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Kim SJ, Gil YW, Sung IH. Preoperative patient's expectations and clinical outcomes after rheumatoid forefoot deformity reconstruction by joint sacrificing surgery. JOURNAL OF RHEUMATIC DISEASES 2024; 31:33-40. [PMID: 38130962 PMCID: PMC10730808 DOI: 10.4078/jrd.2023.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
Objective To study the clinical and radiologic factors related with overall patient satisfaction of joint scarifying reconstruction on severe rheumatoid forefoot deformity (RFD). Methods Forty cases of RFD were retrospectively enrolled. A questionnaire on the factors for patient's expectations and satisfactions of the greater and lesser toes was administered, including repression of relapse in deformity (D), pain reduction (P), improvement in shoe wearing (S), barefoot activity (B), and appearance (A). Overall satisfaction were assessed using the 5-digit-scale. Hallux valgus angle, 1, 2 intermetatarsal angle, and other radiologic parameters were measured. Pearson's correlation and multiple linear regression analyses were used to evaluate the relationships between these factors and overall satisfaction. Results Overall satisfaction was 4.0±0.82. Postoperative radiologic parameters were corrected in adequate range. Visual analog scale (VAS) was reduced from 7.2±2.1 to 2.2±1.8. For the greater toe, patient's expectations (D, P, S, B, and A) were 4.2, 4.1, 3.0, 2.5, 2.7 and satisfactions were 4.2, 4.0, 3.4, 3.5, 3.3, respectively. For the lesser toes, patient's expectations (D, P, S, B, and A) were 3.9, 4.1, 3.4, 3.0, 2.8, and satisfactions were 3.4, 4.0, 3.4, 3.6, 2.9, respectively. Satisfactions with P and B, and reduction amounts of VAS were significantly correlated with overall satisfaction. Conclusion Although forefoot reconstruction with a joint sacrificing procedure is non-physiological, it could be a good surgical option for severe RFD. Each patient's expectations and satisfactions with this procedure could vary. Thus, it seems important to inform patients preoperatively that expectation could be fulfilled well or less.
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Affiliation(s)
- Sung-Jae Kim
- Department of Orthopedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Young-Woon Gil
- Department of Orthopedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Il-Hoon Sung
- Department of Orthopedic Surgery, Hanyang University College of Medicine, Seoul, Korea
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2
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Horita M, Nishida K, Kaneda D, Hashizume K, Nasu Y, Nakahara R, Saiga K, Ohashi H, Watanabe M, Ozaki T. Subjective and Objective Outcomes of Surgery for Rheumatoid Forefoot Deformities Under the Current Treatment Paradigm. J Foot Ankle Surg 2022; 61:53-59. [PMID: 34303577 DOI: 10.1053/j.jfas.2021.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 12/16/2020] [Accepted: 06/08/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Masahiro Horita
- Orthopaedic Surgeon, Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keiichiro Nishida
- Associate Professor, Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Daisuke Kaneda
- Orthopaedic Surgeon, Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kenzo Hashizume
- Orthopaedic Surgeon, Department of Rehabilitation, Japan Labour Health and Welfare Organization, Okayama Rosai Hospital, Okayama, Japan
| | - Yoshihisa Nasu
- Assistant Professor, Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Ryuichi Nakahara
- Assistant Professor, Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Kenta Saiga
- Assistant Professor, Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Hideki Ohashi
- Orthopaedic Surgeon, Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masahito Watanabe
- Orthopaedic Surgeon, Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshifumi Ozaki
- Professor, Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Noguchi T, Hirao M, Tsuji S, Ebina K, Tsuboi H, Etani Y, Akita S, Hashimoto J. Association of Decreased Physical Activity with Rheumatoid Mid-Hindfoot Deformity/Destruction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910037. [PMID: 34639346 PMCID: PMC8508320 DOI: 10.3390/ijerph181910037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 12/01/2022]
Abstract
Foot/ankle problems remain important issues in rheumatoid arthritis (RA) patients. Although forefoot deformity generally takes a major place in surgical treatment, concomitant mid-hindfoot deformity is also commonly seen. In this situation, it can be easy to overlook that mid-hindfoot deformity can also induce or exacerbate clinical problems behind the forefoot events. Thus, the relationship between mid-hindfoot deformity/destruction and physical activity/ADL was investigated. Radiographic findings of 101 lower limbs (59 patients) were retrospectively evaluated. Alignment parameters in the lower extremity and joint destruction grade (Larsen grade) were measured. The timed-up-and-go (TUG) test, modified health assessment questionnaire (mHAQ), pain, self-reported scores for the foot and ankle (SAFE-Q), and RA disease activity were investigated to assess clinical status. The relationships among these parameters were evaluated. Subtalar joint destruction was correlated with TUG time (r = 0.329), mHAQ score (r = 0.338), and SAFE-Q: social functioning (r = 0.332). TUG time was correlated with the HKA (r = −0.527), talo-1st metatarsal angle (r = 0.64), calcaneal pitch angle (r = −0.433), M1-M5A (r = −0.345), and M2-M5A (r = −0.475). On multivariable linear regression analysis, TUG time had a relatively strong correlation with the talo-1st metatarsal angle (β = 0.452), and was negatively correlated with calcaneal pitch angle (β = −0.326). Ankle joint destruction was also correlated with TUG time (β = 0.214). Development of structural problems or conditions in mid-hindfoot, especially flatfoot deformity, were related with decreased physical activity in RA patients. Wearing an insole (arch support) as a preventative measure and short foot exercise should be considered from the early phase of deformity/destruction in the mid-hindfoot in the management of RA.
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Affiliation(s)
- Takaaki Noguchi
- Department of Orthopaedic Surgery, National Hospital Organization, Osaka Minami Medical Center, 2-1 Kidohigashimachi, Kawachinagano 586-8521, Osaka, Japan; (T.N.); (S.T.); (S.A.); (J.H.)
| | - Makoto Hirao
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita 565-0871, Osaka, Japan;
- Correspondence: ; Tel.: +81-6-6879-3552; Fax: +81-6-6879-3559
| | - Shigeyoshi Tsuji
- Department of Orthopaedic Surgery, National Hospital Organization, Osaka Minami Medical Center, 2-1 Kidohigashimachi, Kawachinagano 586-8521, Osaka, Japan; (T.N.); (S.T.); (S.A.); (J.H.)
| | - Kosuke Ebina
- Department of Musculoskeletal Regenerative Medicine, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita City 565-0871, Osaka, Japan;
| | - Hideki Tsuboi
- Department of Orthopaedic Surgery, Osaka Rosai Hospital, 1179-3 Kita Ward Nagasonecho, Sakai 591-8025, Osaka, Japan;
| | - Yuki Etani
- Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita 565-0871, Osaka, Japan;
| | - Shosuke Akita
- Department of Orthopaedic Surgery, National Hospital Organization, Osaka Minami Medical Center, 2-1 Kidohigashimachi, Kawachinagano 586-8521, Osaka, Japan; (T.N.); (S.T.); (S.A.); (J.H.)
| | - Jun Hashimoto
- Department of Orthopaedic Surgery, National Hospital Organization, Osaka Minami Medical Center, 2-1 Kidohigashimachi, Kawachinagano 586-8521, Osaka, Japan; (T.N.); (S.T.); (S.A.); (J.H.)
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Koutsouradis P, Savvidou OD, Stamatis ED. Arthrodesis of the first metatarsophalangeal joint: The “when and how”. World J Orthop 2021; 12:485-494. [PMID: 34354936 PMCID: PMC8316842 DOI: 10.5312/wjo.v12.i7.485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/18/2021] [Accepted: 07/12/2021] [Indexed: 02/06/2023] Open
Abstract
Arthrodesis of the first metatarsophalangeal (MTP) joint has been established as the “gold standard” for the treatment of several first ray disorders, due to its perceived efficacy and the consistently reported good results in the literature. Arthrodesis is a commonly performed procedure for the treatment of end stage arthritis, rheumatoid arthritis with severe deformity, selected cases of severe hallux valgus (with or without signs of degenerative joint disease), as well as a salvage procedure after failed previous operation of the first ray. The goals of a successful 1st MTP arthrodesis are pain alleviation and deformity correction in order to restore a comfortable gait pattern and to improve shoe wear. Several techniques have been reported with several proposals regarding the preparation of the articular surfaces and the method of definitive fixation. As with any given surgical procedure, various complications may occur after arthrodesis of the 1st MTP joint, namely delayed union, nonunion, malunion, irritating hardware, etc.
