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

A clinical practice guideline for the management of the foot and ankle in rheumatoid arthritis

Rheumatoid arthritis causes progressive joint destruction in the long term, causing a deterioration of the foot and ankle. A clinical practice guideline has been created with the main objective of providing recommendations in the field of podiatry for the conservative management of rheumatoid arthritis. Thus, healthcare professionals involved in foot care of adults with rheumatoid arthritis will be able to follow practical recommendations. A clinical practice guideline was created including a group of experts (podiatrists, rheumatologists, nurses, an orthopaedic surgeon, a physiotherapist, an occupational therapist and patient with rheumatoid arthritis). Methodological experts using GRADE were tasked with systematically reviewing the available scientific evidence and developing the information which serves as a basis for the expert group to make recommendations. Key findings include the efficacy of chiropody in alleviating hyperkeratotic lesions and improving short-term pain and functionality. Notably, custom and standardized foot orthoses demonstrated significant benefits in reducing foot pain, enhancing physical function, and improving life quality. Therapeutic footwear was identified as crucial for pain reduction and mobility improvement, emphasizing the necessity for custom-made options tailored to individual patient needs. Surgical interventions were recommended for cases which were non-responsive to conservative treatments, aimed at preserving foot functionality and reducing pain. Moreover, self-care strategies and education were underscored as essential components for promoting patient independence and health maintenance. A series of recommendations have been created which will help professionals and patients to manage podiatric pathologies derived from rheumatoid arthritis.

Hurdles in new drug development in rheumatic diseases

INTRODUCTION

Rheumatic diseases are heterogenous conditions with multifactorial underlying physiologic pathogeneses. Despite recent progress in the identification and development of advanced therapies primarily focusing on disrupting the immunological abnormalities that cause these conditions, rheumatic disease management remains challenging in a notable proportion of patients, with many exhibiting uncontrolled or refractory disease activity. New and improved therapies are needed to respond to this treatment gap. However, there are important hurdles that can affect the expedited identification and assessment of new treatments.

METHODS

We present a review of key hurdles in the development of antirheumatic agents, as well as possible solutions to these obstacles.

RESULTS

We highlight the challenges presented by incomplete understanding of the complexity of rheumatic disease pathophysiology and the resultant difficulties in the identification, development, and evaluation of new therapies. We further explore the diversity of the underlying disease processes leading to heterogeneity in patient response to treatment, necessitating the re-design of clinical trials of antirheumatic agents to detect efficacy signals and better inform clinical disease management. Finally, emergent strategies and methodologies with potential to improve upon these hurdles are presented.

CONCLUSION

New and modified study designs and research tools that leverage ongoing advancements in the elucidation of rheumatic disease pathogenesis coupled with progress in methods to mine available data will be instrumental in overcoming current hurdles in antirheumatic drug development.

Short-term efficacy and limitations of foot care in patients with rheumatoid arthritis

OBJECTIVES

Foot and ankle impairments are major issues in patients with rheumatoid arthritis (RA). Foot deformities often lead to skin disorders, such as callosities, ingrown toenails, and interdigital tinea pedis. This study was aimed at investigating the efficacy and limitations of foot care by experts in patients with RA.

METHODS

Thirty-one patients with RA who began receiving foot care from nurses at our institution between September 2020 and February 2023 were included. Responses to a survey using the self-administered foot evaluation questionnaire (SAFE-Q) for patient-reported outcome measures were compared at baseline, the second visit (1.3 ± 0.5 months after baseline), and the third visit (3.6 ± 1.6 months after baseline).

RESULTS

Scores for 'Pain and pain-related' and 'General health and well-being' components of SAFE-Q markedly improved after foot care. On the other hand, there were no significant differences in the scores for 'Physical functioning and daily living', 'Social functioning', and 'Shoe-related' components during observation periods.

CONCLUSIONS

Foot care for rheumatoid feet is effective in providing pain relief and improving general health and well-being. However, physical and social functioning and footwear issues did not improve. Clinicians must understand the effects and limitations of foot care in patients with RA.

