[Presurgical and postsurgical orthotic management of the rheumatoid foot]

Foot complaints remain frequent in patients with rheumatoid arthritis (RA) even in the era of biological anti-rheumatic drugs. Orthotic management of rheumatoid foot disorders is able to improve mobility and thus the quality of life in RA patients. This article highlights the preoperative and postoperative orthotic management of the rheumatoid arthritic foot.

Patients with inflammatory arthropathies undergo feet surgery later in the disease course than hand surgery

OBJECTIVES

Inflammatory arthropathies often results in functional impairment and joint damage and deformity. Hand and foot are frequent locations for surgical interventions. Our objective is to compare disease duration, patient reported health status measures and use of medication in patients with inflammatory arthropathies referred for hand or foot surgery.

METHODS

Patients referred for hand or foot surgery at the Diakonhjemmet Hospital responded to mail surveys preoperatively, including AIMS2, HAQ, SF-36, EQ-5, and visual analogue scales addressing patient global assessment of disease activity, fatigue, general pain and pain in the actual joint. Data on disease duration, surgical treatment and medication were collected from the hospital records.

RESULTS

116 patients (mean (SD) age 57 (13) years, 76% female) with inflammatory arthropathies underwent hand (n=52, mean (SD) age 55 (13) years) or foot (n=64, mean (SD) age 58 (13) years) surgery. Disease duration at the time of surgery was significantly longer for patients referred for foot vs. hand surgery (19 (13) vs. 13 (10) years, p=0.04). Patients undergoing foot surgery used more frequently biological or conventional disease-modifying antirheumatic drug at the time of surgery than patients having hand surgery (50% vs. 71%, respectively, p=0.02). Baseline values for the patient-reported health status measures were mainly similar for the two patient groups.

CONCLUSIONS

Patients undergoing surgical procedures in the foot had significantly longer disease duration and were more frequently on potent medication at the time of surgery than patients undergoing hand surgery. The observation may indicate that the impact of foot damage in inflammatory arthropathies is underestimated.

[Treatment of tarsometatarsal joint injury combined with metatarsal fracture by open reduction and internal fixation]

OBJECTIVE

To evaluate the therapy and the key points of the tarsometatarsal joint injury combined with metatarsal fracture.

METHODS

From Jan. 2006 to Jul. 2008,19 patients with tarsometatarsal joint injury combined with metatarsal fracture were treated with opened reduction and internal fixation of Kirschner wire or screws, included 13 males and 6 females with an average age of 38.1 years ranging from 21 to 56 years. The classification of tarsometatarsal joint injury showed that there were 2 cases of inner column injury, 5 cases of inner and medial column injury, 3 cases of lateral and medial column injury, 9 cases of tri-column injury. There were 8 cases of shaft fracture, 7 of neck fracture, 19 of foundation fracture.

RESULTS

All the incisions were first stage healed without skin necrosis. The healing time of fracture was 11.2 weeks on average. All the patients were followed-up for 6 to 17 months with an average of 12.8 months. According to the standard of AOFAS, the average score was (84.500 +/- 8.553), the results were excellent in 4 cases, good in 9 cases, fair in 3, and poor in 3. The regular daily life was recovered after 6.4 months, 3 patients suffer from mild osteoarthritis.

CONCLUSION

No matter which fixed mode was used, the anatomical reduction was the most important to rebuild arches of the foot and recover medial longitudinal and lateral arch. Rebuilding arches of the foot guaranteed the integrity of the stress point scaffold and avoided the pain and limp. The anatomical reduction of tarsometatarsal joint and metatarsal was also important to rebuild the function of foot.

The surgical reconstruction of rheumatoid midfoot and hindfoot deformities

Dealing with the rheumatoid midfoot and hindfoot is a challenging endeavor. There are numerous perioperative factors that influence surgical outcomes. This article provides a brief overview of the disease process and pertinent details on the surgical management of the rheumatoid midfoot and hindfoot. The pathophysiology, clinical presentation, imaging, conservative treatment options, perioperative management, and surgical intervention for rheumatoid midfoot and hindfoot disease are discussed, with special attention to primary arthrodesis for midfoot and hindfoot reconstruction in the rheumatoid patient, which has been the mainstay of treatment for the last 100 years.

