Management of the foot in rheumatoid arthritis

Radiographic factors associated with painful callosities after forefoot surgery in patients with rheumatoid arthritis

OBJECTIVES

Operative procedures for rheumatoid forefoot deformities have gradually changed from arthrodesis or resection arthroplasty to joint-preserving surgery. Although joint-preserving arthroplasty has yielded good outcomes, painful plantar callosities may occur post-operatively. This study aimed to reveal the radiographic factors associated with painful callosities after joint-preserving surgery for forefoot deformities in patients with rheumatoid arthritis (RA).

METHODS

We retrospectively evaluated 166 feet in 133 patients with RA who underwent forefoot joint-preserving arthroplasty, including proximal rotational closing-wedge osteotomies of the first metatarsal, between January 2012 and December 2015. Logistic regression analysis was performed with the objective variable set as the presence/absence of painful plantar callosities at the final observation and the explanatory variables set as several radiographic factors, including post-operative relative first metatarsal length (RML), amount of dorsal dislocation of the fifth metatarsal (5DD), and arc failure of the lesser toes.

RESULTS

At the final follow-up, 42 of the 166 feet (25.3%) had painful callosities under the metatarsal heads post-operatively. Logistic regression analysis showed that the RML, 5DD, and lesser toes' arc failure were significantly associated with painful callosities.

CONCLUSIONS

We identified that RML, 5DD, and arc failure of the lesser toes were associated with painful plantar callosities after the surgery.

Outcome after resection arthroplasty or shortening oblique osteotomy of the lesser metatarsals combined with arthrodesis of the first metatarsophalangeal joint for severe rheumatoid forefoot deformities

PURPOSE

We investigated objective and patient-reported outcomes after resection arthroplasty or shortening oblique osteotomy (SOO) of the lesser metatarsals combined with arthrodesis of the first metatarsophalangeal (MTP) joint for severe rheumatoid forefoot deformities.

METHODS

17 feet from 14 women (mean age, 67.8 years) underwent resection arthroplasty of the lesser metatarsal heads (MTH resection group), while 13 feet from nine women and two men (mean age, 68.7 years) underwent SOO of the lesser metatarsals (MTH preservation group). Arthrodesis of the first MTP joint was performed in all cases. Mean follow-up in the MTH resection and preservation groups was 25.0 and 21.3 months, respectively. Preoperative and postoperative clinical evaluation included Japanese Society for Surgery of the Foot (JSSF) scale and self-administered foot evaluation questionnaire (SAFE-Q) scores.

RESULTS

Mean total JSSF scale significantly improved from 53.4 to 76.4 in the MTH resection group (p < .001) and from 50.1 to 74.2 in the MTH preservation group (p = .002). Pain and pain-related and shoe-related SAFE-Q subscale scores significantly improved after surgery in both groups. In the MTH resection group, recurrence of painful callosities and claw toe deformity was observed in four and three feet, respectively. In the MTH preservation group, one patient experienced recurrence of painful callosities and one underwent revision surgery for IP joint dislocation.

CONCLUSION

Resection arthroplasty or SOO of the lesser metatarsals combined with arthrodesis of the first MTP joint achieved significant improvement with respect to pain relief, deformity correction, and footwear comfort.

Subjective and Objective Outcomes of Surgery for Rheumatoid Forefoot Deformities Under the Current Treatment Paradigm

We investigated the clinical outcomes of surgical procedures for the treatment of forefoot deformities in patients with rheumatoid arthritis. Twenty feet in 16 women (mean age 62.1 years) underwent corrective osteotomy of the first metatarsal bone with shortening oblique osteotomy of the lesser metatarsophalangeal joints (joint-preservation group), while 13 feet in 12 women (mean age 67.4 years) underwent arthrodesis of the first metatarsophalangeal joint with resection arthroplasty of the lesser metatarsophalangeal joints (joint-sacrifice group); mean follow-up for each group was 25.8 and 23.8 months, respectively. The mean total Japanese Society for Surgery of the Foot (JSSF) scale improved significantly from 64.2 to 89.2 in the joint-preservation group (p < .001), and from 54.2 to 74.2 in the joint-sacrifice group (p = .003). In the joint-preservation group, the postoperative range of motion (ROM) of the joint, walking ability, and activities of daily living scores of the JSSF scale were significantly higher than those in the joint-sacrifice group (p = .001, p = .001, and p = .019, respectively). There were no differences in the subscale scores of the self-administered foot evaluation questionnaire between 2 groups either pre- or postoperatively. No differences in the postoperative complications were found between 2 groups. Although the joint-sacrificing procedure resulted in lower objective outcomes than the joint-preserving procedure regarding the ROM of the joint, the walking ability, and the level of activities of daily living, both procedures resulted in similar treatment outcomes when evaluated by the subjective measures.

OrthoRehab: Development of a New Methodology for the Comparison Study Between Different Types of Ankle-Foot Orthoses in Foot Dysfunction

Foot dysfunction is one of the most likely consequences of rheumatoid arthritis and stroke. It is characterized by severe changes in the gait pattern due to a significant increase in the plantar flexion. Some of these dysfunctions can be compensated by using an ankle–foot orthosis. However, the clinical decision about which orthosis best suits the patient creates a real problem for physicians/therapists.

Purpose: The main goal of this paper is to present a quantitative support tool that can assist the physicians/therapists in deciding which orthosis is most suitable for each subject.

Methodology: In order to achieve such goal, a platform named OrthoRehab was developed, and it was tested in three conditions: without any orthosis and with two different ankle–foot orthoses. The data were acquired in the Gait Laboratory of Rehabilitation Medicine Center of Alcoitão using a VICON NEXUS 1.8.5^® motion capture system that allows the capturing of kinematic and kinetic data.