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Affiliation(s)
- Panagiotis Koutsouradis
- Department of Foot and Ankle Reconstructive Surgery, Mediterraneo Hospital, Athens 16675, Greece
| | - Olga D Savvidou
- First Department of Orthopedic Surgery, National and Kapodistrian University of Athens, “ATTIKON” Hospital, Athens 12462, Greece
| | - Emmanouil D Stamatis
- Department of Foot and Ankle Reconstructive Surgery, Mediterraneo Hospital, Athens 16675, Greece
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He Y, Shan F, Fan C, Zeng X, Yang G, Tang B. Effectiveness of the First Metatarsophalangeal Joint Arthrodesis Versus Arthroplasty for Rheumatoid Forefoot Deformity: A Systematic Review and Meta-Analysis of Comparative Studies. J Foot Ankle Surg 2021; 60:787-794. [PMID: 33775544 DOI: 10.1053/j.jfas.2020.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 02/03/2023]
Abstract
To compare the clinical outcomes of resection arthroplasty of metatarsals 2-5 with either first metatarsophalangeal joint arthrodesis or arthroplasty for rheumatoid forefoot deformity treatment. Comparative studies on the clinical effects of resection arthroplasty of metatarsals 2-5 with either first metatarsophalangeal joint arthrodesis or arthroplasty for the treatment of rheumatoid forefoot deformity were systematically reviewed and a meta-analysis conducted. A total of 337 patients (459 feet) with rheumatoid forefoot deformity from 6 comparative studies were included, with the mean follow-up times ranging from 25 to 80 months in the arthrodesis group and 35 to 102 months in the arthroplasty group. Postoperative pain, satisfaction, hallux valgus angle, the 1st -2nd intermetatarsal angle, adverse events mainly including non-union and the reoperation rate, and pedobarographic data were reported. In the pooled analysis, there were no significant pain score differences between 1st metatarsophalangeal joint arthrodesis and arthroplasty groups (SMD = 0.04, p = .734; I2 = 43.7%, p = .149), but the hallux valgus angle and the 1st -2nd intermetatarsal angle showed significant differences between these 2 groups (For hallux valgus angle, SMD = -0.439, p = .002; I2 = 96.6%, p = .000; for 1st -2nd intermetatarsal angle, SMD = -0.569, p = .000; I2 = 98.2%, p = .000). The rate of non-union varied from 0% to 26% in the arthrodesis group. The reoperation rate varied from 3% to 9.6% in the arthrodesis group and from 4% to 11.6% in the arthroplasty group. A comparison of the procedures showed that first metatarsophalangeal joint arthrodesis with resection arthroplasty of the lesser rays produced similar postoperative pain relief and better maintenance of the hallux valgus angle and the 1st -2nd intermetatarsal angle for rheumatoid forefoot deformity. However, the results should be interpreted with caution due to the high heterogeneity and relatively low quality of the reviewed articles.
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Affiliation(s)
- Yuan He
- Associate Professor, Division of Orthopedics, First People's Hospital of Xining City, Xining, Qinghai, China
| | - Farong Shan
- Associate Professor, Division of Orthopedics, First People's Hospital of Xining City, Xining, Qinghai, China
| | - Cheng Fan
- Resident, Sports Medicine Center, First People's Hospital of Xining City, Xining, Qinghai, China
| | - Xuezhu Zeng
- Resident, Sports Medicine Center, First People's Hospital of Xining City, Xining, Qinghai, China
| | - Guolei Yang
- Resident, Sports Medicine Center, First People's Hospital of Xining City, Xining, Qinghai, China
| | - Bo Tang
- Foot and Ankle Surgeon, Sports Medicine Center, First People's Hospital of Xining City, Xining, Qinghai, China.
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6
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Simonsen MB, Hørslev-Petersen K, Cöster MC, Jensen C, Bremander A. Foot and Ankle Problems in Patients With Rheumatoid Arthritis in 2019: Still an Important Issue. ACR Open Rheumatol 2021; 3:396-402. [PMID: 33943043 PMCID: PMC8207681 DOI: 10.1002/acr2.11258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/15/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To study the prevalence of foot pain in patients with rheumatoid arthritis (RA) and whether including a 12‐joint foot count in addition to the 28‐joint count (from the Disease Activity Score 28 [DAS28]) improved detection of foot or ankle pain. In addition, the association between the self‐reported foot and ankle score (SEFAS), patient‐reported function, and disease‐specific factors was studied. Methods Physician‐reported data (swollen/tender 12‐joint foot count, DAS28, and medication) and patient‐reported data (foot/ankle pain, physical function, global health, and SEFAS) were assessed during a clinical visit. Data were analyzed with t test, χ2 tests, and regression analysis. Results A total of 320 patients with RA were included (mean age 63 years, SD 13 years; 73% women), of whom 69% reported foot or ankle pain. Patients who reported foot or ankle pain had a lower mean age and worse disease activity, general pain, function, and global health (P ≤ 0.016), and fewer were in remission (50% versus 75%; P < 0.001) compared with patients without foot pain. The 12‐joint foot count identified 3.2% and 9.5% additional patients with swollen and tender joints, respectively, compared with the 28‐joint count. The SEFAS was associated with walking problems (β = −2.733; 95% confidence interval [CI] = −3.963 to −1.503) and worse function (β = −3.634; 95% CI = −5.681 to −1.587) but not with joint inflammation severity. Conclusion The prevalence of foot or ankle pain in patients with RA is high. The 12‐joint foot count had minor effects on detecting patients with foot pain. However, the SEFAS contributed additional information on foot problems that was not identified by joint examinations alone.
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Affiliation(s)
- Morten Bilde Simonsen
- Aalborg University, Aalborg, Denmark, and North Denmark Regional Hospital, Hjoerring, Denmark
| | | | | | - Carsten Jensen
- Hospital Lillebaelt, Kolding, Denmark, and University of Southern Denmark, Odense, Denmark
| | - Ann Bremander
- Danish Hospital for Rheumatic Diseases, Sønderborg, Denmark, and University of Southern Denmark, Odense, Denmark, and Lund University, Lund, Sweden
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Zaid HHG, Di W, Yang R, Wu D, Yang M. Surgical Management of Monoarticular Rheumatoid Arthritis of the Fifth Metatarsophalangeal Joint. Orthop Surg 2020; 12:1597-1604. [PMID: 32776484 PMCID: PMC7767787 DOI: 10.1111/os.12725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To investigate the clinical and radiological outcomes in patients with monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint after Weil osteotomy. METHODS From July 2011 to September 2015, 18 feet of 16 rheumatoid arthritis patients who underwent Weil osteotomy of the fifth metatarsal toe with a mean age at the time of surgery of 48.8 ± 7.4 years were reviewed retrospectively. The mean disease duration was 44.6 ± 6.8 months, and the follow-up period was 36 months. Clinical outcomes were evaluated according to the American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal interphalangeal scale (AOFAS), 10-item SF-36 physical functioning and 2-item SF-36 bodily pain, Visual Analogue Scale (VAS), and satisfaction scores. In the radiologic evaluation, fifth metatarsophalangeal angle (MTP-5), lateral deviation angle (LDA), and longitudinal axes of the fifth metatarsal were measured on anterior-posterior (AP) weight-bearing radiographs preoperative and at the last follow-up. RESULTS Clinical assessment showed that the total average of AOFAS was significantly increased from preoperative 53.6 ± 9.0 to 98.7 ± 2.0 points, and the VAS score was significantly decreased from preoperative 4.1 ± 1.5 to 1.1 ± 0.8 points at the last follow-up (P < 0.001). The total averages of SF-36 physical functioning and SF-36 bodily pain were significantly increased from preoperative 48.9 ± 9.0 to 99. ± 2.1 and from 61.4 ± 12.1 to 99.4 ± 2.4 points, respectively, at the last follow-up (P < 0.001). Subjectively, the excellent outcome of the surgery results were rated by 13 patients (81.3%) that underwent surgery and three patients (18.7%) were rated as good. Regarding radiographic parameters, the mean MTP-5 significantly decreased from 21.5° ± 1.2° preoperatively to 10.2° ± 1.2°, the mean LDA significantly decreased from 7.1° ± 1.2° preoperatively to -2.4° ± 1.0°, and the mean length of the fifth metatarsal was significantly shortened from 71.5 ± 1.4 preoperatively to 67.8 ± 1.5 mm at the final follow-up visit (P < 0.001). No malunion, nonunion, necrosis, pseudoarthrosis, or fracture of the fifth metatarsal was found. No exuberant bone growth, perforation of the screw, subluxation, or dislocation was observed. No indications of modification, revision or repeat surgery, or delayed wound healing were observed during follow-up period. CONCLUSION Surgical management of the monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint can achieve good clinical and radiological outcomes, with pain relief and dislocation reduction, as well as high satisfaction and improvement without recurrence or progression during the follow-up period.
