Risk of plantar ulceration in diabetic patients with single-leg amputation R.V. Kanade a , R.W.M. van Deursen a, * , Patricia Price b , Keith Harding b a Research Centre for Clinical Kinaesiology, Department of Physiotherapy, School of Healthcare Studies, Cardiff University, Ty Dewi Sant, Health Park, Cardiff CF14 4XN, United Kingdom b Wound Healing Research Unit, School of Medicine, Cardiff University, Cardiff CF14 4UJ, United Kingdom Received 17 June 2005; accepted 15 October 2005 Abstract Background. There is a disconcerting rate of bilateral limb loss in patients with diabetes. Therefore, this study aimed to explore plantar loading of the surviving foot following unilateral trans-tibial amputation within a wider context of daily walking activity to investigate the precise risk to the surviving limb. Methods. Twenty-one subjects with diabetic neuropathy and trans-tibial amputation were matched for weight; height; age and gender with 21 control subjects with diabetic neuropathy without history of plantar ulceration. Gait parameters, in-shoe plantar pressure distribution and daily walking (using the step activity monitor) were recorded. StudentÕst-tests were used to compare groups (a-level: 0.05). Findings. The trans-tibial amputations group walked almost 30% slower compared to controls (P < 0.01), with reduced cadence (P < 0.01), and shorter strides (P < 0.01). Despite walking slower, the surviving foot showed higher mean peak plantar pressures in the trans-tibial amputations group over the heel (P < 0.001) however there was no significant difference over the I–II and lateral III–IV–V metatarso-phalangeal regions. Pressure time integral was higher over the heel (P < 0.00), I–II (P < 0.01) and III–IV–V metatarso-phalangeal (P < 0.05) in the trans-tibial amputations group. The amputee group walked less steps per day (P < 0.01). Interpretation. Adaptations in gait and level of walking activity affect plantar pressure distribution and ultimately the risk of ulceration to the surviving foot. Therefore rehabilitation measures should consider implications for plantar loading and the poten- tial risk of ulceration to the surviving foot. Ó 2005 Elsevier Ltd. All rights reserved. Keywords: Surviving foot; Plantar ulceration; Diabetic neuropathy; Trans-tibial amputation; Physiotherapy 1. Introduction Individuals with diabetes mellitus (DM) have a fifteen fold higher rate of lower extremity amputation than those without diabetes (Most and Sinnock, 1983). 6– 30% of the amputee population undergo contra-lateral lower extremity amputation within 1–3 years of their ini- tial amputation (Reiber, 1996) and a patient with DM with single limb amputation has a 50% (Hoar, 1962) to 66% (Goldner, 1960) incidence of contra-lateral lower extremity amputation within 5 years. Despite the discon- certing rate of contra-lateral limb loss, this problem appears to be addressed inadequately by the rehabilita- tion care systems owing to the limited evidence in this area (Broomhead et al., 2003). Data from objective gait analysis of the contra-lateral limb following unilateral lower extremity amputation appear to confirm the clin- ical impression that unilateral amputees are more stable and accept increased pressure on their remaining contra- lateral ‘‘limb-at-risk’’ during walking compared to the 0268-0033/$ - see front matter Ó 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.clinbiomech.2005.10.005 * Corresponding author. E-mail address: vandeursenr@cardiff.ac.uk (R.W.M. van Deursen). www.elsevier.com/locate/clinbiomech Clinical Biomechanics 21 (2006) 306–313