Distal tibiofibular bone-bridging in transtibial amputation

BACKGROUND

The creation of a bone bridge between the residual tibia and fibula is a controversial surgical technique used in the performance of transtibial amputation.

METHODS

Twenty consecutive patients who underwent a unilateral transtibial amputation, as a consequence of traumatic injury, had distal tibiofibular bone-bridging performed by a single surgeon. Eight completed the Prosthesis Evaluation Questionnaire (PEQ), a validated outcomes instrument designed to measure patient self-reported health-related quality of life after a lower-extremity amputation. Their responses were compared with those of a previously reported control group of nondiabetic patients who had undergone transtibial amputation with the use of a traditional technique and with those of a previously reported consecutive group of Brazilian patients, including twelve who were diabetic, who had undergone a similar bone-bridge procedure.

RESULTS

The scores in the American bone-bridge group were similar to those in the control group and not as good as those in the Brazilian bone-bridge group. The American bone-bridge and control groups scored lower in the Social Burden, Ambulation, Frustration, Sounds, Utility, and Well-Being domains of the PEQ.

CONCLUSIONS

While many experts in the care of amputees believe that the distal tibiofibular bone-bridge technique improves patient functional outcomes, our small group of patients treated with this procedure did not appear to have better outcomes than a group of patients treated successfully with a standard surgical technique. More information is needed before the bone-bridge technique can be recommended as an important component of standard transtibial amputation surgery.

Osteochondral injury of the hallux in beach soccer players

BACKGROUND

Injury to the metatarsophalangeal or interphalangeal joints of the hallux is an unusual clinical problem.

MATERIALS AND METHODS

This investigation represents a retrospective case series accumulated over a twenty year period of ninety-three beach soccer players who were treated for an osteochondral injury of the hallux metatarsophalangeal or interphalangeal joints of their dominant (kicking) foot.

RESULTS

Eighty-one patients underwent surgical excision of an avascular osteochondral fragment that had been identified by both plain radiography and magnetic resonance imaging. All but two patients were able to return to participation with either minimal or no pain. Two patients progressed to hallux rigidus and metatarsophalangeal joint arthritis.

CONCLUSION

This retrospective case series describes a sports-related injury of the hallux metatarsophalangeal or interphalangeal joints that is likely produced by hyper-flexion or hyperextersion. This descriptive case series might well characterize heretofore unexplained post-traumatic pain and swelling involving the hallux.

Controversies in lower extremity amputation

Using the experience gained from taking care of World War II veterans with amputations, Ernest Burgess taught that amputation surgery is reconstructive surgery. It is the first step in the rehabilitation process for patients with an amputation and should be thought of in this way. An amputation is often a more appropriate option than limb salvage, irrespective of the underlying cause. The decision making and selection of the amputation level must be based on realistic expectations with regard to functional outcome and must be adapted to both the disease process being treated and the unique needs of the patient. Sometimes the amputation is done as a life-saving procedure in a patient who is not expected to walk, but more often it is done for a patient who should be able to return to a full, active life. When considering amputation, the physician should establish reasonable goals when confronted with the question of limb salvage versus amputation, understand the roles of the soft-tissue envelope and osseous platform in the creation of a residual limb, understand the method of weight bearing within a prosthetic socket, and determine whether a bone bridge is a positive addition to a transtibial amputation.

Neutral ring fixation for high-risk nonplantigrade Charcot midfoot deformity

BACKGROUND

Charcot foot arthropathy negatively impacts the health-related quality of life (HRQL) of affected individuals. The disease process often is responsible for the development of significant deformity and disability, often progressing to lower extremity amputation. Many patients are morbidly obese, immunocompromised, and have complex wounds with underlying bony infection or poor bone quality, making operative correction and internal fixation problematic.

METHODS

Using a prospective clinical algorithm, 26 consecutive diabetic adults with multiple diabetic co-morbidities, including morbid obesity, had operative correction of nonplantigrade Charcot midfoot deformity at the midfoot level. Correction was maintained with a neutrally applied three-level ring external fixator. Average body mass index was 38.31 +/- 12.51. Nineteen patients used insulin. Fourteen had open wounds with underlying osteomyelitis. The altered relationship between the forefoot and hindfoot was measured as 14.04 +/- 31.09 degrees in the anteroposterior axis, and 16.70 +/- 17.47 degrees in the lateral axis before surgery. Surgery included Achilles tendon lengthening, excision of infected bone, correction of the multiplanar deformity, and culture-specific parenteral antibiotic therapy.