Results: The results reveal that OrthoRehab is a user-friendly, easy to apply tool that analyzes very relevant data for the clinical staff.

Conclusion: The developed decision support tool, OrthoRehab, offers a quantitative analysis and provides insight to which orthosis achieves the best performance in comparison with the patient's gait pattern with no orthosis.

Patient-Reported and Radiographic Outcomes of Joint-Preserving Surgery for Rheumatoid Forefoot Deformities: A Retrospective Case Series with Mean Follow-up of 6 Years

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune disorder and a chronic inflammatory disease that can damage joints throughout the body. As dramatic improvements in medical treatment have contributed to reduced progression of joint destruction, surgical methods for the treatment of RA-related forefoot deformities have gradually changed from joint-sacrificing to joint-preserving. The aim of this study was to assess the long-term outcomes, including patient-reported outcomes, of joint-preserving surgery for forefoot deformities associated with RA.

METHODS

This retrospective study included 105 feet in 89 patients with RA who were treated during the period of January 2012 to May 2015 and had a minimum of 5 years of follow-up (mean, 6.0 ± 0.9 years). The patient-reported outcome measure used was the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), which was completed preoperatively and at the latest follow-up (n = 53 feet). The hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the position of the medial sesamoid were measured preoperatively, at 3 months postoperatively, and at the latest follow-up. Cases of delayed wound-healing, hallux valgus recurrence, nonunion at the osteotomy sites, and reoperation were recorded. Kaplan-Meier survival curves were used to determine the estimated survivorship, with reoperation as the end point.

RESULTS

Scores of all 5 subscales of the SAFE-Q demonstrated significant improvement at the latest follow-up. The average HVA and IMA decreased significantly 3 months postoperatively, and these measurements remained significantly lower than the preoperative values (p < 0.01). The position of the medial sesamoid at the latest follow-up improved significantly (p < 0.01). Delayed wound-healing was found at the site of surgery in 21 (20.0%) of the 105 feet. Recurrence of hallux valgus was observed in 11 (10.5%) of the feet. There was no case of nonunion at any osteotomy site. Eleven (10.5%) of the feet required reoperation. The estimated survivorship of the studied joint-preserving surgery at 7 years, with reoperation as the end point, was 89.5%.

CONCLUSIONS

Satisfactory long-term patient-reported and radiographic outcomes after joint-preserving surgery for forefoot deformities associated with RA can be achieved.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Disease activity affects the recurrent deformities of the lesser toes after resection arthroplasty for rheumatoid forefoot deformity

OBJECTIVES

The purpose of this study was to clarify the effect of disease activity on recurrent deformities after resection arthroplasty for forefoot deformities in patients with rheumatoid arthritis (RA).

METHODS

This study included 83 feet in 58 patients with RA who underwent resection arthroplasty of all metatarsal heads, with a minimum follow-up of 2 years. The patients' demographic characteristics, preoperative radiographic findings, and RA disease activity evaluated using the 28-joint disease activity score based on the erythrocyte sedimentation rate (determined preoperatively and at the final follow-up) were compared between feet with and without postoperative recurrent deformities of the toes. Recurrent deformities were assessed separately for the hallux and lesser toes.

RESULTS

Recurrence in the hallux and lesser toes occurred in 23 feet (27.7%) and 13 feet (15.7%), respectively. With respect to recurrent hallux deformity, only the preoperative severity of hallux deformity was associated with recurrence. On the other hand, postoperative deformity of the lesser toes was positively associated with disease activity alone and not with other preoperative factors.

CONCLUSION

Postoperative control of RA disease activity was associated with recurrent deformity of the lesser toes but not that of the hallux after resection arthroplasty of all metatarsals for rheumatoid forefoot deformities.

Effect of an orthosis on foot center of pressure translation for treatment of hallux valgus in patients with rheumatoid arthritis: A report of 17 cases

Objectives

We aimed to investigate the change in the center of pressure (COP) path and distribution with or without orthosis for hallux valgus (HV) in patients with rheumatoid arthritis (RA).

Methods

In total, 17 patients and 21 feet were enrolled. We measured the COP path using the COP path measurement device (F-Scan II system). The HV angle (HVA); the anteroposterior COP path length, which was measured as a percentage of the foot length (%Long); transverse width of the COP path which was measured from the most medial to the most lateral point and expressed as a percentage of maximum foot width (%Trans); and the final site of the walking locus were analyzed by comparing patients with RA with and without orthosis.

Results

Testing without and with the orthosis showed that the HVAs were 31.8° ± 9.3° and 25.2° ± 6.8° (p < 0.001), the %Long values were 61.1% ± 5.5% and 69.2% ± 5.9% (p < 0.001), and the %Trans values were 28.0% ± 9.1% and 30.1% ± 8.3% (p = 0.108). The final site of the walking locus for the 1st interphalangeal joint without and with orthosis were 8 feet (38.1%) and 15 feet (71.4%) (p = 0.020), respectively.

Conclusions

The results indicated that the orthosis for HV improved the walking path and should be considered as a therapeutic option in nonpharmacological treatment of RA.

Radiographic Outcomes of Mobile-Bearing Total Ankle Arthroplasty for Patients With Rheumatoid Arthritis

BACKGROUND

Ankle disorders in patients with rheumatoid arthritis (RA) reduce their quality of life and activities of daily living. The aim of this study was to evaluate the midterm clinical and radiographic outcomes of TAA in patients with RA.