Transcultural adaptation and validation of the Spanish version of the Global Pain Scale

The aim of this study was to perform a cross-cultural adaption and validation of the Global Pain Scale (GPS) to produce a Spanish-language version (GPS-Sp) and to determine the psychometric properties of this instrument. The GPS was cross-culturally translated into Spanish following the guidelines of the International Society for Pharmacoeconomics and Outcomes Research. The initial study population was composed of 384 patients recruited from February to May 2021. All participants were aged at least 18 years and were currently experiencing pain. All gave signed informed consent to take part and completed the Brief Inventory-Sp and GPS-Spain questionnaires. Cronbach's ɑ and test/retest reliability values were calculated and floor/ceiling effects analyzed. Construct validity was assessed by confirmatory factor analysis (CFA). The 370 patients included in the final analysis presented the following characteristics: 36.2% were male and 63.8% were female; mean age 42.6 (19-88) years; mean body mass index 24.99. Internal consistency was good. The Cronbach's ɑ for GPS-Sp was 0.86 and the intraclass correlation coefficient was 0.94 (95% CI; 0.87-0.97). Five main explanatory factors were identified by CFA, which produced the following values: RMSEA = 0.057; CFI = 0.807; GFI = 0.809; NFI = 0.763. No floor/ceiling effect was observed. The GPS-Sp is a valid, reliable and sensitive instrument for assessing pain in a Spanish-speaking population and could facilitate pain relief in this population.

Relationship between Kinesiophobia, Foot Pain and Foot Function, and Disease Activity in Patients with Rheumatoid Arthritis: A Cross-Sectional Study

The main objective of the present study was to determine the relationship between kinesiophobia and pain (general and foot pain), foot function, and disease activity in patients with rheumatoid arthritis (RA). A total of 124 interviews were carried out with participants with RA. Participants were recruited from the Hospital Universitario Virgen de las Nieves de Granada in Spain. Interviews took place in January 2021. Participants completed the following questionnaires during an appointment with their rheumatologist: Foot Function Index (FFI), Tampa Scale for Kinesiophobia (TSK-11), and the Visual Analogue Scale Pain foot (VAS Pain). Furthermore, the Simplified Disease Activity Index (SDAI) was used to measure disease activity. Of the 124 participants, 73% were women, and their mean age was 59.44 years (SD 11.26 years). In the statistical analysis, positive linear correlations (p < 0.001) were obtained between the variables TSK-11 and VAS (related to general pain or foot pain) and FFI (in its three subscales). Additionally, a negative correlation between the TSK-11 and the educational background was shown. This study provided information about the relationship between foot function and pain with different levels of kinesiophobia in patients with RA. Additionally, the educational background of the patient was considered a predictor of whether or not a patient suffered from kinesiophobia.

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.

Assessment of the functional impact of foot involvement in patients with rheumatoid arthritis

AIM OF THE WORK

We aimed to evaluate the impact of foot involvement in patients with rheumatoid arthritis (RA) using the functional foot index (FFI) and to identify predictive factors of the functional impact of foot abnormalities in RA patients.

PATIENTS AND METHODS

This was a cross-sectional study including patients with RA meeting the criteria of the American College of Rheumatology and the European League Against Rheumatism 2010. The main epidemiological data, results of podoscopic and clinical examination of the foot and ankle, biological tests and radiological findings were collected. The presence of foot pain was assessed by a visual analogic scale (0-10), and the functional impact of foot involvement was assessed based on the validated French version of the FFI.