RESULTS

At a minimum 1-year followup, 24 of 26 patients were ulcer and infection free and able to ambulate with commercially-available depth-inlay shoes and custom accommodative foot orthoses. One patient died of unrelated causes, and one had transtibial amputation for persistent infection. Four developed recurrent plantar ulcers, which resolved with excision of underlying bony prominences. There were two stress fractures through olive wire pin sites, one requiring intramedullary nailing. The radiographic anteroposterior axis was corrected to 3.12 +/- 9.42 degrees, and lateral to 10.42 +/- 11.86 degrees after surgery.

CONCLUSIONS

Morbidly obese diabetic individuals with multiple co-morbidities complicating severe Charcot foot deformity can achieve correction of midfoot deformity after operative correction of the deformity and maintenance of that correction with a neutrally applied ring external fixator.

Surgical stabilization of nonplantigrade Charcot arthropathy of the midfoot

Fifty-one adults (28 men, 23 women) with Charcot arthropathy of the midfoot underwent surgical correction. Mean patient age was 58 years (SD, 9.9 years). All affected feet were nonplantigrade and at high risk for ulcers. Before surgery, mean lateral talar-first metatarsal angle was 27.6 degrees (SD, 12.8 degrees). Corrective osteotomy was performed to achieve plantigrade alignment. At minimum 1-year follow-up, 44 of 51 patients had the desired outcome. Mean lateral talar-first metatarsal angle had decreased to 6.4 degrees (SD, 7.7 degrees). Despite its associated high complication rate, corrective osteotomy can help patients become ulcer- and infection-free and maintain their ability to walk with commercially available therapeutic footwear. A treatment algorithm is presented.

The role of ring external fixation in Charcot foot arthropathy

These two morbidly obese patients with severe Charcot foot arthropathy were treated successfully with percutaneous correction of their deformity followed by a stepwise application of a pre-assembled neutrally aligned multiplane ring external fixator. This technique transfers well to the trauma environment in which alignment can be maintained without further violation within the zone of injury. The application of the fine wire ring external fixation has been used for many years to accomplished leg lengthening and correction of deformity. Historically it has required a great deal of experience to apply to complex frames and implement the required daily adjustments. The patient experience often has been an unpleasant ordeal with a high potential for associated morbidity. This negative exposure has prompted practicing orthopedic surgeons to avoid this technique, feeling that it best be left to those in tertiary care setting who are equipped to handle the morbidity and complications. Taking this technology from the domain of the deformity surgeon to the general orthopedic community will require the suppression of bad memories from residency. Using the device solely as a method of maintaining alignment eliminates many of the dynamic attributes that contributes to pain and morbidity. The bone and soft tissues are not stretched, eliminating much of the pain and decreasing the rate of traction-associated pin tract morbidity. Because there is no dynamic of the treatment, the simplified frame can be pre-assembled and have no adjustable components. The experience derived from this application has the potential of expanding the role of ring external fixation. Where the ring has been used previously as method of both obtaining and maintaining alignment, this application uses a simplified neutral version of a complex device to simply maintain alignment in a high risk patient population. Correction of deformity and achieving alignment/reduction of fractures is well within the domain of practicing orthopedic surgeon. Once that correction has been achieved, this application simply maintains that correction. It helps avoid extensive surgical dissection in a poor host and eliminates the need for bone that is mechanically capable of holding internal fixation devices during the bony and soft tissue healing period.

Health-related quality of life in patients with transtibial amputation and reconstruction with bone bridging of the distal tibia and fibula

BACKGROUND

Bone-bridging (arthrodesis of the distal tibia and fibula) at the time of transtibial amputation is a controversial operative technique that is anecdotally reported to improve the weightbearing capacity of the residual limb and to decrease residual limb discomfort.

METHODS

Thirty-two consecutive patients with multiple diagnoses had transtibial amputation with a distal tibial-fibular bone-bridge, all done by a single surgeon (MAP). At an average of 16.3 months after surgery all patients completed the Prosthetics Evaluation Questionnaire (PEQ), a validated outcomes instrument specifically created to evaluate quality of life and functional demands in patients with a lower extremity amputations. Their responses were compared with those of 17 preselected, highly functional transtibial amputees from two academic medical centers who previously had transtibial amputations using a traditional non bone-bridge operative technique; their time since amputation averaged 14.7 years.