METHODS

This retrospective study included patients with a minimum follow-up of 2 years. A total of 37 RA patients (39 ankles) were enrolled in this study from August 2006 to March 2016. All the patients had undergone primary cemented mobile-bearing total ankle arthroplasty (TAA). Nine ankles received arthrodesis of the subtalar joint simultaneously. Patient-reported outcomes were measured preoperatively and at the latest follow-up by Self-Administered Foot-Evaluation Questionnaire (SAFE-Q). Radiographs of the ankle were analyzed preoperatively and at all follow-up visits to measure the periprosthetic radiolucent line, migration of the tibial component, and the subsidence of the talar component. Intraoperative and postoperative complications were recorded. The average duration of follow-up for the entire cohort was 5.0 ± 2.0 years (range 2.1-10.1 years).

RESULTS

All subscales of the SAFE-Q had improved significantly at the latest follow-up. No significant difference was found between the range of motion of the ankle before and after the surgery. Radiolucent lines were observed in 28 (73.7%) ankles. Migration of the tibial component and subsidence of the talar component were found in 8 (21.1%) and 11 (28.9%) ankles, respectively. Intraoperative malleolus fractures occurred in 3 (7.7%) ankles and delayed wound healing in 10 (25.6%) ankles. Four ankles were removed because of deep infection or noninfective loosening, resulting in an implant survival rate of 88.4% (95% CI, 0.76-1.0) at 10 years.

CONCLUSION

The midterm patient-reported outcomes and implant retention rate after cemented mobile-bearing TAA for RA patients were satisfactory. However, a low radiographic implant success rate was observed.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Resection or preservation of the metatarsal heads in rheumatoid forefoot surgery? A randomised clinical trial

BACKGROUND

Despite impressive results of the pharmacological management of rheumatoid arthritis, still certain patients suffer from rheumatoid forefoot problems. Surgical treatment of these forefoot deformities can be an option. In literature no high-quality studies on this topic can be found. The goal of present study is to compare the results of a metatarsal head (MTH) resecting technique with a MTH preserving technique in the operative treatment of severe rheumatoid forefoot deformity.

METHODS

Patients suffering from well-defined rheumatoid forefoot deformity were prospectively enrolled in three institutions. This non-blinded study had a randomised clinical design and eligible patients were randomly assigned to undergo either resection of preservation of the MTH. The primary outcome measure consisted of the AOFAS score. Secondary outcome measures were: the FFI, the VAS for pain and the SF-36.

RESULTS

Twenty-three patients (10 in MTH preservation group) were included and analysed. After one year follow-up no significant differences in AOFAS score and additional outcome factors were found. A total of 10 complications in 23 patients were reported.

CONCLUSIONS

This randomised clinical study did not show significant clinical difference between a MTH resecting and a preserving procedure in patients suffering from rheumatoid forefoot deformity. Both procedures resulted in considerable improvement of pain and activity scores.

Features of patients with rheumatoid arthritis whose debut joint is a foot or ankle joint: A 5,479-case study from the IORRA cohort

Background

Foot and ankle joint disorders are serious issues for patients with rheumatoid arthritis (RA). We compared the differences between patients with RA whose first symptom involved a foot or ankle joint (FOOT group) versus other joints (non-FOOT group) within the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort in our institute.

Patients and methods

In the IORRA survey conducted in April 2016, patients were invited to complete six questionnaires about their first symptom at RA onset, current foot or ankle symptoms, daily living activities, and mental health. Disease activity, clinical laboratory variables, functional disability, quality of life, use and ratio of anti-inflammatory and antirheumatic drugs, daily living activities and mental health were compared between the two groups.

Results

Among 5,637 Japanese patients with RA who participated in the IORRA survey on April 2016, 5,479 (97.2%) responded to the questionnaire regarding their debut joint. Of these patients, 2,402 (43.8%) reported that their first symptom of RA involved a foot or ankle joint. The FOOT group (n = 2,164) had higher disease activity, higher disabilities, lower quality of life, lower activities of daily living, and poorer mental health and used anti-inflammatory drugs at a higher rate and at higher doses compared with the non-FOOT group (n = 2,164). On the other hand, the use of medications to suppress the disease activity of RA was similar between the groups.

Conclusion

Clinicians should pay more attention to foot and ankle joints in daily practice so as not to underestimate the disease activity of RA.

Outcomes of Resection and Joint-Preserving Arthroplasty for Forefoot Deformities for Rheumatoid Arthritis

BACKGROUND

We investigated the clinical outcomes of resection and joint-preserving arthroplasty for forefoot deformities in patients with rheumatoid arthritis.

METHODS

Sixteen feet of 14 women (average age, 67.1 years; range, 53-82) underwent resection arthroplasty of the metatarsal head (resection group), and 18 feet of 15 women (average age, 61.3 years; range, 40-73) underwent a metatarsophalangeal joint-preserving procedure with shortening oblique metatarsal osteotomies of the lesser toes (joint preservation group). The mean disease duration in the resection and joint preservation groups was 23.6 and 19.1 years, and the average follow-up period was 37.3 and 33.5 months, respectively. The classification of Larsen was used to assess the severity of destruction of the metatarsophalangeal (MTP) joint. Preoperative and postoperative clinical evaluation included Japanese Society for Surgery of the Foot (JSSF) score and postoperative complications.

RESULTS

The number of preoperative radiographic destruction of the MTP joints (Larsen grade II, III, IV, and V) was 0, 29, 39, and 12 joints in the resection group and 13, 67, 9, and 1 joints in the joint preservation group. The mean JSSF score improved significantly from 61.3 to 83.9 points in the resection group ( P < .001) and from 62.2 to 90.8 points in the joint preservation group ( P < .001). In the resection group, recurrence of callosities and claw toe deformity was observed in 6 and 3 feet, respectively. In the joint-preserving group, recurrence of callosities and hammer toe deformity was observed in 1 foot each.

