Nonunion Rate Following Primary Arthrodesis for Acute Lisfranc Injuries

Injury to the tarsometatarsal joint (TMT) results in instability throughout the midfoot that does not often improve with conservative management. If instability is identified, surgical intervention is frequently recommended, either open reduction and internal fixation (ORIF) or primary arthrodesis (PA). These 2 treatment options have been compared in the literature multiple times, often reporting similar outcomes. Due to this, as well as the need for subsequent hardware removal after ORIF has led many surgeons towards PA at the index surgery. Concern for nonunion is a leading concern with surgeons who advocate instead for ORIF. The purpose of this study is to review patients who underwent PA and observe nonunion rates. Nonunion at the TMT has been previously studied, but only in the chronic setting. We performed a retrospective study of 34 patients who had PA in the management of an acute Lisfranc injury. The average age in our study was 43.9 years old (range 19-72, SD 17.4) with an average follow-up of 9.4 months (range 4-33, SD 6.2). Radiographs were evaluated for signs of nonunion at regular postoperative intervals. Within the patients included in the study, a total of 71 TMT joints were fused. Overall successful fusion rate was 95.8% at an average of 7.9 weeks (range 6-12, SD 1.4) postoperatively. Individual nonunion rates at the first, second, and third TMT were 0%, 1.4% and 2.8% respectively. Our study demonstrates that primary arthrodesis provides a predictable outcome with low nonunion rates in the management of acute Lisfranc injury.

Structural Foot Characteristics in People With Midfoot Osteoarthritis: Cross-Sectional Findings From the Clinical Assessment Study of the Foot

OBJECTIVE

This study compared radiographic measures of foot structure between people with and without symptomatic radiographic midfoot osteoarthritis (OA).

METHODS

This was a cross-sectional study of adults aged 50 years and older registered with four UK general practices who reported foot pain in the past year. Bilateral weightbearing dorsoplantar and lateral radiographs were obtained. Symptomatic radiographic midfoot OA was defined as midfoot pain in the last 4 weeks, combined with radiographic OA in one or more midfoot joints (first cuneometatarsal, second cuneometatarsal, navicular-first cuneiform, and talonavicular). Midfoot OA cases were matched 1:1 for sex and age to controls with a 5-year age tolerance. Eleven radiographic measures were extracted and compared between the groups using independent sample t-tests and effect sizes (Cohen's d).

RESULTS

We identified 63 midfoot OA cases (mean ± SD age was 66.8 ± 8.0 years, with 32 male and 31 female participants) and matched these to 63 controls (mean ± SD age was 65.9 ± 7.8 years). There were no differences in metatarsal lengths between the groups. However, those with midfoot OA had a higher calcaneal-first metatarsal angle (d = 0.43, small effect size, P = 0.018) and lower calcaneal inclination angle (d = 0.46, small effect size, P = 0.011) compared with controls.

CONCLUSIONS

People with midfoot OA have a flatter foot posture compared with controls. Although caution is required when inferring causation from cross-sectional data, these findings are consistent with a pathomechanical pathway linking foot structure to the development of midfoot OA. Prospective studies are required to determine the temporal relationships between foot structure, function, and the development of this common and disabling condition.

Morphologic analysis of the 1st and 2nd tarsometatarsal joint articular surfaces

Tarsometatarsal joint arthrodesis is used to treat a variety of injuries and deformities in the midfoot. However, the surgical technique has not been optimized, in part due to limited knowledge of morphologic features and variation in the related joints. Previous research has relied primarily on dissection-based anatomical analysis, but quantitative imaging may allow for a more sophisticated description of this complex. Here, we used quantitative micro-CT imaging to examine dimensions, distance maps, and curvature of the four articular surfaces in the first and second tarsometatarsal joints. Image segmentation, articular surface identification, and anatomic coordinate systems were all done with semi or fully automatic methods, and distance and size measurements were all taken utilizing these anatomic planes. Surface curvature was studied using Gaussian curvature and a newly defined measure of curvature similarity on the whole joint and on four subregions of each surface. These data show larger articular surfaces on the cuneiforms, rather than metatarsals, and define the generally tall and narrow articular surfaces seen in these joints. Curvature analysis shows minimally curved opposing convex surfaces. Our results are valuable for furthering knowledge of surgical anatomy in this poorly understood region of the foot.

Radiological findings of fibrocartilaginous coalition of the third tarsometatarsal joint: a retrospective cross-sectional study with computed tomography and magnetic resonance imaging

BACKGROUND

Fibrocartilaginous coalition of the third tarsometatarsal joint has been indicated as an extremely rare form of tarsal coalition in the radiological literature, and most articles concerned with tarsal coalition do not mention involvement of this joint. Only two reports written in the English language that approach this subject were found, an orthopedic report and an anthropological report.

PURPOSE

To evaluate the prevalence of this finding and discuss and illustrate the radiological characteristics of this coalition.

MATERIAL AND METHODS

A retrospective analysis of 614 computed tomography or magnetic resonance imaging scans of the ankle and/or foot, acquired at a health service within a period of three months, was performed to assess the prevalence of this coalition.

RESULTS

Of the examinations characterized as valid for analysis for the purposes of the study, 17 cases compatible with fibrocartilaginous coalition of the third tarsometatarsal joint were found, thus indicating an involvement of approximately 2.97% of the examined feet.

CONCLUSION

Our radiological findings are typical, and the prevalence found in this study was statistically significant, being similar to that described in the anthropological report (3.2%-6.8%).

Clinical features and outcomes in children with bone and joint infections of the ankle or foot

BACKGROUND

The foot and ankle are uncommon sites of bone and joint infections (BJIs) in children. The objectives of the present study were to determine the clinical and bacteriologic features of BJIs and to assess any associated complications and orthopedic sequelae.