Use of bone morphogenetic proteins in arthrodesis: clinical results

Bone grafting is not routinely required in primary arthrodesis in the absence of infection, avascular necrosis, bone defect or previous non-union; when any of the above factors is present, autograft is the gold-standard method. However, donor site morbidity and the quantitative and qualitative limitations of autograft have led to the development of alternatives. This study documents the use of the bone morphogenetic protein BMP-7 in a total of 19 joint fusions (ankle, subtalar, talonavicular, pubic and sacroiliac). Healing rates of 90% and satisfactory subjective functional outcome in 70% of cases were recorded over a minimum follow-up of 15 months. These data should provide a sound foundation for future clinical trials evaluating the application of BMP-7 in the fusion of joints.

[Following-up study on recovery of amputated foot after temporary ectopic implantation]

OBJECTIVE

To study the recovery method and effect of amputated foot after temporary ectopic implantation.

METHODS

Two male patients with amputated foot were treated with temporary ectopic implantation in July 2001 and January 2002. Amputated foot was caused by mechanical injury and crush injury. After 6 hours, temporary ectopic implantation of amputated foot was given and replantation was done 3 months after primary operation. The recovery methods were as follows: automatic and passive motion, high pressure oxygen, massage, protective and positional feeling training, etc. The effects of recovery was observed.

RESULTS

All amputated foots survived after operation, the time of follow-up was 6 years, and 5 years and 7 months. Extension degree of first metatarsal digital joint was 12 degrees and 15 degrees, flex degree of first metatarsal digital joint was 15 degrees and 13 degrees, and extension degree of other metatarsal digital joints was 8 degrees and 9 degrees. Force degree of extension muscle was 4, force degree of flex muscle was 4, and two-point discrimination was 20 mm and 18 mm. Patients recovered their superficial sensibility, touch sense, deep pain sense and topognosis. The skin color and temperature were normal. And the patients could do some housework.

CONCLUSION

Temporary ectopic implantation of amputated foot can recover the function of amputated foot by motor and sensitive recovery methods.

[Treatment of intra-articular calcaneal fractures using Kirschner's wire or calcaneal plate]

OBJECTIVE

To compare the effect and syndrome of treating intra-articular calcaneal fractures using Kirschner's wire or AO calcaneal plate.

METHODS

From March 2003 to March 2006, 71 cases (86 feet) of intra-articular calcaneal fractures were treated with Kirschner's wire or AO calcaneal plate. Among them, 39 cases (48 feet) were treated using Kirschner's wire, male 34, female 5. The age ranged from 15 to 64 years old, 36 on average. The course of illness was from 4 hours to 10 days. There were 9 double side bone fractures and 30 one side bone fractures. Based on Sanders type, Type II were 40 feet, Type III were 7 feet and Type IV was 1 foot. The other 32 cases (38 feet) were treated using AO calcaneal plate, male 30, female 2. The age ranged from 18 to 55 years old, 33 on average. The course of illness was from 4 hours to 10 days. There were 6 double side bone fractures and 26 one side bone fractures. A total of 31 feet belonged to Sanders Type II, 5 to Type III, and 2 to Type IV. The 12-month follow-up, at least, was carried out in order to valuate the patients. The valuating items included: preoperative and postoperative Bohler's angle and Gissane's angle; heel bone height and width (contrast with the opposite side); to judge reposition circs by means of the CT scan and Borden's judgment; function valuation adopting the American Orthopedic Foot & Ankle Society (AOFAS) grade point system.