CONCLUSION

The resection arthroplasty and joint-preserving procedure showed satisfactory clinical outcomes. However, whether both procedures can maintain the good clinical results without the recurrence of forefoot deformity will require longer follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Comparison of outcomes according to fixation technique following the modified Ludloff osteotomy for hallux valgus in patients with rheumatoid arthritis

Background

Clinical and radiological outcomes including fixation stability of osteotomy site were compared in rheumatoid arthritis (RA) patients who underwent modified Ludloff osteotomy to correct hallux valgus with osteotomy site fixation using two screws versus those who underwent additional fixation using a plate.

Methods

The fixation technique performed with two screws was used to fix the osteotomy sites following modified Ludloff osteotomy in 15 patients (15 feet, Group S), while the augmented plate fixation technique was used in 14 patients (16 feet, Group P). Surgical outcomes were analysed using the American Orthopedic Foot and Ankle Society (AOFAS) scores, and radiologic parameters measured before surgery and during follow-up examinations. To evaluate the stability of each osteotomy site fixation technique, the 1–2 inter-metatarsal angle (IMA) and angle of the altered margin of the lateral cortex (AMLC) were measured immediately and 6 weeks after surgery, and variations in the angles were compared. In addition, bone mineral density (BMD) values were compared between patients with correction loss at the osteotomy site and those with no loss of correction.

Results

No significant differences between groups were found for total AOFAS scores before surgery and at the final follow-up. However, significant differences were observed in the 1–2 IMA, beginning at 6 weeks postoperatively and continuing through the final follow-up. The 1–2 IMA and angle of AMLC measured immediately after and 6 weeks after surgery showed significantly greater variation in Group S than in Group P. In Group S, patients with correction loss (5 feet) at osteotomy site showed significantly lower BMD values than those with no loss of correction (10 feet). Despite the lower BMD values of patients in Group P than in Group S, a loss of correction did not occur in these patients.

Conclusions

Correction loss occurred at the osteotomy site within 6 weeks postoperatively in patients who underwent fixation using only the two-screw fixation technique following modified Ludloff osteotomy; such loss could be reduced using the augmented plate fixation technique even in patients with osteoporosis.

Recurrence of deformity after silicone implant and resection arthroplasty of the metatarsophalangeal joint for rheumatoid arthritis: long-term results

OBJECTIVE

To examine the recurrence of deformity after silicone implant arthroplasty combined with resection arthroplasty for severe forefoot deformity in patients with rheumatoid arthritis.

METHODS

We reviewed the long-term results of this procedure for 27 feet in 15 patients. Their average age and disease duration at the time of operation were 58.6 years and 17.5 years, respectively, and the average follow-up period was 10.3 years.

RESULTS

An improved hallux valgus angle (45.3° preoperatively, 23.6° 6 months after operation) was maintained. By contrast, deformity and dislocation of lesser toe had recurred at the final follow-up; the angle between the proximal phalanx and the metatarsal of the second toe improved 13.4° with recurrence of 22.5°, the angle between the proximal phalanx and ground surface improved 22.4° with recurrence of 34.5. Furthermore, claw toe deformity at the final follow-up was significantly worse in the group whose hallux valgus deformity was observed 6 months after operation.

CONCLUSION

This procedure could maintain the alignment of the first metatarsophalangeal joint, but the recurrence of claw toe deformity is a problem and the relation between the first toe and the lesser toe is an important consideration.

Changes in foot function, disease activity, and disability after forefoot resection arthroplasty in patients with rheumatoid arthritis

The purpose of this study was to investigate the changes in foot function, disease activity, and disability in patients with RA after resection arthroplasty of the forefoot (arthroplasty). Arthroplasty was performed on 11 patients with RA. All study patients underwent clinical assessment to measure disease activity (Disease Activity Score in 28 Joints-C-reactive protein, DAS28-CRP), disability (Health Assessment Questionnaire-Disability Index, HAQ-DI) and foot function (Foot Function Index, FFI) at the following stages: preoperatively and 1, 3, and 12 months after surgery. Following arthroplasty, foot function improved significantly, as assessed by FFI total and subscales (pain, disability, and limitation of activity) (P<0.001, P<0.001, P<0.001, and P=0.002, respectively). Disease activity was significantly improved in relation to DAS28-CRP and its subscales of number of swollen joints and patient global assessment (PtGA) (P=0.033, P=0.008, and P=0.038, respectively). There was no significant difference in disability, as assessed by the HAQ-DI and its subscale, HAQ-walking (P=0.150 and P=0.597, respectively). Foot function improved significantly after arthroplasty, and was maintained at 12 months postoperatively. Additionally, our study showed that disease activity and its subscale PtGA improved after arthroplasty.

Forefoot Deformity in Rheumatoid Arthritis: A Comparison of Shod and Unshod Populations

All reported rheumatoid arthritis (RA) forefoot deformities in the literature thus far have arisen from shoe wearing populations. Our aim in this study was to compare hallucal deformities seen in a shod population with an unshod population. A population comparison was undertaken in 2 specialized foot and ankle units, one in India and one in the United Kingdom. In the shod population, there was 1 hallux varus deformity, 10 without hallucal deformity, and 90 hallux valgus deformities. In contrast, in the unshod population, there were 19 hallux varus deformities and 6 hallux valgus deformities. There was great variability in the lesser toe deformity seen. In the shod population, it was most common to see dorsal subluxation or dislocation, with the fifth toe in a varus position. In the unshod population, the most common lesser toe deformity seen was varus deviation or dislocation. Instability of the metatarsophalangeal joint in the rheumatoid foot predisposes it to significant deformity. In the non-shoe wearing population, intrinsic muscle forces and weight bearing forces are the most likely determinants of the deformity, with hallux varus being a more common presenting problem. In the shod population, the external forces of shoe wear dictate the direction of deformity.