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Affiliation(s)
- Hamood H G Zaid
- Department of Orthopedics, The First Hospital of China Medical University, Shenyang, China
| | - Wu Di
- Department of Orthopedics, The First Hospital of China Medical University, Shenyang, China
| | - Rufei Yang
- Department of Rehabilitation Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Di Wu
- Department of Orthopedics, The First Hospital of China Medical University, Shenyang, China
| | - Maowei Yang
- Department of Orthopedics, The First Hospital of China Medical University, Shenyang, China
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8
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Dahmen R, Konings-Pijnappels A, Kerkhof S, Verberne S, Boers M, Roorda LD, van der Leeden M. Higher body mass index is associated with lower foot health in patients with rheumatoid arthritis: baseline results of the Amsterdam-Foot cohort. Scand J Rheumatol 2020; 49:186-194. [PMID: 32154754 DOI: 10.1080/03009742.2019.1663920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective: Obesity is highly prevalent in patients with rheumatoid arthritis (RA), with likely impact on weight-bearing foot joints. We explored the associations between body mass index (BMI) and measures of foot health in patients with RA and foot complaints.Method: We examined patients with RA presenting for their first custom-made therapeutic footwear or foot orthoses. Domains of foot health comprised: foot pain, foot-related activity limitations, forefoot plantar pressure, foot synovitis, and foot deformity. In regression analyses, BMI was the independent variable and foot health domains were the dependent variables.Results: The cohort at baseline comprised 230 patients [mean ± sd age 58 ± 13 years, 80% female, mean ± sd disease duration 10 ± 9 years, and median (interquartile range) BMI 26.7 (23.5-30.1) kg/m2]. Small to modest statistically significant associations were found in the majority of the measures studied between a higher BMI and more foot pain, more foot-related activity limitations, higher in-shoe measured forefoot plantar pressure, and the presence of foot synovitis. No relationships were found between BMI and barefoot measured forefoot plantar pressure or foot deformity.Conclusion: BMI is negatively associated with foot health in patients with RA. Although the clinical relevance of our findings for an individual patient is not immediately obvious, future research should consider BMI as a potential therapeutic target to improve foot health.
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Affiliation(s)
- R Dahmen
- Amsterdam Rehabilitation Research Center/Reade, Amsterdam, The Netherlands
| | | | - S Kerkhof
- Amsterdam Rehabilitation Research Center/Reade, Amsterdam, The Netherlands
| | - S Verberne
- Amsterdam Rehabilitation Research Center/Reade, Amsterdam, The Netherlands
| | - M Boers
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands.,Rheumatology, Amsterdam Rheumatology and Immunology Centre, VU University Medical Centre, Amsterdam, The Netherlands
| | - L D Roorda
- Amsterdam Rehabilitation Research Center/Reade, Amsterdam, The Netherlands
| | - M van der Leeden
- Amsterdam Rehabilitation Research Center/Reade, Amsterdam, The Netherlands.,Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
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9
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Schrier JC, Keijsers NL, Matricali GA, Verheyen CCPM, Louwerens JWK. Resection or preservation of the metatarsal heads in rheumatoid forefoot surgery? A randomised clinical trial. Foot Ankle Surg 2019; 25:37-46. [PMID: 29409260 DOI: 10.1016/j.fas.2017.07.1126] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 03/28/2017] [Accepted: 07/28/2017] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Joost C Schrier
- Dept Orthopaedic Surgery, Medinova Clinics Breda, The Netherlands; Dept Orthopaedic Surgery, Sint Maartenskliniek Nijmegen, The Netherlands.
| | - Noel L Keijsers
- Dept Orthopaedic Surgery, Sint Maartenskliniek Nijmegen, The Netherlands
| | | | - Cees C P M Verheyen
- Dept Orthopaedic Surgery and Traumatology, Isala Hospital Zwolle, The Netherlands
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10
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Horita M, Nishida K, Hashizume K, Nasu Y, Saiga K, Nakahara R, Machida T, Ohashi H, Ozaki T. Outcomes of Resection and Joint-Preserving Arthroplasty for Forefoot Deformities for Rheumatoid Arthritis. Foot Ankle Int 2018; 39:292-299. [PMID: 29415557 DOI: 10.1177/1071100717743996] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Masahiro Horita
- 1 Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keiichiro Nishida
- 1 Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kenzo Hashizume
- 2 Department of Rehabilitation, Okayama Rosai Hospital, Okayama, Japan
| | - Yoshihisa Nasu
- 3 Department of Medical Materials for Musculoskeletal Reconstruction, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kenta Saiga
- 1 Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ryuichi Nakahara
- 4 Department of Musculoskeletal Traumatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takahiro Machida
- 1 Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hideki Ohashi
- 1 Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshifumi Ozaki
- 1 Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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11
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Elsaman AM, Mostafa ES, Radwan AR. Ankle Evaluation in Active Rheumatoid Arthritis by Ultrasound: A Cross-Sectional Study. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:2806-2813. [PMID: 28987543 DOI: 10.1016/j.ultrasmedbio.2017.08.928] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 06/07/2023]
Abstract
Ankle joint evaluation is underestimated in many clinical and sonographic scores used for evaluation and follow-up of rheumatoid arthritis (RA) patients. Agreement on examination parameters is poor among sonographic scores that include the ankle joint. More effort is needed to detect the value of ankle joint examination in RA and assessment of ultrasonographic signs according to frequency, disease duration and activity. The objective of this study was to use ultrasound (US) to detect ankle involvement in active RA and to compare findings with disease duration, disease activity and assessment of ankle bone erosion. A total of 63 RA patients with active disease and 20 controls were included in the study. The tibiotalar and talonavicular joints were examined by US for synovitis and/or effusion in gray-scale and power Doppler modes. The anterior, lateral and posterior ankle tendons were examined for tenosynovitis and tendinosis. Mean age was 35.1 ± 8.3 y, mean disease duration was 22.7 ± 9.6 mo and the mean 28-joint Disease Activity Score-erythrocyte sedimentation rate was 3.05 ± 0.66. Ankle involvement was seen in 28 patients (44.4%). The most frequent pathologies detected were tenosynovitis (30.2%), followed by synovitis (18.3%), erosion (8.7%) and tendinosis (4%). The earliest sonographic signs were tenosynovitis, followed by synovitis, erosion and tendinosis. The right ankle exhibited greater involvement than the left ankle, which was significant with respect to erosions (p = 0.009). The most common tendon affected by tenosynovitis was the tibialis anterior (22.2%), followed by the tibialis posterior (20.6%). Tenosynovitis, especially of the tibialis anterior and posterior, tibiotalar synovitis and erosions should be considered in future US ankle scores for the assessment of RA.