RESULTS

Patients with Kirschner's wire fixed were followed up for 12 to 48 months, and AOFAS score ranged from 75 to 100 points, 90.6 on average. The excellent and good rate was 87.8%. The preoperative Bohler's angle was from 0 to 10 degrees, 7.8 degrees on average, and postoperative from 30 to 40 degrees, 33.2 degrees on average. The preoperation Gissane's angle was 75 to 95 degrees, 84 degrees on average; and postoperative from 115 to 135 degrees, 125 degrees on average. There was significant difference (P < 0.05). The postoperative complications were that 1 foot was the incision edge shallow putrescence and 1 foot was the needle way infection. Patients with AO calcaneal plate fixed were followed up for 12 to 48 months, and AOFAS score was from 49 to 100 points, 87.5 on average. The excellent and good rate was 81.6%. There was no significant difference between the two groups (P > 0.05). The preoperative Bohler's angle ranged from 0 to 15 degrees, 6.5 degrees on average, and postoperative from 25 to 40 degrees, 30.2 degrees on average. The preoperative Gissare's angle was 72 to 92 degrees, 80 degrees on average; and postoperative from 115 to 1300,1200 on average. There was significant difference (P < 0.05). The postoperative complications were that 5 feet were the incision edge shallow putrescence, 1 was the common peroneal nerve hurt, and 1 was the petrous muscle aponeurotic inflammation.

CONCLUSION

There is no remarkable difference between the effects of treating intra-articular calcaneal fractures using plate or Kirschner's wire, but the treatment with Kirschner's wire is not only much easier and more economical, but has smaller wounds and fewer soft tissue problems.

[Acromelic arthritis: a new entity]

PURPOSE OF THE STUDY

Few patients with rheumatoid arthritis present isolated acromelic bone and joint destructions. Concerned joints are wrist, MP, PIP, DIP and forefoot. The aim of the current study is to describe and evaluate the long-term results of wrist, hand and forefoot surgery in an acromelic arthritis group.

MATERIAL AND METHODS

93 patients with acromelic arthritis were included in the study. 202 surgical procedures were performed between 1981 and 2001 in addition to medical treatment. 93 procedures concerned dorsal wrist surgery. The mean follow-up of this group was 7 years (24 months-20 years). 78 synovectomies of radio-carpal and medio-carpal joints with a Sauvé-Kapandji procedure were performed and 10 with a radio-lunate arthrodesis and 5 with other surgeries. The main indication for surgery was severe pain.

RESULTS

Functional results and radiographic evolution (Larsen X-ray classification) were studied. All patients were satisfied or very satisfied and pain was significantly reduced. Radiographic lesions progressed but Larsen's stage remained unchanged in 73% of patients. All patients with forefoot surgery recovered total walk autonomy.

DISCUSSION

Acromelic arthritis is a particular form of rheumatoid arthritis that progresses very slowly. Surgery should be indicated earlier, for a better joint function stabilisation.

Joint-preserving surgery in rheumatoid forefoot: preliminary study with more-than-two-year follow-up

The authors propose a joint-preserving surgery for rheumatoid forefoot deformities as an alternative to the "classic" surgical approach to the rheumatoid forefoot. The main principle is joint preservation by shortening osteotomies of all the metatarsals performed at the primary location of the rheumatoid forefoot lesions, namely the metatarsophalangeal (MTP) joints and metatarsal heads. A scarf osteotomy is normally performed on the first ray. A Weil osteotomy is performed on the lesser metatarsals. Excellent correction of the hallux valgus deformity in the rheumatoid forefoot can be achieved with a scarf osteotomy in 92% of cases without the need for MTP joint arthrodesis. Similarly, 86% of the lateral metatarsal heads can be preserved using Weil osteotomies.

Effects on the metatarsophalangeal joint after simulated first tarsometatarsal joint arthrodesis

