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Doerks F, Riedel L, Einfeldt AK, Windhagen H, Hurschler C, Jakubowitz E. Contribution of various forefoot areas to push-off peak at different speeds and slopes during walking. Gait Posture 2024; 108:264-269. [PMID: 38150947 DOI: 10.1016/j.gaitpost.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/24/2023] [Accepted: 12/20/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Push-off during the terminal stance phase has a major impact on forward progression during walking. During this phase, the ground reaction force is applied to a small area under the forefoot. A better understanding of how single forefoot areas contribute to push-off peak in healthy subjects is needed to develop biomimetic orthopedic devices for forefoot amputees. RESEARCH QUESTION What is the contribution of different forefoot sole areas to push-off peak as a function of speed and slope? METHODS In this analytical study, 15 healthy subjects walked on a treadmill at different speeds (0.8 m/s; 1.2 m/s; 1.6 m/s; max. gait speed) without de-/inclination and on different slopes (-10°; -5°; 0°; 5°; 10°) with normal walking speed. The Novel Pedar-X System was used to measure vertical sole force. Push-off peak of the entire sole was determined and relative contributions of the areas under the hallux, first ray, and toes (I-V) were calculated and analyzed using separate repeated-measures ANOVA (α = 0.05). RESULTS Push-off peak increases with faster walking speeds as well as with 10° inclination. Downhill walking is associated with a reduced push-off peak. The contribution of all forefoot areas increases with faster walking speeds and at a declination of -10°. Push-off contribution of the area under the hallux increases by about 64.6% at fast walking compared to slow walking and this increase is higher than that of the area under the first ray and toes (p < 0.05). SIGNIFICANCE These findings indicate the major role of the hallux in speed generation and the importance of the forefoot during downhill walking. The results show the need for an adequate assistive device even in hallux amputation cases to compensate for deficits in the push-off phase.
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Affiliation(s)
- Frithjof Doerks
- Laboratory of Biomechanics and Biomaterials, Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Lisa Riedel
- Laboratory of Biomechanics and Biomaterials, Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Ann-Kathrin Einfeldt
- Laboratory of Biomechanics and Biomaterials, Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Henning Windhagen
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Christof Hurschler
- Laboratory of Biomechanics and Biomaterials, Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Eike Jakubowitz
- Laboratory of Biomechanics and Biomaterials, Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany.
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Sonoda Y, Maeshige N, Uemura M, Imaoka S, Kawabe N, Hayashi H, Fujii M, Tsuji Y, Furukawa M, Kohzuki M, Terashi H. Effect of Partial Foot Amputation Level on Gait Independence in Patients With Chronic Lower Extremity Wounds: A Retrospective Analysis of a Japanese Multicenter Database. INT J LOW EXTR WOUND 2023:15347346231158864. [PMID: 36814399 DOI: 10.1177/15347346231158864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Partial foot amputation (PFA) is generally planned to minimize the amputation level; nonetheless, the effect of PFA levels on gait independence in amputees remains unclear. This study aimed to investigate the impact of PFA levels of the forefoot on gait independence in patients with chronic lower extremity (LE) wounds. This multicenter retrospective cohort study included 232 hospitalized Japanese patients treated and rehabilitated for chronic LE wounds. A multivariate analysis based on PFA levels was conducted for gait independence at discharge, with age and comorbidities as independent variables. Patients with Lisfranc amputation had significantly less independent gait than patients with more distal amputation and those without amputation (<22% vs >40%; P = .027; Fisher's exact test). Logistic regression analysis revealed that Lisfranc amputation (odds ratio [OR]: 0.257, P = .047), age (OR: 0.559, P = .043), and chronic limb-threatening ischemia (OR: 0.450, P = .010) were independent factors associated with gait independence. Additionally, the regression model confirmed discrimination performance using the C index (0.691, P < .001) with receiver operating characteristic analysis. In patients with chronic LE wounds undergoing PFA, Lisfranc amputation was negatively associated with gait independence.