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Affiliation(s)
- Ahmed M Elsaman
- Department of Rheumatology and Rehabilitation, Sohag University Hospital, Sohag, Egypt.
| | - Ehab Saad Mostafa
- Department of Rheumatology and Rehabilitation, South Valley University Hospital, Qena, Egypt
| | - Ahmed R Radwan
- Department of Rheumatology and Rehabilitation, Sohag University Hospital, Sohag, Egypt
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12
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Abstract
BACKGROUND Rheumatoid arthritis is a chronic disease affecting multiple joints of the body. More than 90% of patients affected by rheumatoid arthritis develop foot or ankle pain over the course of their disease. The purpose of the current study was to report ankle dorsiflexion in rheumatoid arthritis patients as well as a control group utilizing a validated measurement instrument. METHODS Using a previously validated device, 70 patients presenting with rheumatoid arthritis and 70 controls were measured for ankle range motion and isolated gastrocnemius contractures. Clinical and goniometer measurement of ankle range of motion was also performed. RESULTS The rheumatoid arthritis group had a mean dorsiflexion of 12.3 degrees compared to a mean of 17.3 degrees in the control group ( P < .05). The difference in dorsiflexion was significantly less utilizing a goniometer than using the validated device, which may be due to measurement technique and external landmarks ( P < .05). CONCLUSION Patients with rheumatoid arthritis had less ankle dorsiflexion than the control group. The clinical significance of this study is that it provides evidence that patients with rheumatoid arthritis have decreased ankle dorsiflexion even despite a lack of foot and ankle pain. In light of the high lifetime incidence of foot and ankle pain in these patients, this study provides some evidence that the decreased ankle dorsiflexion may be a contributing factor in foot and ankle pain, but further studies are needed. LEVEL OF EVIDENCE Level II, prospective cohort study.
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Affiliation(s)
| | - Adam Green
- 2 Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
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13
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Carter K, Lahiri M, Cheung PP, Santosa A, Rome K. Prevalence of foot problems in people with inflammatory arthritis in Singapore. J Foot Ankle Res 2016; 9:37. [PMID: 27594920 PMCID: PMC5010761 DOI: 10.1186/s13047-016-0169-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/26/2016] [Indexed: 01/21/2023] Open
Abstract
Background Foot problems are highly prevalent in people with inflammatory arthritis reported from studies in the UK, Europe and New Zealand, but there is limited evidence from Southeast Asia. The study aim was to evaluate the prevalence of foot problems in people with inflammatory arthritis in Singapore. Methods People with inflammatory arthritis were recruited from the rheumatology outpatient clinic of a tertiary hospital in Singapore. Disease and clinical characteristics included age, sex, disease duration, current blood tests and medications. The Leeds Foot Impact Scale was used to evaluate foot impairment/disability and the Modified Health Assessment Questionnaire was used to assess global function. Results We recruited 101 people with inflammatory arthritis, of which 50 % were female. The majority of participants were Chinese (70 %). The mean (SD) age was 52 (15) years, and the mean (SD) disease duration was 9.3 (0.3) years. The most commonly reported inflammatory arthritic conditions were rheumatoid arthritis (46), gout (31) and spondyloarthritis (15 %). The mean (SD) of the total Leeds Foot Impact Scale was 17 (13) indicating moderate to severe levels of foot impairment and activity limitation. Over 80 of participants reported foot pain during the course of their condition, and 48 % reported current foot pain. Despite the high prevalence of foot pain, only 21 participants (21 %) had been referred to a podiatrist. Conclusion This is the first study to investigate the prevalence of foot problems in people with inflammatory arthritis from Singapore. The majority of the participants reported foot problems, but had not been referred to a podiatry service. Electronic supplementary material The online version of this article (doi:10.1186/s13047-016-0169-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- K Carter
- Podiatry Department, Rehabilitation Centre, National University Health System Singapore, Singapore, Singapore
| | - M Lahiri
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ; Division of Rheumatology, Department of Medicine, National University Health System Singapore, Singapore, Singapore
| | - P P Cheung
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ; Division of Rheumatology, Department of Medicine, National University Health System Singapore, Singapore, Singapore
| | - A Santosa
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ; Division of Rheumatology, Department of Medicine, National University Health System Singapore, Singapore, Singapore
| | - K Rome
- Health and Rehabilitation Research Institute, Faculty of Health and Environmental Sciences, AUT University, Auckland, New Zealand
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14
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Sawachika F, Uemura H, Katsuura-Kamano S, Yamaguchi M, Bahari T, Miki K, Todo S, Inoo M, Onishi I, Kurata N, Arisawa K. Changes in foot function, disease activity, and disability after forefoot resection arthroplasty in patients with rheumatoid arthritis. THE JOURNAL OF MEDICAL INVESTIGATION 2016; 63:38-44. [PMID: 27040050 DOI: 10.2152/jmi.63.38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Fusakazu Sawachika
- Department of Preventive Medicine, Institute of Biomedical Sciences, the University of Tokushima Graduate School
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15
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Erosions in the foot at baseline are predictive of orthopaedic shoe use after 10 years of treat to target therapy in patients with recent onset rheumatoid arthritis. Clin Rheumatol 2015; 35:2101-2107. [PMID: 26694056 PMCID: PMC4960271 DOI: 10.1007/s10067-015-3145-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 11/25/2015] [Accepted: 12/06/2015] [Indexed: 11/17/2022]
Abstract
The objective of this study is to investigate if foot joint damage due to rheumatoid arthritis (RA) can predict whether patients will start wearing orthopaedic shoes (OS) within 10 years after treatment start. Data from recent onset RA patients with 10 years follow-up from the BeSt (Dutch acronym for treatment strategies) study were used. Treatment was tightly controlled, targeted at disease activity score (DAS) ≤2.4, according to 1 of 4 pre-specified treatment strategies. After 10 years of follow-up, orthopaedic shoe use was recorded in 285/508 patients (responders to questionnaires at 10 years). Between-group differences for orthopaedic shoe users and non-users were calculated at baseline, after 10 years, and change scores over the 10-year period were calculated. Predictors for orthopaedic shoe use were identified by univariable and multivariable logistic regression analyses. Orthopaedic shoe use was reported by 57/285 patients after 10 years. Orthopaedic shoe users had more joint damage, joint swelling and pain in the feet already at baseline and after 10 years. At both time points, DAS of orthopaedic shoe users and non-users was similar. Multivariable logistic regression showed that dichotomized foot erosions score (cut-off ≥1 erosion) (OR 2.42), anti-citrullinated protein antibodies (ACPA) (OR 4.64) and DAS (OR 1.77) were independent predictors of orthopaedic shoe use. Despite intensive targeted treatment, 57/285 recent onset RA patients started using orthopaedic shoes over 10 year of follow-up. Presence of foot erosions at treatment start predicts orthopaedic shoe use after 10 years. The risk of orthopedic shoe use increased for ACPA-positive patients and for those with higher baseline disease activity.
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16
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Nash WJ, Al-Nammari S, Khan WS, Pengas IP. Surgical management of the forefoot in patients with rheumatoid arthritis - a review article. Open Orthop J 2015; 9:78-83. [PMID: 25861409 PMCID: PMC4384227 DOI: 10.2174/1874325001509010078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/25/2015] [Accepted: 02/03/2015] [Indexed: 11/22/2022] Open
Abstract
Foot and ankle pathologies cause a significant disease burden on rheumatoid patients. Forefoot pathologies causes pain, callosities and possibly ulceration, and can cause problems with footwear. Forefoot correction in rheumatoid patients has historically comprised of excision of diseased joints. While satisfaction was high with this procedure, complications, changing expectations and improvement in medical therapy have raised expectation of patients, physicians and surgeons alike. This review assesses the role of joint preserving osteotomies and arthrodesis, as well as associated complications. It also describes the role of the multidisciplinary team in the management of these patients.
