The Assessment and Perioperative Management of Patients With Rheumatoid Arthritis:

The rheumatoid forefoot

Rheumatoid arthritis (RA) manifests itself in a variety of ways, with its effect being seen in around 90 % of sufferers' feet. The foot has been found to be the most common reason for incapacity in patients with RA, with the forefoot the most common area. The foot is second, behind only the hand, as the most common place for manifestation of RA. Pain in the foot is commonly the most debilitating condition, which causes the patient to seek specialist help. As well as pain, foot deformities such as hallux valgus and claw toes are common complaints. These symptoms often arise as a result of continued walking on an unstable foot, leading to painful callosities and dislocation of the metatarsophalangeal joints. Other conditions, such as pannus formation and Morton's neuroma, can be related to RA. This review sets out what we believe to be a successful approach to the rheumatoid forefoot, which aims at the relief of pain and the preservation of ambulation. Key to a successful outcome is appropriate medical control with a multidisciplinary approach that enables close liaison between orthopaedic surgeons, orthotists, and rheumatologists. Combined clinics provide this multidisciplinary care. Those treating RA need to be aware of the high incidence of foot involvement and how early intervention may benefit the patient. The aim of this article is to present current evidence to enable people to develop a treatment algorithm for this condition.

Controversies in total ankle replacement

Although there exist general guidelines regarding which patients are "suitable" candidates for total ankle replacement, these guidelines tend to be very conservative, much like those of knee and hip replacement from decades ago. There are also no direct comparison studies of one total ankle replacement design with another. Because of the paucity of data, surgeons are left to surmise the opinion based on limited studies, as well as industry-sponsored data and advertising material. This article examines several key, controversial issues that apply to total ankle replacement. Recommendations and points for thought are provided.

Scarf and Weil metatarsal osteotomies of the lateral rays for correction of rheumatoid forefoot deformities: a systematic review

Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays has recently been proposed for the treatment of global rheumatoid forefoot deformities because of the perceived benefit of sparing the metatarsal-phalangeal joints. Furthermore, it has been proposed that undergoing this form of global forefoot reconstruction is reliable based on specific preoperative and intraoperative techniques used to realign the individual rays. Finally, it has been proposed that performing global forefoot reconstruction in the rheumatoid patient population can be safely performed and does not prevent the ability to perform revision surgery. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays for the treatment of global rheumatoid forefoot deformities. Information from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved patients undergoing Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays, evaluated patients at mean follow-up of 12-months or longer duration, commented on the reliability of metatarsal realignment, and included details of complications, as well as the incidence and severity of wound-healing complications. Two studies were identified that met the inclusion criteria involving only 8 patients (8 feet) with 1 patient undergoing surgical revision in the form of arthrodesis secondary to development of a septic first metatarsal-phalangeal joint. Partial incision dehiscence developed in 2 patients, 1 healed with local wound care and the other led to the septic first metatarsal-phalangeal joint mentioned previously. Finally, stress fracture of the third metatarsal and fourth metatarsals developed that healed without problems in one other patient. Rather than providing strong evidence for or against the use of Scarf osteotomy of the first ray combined with Weil distal oblique shortening osteotomies of the lateral rays for the treatment of global rheumatoid forefoot deformities, the results of this systematic review make clear the need for methodologically sound prospective cohort studies and randomized controlled trials that focus on the use of this form of surgical intervention.

The complications encountered with the rheumatoid surgical foot and ankle

Rheumatoid arthritis (RA) is a chronic, degenerative, systemic disease that leads to the destruction of articular cartilage of the joints. Complications, including infection, delays in wound healing, malunion, nonunion, implant failure, and degeneration of adjacent joints soon after primary fusion, have been described in the literature and are generally accepted as commonplace in reconstructive surgeries of the foot and ankle. The combined efforts of the surgeon and supporting physicians to maintain optimal health for the patient, along with the principles discussed in this article, can lead to superior outcomes with fewer complications in the postoperative course.

Wound healing complications and infection following surgery for rheumatoid arthritis

The goal of the foot and ankle surgeon is to achieve balanced correction of deformity in patients who have rheumatoid arthritis (RA) while minimizing the risk for complications. To achieve these goals, a large number of procedures may be required at a single or in a staged operative setting. In this article, the evaluation of the patient to assess operative risks and the management of perioperative complications in the RA foot and ankle patient are presented.