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Affiliation(s)
- Yuma Sonoda
- Advanced Research Center for Well-being, 12885Kobe University, Kobe, Hyogo, Japan
| | - Noriaki Maeshige
- 91723Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Hyogo, Japan
| | - Mikiko Uemura
- 91723Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Hyogo, Japan
- 38082Faculty of Health Science, Kansai University of Welfare Sciences, Kashiwara, Osaka, Japan
| | - Shinsuke Imaoka
- 38411Department of Rehabilitation, Oita Oka Hospital, Oita, Oita, Japan
| | - Nobuhide Kawabe
- 13101Faculty of Makuhari Human Care, Tohto University, Makuhari, Chiba, Japan
| | - Hisae Hayashi
- 38291Faculty of Health and Medical Sciences, Aichi Shukutoku University, Nagakute, Aichi, Japan
| | - Miki Fujii
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
- Division of Regenerative Therapy, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yoriko Tsuji
- Unit of Podiatric Medicine, 38303Kobe University Graduate School of Medicine, Department of Plastic Surgery, Kobe, Hyogo, Japan
| | | | - Masahiro Kohzuki
- 13302Department of Health Sciences, Yamagata Prefectural University of Health Sciences, Yamagata, Yamagata, Japan
| | - Hiroto Terashi
- 38303Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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de Oliveira FCL, Williamson S, Ardern CL, Fagher K, Heron N, Janse van Rensburg DCC, Jansen MGT, Kolman N, O'Connor SR, Saueressig T, Schoonmade L, Thornton JS, Webborn N, Pluim BM. Association between the level of partial foot amputation and gait: a scoping review with implications for the minimum impairment criteria for wheelchair tennis. Br J Sports Med 2022; 57:bjsports-2022-105650. [PMID: 36588404 DOI: 10.1136/bjsports-2022-105650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This scoping review examines how different levels and types of partial foot amputation affect gait and explores how these findings may affect the minimal impairment criteria for wheelchair tennis. METHODS Four databases (PubMed, Embase, CINAHL and SPORTDiscus) were systematically searched in February 2021 for terms related to partial foot amputation and ambulation. The search was updated in February 2022. All study designs investigating gait-related outcomes in individuals with partial foot amputation were included and independently screened by two reviewers based on Arksey and O'Malley's methodological framework and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. RESULTS Twenty-nine publications with data from 252 participants with partial foot amputation in 25 studies were analysed. Toe amputations were associated with minor gait abnormalities, and great toe amputations caused loss of push-off in a forward and lateral direction. Metatarsophalangeal amputations were associated with loss of stability and decreased gait speed. Ray amputations were associated with decreased gait speed and reduced lower extremity range of motion. Transmetatarsal amputations and more proximal amputations were associated with abnormal gait, substantial loss of power generation across the ankle and impaired mobility. CONCLUSIONS Partial foot amputation was associated with various gait changes, depending on the type of amputation. Different levels and types of foot amputation are likely to affect tennis performance. We recommend including first ray, transmetatarsal, Chopart and Lisfranc amputations in the minimum impairment criteria, excluding toe amputations (digits two to five), and we are unsure whether to include or exclude great toe, ray (two to five) and metatarsophalangeal amputations. TRIAL REGISTRATION The protocol of this scoping review was previously registered at the Open Science Framework Registry (https://osf.io/8gh9y) and published.
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Affiliation(s)
- Fábio Carlos Lucas de Oliveira
- Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
- Research Unit in Sport and Physical Activity (CIDAF), University of Coimbra, Coimbra, Portugal
| | | | - Clare L Ardern
- Department of Family Practice, The University of British Columbia, Vancouver, British Columbia, Canada
- Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Kristina Fagher
- Rehabilitation Medicine Research Group, Department of Health Sciences, Lund University, Lund, Sweden
| | - Neil Heron
- Center for Public Health, Queen's University Belfast, Belfast, UK
- School of Medicine, Keele University, Staffordshire, UK
| | | | - Marleen G T Jansen
- Toptennis Department, Royal Netherlands Lawn Tennis Association (KNLTB), Amstelveen, The Netherlands
- Center for Human Movement Sciences, University Medical Centre Groningen, Groningen, The Netherlands
| | - Nikki Kolman
- Center for Human Movement Sciences, University Medical Centre Groningen, Groningen, The Netherlands
- Knowledge Centre for Sport & Physical Activity, Utrecht, The Netherlands
| | | | | | - Linda Schoonmade
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jane S Thornton
- Department of Family Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Nick Webborn
- IPC Medical Committee, Bonn, Germany
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Babette M Pluim
- Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- Amsterdam Collaboration on Health & Safety in Sports (ACHSS), AMC/VUmc IOC Research Center of Excellence, Amsterdam, The Netherlands
- Medical Department, Royal Netherlands Lawn Tennis Association (KNLTB), Amstelveen, The Netherlands
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Wearable Sensor for Assessing Gait and Postural Alterations in Patients with Diabetes: A Scoping Review. Medicina (B Aires) 2021; 57:medicina57111145. [PMID: 34833363 PMCID: PMC8621058 DOI: 10.3390/medicina57111145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/16/2021] [Accepted: 10/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background and Objectives: Diabetes mellitus is considered a serious public health problem due to its high prevalence and related complications, including gait and posture impairments due to neuropathy and vascular alterations and the subsequent increased risk of falls. The gait of patients with diabetes is characterized by alterations of the main spatiotemporal gait parameters such as gait velocity, cadence, stride time and length, which are also known to worsen with disease course. Wearable sensor systems can be used for gait analysis by providing spatiotemporal parameters and postural control (evaluated from the perspective of body sway), useful for investigating the disease progression. Thanks to their small size and low cost of their components, inertial measurement units (IMUs) are easy to wear and are cheap tools for movement analysis. Materials and Methods: The aim of this study is to review articles published in the last 21 years (from 2000 to 2021) concerning the application of wearable sensors to assess spatiotemporal parameters of gait and body postural alterations in patients with diabetes mellitus. Relevant articles were searched in the Medline database using PubMed, Ovid and Cochrane libraries. Results: One hundred and four articles were initially identified while searching the scientific literature on this topic. Thirteen were selected and analysed in this review. Wearable motion sensors are useful, noninvasive, low-cost, and objective tools for performing gait and posture analysis in diabetic patients. The IMUs can be worn at the lumber levels, tibias or feet, and different spatiotemporal parameters of movement and static posture can be assessed. Conclusions: Future research should focus on standardizing the measurement setup and selecting the most informative spatiotemporal parameters for gait and posture analysis.