RESULTS

The "nonselected" consecutive patients with a bone-bridged residual limb scored higher (more favorable) in the Ambulation (p = 0.037) and Frustration (p < 0.001) domains of the PEQ and lower (less favorable) in the Appearance (p = 0.025) subscale. Their scores were similar in the other six domains.

CONCLUSIONS

Patients of multiple ages with multiple diagnoses who had bone-bridging of the distal tibia and fibula at the time of transtibial amputation had scores on a validated outcomes instrument that were better than or comparable to those of a selected group of highly functional transtibial amputees. The results of this study suggest that bone-bridging at the time of transtibial amputation may enhance patient-perceived functional outcomes.

Cytokine-induced osteoclastic bone resorption in charcot arthropathy: an immunohistochemical study

BACKGROUND

Charcot arthropathy is a chronic, progressive destructive process affecting bone architecture and joint alignment in people lacking protective sensation. The etiologic factors leading to progressive bone resorption have not been elucidated. The purpose of this study was to histologically examine surgical specimens with Charcot arthropathy for cell type and immunoreactivity of known cytokine mediators of bone resorption.

METHODS

Tissue samples of 20 specimens with known Charcot arthropathy were stained for Hematoxylin and Eosin (H&E) to quantify cell type. Nine of the specimens were stained with interleukin-1 (IL-1) antibody, nine with tumor necrosis factor (TNF) alpha antibody, and nine with interleukin-6 (IL-6) antibody. Distribution of staining was graded as focal (less than 10% of cells), moderate (10% to 50% of cells), and diffuse (more than 50% of cells) by two independent investigators. Inflammatory cells in tissue sections of rheumatoid synovium served as a positive control.

RESULTS

Osteoclasts were seen in excessive numbers lining the resorptive bone lacunae. There was a disproportionate increase in osteoclasts to osteoblasts in the Charcot-reactive bone. In each case, osteoclasts demonstrated immunoreactivity for IL-1, IL-6 and TNF-alpha with a grade of moderate or diffuse reactivity.

CONCLUSION

The findings of excessive osteoclastic activity in the environment of cytokine mediators of bone resorption (IL-1, IL-6, and TNF-alpha) suggest enhanced bone resorption through the stimulation of osteoclastic progenitor cells as well as mature osteoclasts. Alteration in the synthesis, secretion, or activity of these important regulatory molecules through the use of pharmacologic agents may, in turn, alter bone remodeling and loss and lead to accelerated healing without collapse or malalignment.

Treatment of Eichenholtz stage I Charcot foot arthropathy with a weightbearing total contact cast

BACKGROUND

Initial treatment of Eichenholtz stage I Charcot arthropathy of the foot generally is total contact casting and nonweightbearing. This method, however, often is time-consuming and has a poor result. This study was done to determine the success rate of total contact casting in a small group of patients and to establish a benchmark time period for treatment.

METHODS

Ten subjects with acute Eichenholtz stage I (stage of development) Charcot foot arthropathy were prospectively treated with weightbearing total contact cast therapy, undergoing biweekly cast changes. One subject did not complete the study. Subjects were monitored with biweekly clinical examination, limb volume measurement, and radiographs. The average age was 58.2 (range 39 to 72) years and weight was 216.9 (range 160 to 275) pounds.

RESULTS

All subjects were able to use commercially available depth-inlay shoes and custom accommodative foot orthoses at an average of 9.2 (range 8 to 16) weeks. One subject developed a superficial ulcer that resolved with footwear modification.

CONCLUSION

This preliminary study supports the use of total contact cast therapy and weightbearing in the treatment of acute Charcot foot arthropathy. When the total contact cast was changed every 14 days, all subjects were able to use commercially available depth-inlay shoes and custom orthoses.

Health related quality of life in patients with supination-external rotation stage IV ankle fractures

BACKGROUND

While open reduction of displaced ankle fractures generally is accepted as the standard of care, relatively little is known about the health related quality of life after treatment. It is generally accepted that clinical results of treatment for supination-external rotation stage IV ankle fractures are favorable. The goal of this investigation was to determine the relationship between clinical results and health-related quality of life outcome measures in a consecutive series of patients treated for closed supination-external rotation stage IV ankle fractures.

METHODS

Twenty-six of 156 patients who had operative treatment for closed, displaced supination-external rotation stage IV ankle fractures during a 9-year period, completed the Short Musculoskeletal Function Assessment (SMFA) outcome questionnaire. Radiographs and clinical records were reviewed to determine quality of operative repair, postoperative morbidity, and the development of post-traumatic arthritis.