METHODS

We performed a retrospective, single-center study of children treated for foot or ankle BJIs between 2008 and 2018 in a French university medical center. A total of 23 children were included. The median age at diagnosis was 9.1 years. Osteomyelitis was noted in 14 cases; it involved the calcaneus in seven cases, the distal fibula in four cases, the first metatarsal in two cases, and the distal tibia in one case. Arthritis affected the ankle in six cases and the cuneiform-cuboidal joint in one case. In two cases, osteoarthritis of the ankle was associated with distal osteomyelitis of the tibia. Clinical, radiological, and bacteriological parameters, surgical procedures, complications, and sequelae were recorded and analyzed.

RESULTS

The median (range) time to diagnosis was 3.18 days (0-10), and trauma was reported in four cases. Fever was present on admission in 18 cases, and the serum C-reactive protein level was elevated in 22 cases. Standard X-rays showed osteolysis in one case and bone sequestration in another. Staphylococcusaureus was identified in 10 cases. Surgery was performed in 17 cases. A subperiosteal abscess that required surgical drainage complicated 10 cases of osteomyelitis. No recurrence was observed. At the last follow-up, the median (range) age was 11.9 years (1.5-19). Sequelae (spontaneous tibia-talus fusion, first metatarsal epiphysis fusion, and varus deformity of the hindfoot) were observed in three cases, all of which were initially complicated by an abscess.

CONCLUSION

Physicians should be aware that pediatric BJIs of the lower limb may involve the foot and ankle. S. aureus is frequently involved. In cases of osteomyelitis, complications are closely associated with subperiosteal abscesses justifying an early diagnosis. These BJIs must be treated rapidly, and the risk of sequelae justifies long-term follow-up.

Septic arthritis due to non-tuberculous mycobacterium without effusion

Septic arthritis is an important but difficult to make diagnosis that leads to significant morbidity and mortality. Joint effusion is generally accepted to be a highly sensitive finding in septic arthritis; however, final diagnosis requires synovial fluid studies. Without a significant joint effusion, it is difficult to obtain synovial fluid. In this case report, we describe the presentation and diagnosis of septic arthritis in the first MTP due to mycobacterium chelonae in a 69 year old man with a history of gout and immunosuppression due to a heart transplant. There was notably no significant effusion in the joint on clinical examination or bedside ultrasound. As the patient was immunosuppressed, arthrocentesis was performed under ultrasound guidance. A needle was clearly visualized in the joint; however, minimal synovial fluid was obtained. The fluid grew Mycobacterium chelonae in culture. Subsequent joint washout revealed purulent synovial fluid that grew out the same bacteria. This case emphasizes the importance of obtaining synovial fluid to evaluate for septic arthritis, even when joint effusion is absent. Ultrasound guidance can facilitate this.

Ultrasound as a Diagnostic Tool in the Assessment of Lisfranc Joint Injuries

OBJECTIVES

Ligamentous Lisfranc injuries are frequently overlooked because of subtle clinical presentations and diagnostic difficulties. The dorsal Lisfranc ligament (DLL) is easily visualized with ultrasound (US), which can provide quick, cost-effective diagnoses of disorders but is not considered standard clinical practice. This study sought to compare DLL measurement accuracy between US and cadaveric dissection.

METHODS

Ultrasound images of 22 embalmed cadaveric feet were obtained with an M-Turbo US machine and a 6-13-MHz linear array (FUJIFILM SonoSite, Inc, Bothell, WA). Images were measured in the US unit and again with ImageJ software (National Institutes of Health, Bethesda, MD). Specimens were dissected, and DLL morphologic characteristics were recorded.

RESULTS

Twenty-two specimens were scanned, however 4 were excluded, leaving a sample of 11 male and 7 female cadaveric specimens (mean age ± SD, 80.3 ± 14.03 years). The DLL length differences between SonoSite (8.39 ± 1.27 mm) and ImageJ (8.25 ± 1.84 mm) were not significant (P > .05). Both US DLL measurements significantly differed from the gross dissection measurement (10.8 ± 1.85 mm; P < .001). The morphologic characteristics of the DLL at dissection were consistent. Overall, 70% to 80% of the ligament length was represented by US compared to dissection. The dorsal joint space did not differ significantly between SonoSite (2.19 ± 0.49 mm) and ImageJ (2.05 ± 0.52; P > .05). Both US measurements were also significantly larger than dissection measurements (1.04 ± 0.24; P < .001). Intraclass correlation coefficients indicated good reliability for the DLL length (0.835) and moderate reliability for the dorsal joint space (0.714).

CONCLUSIONS

The DLL is underrepresented but easily distinguished by US, demonstrating its utility in Lisfranc injury diagnosis. Thus, we propose a 4-component assessment involving US, which may provide more rapid, cost-effective diagnoses of subtle Lisfranc injuries.

Imaging in Lisfranc injury: a systematic literature review

OBJECTIVES

To systematically review current diagnostic imaging options for assessment of the Lisfranc joint.

MATERIALS AND METHODS

PubMed and ScienceDirect were systematically searched. Thirty articles were subdivided by imaging modality: conventional radiography (17 articles), ultrasonography (six articles), computed tomography (CT) (four articles), and magnetic resonance imaging (MRI) (11 articles). Some articles discussed multiple modalities. The following data were extracted: imaging modality, measurement methods, participant number, sensitivity, specificity, and measurement technique accuracy. Methodological quality was assessed by the QUADAS-2 tool.

RESULTS

Conventional radiography commonly assesses Lisfranc injuries by evaluating the distance between either the first and second metatarsal base (M1-M2) or the medial cuneiform and second metatarsal base (C1-M2) and the congruence between each metatarsal base and its connecting tarsal bone. For ultrasonography, C1-M2 distance and dorsal Lisfranc ligament (DLL) length and thickness are evaluated. CT clarifies tarsometatarsal (TMT) joint alignment and occult fractures obscured on radiographs. Most MRI studies assessed Lisfranc ligament integrity. Overall, included studies show low bias for all domains except patient selection and are applicable to daily practice.

CONCLUSIONS

While conventional radiography can demonstrate frank diastasis at the TMT joints; applying weightbearing can improve the viewer's capacity to detect subtle Lisfranc injury by radiography. Although ultrasonography can evaluate the DLL, its accuracy for diagnosing Lisfranc instability remains unproven. CT is more beneficial than radiography for detecting non-displaced fractures and minimal osseous subluxation. MRI is clearly the best for detecting ligament abnormalities; however, its utility for detecting subtle Lisfranc instability needs further investigation. Overall, the available studies' methodological quality was satisfactory.