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Abstract
Biomechanical changes to the lower extremity in patients with diabetes mellitus are typically greatest with peripheral neuropathy, although peripheral arterial disease also impacts limb function. Changes to anatomic structures can impact daily function. These static changes, coupled with kinetic and kinematic changes of gait, lead to increased vertical and shear ground reactive forces, resulting in ulcerations. Unsteadiness secondary to diminished postural stability and increased sway increase fall risk. These clinical challenges and exacerbation of foot position and dynamic changes associated with limb salvage procedures, amputations, and prostheses are necessary and can impact daily function, independence, quality of life, and mortality.
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Affiliation(s)
- Jonathan M Labovitz
- Clinical Education and Graduate Services, College of Podiatric Medicine, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766, USA.
| | - Dana Day
- College of Podiatric Medicine, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766, USA; Chino Valley Medical Center, Chino, CA 91710, USA
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Aprile I, Galli M, Pitocco D, Di Sipio E, Simbolotti C, Germanotta M, Bordieri C, Padua L, Ferrarin M. Does First Ray Amputation in Diabetic Patients Influence Gait and Quality of Life? J Foot Ankle Surg 2018; 57:44-51. [PMID: 29268902 DOI: 10.1053/j.jfas.2017.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Indexed: 02/03/2023]
Abstract
It has recently been suggested that first ray amputation in diabetic patients with serious foot complications 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 (6 amputee and 6 nonamputee diabetics, 6 healthy non-diabetic), a sample of amputee diabetic patients were evaluated and compared with a sample of nonamputee diabetic patients and a group of age-matched healthy subjects. Gait biomechanics, quality of life, and pain were evaluated. Compared with 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.
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Affiliation(s)
- Irene Aprile
- Director, Rehabilitation Department, Don Carlo Gnocchi Onlus Foundation, Milan, Italy.
| | - Marco Galli
- Orthopedic Surgeon, Institute of Clinical Orthopaedic, Catholic University, Rome, Italy
| | - Dario Pitocco
- Associate Physician, Department of Internal Medicine, Diabetes Care Unit, Catholic University, Rome, Italy
| | - Enrica Di Sipio
- Research Engineer, Don Carlo Gnocchi Onlus Foundation, Milan, Italy
| | | | - Marco Germanotta
- Research Engineer, Don Carlo Gnocchi Onlus Foundation, Milan, Italy
| | | | - Luca Padua
- Research Head, Don Carlo Gnocchi Onlus Foundation, Milan, Italy; Associate Professor, Department of Geriatrics, Neurosciences and Orthopaedics, Catholic University of the Sacred Heart, Rome, Italy
| | - Maurizio Ferrarin
- Research Head, Biomedical Technology Department, IRCCS Don Carlo Gnocchi Foundation, Milan, Italy
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7
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Darter BJ, Bastian AJ, Wolf EJ, Husson EM, Labrecque BA, Hendershot BD. Locomotor adaptability in persons with unilateral transtibial amputation. PLoS One 2017; 12:e0181120. [PMID: 28704467 PMCID: PMC5507533 DOI: 10.1371/journal.pone.0181120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/26/2017] [Indexed: 11/18/2022] Open
Abstract
Background Locomotor adaptation enables walkers to modify strategies when faced with challenging walking conditions. While a variety of neurological injuries can impair locomotor adaptability, the effect of a lower extremity amputation on adaptability is poorly understood. Objective Determine if locomotor adaptability is impaired in persons with unilateral transtibial amputation (TTA). Methods The locomotor adaptability of 10 persons with a TTA and 8 persons without an amputation was tested while walking on a split-belt treadmill with the parallel belts running at the same (tied) or different (split) speeds. In the split condition, participants walked for 15 minutes with the respective belts moving at 0.5 m/s and 1.5 m/s. Temporal spatial symmetry measures were used to evaluate reactive accommodations to the perturbation, and the adaptive/de-adaptive response. Results Persons with TTA and the reference group of persons without amputation both demonstrated highly symmetric walking at baseline. During the split adaptation and tied post-adaptation walking both groups responded with the expected reactive accommodations. Likewise, adaptive and de-adaptive responses were observed. The magnitude and rate of change in the adaptive and de-adaptive responses were similar for persons with TTA and those without an amputation. Furthermore, adaptability was no different based on belt assignment for the prosthetic limb during split adaptation walking. Conclusions Reactive changes and locomotor adaptation in response to a challenging and novel walking condition were similar in persons with TTA to those without an amputation. Results suggest persons with TTA have the capacity to modify locomotor strategies to meet the demands of most walking conditions despite challenges imposed by an amputation and use of a prosthetic limb.