A first tarsometatarsal (TMT) arthrodesis is a common procedure; however; the biomechanical effects on the first metatarsophalangeal (MTP) joint are not well understood. Instant centers of rotation range of motion have been used as biomechanical parameters to determine function of the first MTP joint. The effects that a simulated first TMT joint arthrodesis has on the distribution of instant centers of rotation and resistance to dorsiflexion the first MTP joint were investigated. Five lower extremity limbs were mounted onto a custom-loading frame. A 3-dimensional tracking system was placed along the first ray. A tilting platform that simulates propulsion was used to calculate the instant centers of rotation. A hinged platform was used to determine the motion of the first MTP joint at 40 N of force. Both parameters were measured before and after simulated first TMT joint arthrodesis. Instant centers of rotation were mathematically calculated with a modified Reuleaux method. The standard deviation between instant centers of rotation was found to be significantly reduced (P = .05) after the simulated first TMT arthrodesis. There was an average of a 25% (P = .01) increase in dorsiflexion of the MTP joint after a simulated first TMT arthrodesis. The findings of this study suggest that first TMT arthrodesis does not have a negative effect on the first MTP joint. There was no reduction of the intrametatarsal angle and plantar flexion or shortening of the metatarsal. Thus, the change in biomechanics of the first MTP joint can only be attributed to elimination of the first TMT joint motion.

Medial column procedures in the acquired flatfoot deformity

This article focuses on the medial column procedures for the treatment of the acquired flatfoot. When performing a medial column procedure alone, in combination with soft tissue reconstruction, or with concomitant lateral bony procedure, the deformity being addressed should include significant abduction or collapse through the talonavicular (TN), naviculocuneiform (NC), or tarsometatarsal (TMT) joints. The procedures covered in this article include arthrodesis of the TN, NC, and metatarsocuneiform (MTC) joints, together or in isloation. Osteotomies of the cuneiforms will also be addressed.

Management of the rigid adult acquired flatfoot deformity

The optimal management of the adult acquired flatfoot requires careful assessment of the deformity. Although it is essential to recognize the location and degree of malalignment, it is of equal importance to appreciate whether the deformity is flexible or rigid. For patients undergoing surgery for a flexible flatfoot, various soft tissue procedures and bony osteotomies may be used to restore alignment while preserving joint motion. However, for patients undergoing surgery for a rigid deformity, such procedures are indicated less often, and arthrodesis is usually necessary.

Ankle/hindfoot arthrodesis in rheumatoid arthritis improves kinematics and kinetics of the knee and hip: a prospective gait analysis study

OBJECTIVES

To evaluate the effects of ankle/hindfoot arthrodesis in rheumatoid arthritis (RA) patients on gait pattern of the knee and hip.

METHODS

In this prospective follow-up study, 14 RA patients scheduled for ankle/hindfoot arthrodesis (talo-calcaneal, talo-navicular, calcaneo-cuboid and/or talo-crural joints) and 14 age- and sex-matched healthy controls were included. Three-dimensional gait analyses of joint angles, moments and work were performed at the index operation and after 13 months of follow-up. Each patient underwent clinical assessments of pain while walking, overall evaluation of disease activity, Health Related Quality of Life Questionnaire (EQ-5D), activity limitations, maximum walking distance, difficulty with walking surface and gait abnormality. For comparisons of pre- vs post-operative conditions, Wilcoxon's matched pairs test and Friedman ANOVA by rank test were used.

RESULTS

At follow-up after ankle/hindfoot fusion surgery, RA patients demonstrated a statistically significant improvement in mean range of joint motions, moments and work in the overlying joints such as the knee and hip. Moreover, there was significantly less pain, disease activity, activity limitation, difficulty with walking surface and gait abnormality. EQ-5D and maximum walking distance were also significantly improved at follow-up.

CONCLUSIONS

Our results demonstrate that ankle/hindfoot arthrodesis in RA is an effective intervention to reduce pain and to improve Health Related Quality of Life and functional ability. Moreover, the overlying leg joints experience an improvement in joint motion, muscle-generated joint moments and work during walking. Three-dimensional gait analysis may assist future investigations of the effects of orthopaedic surgery on functional mobility in RA to prevent irreversible disablement.

Stage IV posterior tibial tendon rupture

Adult acquired flatfoot deformity progresses through well defined stages as set out by Johnson and Strom. Myerson modified this classification system with the addition of a fourth, more advanced stage of the disease. This stage describes the involvement of the tibiotalar joint in addition to the hindfoot malalignment seen in stages II and III. This most advanced stage is comprised of a hindfoot valgus deformity, resulting from degeneration of the posterior tibial tendon, with associated valgus tilting of the talus within the mortise. The deformity at the tibiotalar joint may or may not be rigid. Although rigid deformities are still best treated with fusions of the ankle and hindfoot, supple tibiotalar deformity may be treated with joint sparing procedures involving reconstructive procedures of the foot and deltoid ligaments.