Evidence of Diagnostic and Treatment Delay in Seronegative Rheumatoid Arthritis: Missing the Window of Opportunity

OBJECTIVES

To compare the time from first joint swelling to fulfillment of the American College of Rheumatology/European League Against Rheumatism classification criteria between patients with seropositive and seronegative rheumatoid arthritis (RA) and to assess the impact of seronegative status on the time from first joint swelling to initiation of disease-modifying antirheumatic drug (DMARD) therapy and achievement of remission.

PATIENTS AND METHODS

Times from first provider-documented joint swelling to fulfillment of the 1987 and 2010 American College of Rheumatology/European League Against Rheumatism criteria and to the clinical diagnosis of RA were measured in a population-based cohort of adults with incident RA between January 1, 2009, and December 31, 2014. Disease characteristics and achievement of remission were compared between seropositive (rheumatoid factor positive and/or anti-citrullinated peptide antibody positive) and seronegative (rheumatoid factor negative/anti-citrullinated peptide antibody negative) patients.

RESULTS

The median time from first joint swelling to fulfillment of the 1987 (48 [interquartile range (IQR), 0-300] days vs 2 [IQR, 0-45] days; P=.001) and 2010 (14 [IQR, 0-196] days vs 0 [IQR, 0-29] days; P=.004) classification criteria and the median time from first joint swelling to the clinical diagnosis of RA (187 [IQR, 13-503] days vs 11 [IQR, 0-76] days; P<.001) were significantly longer in seronegative patients than in seropositive patients. The median time from first joint swelling to first prescribed DMARD therapy was significantly longer in seronegative patients (40 [IQR, 5-199] days vs 14 [IQR, 0-73] days; P=.01). Patients with seronegative RA were less likely to achieve remission (28% vs 50% at 5 years after fulfillment of the 2010 criteria; P=.007), but there was no difference when the patient global score was removed from the remission definition.

CONCLUSION

Patients with seronegative RA experienced a delay in diagnosis, according to both the 1987 and 2010 classification criteria, as well as a delay in the initiation of DMARD therapy. Patients with seronegative RA were also less likely to attain remission, suggesting that the window of opportunity for intervention may be more frequently missed in this group.

In vitro evaluation of a medial approach for intra-articular injection of the tarsometatarsal joints of horses

OBJECTIVE

To develop a reliable method for injection of the tarsometatarsal (TMT) joint of horses through a medial approach and to characterize anatomy of the synovial recesses of the TMT joint with CT.

SAMPLE

13 pairs of fresh cadaveric equine tarsi.

PROCEDURES

TMT joints were assessed with radiography and CT. Twelve pairs of TMT joints were assigned to an experienced veterinarian (8 joints) or veterinary student (16 joints) for injection with contrast medium through a medial or a lateral approach. Every TMT joint was then reexamined radiographically and with CT to assess diffusion of contrast medium. The number of attempts for the lateral and medial approaches between and within investigators was evaluated, which included evaluation of the diffusion of contrast solution in relation to the approach used.

RESULTS

All 24 TMT joints were successfully injected, as confirmed with radiography and CT. There was no significant difference in the number of attempts between the medial and lateral approaches and between investigators. No significant difference was detected in the distribution of contrast medium in each synovial recess between the medial and lateral approaches.

CONCLUSIONS AND CLINICAL RELEVANCE

The medial approach described here for injection of the TMT joint of horses was highly reliable. It involved use of an easily palpable anatomic landmark on the mediodistal aspect of the TMT joint. An established alternative method for injection of the TMT joint may be useful in clinical practice for diagnostic and therapeutic purposes, although a medial approach may increase risk of injury to veterinarians.

The relevance of ultrasound examination of the foot and ankle in patients with rheumatoid arthritis - a review of the literature

Rheumatoid arthritis (RA) is an inflammatory disease characterized by symmetrical involvement of the joints and tendons, especially of the hands and wrists, but also of the feet and ankles from the very beginning of the disease. For the patient, the foot and ankle involvement is equally important as the other joints, since it affects the functionality of the feet and the quality of life of the patients. It is already known that subclinical involvement of the ankles and feet occurs even in patients that are considered in clinical remission, thus they do not need for changes of therapy, but still might benefit from it. In spite of this, theclinicians do not give enough care to the ankle and foot in RA patients, especially if asymptomatic, resulting future deformities, joint damage and feet disability. In order to show the importance of the feet and ankles in RA patients and to demonstrate the indispensable role of ultrasonography (US) for that purpose, at the same time displaying the US abnormalities that should draw our attention, we performed this review of the literature.

Involvement of foot in patients with spondyloarthritis: Prevalence and clinical features

BACKGROUND

The purpose of this study was to evaluate the foot involvement in a group of patients with spondyloarthritis in regard to symptoms, type and frequency of deformities, location and radiological changes.

METHODS

We conducted a cross sectional study including 60 patients with spondyloarthritis over a period of six months. Anamnesis, clinical examination, podoscopic examination, biological tests and X-rays of feet were done for each patient.

RESULTS

Foot involvement was found in 31 patients (52%). It was symptomatic in 35% of cases and inaugural in 42% of cases. The most frequent site was the hindfoot (22 patients/31). Radiological findings were: erosion (17%), reconstruction (33%), erosion and reconstruction (50%). Forefoot involvement was found in 18/31 patients. Forefoot deformities were found in 9 patients. Two patients had sausage toe and feet skin abnormalities were observed in 12 patients. At podoscopic examination, 23 patients had abnormal footprints. Foot involvement was more frequent in peripheral spondyloarthritis (p=0.008). Patients with foot involvement had an advanced age of disease onset (p=0.05), a shorter disease duration (p=0.038) and more comorbidities (p=0.039). Foot involvement was correlated with C Reactive protein (p=0.043).