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Affiliation(s)
- Benjamin J. Darter
- Department of Physical Therapy, Virginia Commonwealth University, Richmond, Virginia, United States of America
- Department of Research, Hunter Holmes McGuire Veteran Affairs Medical Center, Richmond, Virginia, United States of America
- * E-mail:
| | - Amy J. Bastian
- Kennedy Krieger Institute, Baltimore, Maryland, United States of America
- Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Erik J. Wolf
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- DoD-VA Extremity Trauma and Amputation Center of Excellence (EACE), Bethesda, Maryland, United States of America
| | - Elizabeth M. Husson
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- BADER Consortium, University of Delaware, Newark, Delaware, United States of America
| | - Bethany A. Labrecque
- Department of Physical Therapy, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Brad D. Hendershot
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
- DoD-VA Extremity Trauma and Amputation Center of Excellence (EACE), Bethesda, Maryland, United States of America
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
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Ammendola M, Sacco R, Butrico L, Sammarco G, de Franciscis S, Serra R. The care of transmetatarsal amputation in diabetic foot gangrene. Int Wound J 2016; 14:9-15. [PMID: 27696694 DOI: 10.1111/iwj.12682] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 08/26/2016] [Accepted: 09/12/2016] [Indexed: 12/19/2022] Open
Abstract
Diabetic foot ulcerations may determine minor or major amputation, with a high impact on patients' life expectation and quality of life and on economic burden. Among minor amputations, transmetatarsal amputation (TMA) appears to be the most effective in terms of limb salvage rates and in maintaining foot and ankle biomechanics. In spite of this, TMA needs particular pre- and postoperative management in order to avoid the frequent failure rates. A systematic review was undertaken of studies concerning TMA and its care in diabetic foot gangrene. Studies were identified by searching the MEDLINE, Scopus and Science Direct databases until 13 January 2016. All studies were assessed using the Downs and Black quality checklist. Of the 348 records found, 86 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 35 manuscripts because of the following reasons: (1) no innovative or important content, (2) no multivariable analysis, (3) insufficient data, (4) no clear potential biases or strategies to solve them, (5) no clear endpoints and (6) inconsistent or arbitrary conclusions. The final set included 51 articles. In the current literature, there are less data about TMA, indication for the selection of patients, outcomes and complications. Generally, the judgment of an experienced physician is one of the best indicators of subsequent healing. Ankle brachial indices, toe pressures, laser Doppler skin perfusion pressures, angiography and Doppler assessment of foot vasculature may help physicians in this decision. In any case, despite the presumed lower healing rate, it is reasonable to pursue a TMA in a patient with a higher likelihood of continued ambulation. Furthermore, tailored wound closure, adjuvant local treatments and the choice of the most appropriate antibiotic therapy, when infection occurs, are pivotal elements for the success of TMA procedures. TMA is a valuable option for diabetic foot gangrene that can prevent major limb loss and minimise loss of function, thus improving the quality of life for diabetic patients.
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Affiliation(s)
- Michele Ammendola
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Rosario Sacco
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Lucia Butrico
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Giuseppe Sammarco
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Stefano de Franciscis
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy.,Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy.,Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
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What Role Does Function Play in Deciding on Limb Salvage versus Amputation in Patients With Diabetes? Plast Reconstr Surg 2016; 138:188S-195S. [DOI: 10.1097/prs.0000000000002713] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Partial foot amputations have become common procedures for the foot and ankle surgeon as part of a limb salvage practice. These procedures are highly technique driven and there are many complex factors that affect the outcome and longevity. Appropriate surgical planning must be used with every partial foot amputation to ensure a plantigrade foot with the least potential for future breakdown. When performed appropriately, these amputations have great success with lower energy expenditure and decreased mortality compared with below-knee or above-knee amputations.
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Affiliation(s)
- Caitlin S Garwood
- Department of Plastic Surgery, Center for Wound Healing and Hyperbaric Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Road, Northwest, Washington, DC 20007, USA
| | - John S Steinberg
- Department of Plastic Surgery, Center for Wound Healing and Hyperbaric Medicine, MedStar Georgetown University Hospital, Georgetown University School of Medicine, 3800 Reservoir Road, Northwest, Washington, DC 20007, USA; Podiatric Residency Program, MedStar Washington Hospital Center, 110 Irving Street, Northwest, Washington, DC 20010, USA.