LEVELS OF EVIDENCE

Prognostic, Level III: Case control study.

A comparative study on the results of the modified Ludloff osteotomy for hallux valgus deformities with minimal erosion of the metatarsophalangeal joints in rheumatoid patients versus non-rheumatoid patients

OBJECTIVES

We aimed to compare the outcomes of joint-preserving surgery for hallux valgus deformities with minimal erosion of the metatarsophalangeal joint in rheumatoid patients with non-rheumatoid controls, and to determine the prognostic factors of recurrence in rheumatoid patients.

METHODS

A total of 18 rheumatoid patients (20 feet, Group I) and 35 non-rheumatoid patients (39 feet, Group II) were included. The mean follow-up was 29.6 months. Radiographic and clinical outcomes were compared. To identify the prognostic factors for recurrences in rheumatoid patients, subgroup analyses were done in Group I.

RESULTS

Most of the outcomes showed favorable results in both groups. However, Group II had better results in hallux valgus angle (HVA) (15.9° vs. 7.9°, p < 0.001), and in sesamoid position (p = 0.040) at final follow-up. Group I showed higher recurrence rate (50% vs. 0%). The final American Orthopaedic Foot and Ankle Society score was better in Group II (82.1 vs. 90.7, p = 0.014). The large preoperative HVA, non-performance of Akin osteotomy, and insufficient reduction of sesamoid position were related to recurrence in rheumatoid patients.

CONCLUSIONS

Joint-preserving surgery for hallux valgus deformities in rheumatoid forefoot deformity showed favorable results in mid-term follow-up; however, it should be warned of possible recurrent deformities.

Arthrodesis of the wrist in rheumatoid arthritis

In rheumatoid arthritis the small joints of the feet and hands are the first targets of the autoimmune process. In about one half of the patient the wrist is involved in the first stages of the disease (two years) increasing up to nearly 90 percent after a decade often including both sides. Osteoarthritis of the wrist is one of the most common conditions encountered by hand surgeons. One aim of all treatment options is to achieve the best possible hand function without pain. If conservative treatment fails, operative treatment is necessary. Choice of surgical treatment depends on the soft tissue and bone situation. Techniques can be differentiated by joint preservation or joint replacement. The first include radio-synoviorthesis, synovectomy and tendon repair, the latter resection-arthroplasty, total joint arthroplasty and arthrodesis. In this paper arthrodesis of the wrist as one treatment option is reviewed.

Rheumatoid forefoot reconstruction: outcome of 1st metatarsophalangeal joint fusion and the Stainsby procedure in the lesser toes

BACKGROUND

Rheumatoid arthritis is a chronic inflammatory disease involving connective tissue and joints. The most common rheumatoid forefoot deformities are hallux valgus and clawed lesser toes. There are a number of surgical procedures that have been described offering symptomatic relief and anatomical correction.

OBJECTIVES

This prospective case series aims to assess outcome in patients with rheumatoid forefoot deformities who underwent a novel combination of 1st metatarsophalangeal joint fusions and Stainsby procedures.

METHODS

Thirteen procedures were performed on 12 consecutive patients with an age range of 55-71 (mean=62) between 02/2009 and 05/2011. AOFAS scoring was performed preoperatively and again six and 12 months post-surgery. Hallux valgus (HVA) and intermetatarsal angles (IMA) were measured preoperatively and six weeks and six months postoperatively.

RESULTS

The mean AOFAS score increased from 46 to 72, 12 months postoperatively. The mean HVA reduced from 48° preoperatively to 14° six months postoperatively. The IMA decreased from 15° to 10° six months postoperatively.

CONCLUSIONS

The novel approach of 1st metatarsophalangeal fusion combined with lesser toe metatarsal head sparing is an effective procedure that reduces forefoot deformity and pain.

Radiologic patterning of joint damage to the foot in rheumatoid arthritis

OBJECTIVE

Foot and ankle deformities greatly affect the quality of life of rheumatoid arthritis (RA) patients. The aim of this study was to elucidate the pattern of destruction of the RA foot and its impact on patients.

METHODS

We cross-sectionally investigated RA patients (274 patients and 542 feet) using radiographs. The grade of joint destruction was assigned using Larsen's grading system for 12 joints in the foot and ankle. Cluster analysis was performed using the K-means method to classify the pattern of joint destruction. Of the 274 patients evaluated radiographically, 212 were assessed for functional disability using questionnaires.

RESULTS

Cluster analysis revealed that 542 feet were divided into 5 clusters, named according to the characteristic distribution of joint destruction: cluster I (normal type), cluster II (forefoot type), cluster III (midfoot type), cluster IV (mid-hindfoot type), and cluster V (combined type). Radiographic measurements revealed the characteristic deformities of each cluster: splay foot for cluster II, flat foot for cluster III, hindfoot malalignment for cluster IV, and mixtures of these characteristics for cluster V. A distribution map of each cluster based on disease duration revealed that cluster III peaked in cases of 5-10-year disease duration and subsequently decreased, followed by a gradual increase of cluster IV and cluster V. Cluster IV and cluster V showed significant changes in functional disability compared to cluster III.

CONCLUSION

This report is the first to reveal the pattern of RA foot deformities and their impact on patients using statistical measures in a large series.

Clinical and functional evaluation of forefoot reconstruction in patients with rheumatoid arthritis

Objective

to evaluate the long-term results from reconstruction of the forefoot in patients with rheumatoid arthritis who underwent arthrodesis of the metatarsophalangeal joint of the hallux, resection arthroplasty of the heads of the lateral metatarsals and correction of the deformities of the smaller toes through arthrodesis of the proximal interphalangeal joint or closed manipulation.