CONCLUSION

In our study, foot involvement and foot symptoms were seen frequently in spondyloarthritis and it is associated with late onset of the disease and with higher inflammation in blood tests.

Imaging in Foot and Ankle Instability

This article reviews the imaging aspects relevant to ligamentous instabilities of the foot and ankle with a focus on MRI and ultrasound imaging. A pictorial review of the anatomy of the medial and lateral ankle ligaments, syndesmosis, spring ligament, Lisfranc complex, hallux sesamoid complex, and lesser toe plantar plate as seen on MRI is presented. Selected cases of ligamentous pathology relevant to foot and ankle instability are presented. The value of imaging in the assessment of foot and ankle instability is reviewed.

Evaluation of peritalar subluxation in adult acquired flatfoot deformity using computed tomography and weightbearing multiplanar imaging

BACKGROUND

The aim of this study was to assess the inferior talus-superior talus (inf-tal-sup-tal) angle (previously proven reliable in multiplanar-weight bearing imaging (MP-WB)) on both computed tomography (CT) and MP-WB scans. We sought to compare the angle between the two modalities in both AAFD and control groups, as well as to compare the groups to each other.

METHODS

Inf-tal-sup-tal angles were compared between a stage II AAFD group (n=38) with routine MP-WB and CT scans and a control group (n=20) with preoperative CT scans for lisfranc injuries and normal hindfoot alignment after healing.

RESULTS

The CT inf-tal-sup-tal angle was significantly greater in AAFD compared to control (AAFD, 12±6; control, 5±4; p<0.001), but was even greater with MP-WB. There was no significant correlation between inf-tal-sup-tal angles on MP-WB and CT (Pearson's=0.29, p=0.08).

CONCLUSIONS

MP-WB imaging proved to be correlated more strongly with AAFD than CT by revealing greater hindfoot valgus. This confirmed that CT scans are useful in predicting AAFD, but cannot be used as a surrogate for MP-WB scans.

Following the correction of varus deformity of the knee through total knee arthroplasty, significant compensatory changes occur not only at the ankle and subtalar joint, but also at the foot

PURPOSE

This study aimed to assess radiological changes of the ankle joint, subtalar joint and foot following the correction of varus deformity of the knee with total knee arthroplasty (TKA). It was hypothesized that following the correction of varus deformity by TKA, compensatory reactions would occur at the subtalar joint in accordance with the extent of the correction.

METHODS

For this prospective study, 375 knees of patients who underwent TKA between 2011 and 2012 were enrolled. The varus angle of the knee, talar tilt of the ankle joint (TT), ground-talar dome angle of the foot (GD), anterior surface angle of the distal tibia and lateral surface angle of the distal tibia, heel alignment ratio (HR), heel alignment angle (HA), and heel alignment distance (HD) were measured on radiographs obtained pre-operatively and at post-operative 6 months.

RESULTS

The mean correction angle in varus deformity of the knee was 10.8 ± 4.1°. TT and GD changed significantly from 0.4 ± 1.9° and 6.5 ± 3.1° pre-operatively to 0.1 ± 1.8° and 0.2 ± 2.1°, respectively (p = 0.007, p < 0.001). No correlation was found between the preop-postop variance in mechanical axis of the lower extremity (MA) and TT, but there was a strong correlation between the preop-postop variance in MA and GD (r = 0.701). HR, HA and HD also changed significantly post-operatively, and the preop-postop variance in MA showed correlations with the preop-postop variances in HR, HA and HD (r = 0.206, - 0.348, and - 0.418). TT and the three indicators of hindfoot alignment all shifted to varus whereas GD was oriented in valgus.

CONCLUSION

Following the correction of varus deformity of the knee through TKA, significant compensatory changes occurred not only at the ankle and subtalar joints, but also at the foot. The findings of this study are useful in predicting the orientation of changes in the ankle and subtalar joints and the foot following TKA, and in determining the sequence of surgery when both the ankle and knee have a problem. In other words, changes in the parts of the lower extremity below the ankle joint following the correction of varus deformity of the knee must be considered when TKA is planned and performed. Patients who have problems at the ankle, subtalar, and foot joints in addition to varus deformity of the knee are recommended to undergo knee joint correction first.

LEVEL OF EVIDENCE

II.

A case of regional migratory osteoporosis

We present the case of a middle-aged man with three episodes of regional migratory osteoporosis of the lower extremities occurring over a period of 8 years. Symptoms included a sudden onset of unilateral bone and joint pain. After initiation of pamidronate treatment, symptoms improved significantly. Regional migratory osteoporosis is a rare, but probably underdiagnosed condition with an unclear etiology. This case illustrates the importance of recognition of the disease in order to inform the patient, start treatment, and prevent unnecessary invasive procedures. Although in literature, not much is reported about treatment strategies, our patient was successfully treated with pamidronate after failure of oral bisphosphonates.

[Triple arthrodesis for correction of cavovarus deformity]

OBJECTIVE

The aim is to correct the underlying cavovarus deformity and to achieve a pain-free and stable hindfoot.

INDICATIONS

Rigid neurologic, posttraumatic, congenital, and idiopathic cavovarus deformities.

CONTRAINDICATIONS

General surgical or anesthesiological risks, infections, critical soft tissue conditions, neurovascular impairment of the lower extremity, noncompliance, patients with severely reduced bone quality, insulin-dependent diabetes mellitus, smoking.

SURGICAL TECHNIQUE

The talonavicular and subtalar joints are exposed using a single medial approach. Joint cartilage is carefully debrided. Hindfoot reposition with complete correction of cavovarus deformity in all three planes. Joints are stabilized using cannulated screws, followed by wound closure.

POSTOPERATIVE MANAGEMENT

A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 using a stabilizing walking boot or cast for 6 weeks with 15 kg partial weight bearing. Clinical and radiographic follow-up 6 weeks postoperatively to assess osseous consolidation at the arthrodesis site. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is gradually initiated.