Bioadjuvants for complex ankle and hindfoot reconstruction

Many reconstructive options exist for symptomatic hindfoot and ankle problems. Hindfoot and tibiotalar fusions are reliable procedures with consistent results. Unfortunately, many potential complications have been cited throughout the literature. Although the most important aspect in any fusion surgery is meticulous technique, advances in technology, including PRP, bone stimulators, and BMPs seem to be useful additions in the quest to achieve solid fusions with decreased complications.

Comparison of two methods of joint distraction for arthrodesis of the foot

A study was conducted to compare the efficacy of two methods of obtaining the joint exposure needed to perform arthrodesis or exploration of various joints of the foot. The investigation was performed by means of simulated arthrodesis in a cadaveric model. On each specimen, a single investigator performed standard incisions and dissection as typically performed for surgical arthrodesis of the first metatarsocuneiform, naviculocuneiform, medial intercuneiform, talonavicular, calcaneocuboid, and subtalar joints. Each joint was exposed and distracted once using the Tarsal Joint Distractor (Orthovation LLC, Sealy, Texas) and once using the Inge Laminar Spreader (K-Medic, Northvale, New Jersey). While a given joint was distracted, a calibrated digital photograph of the exposed joint was taken from an angle best representing the surgeon's view of the articular space. Digital images were analyzed to calculate the maximum distance between articular surfaces and the total area of articular surfaces exposed while distracted. Thirty-six joints involving six feet were distracted using each device. The mean area of articular exposure was 178.3 mm(2) for the Tarsal Joint Distractor and 116.4 mm(2) for the Inge Laminar Spreader (P = .0001). The mean distance of distraction was 8.1 mm for the Tarsal Joint Distractor and 6.5 mm for the Inge Laminar Spreader (P = .0001). An average of 53.1% more exposure and 25.2% more distance between distracted surfaces was achieved when using the Tarsal Joint Distractor. The Tarsal Joint Distractor provides significantly better visualization of articular spaces typical of midfoot and rearfoot arthrodesis procedures than the Inge Laminar Spreader.

Trephine arthrodesis of the foot and ankle: indications, operative technique, and long-term follow-up

We conducted a retrospective analysis of trephine arthrodesis in a total of 22 joints in 15 feet to determine the efficacy of this procedure in the foot and ankle. Twelve of the 22 joints that were fused involved the tarsometatarsal articulations, 3 the naviculocuneiform joint, 6 the subtalar joint, and 1 the ankle. A successful fusion rate of 95% (21/22) was achieved. These results lend evidence that the trephine arthrodesis technique can be used with satisfactory results and confidence in the foot and ankle.

Ankle arthrodesis for failed total ankle replacement

Between 1999 and 2005, 23 failed total ankle replacements were converted to arthrodeses. Three surgical techniques were used: tibiotalar arthrodesis with screw fixation, tibiotalocalcaneal arthrodesis with screw fixation, and tibiotalocalcaneal arthrodesis with an intramedullary nail. As experience was gained, the benefits and problems became apparent. Successful bony union was seen in 17 of the 23 ankles. The complication rate was higher in ankles where the loosening had caused extensive destruction of the body of the talus, usually in rheumatoid arthritis. In this situation we recommend tibiotalocalcaneal arthrodesis with an intramedullary nail. This technique can also be used when there is severe arthritic change in the subtalar joint. Arthrodesis of the tibiotalar joint alone using compression screws was generally possible in osteoarthritis because the destruction of the body of the talus was less extensive. Tibiotalocalcaneal arthrodesis fusion with compression screws has not been successful in our experience.