RESULTS

There were no postoperative complications. Of the 26 patients who returned the SMFA questionnaires, 19 had "good," and seven had "fair" reduction of their fractures. Six showed radiographic evidence of arthritis at followup. Study participants reported scores that were similar to the general population in five of the six domains of the SMFA. Their scores in the mobility index were statistically less favorable (23.72 vs. 13.61, p = 0.016) when compared to the general population. Participants with "good" operative reductions and no evidence of arthritis at followup showed no significant difference to the general population. Participants with either a "fair" operative reduction or evidence of postoperative arthritis at followup had less favorable scores in the daily activities (mean 13.45 vs. 11.82, p = 0.004), mobility (43.43 vs. 13.61, p = 0.001), dysfunction (32.89 vs. 12.70, p = 0.014), and bother (35.80 vs. 13.77, p = 0.020) domains, when compared to the general population.

CONCLUSIONS

The results of this investigation suggest that patients with excellent radiographic operative reductions and no arthritis as early as 6 months after surgery sustain no lasting unfavorable effect on health related quality of life. Patients with "fair" radiographic reduction, or presence of arthritis or both at followup, are likely to have a negative effect on their quality of life.

Cutaneous thermal sensitivity in diabetic neuropathy

BACKGROUND

The goal of this investigation was to determine if cutaneous thermal sensitivity could be used as a discriminator of peripheral neuropathy in diabetic subjects who were sensate to the Semmes-Weinstein 5.07 monofilament.

METHODS

Sixty adult subjects were separated into two groups. The control group (A) was composed of 30 young healthy individuals without a history of diabetes. The focus group (B) was composed of 26 individuals with adult onset diabetes and four with juvenile onset. All of the subjects underwent thermal sensitivity testing in peripheral nerve root dermatomes of their hands and feet. Testing was performed with custom devices fabricated from materials with different thermal conduction capacities (copper, steel, glass, and plastic). Similar tests were performed with glass tubes containing heated or cooled water to develop a range of thermal sensitivity for the subjects.

RESULTS

There was a strong relationship between cold perception and stimulation with the copper probe in dermatomes of the radial nerve of the upper limb and the superficial peroneal dermatome of the lower limb.

CONCLUSIONS

Thermal sensitivity to copper and cold stimulation may be more discriminative and have a higher threshold than sensitivity to the Semmes-Weinstein monofilament. This simple method may have a role in the early detection of peripheral neuropathy in adult-onset diabetes mellitus.

Reliability of AOFAS diabetic foot questionnaire in Charcot arthropathy: stability, internal consistency, and measurable difference

BACKGROUND

The development of Charcot changes is known to be associated with a high rate of recurrent ulceration and amputation. Unfortunately, the effect of Charcot arthropathy on quality of life in diabetic patients has not been systematically studied because of a lack of a disease-specific instrument. The purpose of this study was to develop and test an instrument to evaluate the health-related quality of life of diabetic foot disease.

METHODS

Subjects diagnosed with Charcot arthropathy completed a patient self-administered questionnaire, and clinicians completed an accompanying observational survey. The patient self-administered questionnaire was organized into five general sections: demographics, general health, diabetes-related symptoms, comorbidities, and satisfaction. The scales measured the effect in six health domains: 1) general health, 2) care, 3) worry, 4) sleep, 5) emotion, and 6) physicality. The psychometric properties of the scales were evaluated and the summary scores for the Short-Form Health Survey (SF-36) were compared to published norms for other major medical illnesses.

RESULTS

Of the 89 enrolled patients, 57 who completed the questionnaire on enrollment returned a second completed form at 3-month followup. Over the 3-month followup period most of the patients showed an improvement in the Eichenholtz staging. The internal consistency of most was moderate to high and, in general, the scale scores were stable over 3 months. However, several of the scales suffered from low-ceiling or high-floor effects. Patients with Charcot arthropathy had a much lower physical component score on enrollment than the reported norms for other disease conditions, including diabetes.

CONCLUSIONS

Quality of life represents an important set of outcomes when evaluating the effectiveness of treatment for patients with Charcot arthropathy. This study represents an initial attempt to develop a standardized survey for use with this patient population. Further studies need to be done with larger groups of patients to refine the tool and to begin the validation process. The instrument developed could be used for comparing treatment strategies for Charcot arthropathy.