RESULTS

Fifty RA patients with an average age of 59.3 ± 9.9 years [39-79] were included, and 80% of them had foot involvement. Foot pain was present in 32 patients (64%), most frequently situated in the forefoot (56%). The average FFI score was 33.67 ± 30.53 [0-92.67]. The following factors had a significant association with the FFI score: an occupation soliciting the feet (p = 0.001), disease duration (p = 0.033, r = 0,302), the Health Assessment Questionnaire (p = 0.0001, r = 0,480), body mass index (p = 0.0001, r = 0,654), the presence of podiatric abnormalities (p = 0.0001) and Visual Analog Scale foot pain (p = 0.0001, r = 0,854). A significant association was also found between the FFI score and the presence of a hallux valgus (p = 0.004), a spread of the forefoot (p = 0.029), a claw of the toes (p = 0.002), a triangular forefoot (p = 0.0001), a quintus varus (p = 0.002), flat feet (p = 0.0001) and a valgus of the hindfoot (p = 0.001).

CONCLUSION

Due to the high frequency of foot involvement and its significant functional impact, meticulous examination of the feet and assessment of their functional impact must be one of the parameters for monitoring the disease. Its impact on one's quality of life can be important.

LEVEL OF CLINICAL EVIDENCE

4 (cohort studies, non experimental, observational studies).

Ankle arthrodesis using a retrograde intramedullary rod with fins for highly destructive joints in elderly patients with rheumatoid arthritis: A report of two cases

Herein, we present two cases of older adult patients with highly destructive changes in ankle joints (Larsen grade IV) who underwent retrograde intramedullary ankle nail fixation with fins. In both patients, bony union was achieved, and full weight-bearing was attained at 3 months after surgery.

Region specificity of rheumatoid foot symptoms associated with ultrasound-detected synovitis and joint destruction

OBJECTIVES

We aimed to clarify the clinical implication of ultrasound (US)-detected foot joint inflammation in tightly controlled patients with rheumatoid arthritis (RA).

METHODS

We evaluated bilateral foot joints (second to fifth metatarsophalangeal joints of forefoot; tarsometatarsal, cuneonavicular and midtarsal joints of midfoot) of 430 RA patients for synovitis using Power Doppler (PD) imaging by US. We made a cross-sectional and a 3-year longitudinal analysis about the associations of US-detected synovitis with clinical, laboratory and radiographic data as well as foot-specific outcomes using a self-administered foot evaluation questionnaire (SAFE-Q).

RESULTS

The US-detected foot synovitis was seen in 28% of patients. The US-detected synovitis was closely related to 28 joint-disease activity score (DAS28) more in the forefoot than in the midfoot, while related to joint destruction in both. Multiple regression analyses showed significant associations between midfoot PD positivity and SAFE-Q in the remission group. SAFE-Q was worsened after the 3-year interval, but PD positivity at baseline did not contribute to the changes. On the other hand, destruction of the joints with US-detected synovitis significantly progressed in 3 years than with not.

CONCLUSIONS

US-detected synovitis on foot joints were related to systemic inflammation, clinical symptoms, and future joint destruction with region specificity.

How reliable is assessment of joint swelling and tenderness over socks or stockings in patients with established rheumatoid arthritis?

OBJECTIVES

Physicians tend to omit examinations of the foot and ankle in routine practice because it consumes a lot of time when working within tight time constraints. Although barefoot examination is critical to assess disease activity of rheumatoid arthritis (RA), we think occasional examination of foot over socks or stockings is better than not examining foot at all. The aim of this study was to assess the accuracy of foot examinations over socks or stockings in patients with RA.

METHODS

Sixty patients with RA were enrolled in this study. A rheumatologist and a senior resident performed foot examinations on each patient over socks, over stockings, and on bare foot to assess swelling and tenderness. Concordance rates between the barefoot examination and the examinations over socks or stockings by each examiner were investigated.

RESULTS

The rheumatologist had a concordance rate of 94.4% over socks and 98.8% over stockings. The senior resident had a concordance rate of 95.6% over socks and 98.5% over stockings.

CONCLUSIONS

Foot examinations over socks and stockings had high concordance rates with the barefoot examination, and it may be an option for decreasing foot and ankle examination time in RA patients.

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.

