS Ankle dorsiflexion peak 8.34 NS NS NS Data presented as mean ± standard deviation. NASS-L and ankle in our subjects were similar and. fies the kinematic behavior of all the lower limb joints.40 ± 8.69. but also between the ADP latter. Although FRA seems to affect gait less than a more proximal garding the biomechanical data. it is important to were largely outside the control range for a considerable portion of reduce the plantar pressure in these patients (e. in the DP group. accordingly. For example.72 −2. 5 clearly indicate that marked differences were present. In contrast. We believe that the risk of new ulceration.59. and ankle joints tation. first ray on gait.66 ± 2. the angular trajectories of the hip. p < . p < . without a toe filler) to ascertain the true effect of a missing and hip extension peak (r = −0. DPs. Unlike the NASS-P correlated positively with step length (r = 0.05).02 −3. and hip extension peak. in keeping with the findings from Rao et al (36). p < . The ADPs exhibited a (Fig.56 52. they found that the ROM. knee ROM. will be greater for those undergoing FRA rather than a more shown in Fig. p < . HSs. ankle ROM. That such marked deviations did not result in statisti.19 21. range of motion. knee flexion peak. This finding suggests that FRA modi- peak (r = 0.48 ± 3.51 −12.30 −7. so was the correlated positively with step length (r = 0.05) and negatively with step width (r = −0.03 39.61.05). p < . cally significant differences in the numeric parameters was likely A recent meta-analysis (41) reported a high occurrence of more because of the limited sample size and the marked degree of proximal amputation after transmetatarsal amputation.05).05). they tively with step width (r = −0. diabetic patients. using a shoe with the gait cycle.

In conclusion. Each curve represents the average of trials and subjects for each group. specific gait rehabilitation treatment . diabetic patient (n = 6). One possible reason for this finding is that diabetic and the lack of kinetic gait data and speed-matched controls (because neuropathy affects 50% of ADPs but only 1 in 6 of DPs. and. sive than other surgical treatments. was deteriorated compared with those of our diabetic patients thy increases (6). that the ADPs complained of neuropathic pain symptoms more often The potential limitations of our study were the small sample size than did the DPs. a reduction in ankle ROM (p < . FRA negatively affects the gait ropathic pain. DP. / The Journal of Foot & Ankle Surgery 57 (2018) 44–51 Fig. and ankle joint kinematic for the 3 groups. Hip. amputee diabetic patient (n = 6). but also from more severe neu. of very low subject compliance. we found that in chronic complications associated with diabetes and the consequent our amputated patients neuropathic pain was increased and QoL greater risk of biomechanical worsening as the severity of neuropa. which decreased further because they cant correlation between QoL and pain and the biomechanical data were asked to walk barefoot). without amputation. ADP. a reduction in the knee flexion peak (p < . when compared with HS. although less inva- not only from the missing first ray. The signifi. knee. Aprile et al.50 I. 5. Moreover. Our findings further support the progressive nature of strategies in patients with diabetes. The curve for the healthy subject (HS) group (n = 6) was associated with ±1 standard deviation range. our results have showed that. finally.05) in ADP when compared with HS. Therefore.05) in ADP. Statistical analysis showed a reduction in the hip ex- tension peak (p < . suggests that the abnormal gait performance in the ADPs might result.01) in ADP when compared both with DP and HS.

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