Methods

seventeen patients (27 feet) who underwent forefoot reconstruction surgery by means of arthrodesis of the first metatarsophalangeal joint, resection of the heads of the lateral metatarsals and correction of the deformities of the smaller toes, were studied retrospectively. The mean follow-up was 68 months (12–148 months); the mean age was 52 years (range: 20–75 months); and four patients were male and 13 were female.

Results

the results were classified as excellent in 17 feet, good in two, fair in four and poor in two. The mean score on the AOFAS scale was 70 points; 21 feet (78%) were found to be asymptomatic; and six feet (22%) presented some type of symptom. Three feet presented pseudarthrosis, and one of these successfully underwent revision of the arthrodesis. There was no significant difference in scoring on the AOFAS scale or in the consolidation rate, between using a plate and screws and using Kirschner wires for fixation of the arthrodesis.

Conclusion

arthrodesis of the first metatarsophalangeal joint with resection arthroplasty on the heads of the lateral metatarsals and correction of the deformities of the smaller toes, which was used in forefoot reconstruction in rheumatoid patients, showed good long-term results with a high satisfaction rate among the patients and clinical-functional improvement.

Involvement of valgus hindfoot deformity in hallux valgus deformity in rheumatoid arthritis

The involvement of valgus hindfoot deformity in hallux valgus deformity was confirmed in a rheumatoid arthritis case with a destructive valgus hindfoot deformity. Correction of severe valgus, calcaneal lateral offset, and pronated foot deformity instantly normalized hallux valgus deformities postoperatively. Thus, careful hindfoot status evaluation is important when assessing forefoot deformity, including hallux valgus, in rheumatoid arthritis cases.

The Weil osteotomy for correction of the severe rheumatoid forefoot

PURPOSE

In rheumatoid arthritis the metatarsophalangeal (MTP) joints are predominantly affected with resultant metatarsalgia and dislocation. Therapy options include many different surgical procedures with results that are not always satisfying. We present the oblique Weil metatarsal osteotomy as a treatment option for the rheumatic forefoot.

METHODS

A total of 216 osteotomies in 63 consecutive patients (72 feet) with a mean age at the time of surgery of 59.3 years and long-standing rheumatoid arthritis were observed prospectively for an average of 57.4 months (minimum 36 months). All patients received a Weil osteotomy of the lesser metatarsals with at least one additional procedure of the forefoot. Patients were evaluated prospectively for clinical outcome by the American Orthopaedic Foot and Ankle Society (AOFAS) lesser MTP-interphalangeal scale and subjective satisfaction. In the radiological evaluation weight-bearing X-rays were analysed for alignment, shortening and union.

RESULTS

American Orthopaedic Foot and Ankle Society score increased significantly from 21.9 ± 6.7 to 63.3 ± 9.8 (p < 0.05). The increase was significant for all subgroups regarding pain, function and alignment. All joints were dorsally dislocated preoperatively; a subluxation was present in 13.6 % at follow-up. There was a significant decrease of callositas in 82 %, a decrease in need for orthopaedic shoes in 61 %, a decrease of MTP joint stiffness in 96 % and a relief of severe pain in 97 % of all patients. No metatarsal head dislocation or necrosis, pseudoarthrosis or screw perforation was observed. Of 63 patients, 55 (88 %) subjectively reported excellent or good results.

CONCLUSIONS

We conclude that the Weil procedure for lesser metatarsals is a satisfactory method for correcting the rheumatic forefoot and can be recommended as an approach for the future.

Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options

Despite recent advances in pharmacological management of rheumatoid arthritis, forefoot deformity, with its symptoms, remains a common problem, often requiring operative treatment. Typical deformities in these patients comprise hallux valgus and deformity of the lesser metatarsophalangeal (MTP) joints and toes. With regard to the lesser rays the standard operative procedure, advocated for the disabling forefoot pain in these patients, remains metatarsal head resection. It should be considered that with increasing success of pharmacological treatment the degree of forefoot deformity in these patients is becoming less and that resection of the lesser MTP joints is becoming more and more superfluous. This supports a trend towards metatarsal head-preserving surgery. The optimal treatment of the hallux deformity remains unclear. Fusion of the first MTP joint is, generally, recommended. This article will discuss the current surgical options in rheumatoid forefoot pathology.

Kinematic changes in patients with double arthrodesis of the hindfoot for realignment of planovalgus deformity

Double fusion (i.e., fusion of the subtalar and talonavicular joint) represents a modification of triple arthrodesis preserving integrity of the calcaneocuboidal joint. Our aims were (1) to evaluate dynamic plantar pressure distribution in patients undergoing double arthrodesis, (2) to obtain a comparison of kinematic changes to healthy feet, (3) to evaluate the influence of radiographic alignment, and (4) to assess functional outcome. Sixteen feet (14 patients) treated by double fusion due to fixed planovalgus deformity were included. Dynamic plantar pressure distribution was assessed using a capacitive pressure platform. Results were compared with a demographically matched control group. Clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) score and radiographic assessment included measurement of talometatarsal, calcaneal pitch, and talocalcaneal (TC) angle on lateral radiographs. Significant differences in plantar pressure distribution were found for maximum force of the hindfoot, midfoot, and big toe region: While the hindfoot and hallux represented decreased load in the double arthrodesis patients, load increased in the midfoot region compared with healthy controls. The lateral talus-first metatarsal-angle increased from -16.3° to -8.2°, and the TC angle decreased from 41.3° to 35.8° (p < 0.05). The pre- and post-operative AOFAS score increased from 37 points (SD, 16.3) to 70 points (SD, 16.7). These results revealed that double arthrodesis represents a reliable method for correction of planovalgus deformity. Compared with healthy feet, force transmission of the midfoot is increased whereas push-off force decreases.