Ankle arthrodesis with a retrograde femoral nail for Charcot ankle arthropathy

BACKGROUND

Tibiocalcaneal arthrodesis with retrograde intramedullary nailing has gained acceptance as a salvage procedure for a multitude of ankle and hindfoot disorders and is frequently used in Charcot arthropathy of the ankle. Because of the severe osteopenia often associated with Charcot arthropathy of the ankle, an area of stress concentration leading to stress fracture at the proximal aspect of the nail has been identified.

METHODS

To determine if this potential complication can be avoided, nine consecutive diabetic individuals with Charcot arthropathy of the ankle had ankle arthrodesis with a longer retrograde femoral nail. The average age of the patients was 52.3 years. Their average weight was 102.6 kg.

RESULTS

Fusion was evident on radiographs in all nine patients at an average of 10.5 weeks. None of the patients developed a stress fracture or evidence of stress concentration at the proximal metaphyseal tip of the nails. One wound infection resolved after debridement and antibiotic therapy, and one postoperative hematoma resolved without surgery. At an average 32-month followup, all patients were ambulatory, using commercially available therapeutic footwear. None had developed a new foot ulcer, infection, or new episode of Charcot arthropathy.

CONCLUSIONS

The use of a retrograde femoral nail for ankle arthrodesis in patients with Charcot arthropathy appears to decrease the risk of stress fracture compared with shorter nails without increasing the risk of other complications.

Diabetic foot care: multilingual translation of a patient education leaflet

The American Orthopaedic Foot and Ankle Society "Diabetic Foot Care" patient education leaflet was revised to improve the layout and emphasis of key concepts of preventive care. This included review of daily foot and shoe examination, danger signs, daily washing and foot care, shoe fitting, medical care, and avoidance of dangerous acts. The leaflet was expanded to occupy two sides of a page, retaining the capability of production in tear-off sheet format to facilitate distribution to patients in the clinical office. Furthermore, the leaflet was translated into 19 other languages for diabetic patients in the United States and around the world with limited English language comprehension.

Current topics review: Charcot neuroarthropathy of the foot and ankle

Charcot arthropathy is a destructive process, most commonly affecting joints of the foot and ankle in diabetics with peripheral neuropathy. Affected individuals present with swelling, warmth, and erythema, often without history of trauma. Bony fragmentation, fracture, and dislocation progress to foot deformity, bony prominence, and instability. This often causes ulceration and deep infection that may necessitate amputation. Instability or deformity may limit the ability to use standard footwear. Treatment is focused on providing a stable and plantigrade foot for functional ambulation with accommodative footwear and orthoses. Historically, treatment had included nonweightbearing immobilization for the acute phase, and surgery had been reserved only for infection, unresolved skin ulceration, or deformity that precluded the use of therapeutic footwear. Current controversies include weightbearing in the acute or reparative phases and early surgical stabilization. Foot-specific patient education and continued periodic monitoring may reduce the morbidity and associated expense of treating the complications of this disorder and may improve the quality of life in this complex patient population.

Health-related quality of life of patients with diabetes and foot ulcers

Thirty-four patients with diabetes who attended a university diabetic foot clinic for treatment of a foot ulcer completed the American Academy of Orthopaedic Surgeons Musculoskeletal Outcomes Measure. The purpose of the study was to measure the impact of foot ulcers in patients with diabetes on the physical, mental, emotional, and social aspects of patients' lives. Thirty had at least a high school education. Only six were employed at the time. Nineteen were retired or disabled due to poor health. Sixteen were obese, 10 were considered overweight, and eight had a BMI within the acceptable range. Subjects had an average of four to five bodily systems affected by comorbid illness for which they were receiving treatment, some of which limited their activities. Approximately 85% of the study population required some type of ambulatory assist device or were unable to ambulate independently. The study population was significantly limited in performing all physical activities, especially those requiring use of the foot and ankle, and viewed their own health as being significantly worse than that of the general population. All stated that their foot/ankle disease interfered with their lives. Pain was not a significant component of their disability. The results of this study confirm the hypothesis that foot ulcers in patients with diabetes have a negative impact on quality of life in affected individuals.

Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society

Foot infection is the most common reason for hospital admission of diabetic patients in the United States. Foot ulceration leads to deep infection, sepsis, and lower extremity amputation. Prophylactic foot care has been shown to decrease patient morbidity, decrease the utilization of expensive resources, and decrease the risk for amputation and premature death. The Diabetes Committee of the American Orthopaedic Foot and Ankle Society has developed guidelines for the implementation of this type of prophylactic foot care. The screening examination includes evaluation for peripheral neuropathy, skin integrity, ulcers or wounds, deformity, vascular insufficiency, and footwear. Foot-specific patient education includes instruction on self-examination and foot care practices. Individualized foot-specific patient education is indicated for patients with peripheral neuropathy. Treatment is outlined based on risk level, which is determined by the presence of peripheral neuropathy, deformity, and ulcer history. Treatment combines patient education, orthoses, footwear, and a timetable for ongoing skin and nail care. Ulcer care includes paring of calluses, debridement of infected or nonviable tissue, dressings, and off-loading. Specialty assistance may be required from a vascular surgeon, orthopaedic surgeon, podiatrist, endocrinologist/diabetologist, infectious disease consultant, radiologist, and pedorthist.

Disease knowledge in patients attending a diabetic foot clinic

BACKGROUND

Foot-specific patient education is an essential element of a health system diabetic foot program. Foot-specific patient education must be individualized, because of cognitive deficits in individuals with long-standing diabetes.

METHODS

Two hundred and two consecutive patients attending diabetic foot specialty clinics were asked to provide demographics and complete a 10-question multiple-choice questionnaire. All attended the clinics because of their high-risk status for the development of diabetic foot infection or ulcers. All received ongoing foot-specific patient education.

RESULTS

In spite of this ongoing patient education program, only approximately 80% were able to respond appropriately to simple questions related to the care of their "at-risk" feet.

CONCLUSION

This simple quality initiative reinforces the notion that patients with diabetes who are at risk for the development of diabetic foot ulcers should receive ongoing foot-specific patient education. This information needs to be constantly reinforced, as retention drops with time.

Arthrodesis of the first metatarsophalangeal joint

Arthrodesis has emerged as the primary salvage procedure for severe osteoarthritis of the first metatarsophalangeal (MTP) joint. Forty-three patients underwent arthrodesis of the first MTP joint with stabilization provided by either 2 crossed lag-screws or a dorsal plate and screws. First MTP joint arthrodesis was the primary procedure for 46 of the 54 treated feet. Joint surfaces were shaped into a ball-and-socket configuration to augment joint surface contact and facilitate alignment for arthrodesis. Postoperative care involved using a compressive bandage, a surgical shoe, and a cane, crutches, or a walker. Partial weight-bearing was allowed immediately after surgery. Few casts were used postoperatively. At a mean of 21.7 months (median, 13.5 months), 34 of the 43 patients completed a brief telephone survey about surgical outcomes. Radiographic measurements of intermetatarsal, hallux valgus, inclination, and dorsiflexion angles were made preoperatively and postoperatively. Mean time to fusion was 7.3 weeks; arthrodesis was successful for 50 of 52 feet (radiographs were missing for 2 of the 54 feet treated). Internal fixation devices were removed from 5 feet. Thirty (88.2%) of the 34 patients rated their result as excellent or good; the other 4 (11.8%) rated their result as poor.

Health-related quality of life for patients with rheumatoid arthritis foot involvement

HYPOTHESIS

Rheumatoid arthritis is a common disabling form of arthritis that frequently affects the hands and feet. With time, the majority of affected individuals will become disabled.

METHODS

Sixty-nine consecutively selected mild to moderately affected individuals with rheumatoid arthritis provided demographic data and agreed to complete the Short Musculoskeletal Function Assessment (SFMA) instrument. Focus group subjects selectively used minimally adaptive nonprescription footwear. Control subjects had similar disease expression, but did not alter their choice of footwear due to their disease.

RESULTS

Adult patients with rheumatoid arthritis demonstrate a significant negative impact on their quality of life with mild or moderate disease expression, as evidenced by poor scores in all six domains of the SFMA. Subjects who used even mildly adaptive nonprescription footwear demonstrated a statistically significant negative impact in mobility (p < .044) and functional index (p < .052) domains as compared with the control population having similar overall disease expression. Focus subjects also demonstrated a trend to less favorable scores in the arm and hand domain. Mean scores of the daily activity, emotional status, and bother index domains fared worse than population norms, but there was no statistical difference between subjects using, or not using, adaptive footwear.

CONCLUSIONS

Individuals affected with mild to moderate rheumatoid arthritis are disabled as compared with the general population. There is a severe negative impact on mobility and functional capacity when the disease process begins to affect their feet.