RESULTS

Between January 2012 and July 2014, triple arthrodesis was performed in 11 patients with a mean age of 62 ± 14 years due to cavovarus deformity. The mean follow-up was 34 ± 8 months (range 24-48 months). In all patients, the cavovarus deformity was substantially corrected. Significant pain relief from 7.1 ± 2.2 (range 5-10) to 1.8 ± 1.5 (range 0-4) on the visual analogue scale was observed.

Comparison of the effects of forefoot joint-preserving arthroplasty and resection-replacement arthroplasty on walking plantar pressure distribution and patient-based outcomes in patients with rheumatoid arthritis

Purpose

The purpose of this retrospective study is to clarify the difference in plantar pressure distribution during walking and related patient-based outcomes between forefoot joint-preserving arthroplasty and resection-replacement arthroplasty in patients with rheumatoid arthritis (RA).

Methods

Four groups of patients were recruited. Group1 included 22 feet of 11 healthy controls (age 48.6 years), Group2 included 36 feet of 28 RA patients with deformed non-operated feet (age 64.8 years, Disease activity score assessing 28 joints with CRP [DAS28-CRP] 2.3), Group3 included 27 feet of 20 RA patients with metatarsal head resection-replacement arthroplasty (age 60.7 years, post-operative duration 5.6 years, DAS28-CRP 2.4), and Group4 included 34 feet of 29 RA patients with metatarsophalangeal (MTP) joint-preserving arthroplasty (age 64.6 years, post-operative duration 3.2 years, DAS28-CRP 2.3). Patients were cross-sectionally examined by F-SCAN II to evaluate walking plantar pressure, and the self-administered foot evaluation questionnaire (SAFE-Q). Twenty joint-preserving arthroplasty feet were longitudinally examined at both pre- and post-operation.

Results

In the 1^st MTP joint, Group4 showed higher pressure distribution (13.7%) than Group2 (8.0%) and Group3 (6.7%) (P<0.001). In the 2^nd-3^rd MTP joint, Group4 showed lower pressure distribution (9.0%) than Group2 (14.5%) (P<0.001) and Group3 (11.5%) (P<0.05). On longitudinal analysis, Group4 showed increased 1^st MTP joint pressure (8.5% vs. 14.7%; P<0.001) and decreased 2^nd-3^rd MTP joint pressure (15.2% vs. 10.7%; P<0.01) distribution. In the SAFE-Q subscale scores, Group4 showed higher scores than Group3 in pain and pain-related scores (84.1 vs. 71.7; P<0.01) and in shoe-related scores (62.5 vs. 43.1; P<0.01).

Conclusions

Joint-preserving arthroplasty resulted in higher 1^st MTP joint and lower 2^nd-3^rd MTP joint pressures than resection-replacement arthroplasty, which were associated with better patient-based outcomes.

Prominent midfoot involvement in children with enthesitis-related arthritis category of juvenile idiopathic arthritis

Foot involvement is common in juvenile idiopathic arthritis (JIA) but is often unrecognized and difficult to treat. This study was done to assess clinical and radiological involvement of the feet and its impact on function in Indian children with enthesitis-related arthritis (ERA). We enrolled consecutive children with ERA with disease duration of less than 5 years. All patients underwent clinical examination of the feet and filled the juvenile arthritis foot index (JAFI) questionnaire. Ultrasound (US) of foot joints and entheses and extremity magnetic resonance imaging (MRI) scan of one foot were done. Fifty-five patients (53 boys), with median 14 years and disease duration 1.9 years, were included. Thirty-seven of 46 were HLA-B27-positive. Mean juvenile spondyloarthritis disease activity (JSpADA) index and juvenile idiopathic arthritis disease activity scrore-10 (JADAS10) scores were 4 and 14.25. Forty-six had history of foot pain, 36 had foot involvement on examination (15 ankle, 8 subtalar, 24 midfoot, 10 forefoot, and 21 tendoachilles), and 7 had plantar fascia involvement. On US (N = 55), 16 had ankle involvement and 8 had subtalar involvement, and 19 patients had midfoot arthritis, 24 had tendoachilles enthesitis, and 11 had plantar fasciitis. On MRI (N = 50), 27 had midfoot involvement. Thirty-three had bone edema. Fourteen had midfoot enthesitis and 17 had tenosynovitis. Clinical and US had 82% concordance at the midfoot and 90% at the ankle. MRI had 74% concordance with examination and 72% with US at the midfoot. The median JAFI scores were as follows: total JAFI = 4 (0-11), impairment = 1, activity limitation = 2, and participation restriction = 1. JAFI total and individual domains correlated with JADAS10, JSpADAS, and childhood health assessment questionnaire (CHAQ) but not duration of foot disease. JAFI was higher in children with midfoot arthritis on US. Foot joints and entheses are involved in a substantial proportion of patients with ERA patients and the midfoot is commonly involved. Foot disease produces significant functional limitation.

Ultrasound of the osteoarthritic joint

Ultrasound (US) has acquired an increasing role in the assessment of joint and periarticular abnormalities in osteoarthritis (OA). It is able to image a large set of abnormalities in this disease which include both inflammatory and structural changes at different peripheral joint sites and it is helpful in guiding local procedures that can be easily and safely performed with optimal patient's tolerance. US is a feasible imaging modality that has become a bedside procedure in the rheumatology clinical practice, thus filling the gap between clinical and radiographic evaluations of patients with OA. The present review focuses and summarises the currently available data on the applications of US in OA.

A reduced 12-joint ultrasound examination predicts lack of X-ray progression better than clinical remission criteria in patients with rheumatoid arthritis

To study the predictive value of clinical remission definitions and ultrasound (US) examination on X-ray progression in rheumatoid arthritis (RA). This was an observational prospective multicenter 1-year follow-up cohort of RA patients with moderate disease activity (3.2 < DAS28 ≤ 5.1) who started anti-TNF therapy. DAS28ESR, DAS28CRP, SDAI, CDAI, and ACR/EULAR remission criteria were applied and reduced 12-joint US examination was performed at baseline and at 6 and 12 months. At baseline and month 12, radiographs of hands and feet were obtained in a subset of patients. A blind independent reader scored radiographs. X-ray progression was defined as Sharp van der Heijde change score >1 and no progression was defined as ≤0. 319 of 357 patients completed the study; patients had a mean (SD) age of 53.5 (13.1) years, with a disease duration of 7.5 (7.1) years. Laboratory, clinical, and US values significantly improved at month 6, except CRP, with additional improvement at month 12. Remission and low disease activity rates increased at follow-up. In the subset of 115 patients with radiological studies, clinical remission by any definition was not significantly associated with X-ray progression. Patients without PD signal at baseline and month 6 were a lower risk of X-ray progression than patients with PD signal, OR 0.197 (95% CI 0.046-0.861) and 0.134 (95% CI 0.047-0.378), respectively. Absence of PD signal, but not clinical remission predicts lack of X-ray progression. A feasible 12-joint US examination may add relevant information to RA remission criteria.