Foot and ankle functions and deformities focus on posterior tibial tendon dysfunction using magnetic resonance imaging in patients with rheumatoid arthritis

OBJECTIVES

Posterior tibial tendon dysfunction (PTTD) affects the support of the medial longitudinal arch and stability of the hindfoot. The purpose of this study was to assess the relationships of PTTD with foot and ankle functions and foot deformities in patients with rheumatoid arthritis (RA).

METHODS

A total of 129 patients (258 feet) who underwent magnetic plain and contrast-enhanced magnetic resonance imaging were enrolled in this study. Positive magnetic resonance imaging findings were defined as tenosynovitis and incomplete and complete rupture of the posterior tibial tendon. Foot and ankle functions were assessed using the Japanese Society for Surgery of the Foot standard rating system for the RA foot and ankle scale (JSSF-RA) and self-administered foot evaluation questionnaire. Plain radiographs were examined for the hallux valgus angle, first metatarsal and second metatarsal angle, lateral talo-first metatarsal angle, and calcaneal pitch angle.

RESULTS

PTTD was associated with motion in the JSSF-RA (p = .024), activities of daily living in JSSF-RA (p = .017), and pain and pain-related factors in the self-administered foot evaluation questionnaire (p = .001). The calcaneal pitch angle was significantly lower in the feet with PTTD than in those without PTTD (median: 16.2° vs. 18.0°; p = .007).

CONCLUSIONS

The present study shows that PTTD was associated with foot and ankle functions and flatfoot deformity. Thus, a better understanding of PTTD in patients with RA is important for the management of foot and ankle disorders in clinical practice.

Joint-Preserving Surgery for Forefoot Deformities in Patients with Rheumatoid Arthritis: A Literature Review

The combination of first metatarsophalangeal joint arthrodesis and resection arthroplasty of all lesser metatarsal heads has been historically considered the golden standard treatment for rheumatoid forefoot deformities. However, as recent improved management of rheumatoid arthritis have reduced progression of joint destruction, the surgical treatments for rheumatoid forefoot deformities have gradually changed from joint-sacrificing surgery, such as arthrodesis and resection arthroplasty, to joint-preserving surgery. The aim of this literature review was to provide current evidence for joint-preserving surgery for rheumatoid forefoot deformities. We focused on the indications, specific outcomes, and postsurgical complications of joint-preserving surgery in this review.

Structural and Functional Changes of Hands and Legs in Early Rheumatoid Arthritis

Background and Objectives: The aim of this study was to assess if there are structural and functional changes of hands and legs already in early rheumatoid arthritis (ERA), compared with the population-based control group. Additionally, we aimed to identify if the changes are symmetrical in hands and legs and if there are factors that are associated with these changes. The study was conducted, and, thus far, the results have been controversial. Materials and Methods: The study group consisted of 83 consecutive patients with ERA and 321 control subjects. Dual-Energy X-Ray Absorptiometry (DXA) machine was used to measure bone, lean and fat mass. Inflammation and bone markers, smoking and nutritional habits were assessed, to evaluate the effects of different factors. The 30-Second Chair Stand Test (30-CST) and the Handgrip Strength Test (HST) were used to estimate muscle strength. Results: The presence of ERA was associated with lower arm, leg lean mass and higher fat mass of arm, compared with control subjects. ERA was also associated with lower mean handgrip in HST and worse muscle strength of legs in the 30-CST. Bone mass changes were not so evident both in arms and legs. Smoking habits did not seem to have relevant effect on bone mass, muscle structural and functional changes, both on hands and legs. In ERA, lean mass of arm and leg was negatively associated with C-reactive protein (CRP). The intake of proteins in ERA was not associated with lean mass changes both in hands and legs. Conclusions: Structural and functional changes of hands and legs are different in ERA. ERA patients had higher fat mass of arm, lower lean mass of arm and leg and, accordingly, decreased muscle function. The lowering of lean mass of arm and leg in ERA was associated with the elevation of CRP.

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.