Involvement of valgus hindfoot deformity in hallux valgus deformity in rheumatoid arthritis

The involvement of valgus hindfoot deformity in hallux valgus deformity was confirmed in a rheumatoid arthritis case with a destructive valgus hindfoot deformity. Correction of severe valgus, calcaneal lateral offset, and pronated foot deformity instantly normalized hallux valgus deformities postoperatively. Thus, careful hindfoot status evaluation is important when assessing forefoot deformity, including hallux valgus, in rheumatoid arthritis cases.

Custom foot orthoses for rheumatoid arthritis: A systematic review

OBJECTIVE

To identify and critically appraise the evidence for the effectiveness of custom orthoses for the foot and ankle in rheumatoid arthritis.

METHODS

Studies were identified in appropriate electronic databases (from 1950 to March 2011). The search term "rheumatoid arthritis" with "foot" and "ankle" and related terms were used in conjunction with "orthoses" and synonyms. Included studies were quantitative longitudinal studies and included randomized controlled trials (RCTs), case-control trials, cohort studies, and case series studies. All outcome measures were investigated. Quality assessment was conducted using the Cochrane Collaboration criteria with additional criteria for sample population representativeness, quality of statistical analysis, and compliant intervention use and presence of cointerventions. Meta-analyses were conducted for outcome domains with multiple RCTs. Qualitative data synthesis was conducted for the remaining outcome domains. Levels of evidence were then assigned to each outcome measure.

RESULTS

The inclusion criteria were met by 17 studies. Two studies had high quality for internal validity and 3 studies had high quality for external validity. No study had high quality for both internal and external validity. Six outcome domains were identified. There was weak evidence for custom orthoses reducing pain and forefoot plantar pressures. Evidence was inconclusive for foot function, walking speed, gait parameters, and reducing hallux abductovalgus angle progression.

CONCLUSION

Custom orthoses may be beneficial in reducing pain and elevated forefoot plantar pressures in the rheumatoid foot and ankle. However, more definitive research is needed in this area.

The rheumatoid foot and ankle: current evidence

The management of rheumatoid patients is a complex process due to the chronic, systemic, multi-joint and extra-articular nature of the disease. In comparison, osteoarthritis and post-traumatic arthritis usually involve a single joint and are hence not comparable to rheumatoid pathology. This review sets out to specifically look at studies on rheumatoid patients with interventions for foot or ankle disease. MEDLINE, EMBASE, the Cochrane databases, Current Controlled Trials and the WHO International Clinical Trials Registry Platform are all searched for relevant studies.

Lesser toe deformities

Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft-tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.

Preservation of lesser metatarsophalangeal joints in rheumatoid forefoot reconstruction

BACKGROUND

A standard rheumatoid forefoot reconstruction consists of arthrodesis of the first metatarsophalangeal (MTP) joint and resection arthroplasty of the lesser metatarsal heads. However, preservation of the metatarsal heads has gained renewed interest since the medical treatment of rheumatoid arthritis has improved dramatically.

MATERIAL AND METHODS

Nineteen consecutive patients with severe rheumatoid forefoot deformities underwent 24 forefoot reconstructions including first MTP arthrodesis with lesser MTP resection arthroplasty (resection arthroplasty group, ten feet), arthrolysis (arthrolysis group, six feet), or a combination of both (combined group, eight feet). Subjective, functional, and radiographic results were evaluated at 28 and 133 months (mean) followup.

RESULTS

The overall AOFAS Forefoot Score at short- and long-term followup improved significantly (all p < 0.0001). There were no substantial differences between groups with regard to subjective rating, function, use of orthopaedic aids or shoewear, and walking capacity. Radiographic evaluation revealed a significant increase in axial malalignment of the lesser toes at long-term followup in all groups (all p < 0.018). Sagittal malalignment increased substantially in the resection arthroplasty group only. Reoperation rate was comparable among all groups, and a single third MTP arthrolysis (3%, 1/40) was converted to resection arthroplasty.

CONCLUSION

In combination with first MTP arthrodesis, arthrolysis with preservation of all or only the lateral lesser MTP joints in rheumatoid forefoot reconstruction was a viable and durable alternative to resection arthroplasty when the joint destruction was mild to moderate.

A biomechanical comparison of shape memory compression staples and mechanical compression staples: compression or distraction?

Compression staples are a popular form of fixation for osteotomy and arthrodesis. "Mechanical compression" or "shape memory" designs are commercially available. We performed a biomechanical study comparing these designs. A load cell measured compression across a simulated fusion site. The two designs available were tested and compared. The effect of altering staple limb length was also assessed. The limbs of all mechanical compression staples diverged causing inconsistent compression and distraction. Shape memory staples all achieved consistent compression across the fusion site with significantly greater maximum force when compared to mechanical compression staples (P < 0.001). Staple limb length did not appear to alter compression force generated. Mechanical compression staples cause a distractive force, and we therefore suggest alternate forms of fixation for arthrodesis. Shape memory staples do provide compression and may be suitable for arthrodesis and osteotomy.

Treatment strategies in surgery for rheumatoid arthritis

Rheumatoid arthritis due to the chronic inflammation of the synovial joints leads to permanent articular cartilage and bone damage. Subsequent instability and mutilation of the joint might happen, and the resulting joint pain and stiffness cause impaired function. The degree of damage is traditionally assessed by radiograph and represents a clinical tool for the evaluation of both disease progression and the effectiveness of interventional therapy. The classification of destruction is therefore done with radiograph and the assessment of the clinical picture. Depending on the radiologic stage different therapy concepts, ranging from conservative to operative, are established. It is the goal of surgery to restore motion and function in a painless joint. Surgery can be done to prevent the joint from further destruction or to replace the joint after resection. Different concepts based on radiologic findings are presented in this review.