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11
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Parent A, Pouliot-Laforte A, Laberge M, Hamdy R, Rochelle R, Ballaz L. Articulated vs. fixed carbon-fibre prosthesis after transmetatarsial amputation: a case study. Comput Methods Biomech Biomed Engin 2014; 17 Suppl 1:106-7. [PMID: 25074187 DOI: 10.1080/10255842.2014.931384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- A Parent
- a Sainte-Justine UHC , Montreal , Canada
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12
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Miller JD, Zhubrak M, Giovinco NA, Mills JL, Armstrong DG. The Too Few Toes principle: A formula for limb-sparing low-level amputation planning. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.wndm.2014.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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13
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Deliberations About the Functional Benefits and Complications of Partial Foot Amputation: Do We Pay Heed to the Purported Benefits at the Expense of Minimizing Complications? Arch Phys Med Rehabil 2013; 94:1429-35. [DOI: 10.1016/j.apmr.2013.03.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/19/2013] [Accepted: 03/23/2013] [Indexed: 12/26/2022]
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Transmetatarsal amputation: a case series and review of the literature. J Aging Res 2012; 2012:797218. [PMID: 22811912 PMCID: PMC3397208 DOI: 10.1155/2012/797218] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 05/16/2012] [Indexed: 11/24/2022] Open
Abstract
Foot ulceration is a major cause of morbidity amongst patients with diabetes. In severe cases of ulceration, osteomyelitis and amputation can ensue. A distinct lack of agreement exists on the most appropriate level of amputation in cases of severe foot ulceration/infection to provide predictable healing rates. This paper provides an overview of the transmetatarsal amputation (TMA) as a limb salvage procedure and is written with the perspective and experiences of the Department of Podiatric Surgery at West Middlesex University Hospital (WMUH). We have reflected on the cases of 11 patients (12 feet) and have found the TMA to be an effective procedure in the management of cases of severe forefoot ulceration and infection.
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Hsu WC, Lu TW, Liu MW. LOWER LIMB JOINT POSITION SENSE IN PATIENTS WITH TYPE II DIABETES MELLITUS. BIOMEDICAL ENGINEERING-APPLICATIONS BASIS COMMUNICATIONS 2012. [DOI: 10.4015/s1016237209001362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Diabetes mellitus (DM), of which type II has been described as an international epidemic, is a major cause of death. Diabetic peripheral neuropathy (PN) is a condition secondary to hyperglycemia, where progressive loss of peripheral nerve function, including sensory and motor functions, occurs over time. Early detection of PN-related impairments may be helpful for the management of patients with DM. Among the methods for the evaluation of these impairments, only that for joint position sense (JPS) requires both motor and sensory involvement. The purpose of the current study was to compare the JPS of the lower limb joints in patients with no or mild diabetic PN to those of normal controls both during weight-bearing (WB) and non-weight-bearing (NWB) conditions using 3D motion analysis methods. The results supported the hypothesis that in well controlled diabetic patients with no or mild PN, JPS deficits can be found only at the ankle joint during WB conditions, resulting in overestimation of dorsiflexion angles. This suggests that at the very early stage of development of diabetic PN, distal joint involvement precedes that of proximal joints. Early detection of these changes, through the assessment of the JPS for all the lower limb joints under both NWB and WB conditions, will be helpful for the development of clinical preventive and treatment programs for patients with DM, even if their glucose level are well controlled. Gait and balance training in these patients should emphasize proprioception training exercises during WB conditions.
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Affiliation(s)
- Wei-Chun Hsu
- Institute of Biomedical Engineering, National Taiwan University, Taiwan
| | - Tung-Wu Lu
- Institute of Biomedical Engineering, National Taiwan University, Taiwan
| | - Ming-Wei Liu
- Institute of Biomedical Engineering, National Taiwan University, Taiwan
- Department of Surgery, Taiwan Adventist Hospital, Taiwan
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Terashi H, Kitano I, Tsuji Y, Hashikawa K, Tahara S. A modified transmetatarsal amputation. J Foot Ankle Surg 2011; 50:441-4. [PMID: 21571552 DOI: 10.1053/j.jfas.2011.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Indexed: 02/03/2023]
Abstract
The incidence of the diabetic foot is increasing worldwide. Because evidence has shown that transmetatarsal amputation is associated with fewer failures in amputations of the diabetic foot with or without peripheral arterial disease, improving its management and surgical technique is a mission for the surgeon. Conventional transmetatarsal amputation has held firm, however, for more than 150 years. With a new concept for the transmetatarsal amputation method aimed at a better outcome, we propose a modified procedure for preserving the soft tissue between the metatarsal bones (the vasculature complex with the muscles, periostea, and vessels) and applying it to the distal bone stumps. The purpose of this method is to secure a functional foot by preserving the longitudinal arch. The new method was applied to 11 patients with diabetes mellitus or peripheral arterial disease, or both. All wounds closed successfully. Of the 11 patients, 8 were still alive with no complications. Of these 8 patients, 6 were able to ambulate with a custom-made shoe and 2 used a wheelchair, just as preoperatively. Of the 3 patients who died, 1 died a natural death, 1 died of sepsis, and 1 of cerebral infarction. We believe that the modified transmetatarsal amputation that we have described in this report is a potential breakthrough in the care of patients with forefoot gangrene and may gain acceptance over time.