Midfoot arthrodesis using a locking anterior cervical plate as adjunctive fixation: early experience with a new implant

A retrospective review was performed on 14 patients (20 arthrodeses) who had undergone midfoot arthrodesis with a semi-constrained, locking anterior cervical plate as a form of adjunctive fixation. Fusion sites where the plate was used for the purpose of arthrodesis included the talonavicular joint, medial naviculocuneiform joints, first metatarsal cuneiform joint, and the calcaneal cuboid joint. All arthrodesis sites used one other type of fixation for the purpose of axial compression. Twenty midfoot arthrodesis sites went on to radiographic union at a mean of 9.1+/-1.5 weeks. A single complication of hardware irritation occurred in one patient that resolved after plate removal. This semi-constrained, locking anterior cervical plate appears to be a viable adjunct to fixation constructs for the purpose of midfoot arthrodesis.

Calcaneal lengthening for the planovalgus foot deformity in children with cerebral palsy

The authors studied the outcomes of calcaneal lengthening for the treatment of planovalgus foot deformity in ambulatory children with cerebral palsy (92 feet in 56 children, mean age 9.2 years), attempting to define the surgical indication in terms of the severity of the foot deformity. Sixty-nine cases (75%) showed satisfactory clinical outcomes at an average follow-up of 5.2 years (range 4.0-17.2 years). Gait parameters such as foot progression angle, ankle motion in sagittal plane, and its power generation improved after operation. Preoperative talocalcaneal angle, talo--first metatarsal angle, and calcaneal pitch on weight-bearing lateral radiographs were predictive of the satisfactory results of the index operation. The authors conclude that calcaneal lengthening is an effective procedure for moderate to severe planovalgus foot deformities in children with cerebral palsy, but there is a limit under which the index operation can be performed safely: less than 35 degrees of talocalcaneal angle, less than 25 degrees of talo--first metatarsal angle, and more than 5 degrees of calcaneal pitch on weight-bearing lateral radiographs.

Adult acquired flexible flatfoot, treated by calcaneocuboid distraction arthrodesis, posterior tibial tendon augmentation, and percutaneous Achilles tendon lengthening: a prospective outcome study of 20 patients

BACKGROUND

Several methods for the treatment of acquired flexible flatfoot have been described.

PATIENTS AND METHODS

We followed the outcome of calcaneocuboid distraction arthrodesis with lengthening of the lateral column prospectively in 20 patients (20 feet). The mean age of the patients was 55 (30-66) years and 16 were women. The lateral column lengthening was combined with percutaneous lengthening of the Achilles tendon and augmentation of the posterior tibial tendon in all patients. Fixed forefoot supination, hallux valgus, and/or symptomatic arthrosis, were corrected with arthrodesis of the first cuneiform-metatarsal joint (n = 8) and arthrodesis of the naviculocuneiform joint (n = 2). The Foot Function Index (FFI) and American Orthopedic Foot and Ankle Society (AOFAS) Clinical Rating Index hindfoot score (CRI) were completed preoperatively and at follow-up. Follow-up time was 25 (13-39) months. All patients were physically examined at follow-up at the outpatient clinic, and the overall satisfaction rate was registered. Standardized weight-bearing radiographs were taken preoperatively and at follow-up. The lateral and dorsoplantar talometatarsal angle was measured, together with the ground-navicular distance.

RESULTS

At follow-up, 17/20 feet had complete relief of pain or only minor symptoms. The overall patient satisfaction rate was excellent or good in 15 patients and 17 patients reported an increase in daily and/or recreational activities. 3 patients complained of pain at the distraction site and/or cuboid-MT5 joint, without signs of arthrosis. All but 1 patient would have chosen to undergo the same procedure given the same circumstances. The improvement in both the FFI and CRI was statistically significant. On radiographic examination, the lateral and dorsoplantar talometatarsal angle and the ground-navicular distance improved significantly. Nonunion developed in 2 patients and united after bone grafting. 3 patients had either paresthesia or anesthesia in the distribution area of the sural nerve.

INTERPRETATION

We found good short-term results after calcaneocuboid distraction arthrodesis, percutaneous tendon Achilles lengthening, and medial soft tissue augmentation for the treatment of degenerative/acquired flexible flatfoot. Pain or discomfort along the lateral aspect of the foot is the most common and worrying postoperative complaint.