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Affiliation(s)
- W J Nash
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
| | - S Al-Nammari
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
| | - W S Khan
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
| | - I P Pengas
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, UK
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17
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Ikeda T, Kaminaka C, Yamamoto Y, Furukawa F. Disseminated cryptococcosis-induced skin ulcers in a patient with autoimmune hepatitis. Case Rep Dermatol 2014; 6:98-102. [PMID: 24761142 PMCID: PMC3995400 DOI: 10.1159/000360978] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report the case of a 68-year-old woman with autoimmune hepatitis (AIH) who had leg ulcers induced by disseminated cryptococcosis. She had received prednisolone for her AIH at 20 mg/day for maintenance. On the initial visit, she complained of a painful ulcer that had round, shallow pockets with erythema and erythematous subcutaneous indurations on the right thigh. Several metacarpophalangeal joints and wrist joints were swollen, with tenderness and stiffness in the morning for over 3 h. Her serum rheumatoid factor was high. Since other autoimmune disorders such as rheumatoid arthritis can present with AIH, it was necessary to distinguish it from ulcers due to rheumatoid arthritis, although the characteristic features of these ulcers seemed to be different. A biopsy specimen from the erythematous skin showed globe-shaped organisms in the dermis and subcutaneous tissues; vasculitis and phlebostasis were not observed. The results from computed tomography scans and sputum culture led to the diagnosis of disseminated cryptococcosis. The administration of fluconazole, fosfluconazole, and voriconazole for about 2 months improved the cryptococcal pneumonia, but the size of the skin ulcer enlarged. The administration was changed to itraconazole, which reduced the size. Cryptococcal infections occur more commonly in immunocompromised hosts, including patients under immunosuppressive therapies such as corticosteroids. The possibility that the skin ulcers in immunocompromised hosts may be caused by cryptococcosis should be considered.
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Affiliation(s)
- Takaharu Ikeda
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Chikako Kaminaka
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Yuki Yamamoto
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Fukumi Furukawa
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
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18
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Firth J, Waxman R, Law G, Nelson EA, Helliwell P, Siddle H, Otter S, Butters V, Baker L, Hryniw R, Bradley S, Loughrey L, Alcacer-Pitarch B, Davies S, Tranter J. The predictors of foot ulceration in patients with rheumatoid arthritis. Clin Rheumatol 2013; 33:615-21. [DOI: 10.1007/s10067-013-2428-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 10/04/2013] [Accepted: 10/24/2013] [Indexed: 11/28/2022]
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19
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Louwerens JWK, Schrier JCM. Rheumatoid forefoot deformity: pathophysiology, evaluation and operative treatment options. INTERNATIONAL ORTHOPAEDICS 2013; 37:1719-29. [PMID: 23892468 PMCID: PMC3764283 DOI: 10.1007/s00264-013-2014-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/25/2013] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Jan Willem K Louwerens
- Department of Orthopaedic Surgery, Foot and Ankle Reconstruction Unit, St Maartenskliniek, Nijmegen, The Netherlands.
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20
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Marsman AF, Dahmen R, Roorda LD, van Schaardenburg D, Dekker J, Britsemmer K, Knol DL, van der Leeden M. Foot-related health care use in patients with rheumatoid arthritis in an outpatient secondary care center for rheumatology and rehabilitation in The Netherlands: A cohort study with a maximum of fifteen years of followup. Arthritis Care Res (Hoboken) 2013; 65:220-6. [DOI: 10.1002/acr.21787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 06/22/2012] [Indexed: 11/11/2022]
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21
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Carl HD, Swoboda B. [Presurgical and postsurgical orthotic management of the rheumatoid foot]. Z Rheumatol 2012; 71:680-4. [PMID: 23052558 DOI: 10.1007/s00393-012-0970-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Foot complaints remain frequent in patients with rheumatoid arthritis (RA) even in the era of biological anti-rheumatic drugs. Orthotic management of rheumatoid foot disorders is able to improve mobility and thus the quality of life in RA patients. This article highlights the preoperative and postoperative orthotic management of the rheumatoid arthritic foot.
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Affiliation(s)
- H D Carl
- Abteilung für Orthopädische Rheumatologie, Friedrich-Alexander-Universität Erlangen-Nürnberg, Im Waldkrankenhaus St. Marien, Rathsberger Str. 57, 91054, Erlangen, Deutschland.
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Borman P, Ayhan F, Tuncay F, Sahin M. Foot problems in a group of patients with rheumatoid arthritis: an unmet need for foot care. Open Rheumatol J 2012; 6:290-5. [PMID: 23066434 PMCID: PMC3468872 DOI: 10.2174/1874312901206010290] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 08/30/2012] [Accepted: 09/02/2012] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the foot involvement in a group of RA patients in regard to symptoms, type and frequency of deformities, location, radiological changes, and foot care. PATIENTS AND METHODS A randomized selected 100 rheumatoid arthritis (RA) patients were recruited to the study. Data about foot symptoms, duration and location of foot pain, pain intensity, access to services related to foot, treatment, orthoses and assistive devices, and usefulness of therapies were determined by the questionnaire. Radiological changes were assessed according to modified Larsen scoring system. The scores of disease activity scale of 28 joints and Health Assessment Questionnaire indicating the functional status of RA patients were collected from patient files. RESULTS A total of 100 RA patients (90 female, 10 male) with a mean age of 52.5 ±10.9 years were enrolled to the study. Eighty-nine of the 100 patients had experienced foot complaints/symptoms in the past or currently. Foot pain and foot symptoms were reported as the first site of involvement in 14 patients. Thirty-six patients had ankle pain and the most common sites of the foot symptoms were ankle (36%) and forefoot (30%) followed by hindfoot (17%) and midfoot (7%) currently. Forty-nine of the patients described that they had difficulty in performing their foot care. Insoles and orthopedic shoes were prescribed in 39 patients, but only 14 of them continued to use them. The main reasons for not wearing them were; 17 not helpful (43%), 5 made foot pain worse (12.8%), and 3 did not fit (7.6%). Foot symptoms were reported to be decreased in 24 % of the subjects after the medical treatment and 6 patients indicated that they had underwent foot surgery. Current foot pain was significantly associated with higher body mass index and longer disease duration, and duration of morning stiffness. The radiological scores did not correlate with duration of foot symptoms and current foot pain (p>0.05) but the total number of foot deformities was found to be correlated with Larsen scores (p<0.05). CONCLUSION In our study, foot involvement and foot symptoms were seen frequently in RA but there is an unmet need for provision and monitoring of foot care in patients suffering from this chronic disease.
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Affiliation(s)
- Pinar Borman
- Ankara Training and Research Hospital, Clinic of Physical Medicine and Rehabilitation, Cebeci, Ankara, Turkey
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Firth J, Nelson A, Briggs M, Gorecki C. Experiences of healthcare provision for foot ulceration occurring in people with rheumatoid arthritis. Musculoskeletal Care 2012; 11:159-67. [PMID: 23027645 DOI: 10.1002/msc.1036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Participants with rheumatoid arthritis (RA) report that foot ulceration has an impact on their health-related quality of life (HRQL) across physical, social and psychological domains. What is not known is how experiences of healthcare provision influence HRQL. The present study set out to map the patent journey while integrating the impact on HRQL. METHODS A purposive sample of RA patients with open foot ulceration was recruited from podiatry clinics in West Yorkshire (UK) between May 2008 and June 2009. Patients with diabetes were excluded (the impact of foot ulceration in this group is well established). In-depth interviews were taped and transcribed. A framework approach to data management was used to facilitate a case- and theme-based analysis. RESULTS Twenty-three RA patients (18 female, five male; aged 45-88 years) participated. Two themes and five sub-themes were identified. The patient journey theme comprised the following sub-themes: access to care; knowledge acquisition; care pathways and continuity of care. Patient-professional relationships comprised the sub-themes: therapeutic patient-professional relationships and task-orientated care. The journey took a highly variable course that was influenced by patient-specific factors (past experience of ulceration; symptomology; knowledge and self-efficacy); service-specific factors (access to care and care pathways) and professional-specific factors (knowing and trusting someone; holism). CONCLUSIONS The present study highlights the need for clearer care pathways for patients affected by foot ulceration improved patient education and better coordination of care.