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Affiliation(s)
- Hiroto Terashi
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
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17
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Abstract
Amputations of the lower extremity may result from several etiologic factors. Most amputations performed in the United States result from a dysvascular limb. A majority of the population with vascular impairment comprises people with diabetes. These individuals frequently have comorbidities that may also affect the ultimate outcome of amputation. Loss of protective sensation, propensity toward infection, and visual and balance impairment all create additional issues with postamputation gait in the population with diabetes. Amputations about the foot and ankle affect gait and energy consumption. More gait disturbances tend to be seen as amputation level becomes more proximal; however, loss of the metatarsophalangeal joints has a profound effect, regardless of the proximal level of amputation. Soft tissue balance is key to maximizing gait, particularly prevention of equinus and equinovarus deformity from unopposed plantarflexors. Orthotic, prosthetic, and shoe modifications can help minimize gait abnormalities; however alterations of ground reaction force and center of pressure may still remain.
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Affiliation(s)
- Richard M Marks
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, 53226, USA.
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18
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Petrofsky JS, Cuneo M. Correlation Between Gait, Balance, and Age When People Are Standing and Walking in Normal, Subdued, and No Light Conditions. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2009. [DOI: 10.1080/j148v26n03_02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Guldemond NA, Leffers P, Walenkamp GHIM, Schaper NC, Sanders AP, Nieman FHM, van Rhijn LW. Prediction of peak pressure from clinical and radiological measurements in patients with diabetes. BMC Endocr Disord 2008; 8:16. [PMID: 19055706 PMCID: PMC2637873 DOI: 10.1186/1472-6823-8-16] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 12/02/2008] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Various structural and functional factors of foot function have been associated with high local plantar pressures. The therapist focuses on these features which are thought to be responsible for plantar ulceration in patients with diabetes. Risk assessment of the diabetic foot would be made easier if locally elevated plantar pressure could be indicated with a minimum set of clinical measures. METHODS Ninety three patients were evaluated through vascular, orthopaedic, neurological and radiological assessment. A pressure platform was used to quantify the barefoot peak pressure for six forefoot regions: big toe (BT) and metatarsals one (MT-1) to five (MT-5). Stepwise regression modelling was performed to determine which set of the clinical and radiological measures explained most variability in local barefoot plantar peak pressure in each of the six forefoot regions. Comprehensive models were computed with independent variables from the clinical and radiological measurements. The difference between the actual plantar pressure and the predicted value was examined through Bland-Altman analysis. RESULTS Forefoot pressures were significant higher in patients with neuropathy, compared to patients without neuropathy for the whole forefoot, the MT-1 region and the MT-5 region (respectively 138 kPa, 173 kPa and 88 kPa higher: mean difference). The clinical models explained up to 39 percent of the variance in local peak pressures. Callus formation and toe deformity were identified as relevant clinical predictors for all forefoot regions. Regression models with radiological variables explained about 26 percent of the variance in local peak pressures. For most regions the combination of clinical and radiological variables resulted in a higher explained variance. The Bland and Altman analysis showed a major discrepancy between the predicted and the actual peak pressure values. CONCLUSION At best, clinical and radiological measurements could only explain about 34 percent of the variance in local barefoot peak pressure in this population of diabetic patients. The prediction models constructed with linear regression are not useful in clinical practice because of considerable underestimation of high plantar pressure values. Identification of elevated plantar pressure without equipment for quantification of plantar pressure is inadequate. The use of quantitative plantar pressure measurement for diabetic foot screening is therefore advocated.
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Affiliation(s)
- Nick A Guldemond
- Department of Orthopaedic Surgery, University Hospital Maastricht, the Netherlands
| | - Pieter Leffers
- Department of Epidemiology, University Maastricht, the Netherlands
| | - Geert HIM Walenkamp
- Department of Orthopaedic Surgery, University Hospital Maastricht, the Netherlands
| | - Nicolaas C Schaper
- Department of Rehabilitation Medicine, University Hospital Maastricht, the Netherlands
| | - Antal P Sanders
- Department of Internal Medicine, University Hospital Maastricht, the Netherlands
| | - Fred HM Nieman
- Department of Clinical Epidemiology and Medical Technology Assessment, University Hospital Maastricht, the Netherlands
| | - Lodewijk W van Rhijn
- Department of Orthopaedic Surgery, University Hospital Maastricht, the Netherlands
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20
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Schweinberger MH, Roukis TS. Intramedullary screw fixation for balancing of the dysvascular foot following transmetatarsal amputation. J Foot Ankle Surg 2008; 47:594-7. [PMID: 19239874 DOI: 10.1053/j.jfas.2007.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Indexed: 02/03/2023]
Abstract
Transmetatarsal amputation is a viable alternative to more proximal pedal amputations or leaving a deformed partial forefoot amputation. Balancing the transmetatarsal amputation in order to correct soft-tissue deformities is an accepted approach and consists of various tendon transfers, However, in the recently re-vascularized limb or in those patients who can not undergo re-vascularization, additional incisions to balance the transmetatarsal amputation are not performed. The authors present a simple and effective technique utilizing a large diameter, cannulated screw extending from the residual first metatarsal across the midfoot and into the talus after the foot has been manually corrected, which is useful for patients undergoing transmetatarsal amputation who can not undergo soft-tissue balancing.