Clinical guidance for podiatrists in the management of foot problems in rheumatic disorders: evaluation of an educational programme for podiatrists using a mixed methods design

Background

Foot and ankle problems are common in rheumatic disorders and often lead to pain and limitations in functioning, affecting quality of life. There appears to be large variability in the management of foot problems in rheumatic disorders across podiatrists. To increase uniformity and quality of podiatry care for rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthritis (SpA), and gout a clinical protocol has been developed.

Research objectives

[1] to evaluate an educational programme to train podiatrists in the use of the protocol and [2] to explore barriers and facilitators for the use of the protocol in daily practice.

Method

This study used a mixed method design and included 32 podiatrists in the Netherlands. An educational programme was developed and provided to train the podiatrists in the use of the protocol. They thereafter received a digital questionnaire to evaluate the educational programme. Subsequently, podiatrists used the protocol for three months in their practice. Facilitators and barriers that they experienced in the use of the protocol were determined by a questionnaire. Semi-structured interviews were held to get more in-depth understanding.

Results

The mean satisfaction with the educational programme was 7.6 (SD 1.11), on a 11 point scale. Practical knowledge on joint palpation, programme variation and the use of practice cases were valued most. The protocol appeared to provide support in the diagnosis, treatment and evaluation of foot problems in rheumatic disorders and the treatment recommendations were clear and understandable. The main barrier for use of the protocol was time. The protocol has not yet been implemented in the electronic patient file, which makes it more time consuming. Other experienced barriers were the reimbursement for the treatment and financial compensation.

Conclusions

The educational programme concerning the clinical protocol for foot problems in rheumatic disorders appears to be helpful for podiatrists. Podiatrists perceived the protocol as being supportive during patient management. Barriers for use of the protocol were identified and should be addressed prior to large scale implementation. Whether the protocol is also beneficial for patients, needs to be determined in future research.

Morpho-structural characteristics of feet in patients with rheumatoid arthritis: A cross sectional study

Objective: The aim of this study was to evaluate and classify the types and incidences of foot deformities in patients with Rheumatoid Arthritis (RA). Methods: A cross-sectional study with convenience sample was obtained of 220 patients with foot pain and RA classification criteria (approved by the American College of Rheumatology and the European League against Rheumatism in 2010). A series of outcomes were assessed to measure the morphological characteristics of the feet. The Foot Posture Index (FPI), the Manchester Scale of Hallux Valgus and the Nijmegen classification of forefoot disorders were assessed. Results: The most common foot posture according to the FPI assessment are the pronated position in the left foot (32.7% of participants) and the neutral position in the right foot (34.1% of participants). The disease progression causes more developed and serious foot deformities. 1.82% of patients present a severe level of Hallux Valgus before 10 years of disease evolution whereas 4.09% of patients present a severe level of Hallux Valgus after 10 years of disease evolution. Conclusions: The most common foot type in patients with RA is the pronated foot type with deformities in the MTP joints without Hallux Valgus. However, a percentage of patients with RA presents supinated foot type. The evolution of the disease shows some morphological changes in terms of patient's feet. The presence of more developed foot deformities is increased, such us Hallux Valgus or MTP joints deformity (Grade 3 in the Nijmegen classification scale).

Do ankle, hindfoot, and heel ultrasound findings predict the symptomatology and quality of life in rheumatoid arthritis patients?