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Affiliation(s)
- Jill Firth
- Pennine Musculoskeletal Partnership Ltd, Oldham, UK.
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Armstrong DG, Fiorito JL, Leykum BJ, Mills JL. Clinical efficacy of the pan metatarsal head resection as a curative procedure in patients with diabetes mellitus and neuropathic forefoot wounds. Foot Ankle Spec 2012; 5:235-40. [PMID: 22715496 DOI: 10.1177/1938640012449038] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of the pan metatarsal head resection (PMHR) compared with nonsurgical management of wounds in the forefoot in people with diabetes. METHODS The authors evaluated 92 patients with diabetes (66.3% male), with ulcers classified as University of Texas grade 1A or 2A at the plantar aspect of the forefoot using a case-control model. Cases were patients treated with multiple metatarsal head resections for multiple metatarsal head wounds, and controls received standard nonsurgical care. Both groups received standard off-loading and wound care. Outcomes included time to healing, reulceration, infection, and amputation. RESULTS Patients in the surgery group (SG) healed significantly faster than those in the standard therapy group (ST; 84.2 ± 39.9 days for the ST vs 60.1 ± 27.9 days for the SG; P = .003) and had fewer recurrent ulcers (39.1% for the ST vs 15.2% for the SG; P = .02; odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.3-9.7) and infections during 1 year of follow-up (64.5% for the ST vs 35.5% for the SG; P = .047; OR = 2.4; 95% CI = 1.0-6.0). There was no significant difference in the proportion of patients receiving an incident amputation in the follow-up period (13.0% for the ST vs 6.5% for the SG; P = .5). CONCLUSION The results of this study suggest that the PMHR may be associated with shorter times to healing and lower morbidity compared with standard care alone in patients without digital gangrene and with multiple plantar forefoot ulcers.
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Otter SJ, Lucas K, Springett K, Moore A, Davies K, Young A, Walker-Bone K. Identifying patient-reported outcomes in rheumatoid arthritis: the impact of foot symptoms on self-perceived quality of life. Musculoskeletal Care 2012; 10:65-75. [PMID: 22337478 DOI: 10.1002/msc.1001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The importance of patient-reported outcome measures in healthcare is increasingly recognized but these need to be patient generated. Given that foot symptoms are very common in rheumatoid arthritis (RA), we chose a patient-centred model with which to investigate the patients' perspective on how their foot symptoms affected them as individuals and impacted on their self-perceived quality of life, rather than using the traditional approaches of clinical examination (e.g. prevalence of deformities) or radiological assessments. METHODS A 33-item self-administered postal questionnaire was sent to all people with RA attending outpatient clinics in three hospitals over the course of one month (n=390). The questionnaire used both quantitative and qualitative approaches to enquire about the nature and extent of foot complaints and how respondents believed this affected their quality of life. RESULTS In total, 190 usable replies were received (49%). Nearly all respondents (n=177; 93.2%) reported that their quality of life was adversely affected by their foot complaint(s), with over half describing their quality of life as being badly or very badly affected. When asked to rate how severely foot complaints affected their quality of life using a 10 cm visual analogue scale, the mean score was 5.36 (range 0-10 ± SD 3), indicating that foot complaints have a moderate-to-severe effect on quality of life. Those aspects of daily living most significantly affected were: the ability to walk and the ability to wear a variety of shoes. CONCLUSION This study demonstrated that people with RA focus on different aspects of the impact of their disease to doctors. Rather than foot deformity or ulceration, disease activity score or health assessment questionnaire score, patients were easily able to pinpoint the key negativities of living with RA in their feet and indicated choice of footwear and ability to walk as crucial. This study and similar ones are key to identifying appropriate patient-reported outcome measures.
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Affiliation(s)
- S J Otter
- School of Health Professions, University of Brighton, Brighton, UK.
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Siddle HJ, Firth J, Waxman R, Nelson EA, Helliwell PS. A case series to describe the clinical characteristics of foot ulceration in patients with rheumatoid arthritis. Clin Rheumatol 2011; 31:541-5. [PMID: 22052587 DOI: 10.1007/s10067-011-1886-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 09/01/2011] [Accepted: 10/18/2011] [Indexed: 01/12/2023]
Abstract
The aim of this study was to describe the clinical characteristics of foot ulceration in patients with rheumatoid arthritis (RA). Adults with RA and current foot ulceration but without diabetes were recruited. Clinical examination included assessment of RA disease activity, foot deformity, peripheral vascular disease, neuropathy and plantar pressures. Location, wound characteristics and time to healing were recorded for each ulcer. Participants completed the Health Assessment Questionnaire and Leeds Foot Impact Scale. Thirty-two cases with 52 current ulcers were recruited. Thirteen patients (41%) experienced more than one current ulcer: 5 (16%) had bilateral ulceration, 15 (47%) had previous ulceration at a current ulcer site. The majority (n = 33) of open ulcers were located over the dorsal aspect of the interphalangeal joints (n = 12), plantar aspect of the metatarsophalangeal joints (MTPJs) (n = 12) and medial aspect of first MTPJs (n = 9). In ulcerated limbs (n = 37), ankle brachial pressure index (ABPI) was <0.8 in 2 (5%); protective sensation was reduced in 25 (68%) and peak plantar pressures were >6 kg/cm(2) in 6 (16%). Mean ulcer size was 4.84 by 3.29 mm. Most ulcers (n = 42, 81%) were superficial; five (9.6%) were infected. Time to healing was available for 41 ulcers: mean duration was 28 weeks. Three ulcers remained open. In conclusion, foot ulceration in RA is recurrent and multiple ulcers are common. Whilst ulcers are small and shallow, time to achieve healing is slow, posing infection risk. Reduced protective sensation is common in affected patients. The prevalence of arterial disease is low but may be under estimated due to high intolerance of ABPI.
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Affiliation(s)
- Heidi J Siddle
- Division of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Second Floor, Chapel Allerton Hospital, Chapeltown Road, LS7 4SA Leeds, UK.
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Firth J, Nelson EA, Briggs M, Gorecki C. A qualitative study to explore the impact of foot ulceration on health-related quality of life in patients with rheumatoid arthritis. Int J Nurs Stud 2011; 48:1401-8. [PMID: 21696734 DOI: 10.1016/j.ijnurstu.2011.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 05/23/2011] [Accepted: 05/25/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The overall prevalence of foot ulceration occurring in patients with rheumatoid arthritis is estimated at 10-13% in the UK, with a high rate of recurrence. In contrast with diabetes, there has been a lack of research in this area and the impact of the problem from a patient perspective is poorly understood. OBJECTIVE To explore the added impact of foot ulceration on health-related quality of life in non-diabetic patients with rheumatoid arthritis. DESIGN Qualitative research design to elicit patient experiences. SETTINGS Participants were recruited from hospital and community podiatry clinics in West Yorkshire (UK) between May 2008 and June 2009. PARTICIPANTS A purposive sample of 23 adults with RA and open foot ulceration; patients with diabetes were excluded. METHODS In-depth interviews were conducted with 23 participants using a topic guide. Framework analysis was employed to facilitate a case and theme based approach to identifying descriptive and explanatory accounts of the impact of foot ulceration on health-related quality of life. RESULTS Participants indicated that foot ulceration impacted on their health-related quality of life across physical, social and psychological domains. Pain attributed to the ulcer was linked to new walking disability, affecting participants' lives in every domain. Pain and walking disability added to existing limitations in undertaking household tasks and personal care independently. Keeping the ulcer dry was a major problem for many in relation to personal hygiene. Participants described new restrictions in leisure activities which reduced social participation. Increased footwear/clothing restrictions affected self esteem and altered body image. An economic cost was attached to wound care and footwear alterations. Low mood, anxiety, frustration were attributed to the added impact of foot ulceration on their lives. Perceptions of impact fluctuated over time in relation to physical symptoms experienced by participants and the additional social limitations posed by the ulcer. CONCLUSION Foot ulceration has an additional impact on health-related quality of life over and above the impact of rheumatoid arthritis in every domain. Whilst prevention is the ultimate goal, high rates of recurrence mean that clinicians need to consider ways to improve quality of life for affected patients throughout the patient journey.