The impact of rheumatoid foot on disability in Colombian patients with rheumatoid arthritis

BACKGROUND

Alterations in the feet of patients with rheumatoid arthritis (RA) are a cause of disability in this population. The purpose of this research was to evaluate the impact that foot impairment has on the patients' global quality of life (QOL) based on validated scales and its relationship to disease activity.

METHODS

This was a cross-sectional study in which 95 patients with RA were enrolled. A complete physical examination, including a full foot assessment, was done. The Spanish versions of the Health Assessment Questionnaire (HAQ) Disability Index and of the Disease Activity Score (DAS 28) were administered. A logistic regression model was used to analyze data and obtain adjusted odds ratios (AORs).

RESULTS

Foot deformities were observed in 78 (82%) of the patients; hallux valgus (65%), medial longitudinal arch flattening (42%), claw toe (lesser toes) (39%), dorsiflexion restriction (tibiotalar) (34%), cock-up toe (lesser toes) (25%), and transverse arch flattening (25%) were the most frequent. In the logistic regression analysis (adjusted for age, gender and duration of disease), forefoot movement pain, subtalar movement pain, tibiotalar movement pain and plantarflexion restriction (tibiotalar) were strongly associated with disease activity and disability. The positive squeeze test was significantly associated with disability risk (AOR = 6,3; 95% CI, 1.28-30.96; P = 0,02); hallux valgus, and dorsiflexion restriction (tibiotalar) were associated with disease activity.

CONCLUSION

Foot abnormalities are associated with active joint disease and disability in RA. Foot examinations provide complementary information related to the disability as an indirect measurement of quality of life and activity of disease in daily practice.

Subtalar and talonavicular arthrodesis through a single medial approach for the correction of severe planovalgus deformity

We describe a retrospective review of the clinical and radiological parameters of 32 feet in 30 patients (10 men and 20 women) who underwent correction for malalignment of the hindfoot with a modified double arthrodesis through a medial approach. The mean follow-up was 21 months (13 to 37). Fusion was achieved in all feet at a mean of 13 weeks (6 to 30). Apart from the calcaneal pitch angle, all angular measurements improved significantly after surgery. Primary wound healing occurred without complications.

The isolated medial approach to the subtalar and talonavicular joints allows good visualisation which facilitated the reduction and positioning of the joints. It was also associated with fewer problems with wound healing than the standard lateral approach.

Treatment of the wrist in rheumatoid arthritis

Wrist involvement is common in rheumatoid arthritis and affects up to 50% of patients within the first 2 years after the onset of the disease, including bilateral involvement. It is a progressive disease that destroys the articular cartilage and surrounding soft tissues, thus leading to severe deformities. Radiological changes are characteristic and include narrowing of the joint line, cysts, and periarticular osteoporosis. Clinical changes are characterized by different scoring systems, indicating different therapeutic options. Surgical orthopedic treatment options include joint-preserving techniques to prevent further damage (radiosynoviorthesis, synovectomy, or axial correction with tendon transfers in earlier stages) and joint replacing techniques to restore function (arthrodesis, resection arthroplasty or total joint arthroplasty in later stages). This article reviews pathologic changes in the rheumatoid hand and their surgical treatment alternatives.

Fusion of the wrist in rheumatoid arthritis

We retrospectively compared wrist arthrodesis using the Mannerfelt technique in 19 or an AO-plate in 23 patients with long-standing rheumatoid arthritis. The mean follow-up was for 76 months.

Compared with the Mannerfelt fusion group, patients in the AO-plate group reported greater satisfaction with their wrist function (74% vs 37%, p = 0.015). Complications were reported in six wrists in the AO-plate group and two wrists in the Mannerfelt fusion group (p = 0.258). At final follow-up, 95% of patients (41) reported either no pain or only mild pain. There was improvement in flexion of the finger joints in both groups but no significant improvement in the extension lag in either group.

Both methods relieve pain and improve function. Overall, the activities of daily living scores and the patients’ subjective assessment of outcome tended to be higher in the AO-plate group than in the Mannerfelt fusion group, although the difference was not statistically significant. Similarly, although more postoperative complications occurred in the AO-plate group, the difference between the two groups was not statistically significant.

Arthrodesis versus Mayo resection

In a prospective randomised study 31 patients were allocated to either arthrodesis or Mayo resection of the first metatarsophalangeal joint as part of a total reconstruction of the rheumatoid forefoot. Of these, 29 were re-examined after a mean of 72 months (57 to 80), the Foot Function Index was scored and any deformity measured. Load distribution was analysed using a Fscan mat in 14 cases, and time and distance were measured in 12 of these patients using a 3D Motion system. We found excellent patient satisfaction and a significant, lasting reduction of the Foot Function Index, with no statistically significant differences between the groups. There were no significant differences in recurrence of the deformity, the need for special shoes, gait velocity, step length, plantar moment, mean pressure or the position of the centre of force under the forefoot. The cadence was higher and the stance phase shorter in the fusion group.

These results suggest that a Mayo resection may be an equally good option for managing the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot.

[Planning of orthopedic surgery for rheumatoid arthritis]

The inflammatory process in rheumatoid arthritis is progressive and ends in destruction of the cartilage. Subsequent instability and mutilation of the joint might happen. The classification of destruction can be done by X-rays and assessment of the clinical picture. Depending on the radiologic stage different therapy concepts, ranging from conservative to operative, are established. It is the aim of surgery to restore motion and function in a painless joint. Surgery can be done to prevent the joint from further destruction or to replace the joint after resection. Different concepts based on radiologic findings are presented in this review.