Biomechanical investigation of two plating systems for medial column fusion in foot

Background

Arthrodesis of the medial column (navicular, cuneiform I and metatarsal I) is performed for reasons such as Charcot arthropathy, arthritis, posttraumatic reconstruction or severe pes planus. However, the complication rate is still high and mainly resulting from inadequate fixation. Special plates, designed for medial column arthrodesis, seem to offer potential to reduce the complication rate. The aim of this study was to investigate biomechanically plantar and dorsomedial fusion of the medial column using two new plating systems.

Methods

Eight matched pairs of human cadaveric lower legs were randomized in two groups and medial column fusion was performed using either plantar or dorsomedial variable-angle locking compression plates. The specimens were biomechanically tested under cyclic progressively increasing axial loading with physiological profile of each cycle. In addition to the machine data, mediolateral x-rays were taken every 250 cycles and motion tracking was performed to determine movements at the arthrodesis site. Statistical analysis of the parameters of interest was performed at a level of significance p = 0.05.

Results

Displacement of the talo-navicular joint after 1000, 2000 and 4000 cycles was significantly lower for plantar plating (p≤0.039) while there was significantly less movement in the naviculo-cuneiform I joint for dorsal plating post these cycle numbers (p<0.001). Displacements in all three joints of the medial column, as well as angular and torsional deformations between the navicular and metatarsal I increased significantly for each plating technique between 1000, 2000 and 4000 cycles (p≤0.021). The two plating systems did not differ significantly with regard to stiffness and cycles to failure (p≥0.171).

Conclusion

From biomechanical point of view, although dorsomedial plating showed less movement than plantar plating in the current setup under dynamic loading, there was no significant difference between the two plating systems with regard to stiffness and cycles to failure. Both tested techniques for dorsomedial and plantar plating appear to be applicable for arthrodesis of the medial column of the foot and other considerations, such as access morbidity, associated deformities or surgeon's preference, may also guide the choice of plating pattern. Further clinical studies are necessary before definitive recommendations can be given.

Clinical Outcomes and Development of Symptomatic Osteoarthritis 2 to 24 Years After Surgical Treatment of Tarsometatarsal Joint Complex Injuries

BACKGROUND

Injuries to the tarsometatarsal (TMT) joint complex, or Lisfranc injuries, have been reported to result in osteoarthritis (OA) following surgical treatment. Good outcomes with respect to short and medium-term results have been reported. However, long-term results, specifically regarding clinical outcomes and the development of symptomatic OA, are limited. The objectives of this study were to assess clinical outcomes, the occurrence of symptomatic OA, and risk factors for OA at 2 to 24 years after a Lisfranc injury treated surgically with open reduction and internal fixation (ORIF) or with primary arthrodesis.

METHODS

This was a retrospective study involving 61 patients treated surgically at our institution between 1988 and 2009 for an injury to the TMT joint complex. Patients underwent either ORIF with transarticular screws or primary arthrodesis when joint comminution at the TMT level was such that ORIF was not possible. Functional outcomes were assessed according to the American Orthopaedic Foot & Ankle Society (AOFAS) score, the Foot Function Index (FFI), and a visual analog scale (VAS) for pain. Global health was evaluated with the Short Form (SF)-12 Health Survey physical component summary (PCS).

RESULTS

Sixty-one of the 128 patients were available for clinical evaluation, including the use of questionnaires, and radiographic assessment at a mean of 10.9 years postoperatively (range, 2.4 to 23.9 years). Mean scores were as follows: AOFAS score, 79.0; FFI, 16.9, and VAS for pain, 2.5. Radiographic evidence of OA was noted in 44 (72.1%) of the patients, and symptomatic OA, in 54.1%, the latter having worse outcomes. Risk factors for OA were nonanatomic reduction, fracture classification of Myerson type C, and a history of smoking.

CONCLUSIONS

Two to 24 years following surgical treatment to restore and maintain joint anatomy for Lisfranc injuries, we found satisfactory clinical outcome scores and a large number of patients who had returned to their previous level of functioning and employment, with little need for secondary procedures. However, there was a substantial occurrence of posttraumatic OA, as evident on radiographs, albeit the occurrence of symptomatic OA was lower.

LEVEL OF EVIDENCE

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

To what extent is foot pain related to biomechanical changes and ultrasound-detected abnormalities in rheumatoid arthritis?

OBJECTIVES

To investigate the presence of biomechanical abnormalities and ultrasound (US)-detected inflammation and damage in low disease or remission status rheumatoid arthritis (RA) patients with foot complaints.

METHODS

We recruited 136 subjects with foot complaints. Sixty-two were biologic disease-modifying antirheumatic drug-treated RA patients presenting Disease Activity Score-determined remission or low disease activity while the remaining 74 were gender matched controls without rheumatic or musculoskeletal disorders. Both groups underwent a comprehensive podiatric, biomechanical and B-mode and Doppler US assessment of the feet.

RESULTS

Most RA patients and controls were female (77.4% and 83.8%, respectively). There was no statistical difference in the proportion of obese subjects in either group (p=0.792). Inappropriate shoes were used by 50.0% of RA patients and 33.8% of controls (p=0.080). Talalgia, particularly heel pain, was more frequent in the control group, with associated talalgia and metatarsalgia being more prevalent in the RA group (p<0.05). The RA patient group was also more likely to present greater foot deformity, more limited joint movement and biomechanical abnormalities than the controls (p<0.05). US inflammatory and structural changes were significantly more frequent in RA patients than in controls (p<0.05). US structural involvement was significantly associated with limited joint mobility and pathologic biomechanical tests only in RA patients (p<0.05).