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Affiliation(s)
- Jill Firth
- School of Healthcare, Baines Wing, University of Leeds, Leeds LS2 9JT, United Kingdom.
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Backhouse MR, Keenan AM, Hensor EMA, Young A, James D, Dixey J, Williams P, Prouse P, Gough A, Helliwell PS, Redmond AC. Use of conservative and surgical foot care in an inception cohort of patients with rheumatoid arthritis. Rheumatology (Oxford) 2011; 50:1586-95. [PMID: 21504991 PMCID: PMC3157630 DOI: 10.1093/rheumatology/ker130] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Objectives. To describe conservative and surgical foot care in patients with RA in England and explore factors that predict the type of foot care received. Methods. Use of podiatry and type of foot surgery were outcomes recorded in an inception cohort involving nine rheumatology centres that recruited patients with RA between 1986 and 1998 across England. Associations between patient-specific factors and service use were identified using univariate logistic regression analyses. The independence of these associations was then verified through multiple binary logistic regression modelling. Results. Data were collected on 1237 patients with RA [66.9% females, mean (s.d.) age at disease onset = 54.36 (14.18) years, median DAS = 4.09 (1st quartile = 3.04, 3rd quartile = 5.26), median HAQ = 1 (0.50, 1.63)]. Interventions involving the feet in the cohort were low with only 364 (30%) out of 1218 receiving podiatry and 47 (4%) out of 1237 patients having surgery. At baseline, female gender, increasing age at onset, being RF positive and higher DAS scores were each independently associated with increased odds of seeing a podiatrist. Gender, age of onset and baseline DAS were independently associated with the odds of having foot surgery. Conclusions. Despite the known high prevalence of foot pathologies in RA, only one-third of this cohort accessed podiatry. While older females were more likely to access podiatry care and younger patients surgery, the majority of the RA population did not access any foot care.
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Affiliation(s)
- Michael R Backhouse
- Section of Musculoskeletal Disease, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Comparison of foot pain and foot care among rheumatoid arthritis patients taking and not taking anti-TNFα therapy: an epidemiological study. Rheumatol Int 2010; 31:1515-9. [DOI: 10.1007/s00296-010-1700-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 11/21/2010] [Indexed: 10/18/2022]
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Otter SJ, Lucas K, Springett K, Moore A, Davies K, Cheek L, Young A, Walker-Bone K. Foot pain in rheumatoid arthritis prevalence, risk factors and management: an epidemiological study. Clin Rheumatol 2009; 29:255-71. [PMID: 19997766 DOI: 10.1007/s10067-009-1312-y] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 09/23/2009] [Accepted: 10/20/2009] [Indexed: 10/20/2022]
Abstract
Foot involvement is a major feature of rheumatoid arthritis (RA). Most epidemiological studies of the RA foot report radiological changes and results of clinical examination. This study aimed to determine the prevalence of foot symptoms, frequency of foot assessment and access to foot care from the perspective of people with RA. A questionnaire was sent to 1,040 people with RA throughout the UK enquiring about foot symptoms, their anatomical distribution (via validated mannequins) availability of podiatry services and perceived usefulness of interventions for alleviating foot symptoms. Altogether 585 useable replies were received; 93.5% of respondents reported having experienced foot pain, and 35.4% reported current foot pain as the presenting symptom. Most (68.2%) reported moderate or severe foot pain daily. Pain was most prevalent in the forefoot and/or ankle. The main predictive factors for reporting current foot pain were longer disease duration (mean 13 vs 10.3 years, p = 0.009), higher BMI (25.6 vs 24.1 p = 0.001) and the prevalent foot symptoms foot stiffness and numbness (both p < 0.0001). Age, gender and current treatment were not significantly associated. Most (82%) had discussed foot symptoms with their rheumatologist, and only 64% had seen a podiatrist. Reported current adherence to prescribed orthoses was 55.8% and to prescribed shoes was 29.5%. Foot symptoms are ubiquitous in RA and frequently severe. Most patients had discussed their symptoms with their rheumatologist, and only 64% had specifically seen a podiatrist. Despite the remarkable progress in development of new treatment modalities for RA, foot pain remains a common and disabling symptom. Our findings support the need for wider access to specific foot care services and evidence-based, patient-centred interventions.
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Affiliation(s)
- Simon J Otter
- School of Health Professions, University of Brighton, Robert Dodd Building, 49 Darley Rd, Eastbourne, BN20 7UR, UK.
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Queally JM, Zgraj OS, Walsh JC, Butt AJ, D'Souza LG. Use of the modified Stainsby procedure in correcting severe claw toe deformity in the rheumatoid foot: a retrospective review. Foot (Edinb) 2009; 19:110-3. [PMID: 20307460 DOI: 10.1016/j.foot.2009.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 01/19/2009] [Accepted: 01/26/2009] [Indexed: 02/04/2023]
Abstract
INTRODUCTION In claw toe deformity, the plantar plate of the metarsophalangeal joint becomes displaced onto the dorsal aspect of the metatarsal head. The Stainsby procedure replaces the displaced plantar plate to its correct position beneath the metatarsal head. OBJECTIVE In this study we assess the efficacy of a modified Stainsby procedure for the treatment of claw toe deformity. METHODS Thirteen patients were operated on between 2002 and 2008. Eleven patients (13 feet) were available for review with the average follow-up period being 16 months. Clinical examination was performed and AOFAS forefoot scores were measured. RESULTS All 13 (100%) of the feet operated on had severe or moderate pain preoperatively. None had significant pain at review. Plantar callosities were reduced from 13 (100%) feet preoperatively to 1 (9%) foot postoperatively. The AOFAS forefoot score in the eleven patients improved significantly by 40.7 points from a preoperative mean of 20.1 to a mean of 50.2 at review (p<0.001). Ten (91%) of the 11 patients were completely satisfied with the procedure, 1 patient was satisfied with some reservations. CONCLUSION This study demonstrates the modified Stainsby procedure to be effective in correcting claw toe deformity in the rheumatoid patient. It relieves pain, skin callosities and improves overall forefoot function.
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Affiliation(s)
- Joseph M Queally
- Department of Trauma & Orthopaedic Surgery, Mid-Western Regional Orthopaedic Hospital Croom, Limerick, Ireland.
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van der Leeden M, Steultjens MPM, Ursum J, Dahmen R, Roorda LD, Schaardenburg DV, Dekker J. Prevalence and course of forefoot impairments and walking disability in the first eight years of rheumatoid arthritis. ACTA ACUST UNITED AC 2009; 59:1596-602. [PMID: 18975350 DOI: 10.1002/art.24188] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the prevalence and 8-year course of forefoot impairments and walking disability in patients with rheumatoid arthritis (RA). METHODS A total of 848 patients with recent-onset RA from 1995 through the present were included. The patients were assessed annually. Pain and swelling of the metatarsophalangeal (MTP) joints, erosions and joint space narrowing of the MTP joints and first interphalangeal joints, and the Health Assessment Questionnaire walking subscale were analyzed using descriptive and correlational techniques. RESULTS Pain and swelling of > or = 1 MTP joint was present in 70% of patients at baseline, decreasing to approximately 40-50% after 2 years. The forefoot erosion score was > or = 1 in 19% of the patients at baseline, and the prevalence of forefoot erosion increased to approximately 60% after 8 years, during which the mean forefoot erosion score increased from 1.3 to 7.9. At least mild walking disability was present in 57% of patients at baseline, stabilizing at approximately 40% after 1 year. CONCLUSION The prevalence rates for pain and swelling of the MTP joints and walking disability are initially high and then stabilize, but the prevalence and severity of forefoot joint damage increase during an 8-year course of RA. The findings of this study quantitatively emphasize the importance of forefoot involvement in patients with RA.