Objectives: To evaluate the ankle, hindfoot, and heel changes (determined by physical examination, ultrasound and baropodometry) in patients with rheumatoid arthritis, to compare the findings with healthy subjects, and to analyze if these findings are associated with ankle pain and could affect the quality of life. Methods: We enrolled 35 rheumatoid arthritis patients and 35 healthy controls, and evaluated their ankles (tibiotalar joints, tendons), hindfeet (talonavicular, subtalar joints) and heels using clinical examination, DAS28-CRP, RAPID3 for the evaluation of functional status, quality of life in rheumatoid arthritis questionnaire, ultrasound, and baropodometry. Results: The ultrasound inter-observer agreement was good for the subtalar joint, and very good for the other structures. Flat foot was identified in 50% of feet in rheumatoid arthritis patients, with 83.8% having concomitant hindfoot valgus and less subtalar joint synovitis visible from the lateral approach (32.4% vs 55.6%, p = 0.041). The body mass index, RAPID3 and subtalar synovitis were independent predictors for the symptomatic ankle (all p <0.05). Midfoot and heel plantar pressures were higher in rheumatoid arthritis patients compared to healthy controls, but when subtalar synovitis was present, the pressures decreased (avoidance of heel support). Poor quality of life in rheumatoid arthritis patients was independently predicted by DAS28-CRP, RAPID3, disease stage, hindfoot valgus, tibiotalar and subtalar synovitis, tendon pathology, Achilles tendon enthesophytes, calcaneal erosions, plantar fasciitis, and perifasciitis (all p <0.05). Conclusion: The quality of life of rheumatoid arthritis patients is significantly affected by ankle and hindfoot pathology (inflammatory modifications, but also degenerative findings and deformities). Ultrasound scanning is an important tool in the evaluation of inflammatory and degenerative lesions in these regions, and their early detection might contribute to a better therapeutic management in these patients.

Objectives: To evaluate the ankle, hindfoot, and heel changes (determined by physical examination, ultrasound and baropodometry) in patients with rheumatoid arthritis, to compare the findings with healthy subjects, and to analyze if these findings are associated with ankle pain and could affect the quality of life. Methods: We enrolled 35 rheumatoid arthritis patients and 35 healthy controls, and evaluated their ankles (tibiotalar joints, tendons), hindfeet (talonavicular, subtalar joints) and heels using clinical examination, DAS28-CRP, RAPID3 for the evaluation of functional status, quality of life in rheumatoid arthritis questionnaire, ultrasound, and baropodometry. Results: The ultrasound inter-observer agreement was good for the subtalar joint, and very good for the other structures. Flat foot was identified in 50% of feet in rheumatoid arthritis patients, with 83.8% having concomitant hindfoot valgus and less subtalar joint synovitis visible from the lateral approach (32.4% vs 55.6%, p = 0.041). The body mass index, RAPID3 and subtalar synovitis were independent predictors for the symptomatic ankle (all p <0.05). Midfoot and heel plantar pressures were higher in rheumatoid arthritis patients compared to healthy controls, but when subtalar synovitis was present, the pressures decreased (avoidance of heel support). Poor quality of life in rheumatoid arthritis patients was independently predicted by DAS28-CRP, RAPID3, disease stage, hindfoot valgus, tibiotalar and subtalar synovitis, tendon pathology, Achilles tendon enthesophytes, calcaneal erosions, plantar fasciitis, and perifasciitis (all p <0.05). Conclusion: The quality of life of rheumatoid arthritis patients is significantly affected by ankle and hindfoot pathology (inflammatory modifications, but also degenerative findings and deformities). Ultrasound scanning is an important tool in the evaluation of inflammatory and degenerative lesions in these regions, and their early detection might contribute to a better therapeutic management in these patients.

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.

A paradigm shift in studies based on rheumatoid arthritis clinical registries

Clinical research is the study of aspects of patient health or illness that are closely related to clinical practice. In the late 20th and early 21th century, outcomes for patients with rheumatoid arthritis (RA) improved dramatically due to breakthroughs in new drugs. Patient-reported outcome measures now play a significant role in the drug development process as study endpoints in clinical trials of new therapies, and this has led to increased interest in the patient's perspective, drug safety and treatment outcomes in clinical practice. In accordance with these needs, many prospective cohorts for RA patients and registries of biologic disease modifying anti-rheumatic drugs have been actively conducted in the United States and European and Asian countries. A gradual shift is taking place in the major outcomes of clinical research using these prospective cohorts and registries. This article will introduce representative registries for RA in each country set up in the early 2000s and will discuss future perspectives in clinical research on RA patients using such clinical registries.