CONCLUSIONS

RA foot complaints seemed to be linked to US-detected RA involvement and biomechanical abnormalities. Podiatric and US assessments can be useful to help the clinician to optimise the management of RA patients in remission/low disease activity with foot complaints.

Investigations of Potential Phenotypes of Foot Osteoarthritis: Cross-Sectional Analysis From the Clinical Assessment Study of the Foot

OBJECTIVE

To investigate the existence of distinct foot osteoarthritis (OA) phenotypes based on pattern of joint involvement and comparative symptom and risk profiles.

METHODS

Participants ages ≥50 years reporting foot pain in the previous year were drawn from a population-based cohort. Radiographs were scored for OA in the first metatarsophalangeal (MTP) joint, first and second cuneometatarsal, navicular first cuneiform, and talonavicular joints according to a published atlas. Chi-square tests established clustering, and odds ratios (ORs) examined symmetry and pairwise associations of radiographic OA in the feet. Distinct underlying classes of foot OA were investigated by latent class analysis (LCA) and their association with symptoms and risk factors was assessed.

RESULTS

In 533 participants (mean age 64.9 years, 55.9% female) radiographic OA clustered across both feet (P < 0.001) and was highly symmetrical (adjusted OR 3.0, 95% confidence interval 2.1, 4.2). LCA identified 3 distinct classes of foot OA: no or minimal foot OA (64%), isolated first MTP joint OA (22%), and polyarticular foot OA (15%). After adjustment for age and sex, polyarticular foot OA was associated with nodal OA, increased body mass index, and more pain and functional limitation compared to the other classes.

CONCLUSION

Patterning of radiographic foot OA has provided insight into the existence of 2 forms of foot OA: isolated first MTP joint OA and polyarticular foot OA. The symptom and risk factor profiles in individuals with polyarticular foot OA indicate a possible distinctive phenotype of foot OA, but further research is needed to explore the characteristics of isolated first MTP joint and polyarticular foot OA.

Reconstructive Shelf Arthroplasty as a Salvage Procedure for Complex Fifth Tarsometatarsal Joint Complex Injuries: A Case Review and Discussion

High-energy cuboid fractures are rare injuries that are commonly associated with other midfoot trauma. With displacement, operative intervention is critical to restore articular congruity and the length of the lateral column. Failure to achieve this predisposes patients to posttraumatic arthritis and deformity, often necessitating secondary procedures. Although primary open reduction and internal fixation is the standard of care for these injuries, at times the traditional principles of fracture fixation cannot be applied to cuboid fractures. We describe the case of a 45-year-old woman who underwent a reconstructive shelf arthroplasty of the cuboid and fifth tarsometatarsal joint for a severe injury to the lateral column of the midfoot.

Clinical diagnosis of symptomatic midfoot osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot

OBJECTIVE

To derive a multivariable diagnostic model for symptomatic midfoot osteoarthritis (OA).

METHODS

Information on potential risk factors and clinical manifestations of symptomatic midfoot OA was collected using a health survey and standardised clinical examination of a population-based sample of 274 adults aged ≥50 years with midfoot pain. Following univariable analysis, random intercept multi-level logistic regression modelling that accounted for clustered data was used to identify the presence of midfoot OA independently scored on plain radiographs (dorso-plantar and lateral views), and defined as a score of ≥2 for osteophytes or joint space narrowing in at least one of four joints (first and second cuneometatarsal, navicular-first cuneiform and talonavicular joints). Model performance was summarised using the calibration slope and area under the curve (AUC). Internal validation and sensitivity analyses explored model over-fitting and certain assumptions.

RESULTS

Compared to persons with midfoot pain only, symptomatic midfoot OA was associated with measures of static foot posture and range-of-motion at subtalar and ankle joints. Arch Index was the only retained clinical variable in a model containing age, gender and body mass index. The final model was poorly calibrated (calibration slope, 0.64, 95% CI: 0.39, 0.89) and discrimination was fair-to-poor (AUC, 0.64, 95% CI: 0.58, 0.70). Final model sensitivity and specificity were 29.9% (95% CI: 22.7, 38.0) and 87.5% (95% CI: 82.9, 91.3), respectively. Bootstrapping revealed the model to be over-optimistic and performance was not improved using continuous predictors.

CONCLUSIONS

Brief clinical assessments provided only marginal information for identifying the presence of radiographic midfoot OA among community-dwelling persons with midfoot pain.

Diabetic Charcot neuroarthropathy: The diagnosis must be considered in all diabetic neuropathic patients presenting with a hot, swollen foot

The diagnosis of diabetic Charcot neuroarthropathy (CN) is challenging. This is especially true early in the disease process, when its classical presentation of an acutely inflamed foot may masquerade as other more common lower limb conditions. Prompt diagnosis and appropriate treatment reduces the risk of CN causing permanent incapacitating foot deformity or amputation. We report two cases in which the diagnosis was delayed, resulting in long-term sequelae. These cases highlight the importance of considering CN in patients with diabetic peripheral neuropathy, who present with a red, hot, and swollen foot.

Radiologic damage at baseline predicts patient-related outcomes 18 years after the initiation of methotrexate therapy in patients with severe rheumatoid arthritis

OBJECTIVES

We aimed to assess the association of the degree of radiologic damage at baseline with long-term patient-related outcomes (PRO) in patients with severe rheumatoid arthritis (RA).

METHODS

This prospective observational single-centre study (Ratingen, Germany) included all RA patients starting treatment with methotrexate (MTX) between 1980 and 1987. Standardised clinical evaluations and radiographs of hands and feet were obtained at baseline and during the following years. About 18 years later, patients were invited for a re-assessment. PRO were assessed in three dimensions according to the International Classification of Functioning and Disability (ICF). Statistical analyses comprised multivariable models using baseline values for radiologic damage of hands and feet, age, gender, disease duration, rheumatoid factor positivity, measures of disease activity, and response to MTX as covariates.