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Firth J, Helliwell P, Hale C, Hill J, Nelson EA. The predictors of foot ulceration in patients with rheumatoid arthritis: a preliminary investigation. Clin Rheumatol 2008; 27:1423-8. [PMID: 18543055 DOI: 10.1007/s10067-008-0940-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Revised: 05/09/2008] [Accepted: 05/13/2008] [Indexed: 11/30/2022]
Abstract
We explored the predictors of foot ulceration in patients with rheumatoid arthritis (RA). The cases were 15 patients with RA reporting foot ulceration in response to a postal survey of patients sampled from a diagnostic register in secondary care (n = 1,130). The controls were 66 patients with RA randomly sampled from the survey respondents (n = 883) after matching for age, sex and disease duration. Patients with co-existent diabetes were excluded. Clinical examination included the assessment of known risk factors for foot ulceration in diabetes including: neuropathy (insensitivity to 10 g monofilament), peripheral vascular disease (ankle brachial pressure index [ABPI]), foot deformity (Platto indices) and raised plantar pressure (PressureStat readings). A 44 swollen-joint count, the presence of pre-ulcerative lesions and current steroid therapy were identified through univariate analysis as additional potential predictors in patients with RA. Forward step-wise logistic regression analysis showed that the following variables were significant predictors of ulceration: steroid therapy (OR = 9.70, 95%CI = 2.09-45.11, p = 0.004), abnormal ABPI (OR = 13.45, 95%CI = 1.19-151.43, p = 0.035), the presence of pre-ulcerative lesions (OR = 7.40, 95%CI = 1.51-36.30, p = 0.014) and swollen-joint count (OR = 1.25, 95%CI = 1.02-1.53, p = 0.034). Abnormal sensation, foot deformity and raised plantar pressures were not significant predictors of ulceration. The wide confidence intervals for ABPI were due to sparse data with very few abnormal values, and the results of exact logistic regression (more accurate where data is sparse and case matching employed) found that ABPI was no longer a significant predictor (p = 0.054). The significance of the other predictors did not differ substantially. In this preliminary study, abnormal sensation, foot deformity and raised plantar pressures were not significantly associated with foot ulceration but active disease and current steroid therapy were. The contribution of peripheral vascular disease to risk is unclear and further investigation is needed in a larger cohort.
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Affiliation(s)
- Jill Firth
- School of Healthcare, Baines Wing, University of Leeds, Leeds, UK.
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Firth J, Hale C, Helliwell P, Hill J, Nelson EA. The prevalence of foot ulceration in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2008; 59:200-5. [PMID: 18240257 DOI: 10.1002/art.23335] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To establish the prevalence of foot ulceration in patients with rheumatoid arthritis (RA) in secondary care. METHODS A postal survey of all patients with RA (n = 1,130) under the care of rheumatologists in Bradford, West Yorkshire, UK was performed. The prevalence data were validated through clinical examination, case-note review, and contact with health professionals. The false-negative rate was investigated in a subsample of patients (n = 70) who denied any history of ulceration. RESULTS The postal survey achieved a 78% response rate. Following validation, the point prevalence of foot ulceration was 3.39% and the overall prevalence was 9.73%. The false-positive rate was initially high at 21.21%, but use of diagrammatic questionnaire data to exclude leg ulceration reduced the rate to 10.76%. The false-negative rate was 11.76%. The most common sites for ulceration were the dorsal aspect of hammer toes, the metatarsal heads, and the metatarsophalangeal joint in patients with hallux abducto valgus, with 33% of patients reporting multiple sites of ulceration. Patients with open-foot and healed-foot ulceration had significantly longer RA disease duration, reported significantly greater use of special footwear, and had a higher prevalence of foot surgery than ulcer-free patients. CONCLUSION Foot ulceration affects a significant proportion of patients with RA. Further work is needed to establish risk factors for foot ulceration in RA and to target foot health provision more effectively.
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Affiliation(s)
- Jill Firth
- Postgraduate Suite, School of Healthcare, Baines Wing, University of Leeds, Leeds, UK.
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Grondal L, Tengstrand B, Nordmark B, Wretenberg P, Stark A. The foot: still the most important reason for walking incapacity in rheumatoid arthritis: distribution of symptomatic joints in 1,000 RA patients. Acta Orthop 2008; 79:257-61. [PMID: 18484253 DOI: 10.1080/17453670710015067] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Our knowledge of frequency of foot involvement in rheumatoid arthritis (RA) is still often based on a study from Finland in 1956. Great changes in the treatment of RA may have led to a different situation. We investigated the distribution of joint involvement in RA patients today, with special attention given to the feet and subjective walking ability. METHODS 1,000 RA patients answered a questionnaire concerning joints affected, joint surgery, foot problems, and subjectively experienced reasons for walking incapacity. RESULTS In 45% of the patients, the forefoot was involved at the start of the disease. In 17%, the hindfoot/ankle was involved at the start. Only hand symptoms were commoner. 80% of patients reported current foot problems, 86% in the forefoot and 52% in the hindfoot/ankle. Difficulty in walking due to the feet was reported by 71%. For 41% of patients, the foot was the most important part of the lower extremity causing reduced walking capacity, and for 32% it was the only part. INTERPRETATION After the hand, the foot was the most frequently symptomatic joint complex at the start of the disease, but also during active medical treatment. The foot caused walking disability in three-quarters of the cases and-4 times as often as the knee or the hip-it was the only joint to subjectively impair gait.
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Affiliation(s)
- Lollo Grondal
- Department of Molecular Medicine and Surgery, Orthopedic Rehabilitation, Karolinska Institute, Red Cross Hospital, Stockholm, Sweden.
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Turner DE, Helliwell PS, Woodburn J. Methodological considerations for a randomised controlled trial of podiatry care in rheumatoid arthritis: lessons from an exploratory trial. BMC Musculoskelet Disord 2007; 8:109. [PMID: 17986338 PMCID: PMC2225393 DOI: 10.1186/1471-2474-8-109] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Accepted: 11/06/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Whilst evidence exists to support the use of single treatments such as orthoses and footwear, the effectiveness of podiatry-led care as a complex intervention for patients with rheumatoid arthritis (RA) related foot problems is unknown. The aim of this study was to undertake an exploratory randomised controlled parallel arm clinical trial (RheumAFooT) to inform the design and implementation of a definitive trial and to understand the potential benefits of this care. METHODS Patients with a definite diagnosis of RA, stable drug management 3 months prior to entry, and a current history of foot problems (pain, deformity, stiffness, skin or nail lesions, or footwear problems) were recruited from a hospital outpatient rheumatology clinic and randomised to receive 12 months of podiatry treatment or no care. The primary outcome was change in foot health status using the impairment/footwear (LFISIF) and activity limitation/participation restriction (LFISAP) subscales of the Leeds Foot Impact Scale. Disease Activity Score (DAS), Health Assessment Questionnaire (HAQ) score and walking speed (m/s) were also recorded. RESULTS Of the 80 patients identified, 64 patients were eligible to participate in the pilot and 34 were recruited. 16 patients were randomised to receive podiatry led foot care and 18 received no care. Against a backdrop of stable disease (DAS and HAQ scores), there was a statistically significant between group difference in the change in foot health status for foot impairment (LFISIF) but not activity/participation (LFISAP) or function (walking speed) over 12 months. In the podiatry arm, 1 patient declined treatment following randomisation (did not want additional hospital visits) and 3 self-withdrew (lost to follow-up). Patients received an average of 3 consultations for assessment and treatment comprising routine care for skin and nail lesions (n = 3), foot orthoses (n = 9), footwear referral to the orthotist (n = 5), and ultrasound guided intra-articular steroid injection (n = 1). CONCLUSION In this exploratory trial patients were difficult to recruit (stable drug management and co-morbid disease) and retain (lack of benefit/additional treatment burden) but overall the intervention was safe (no adverse reactions). Twelve months of podiatry care maintained but did not improve foot health status. These observations are important for the design and implementation of a definitive randomised controlled trial. TRIAL REGISTRATION ISRCTN: 01982076.
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Affiliation(s)
- Deborah E Turner
- HealthQWest, School of Health & Social Care, Glasgow Caledonian University, Glasgow, UK.
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