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Affiliation(s)
- Monica H Schweinberger
- Limb Preservation Complex Lower Extremity Surgery and Research Fellowship, Podiatric Medical Student CORE Rotation Program, Madigan Army Medical Center, Tacoma, WA 98431, USA
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21
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Biomechanics of Ambulation After Partial Foot Amputation: A Systematic Literature Review. ACTA ACUST UNITED AC 2007. [DOI: 10.1097/jpo.0b013e3180ca8694] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Partial foot amputation may be preferred to more proximal amputation because of the perceived improvement in function associated with preserving foot length and the ankle joint complex, thus enabling normal gait and push-off. Clinically, partial foot amputees display significant wasting of the triceps surae musculature, strongly indicative of disuse. This investigation aimed to examine the belief that preserving residual foot length should be the primary operative objective necessary to maintain normal foot and ankle function. METHOD The gait patterns of eight partial foot amputees and a cohort of matched non-amputee control subjects were analyzed using a peak three-dimensional (3D) motion analysis system incorporating an AMTI force platform (Advanced Mechanical Technology Inc., Waterton, MA). Amputee subjects used their own prostheses for the evaluation. RESULTS Amputations disarticulating the metatarsophalangeal (MTP) joint had little impact on the normal pattern of ankle power generation. However, amputation proximal to the MTP joint level resulted in virtually negligible power generation across the ankle, regardless of residual foot length. Subjects compensated for the lack of ankle power generation by adopting strategies in which the hip became the primary source of power to advance the body forward. CONCLUSIONS The primary reason for a partial foot amputation is to preserve the normal function of the foot and ankle complex associated with push-off. As such, surgery should strive to preserve the metatarsal heads to allow amputees to use the ankle's contribution to walking. Given that amputation proximal to the metatarsal heads compromised the normal propulsive function of the foot and ankle, surgery should not strive to preserve residual foot length to maintain function but should instead aim to achieve good distal tissue coverage and healing, particularly given that the hip joint(s), not the ankle, become the primary source of power for walking.
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Affiliation(s)
- Michael P Dillon
- Centre for Rehabilitation Science and Engineering, School of Mechanical, Manufacturing, and Medical Engineering, Queensland University of Technology, Brisbane, Queensland, Australia.
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Abstract
Partial foot amputations provide advantages and challenges to the patient confronting loss of limb and the rehabilitation team. The partial foot amputation offers the potential for retention of plantar load-bearing tissues that are capable of tolerating the forces involved in weight bearing; this can allow the patient to ambulate with or without a prosthesis. Because of the complexity of the foot-ankle complex and the multiple types of partial foot amputations encountered, choosing the appropriate prosthesis can be challenging. This article explains some of the rationale and common options available for the different levels of amputation.
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Affiliation(s)
- Peter P Yonclas
- Department of Physical Medicine and Rehabilitation, New Jersey Medical School-UMDNJ, Suite 3100 DOC, 90 Bergen Street, Newark, NJ 07109, USA.
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Petrofsky J, Lee S, Bweir S. Gait characteristics in people with type 2 diabetes mellitus. Eur J Appl Physiol 2004; 93:640-7. [PMID: 15578207 DOI: 10.1007/s00421-004-1246-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2004] [Indexed: 10/26/2022]
Abstract
Sixteen control subjects and 15 subjects with type 2 diabetes were examined to compare gait characteristics during walking in a linear path and in turns of 0.33 and 0.66 m diameter. Subjects were excluded if there was diminished sensation in the feet or impairment of strength in the legs. This was done to isolate the effect of diabetes gait independent of loss of sensation. Gait was assessed through contact sensors on the foot, video, and two axis accelerometers mounted bilaterally on the head, shoulders, hips, knees and ankles. The results of these experiments showed that subjects with diabetes walked significantly slower (P<0.05) than control subjects and with a wider stance (P<0.01), both for walking in a linear path (velocity of subjects with diabetes was 62.2% that of controls and stance was 134.9% wider than controls) and when making turns (velocity 50.6% of controls and stance 120.1% wider than that of controls). Accelerometry showed increased flexion/extension and lateral movement of the major joints in subjects with diabetes during both walking in a linear path and turns compared to control subjects. Part of the increased movement at the joints in the subjects with diabetes was due to tremor in both the 8 Hz and 16 Hz bands. These findings suggest that at least some of the increased joint movement during walking in people with diabetes is likely neurological in origin and not related to muscle weakness or loss of sensation in the feet.
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Affiliation(s)
- Jerrold Petrofsky
- Department of Physical Therapy and Internal Medicine, Loma Linda University, Loma Linda, California, CA 92350, USA.
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25
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Abstract
Amputations are not procedures of choice but are often necessary and valuable tools for returning a patient to a more active lifestyle. Because of the comorbidities associated with diabetes, this is an important consideration. A return to a more active existence can reduce the effect of vascular disease, hyperglycemic states, and functional limitations. It is an interesting and not uncommon occurrence for the chronic wound patient, when offered an amputation, to have the procedure because the frequency of needed medical care has stripped him of his independence. The frequency of wound care in the nonhealing wound and its personal demands can be compared with the demands placed on the dialysis patient. The greatest obstacle for the uninitiated surgeon is a sense of hesitancy: Am I moving too fast to amputation as an answer? The ability to make this decision comes with experience and with prioritizing the patient's needs. Life-threatening infections and avascular extremities that are not bypassable are the easier decisions to make, as there is little choice at that point. In deciding whether to amputate, the wise surgeon will take into consideration the medical and mobility needs of each patient and determine level and timing based on understanding of the whole person.
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Affiliation(s)
- Kathleen Satterfield
- Department of Orthopaedics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive/MS 7776, San Antonio, TX 78229, USA.
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Erdemir A, Piazza SJ. Rotational foot placement specifies the lever arm of the ground reaction force during the push-off phase of walking initiation. Gait Posture 2002; 15:212-9. [PMID: 11983495 DOI: 10.1016/s0966-6362(01)00192-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The lever arm of the ground reaction force (GRF) about the talocrural joint axis is a functionally important indicator of the nature of foot loading. Walking initiation experiments (ten subjects; age, 23-29 years) were completed to demonstrate that rotational foot placement is a possible strategy to specify the lever arm. Externally-rotated foot placement resulted in larger lever arms during push-off. A computer simulation of push-off revealed that a decreased lever arm reduces the plantarflexion moment necessary to maintain a constant forward velocity, while increasing the required plantarflexion velocity. Shortening of the foot thus diminishes the muscular force demand but also requires high muscle fiber shortening velocities that may limit the force generating capacity of plantar flexors. Decreased plantar flexion moment and slow walking previously noted in partial-foot amputees may result from shortened lever arms in this manner.
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Affiliation(s)
- Ahmet Erdemir
- Center for Locomotion Studies, The Pennsylvania State University, University Park, PA 16802, USA
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Hastings MK, Mueller MJ, Sinacore DR, Salsich GB, Engsberg JR, Johnson JE. Effects of a tendo-Achilles lengthening procedure on muscle function and gait characteristics in a patient with diabetes mellitus. J Orthop Sports Phys Ther 2000; 30:85-90. [PMID: 10693086 DOI: 10.2519/jospt.2000.30.2.85] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Case report with repeated measures. OBJECTIVES To describe the effects of a tendo-Achilles lengthening (TAL) and total contact casting (TCC) on wound healing, motion, plantar pressure, and function in a patient with diabetes mellitus, peripheral neuropathy, neuropathic ulcer, and limited dorsiflexion range of motion (DFROM). BACKGROUND Limited DFROM has been associated with increased forefoot pressures and skin breakdown. A TAL was expected to increase DFROM and reduce forefoot pressures during walking, but the influence on muscle performance and function was unknown. METHODS AND MEASURES The patient was a 42-year-old man with a 20-year history of type 1 diabetes (NIDDM) and a recurrent neuropathic plantar ulcer. Outcome measures were DFROM, isokinetic plantar flexor muscle peak torque, in-shoe and barefoot peak plantar pressure, physical performance test (PPT) score, and peak ankle and hip moments during walking obtained from an automated gait analysis. All tests were completed pre-TAL, 8 weeks post-TAL (after immobilization in a TCC), and 7 months post-TAL. RESULTS The wound healed in 40 days. The TAL resulted in a sustained increase in DFROM (0 to 18 degrees). Plantar flexor peak torque was reduced by 21% 8 weeks after the TAL compared with the torque before surgery but recovered fully at 7 months. Seven months following TAL, in-shoe forefoot peak plantar pressure was reduced by 55%, barefoot pressure decreased by 14%, PPT score increased by 24%, peak ankle plantar flexor moment remained decreased by 30%, and the peak hip flexor moment increased by 41% during walking. CONCLUSION For this patient, a TAL resulted in short-term deficits in peak plantar flexor torque, but a 7-month follow-up showed improvements in ankle DFROM, walking ability, and a decrease in forefoot in-shoe peak plantar pressure.
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Affiliation(s)
- M K Hastings
- Washington University, School of Medicine, Program in Physical Therapy, St Louis, Mo. 63108-2212, USA.
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