RESULTS

At baseline, the mean disease duration was 8.5 years. The disease was active with a mean number of swollen joints of 18 (out of 32) and a mean erythrocyte sedimentation rate of 55 mm/hour. Radiologic damage was present in 95% of the patients. After 18 years, patient-related outcomes could be assessed in 78/271 patients (29%). Among chosen covariates, only the degree of baseline radiologic damage as measured by the Ratingen score was predictive of all long-term PRO (p<0.016).

CONCLUSIONS

In this cohort including patients with severe RA, baseline radiologic damage was a good long-term predictor of PRO related to all three ICF dimensions.

Radiographic scoring methods in psoriatic arthritis

Psoriatic arthritis (PsA) leads to structural damage that can be an important driver for disability and handicap associated with the disease. Serial radiographs, usually of hands and feet, facilitate follow-up documentation of development of these changes. Semi-quantitative scoring methods are designed to measure the degree of radiographically detectable joint damage, and of changes over time. Several radiographic scoring methods that had been developed originally for rheumatoid arthritis have been adopted for the use in PsA. Four different scoring methods used in PsA are presented with instructions on how to use them: modified Steinbrocker global scoring method; PsA scoring method based on Sharp method for RA; Sharp van der Heijde modified method; and PsA Ratingen score (PARS). Available data on the reliability, sensitivity to change, and use in clinical trials, of these four methods are presented.

Serological and Progression Differences of Joint Destruction in the Wrist and the Feet in Rheumatoid Arthritis - A Cross-Sectional Cohort Study

Objective

To investigate clinical and radiological differences between joint destruction in the wrist and the feet in patients with RA.

Methods

A cross-sectional clinical study was conducted in an RA cohort at a single institution. Clinical data included age, sex and duration of disease. Laboratory data included sero-positivity for anti-cyclic citrullinated peptide (CCP) antibody and RF. Radiological measurements included Larsen grades and the modified Sharp/van der Heijde method (SHS) for the hands/wrists and the feet. Statistical analyses were performed using the Kruskal—Wallis H-test, a dummy variable linear regression model and multivariate logistic regression analysis with 95% confidence interval and odds ratios.

Results

A total of 405 patients were enrolled, and 314 patients were analysed in this study. The duration of disease in the foot-dominant group was significantly less than that in the wrist-dominant group. When patients were subdivided by duration of disease, the Larsen grade of the feet was significantly higher than that of the wrist in the first quadrant subgroup, but this was reversed with increasing duration of disease. Anti-CCP status was a significant predictive factor for joint destruction in the wrist but not in the feet, while RF status was not predictive in either the wrist or the feet.

Conclusions

Joint destruction in the feet started earlier than in the wrist, but the latter progresses faster with increasing duration of disease. Anti-CCP status predicts joint destruction in the wrist better than in the feet.

Association of valine and leucine at HLA-DRB1 position 11 with radiographic progression in rheumatoid arthritis, independent of the shared epitope alleles but not independent of anti-citrullinated protein antibodies

OBJECTIVE

For decades it has been known that the HLA-DRB1 shared epitope (SE) alleles are associated with an increased risk of development and progression of rheumatoid arthritis (RA). Recently, the following variations in the peptide-binding grooves of HLA molecules that predispose to RA development have been identified: Val and Leu at HLA-DRB1 position 11, Asp at HLA-B position 9, and Phe at HLA-DPB1 position 9. This study was undertaken to investigate whether these variants are also associated with radiographic progression in RA, independent of SE and anti-citrullinated protein antibody (ACPA) status.

METHODS

A total of 4,911 radiograph sets from 1,878 RA patients included in the Leiden Early Arthritis Clinic (The Netherlands), Umeå (Sweden), Hospital Clinico San Carlos-Rheumatoid Arthritis (Spain), and National Data Bank for Rheumatic Diseases (US) cohorts were studied. HLA was imputed using single-nucleotide polymorphism data from an Immunochip, and the amino acids listed above were tested in relation to radiographic progression per cohort using an additive model. Results from the 4 cohorts were combined in inverse-variance weighted meta-analyses using a fixed-effects model. Analyses were conditioned on SE and ACPA status.

RESULTS

Val and Leu at HLA-DRB1 position 11 were associated with more radiographic progression (meta-analysis P = 5.11 × 10(-7)); this effect was independent of SE status (meta-analysis P = 0.022) but not independent of ACPA status. Phe at HLA-DPB1 position 9 was associated with more severe radiographic progression (meta-analysis P = 0.024), though not independent of SE status. Asp at HLA-B position 9 was not associated with radiographic progression.

CONCLUSION

Val and Leu at HLA-DRB1 position 11 conferred a risk of a higher rate of radiographic progression independent of SE status but not independent of ACPA status. These findings support the relevance of these amino acids at position 11.

Urate crystal deposition in asymptomatic hyperuricaemia and symptomatic gout: a dual energy CT study

BACKGROUND

The aim of this study was to compare the frequency and volume of dual energy CT (DECT) urate deposits in people with asymptomatic hyperuricaemia and symptomatic gout.

METHODS

We analysed DECT scans of the feet from asymptomatic individuals with serum urate ≥540 µmol/L (n=25) and those with crystal proven gout without clinically apparent tophi (n=33).

RESULTS

DECT urate deposits were observed in 6/25 (24%) participants with asymptomatic hyperuricaemia, 11/14 (79%) with early gout (predefined as disease duration ≤3 years) and 16/19 (84%) with late gout (p<0.001). DECT urate deposition was observed in both joints and tendons in the asymptomatic hyperuricaemia group, but significantly less frequently than in those with gout (p≤0.001 for both joint and tendon sites). The volume of urate deposition was also significantly lower in those with asymptomatic hyperuricaemia, compared with the early and the late gout groups (p<0.01 for both comparisons). Similar urate volumes were observed in the early and late gout groups.

CONCLUSIONS

Although subclinical urate deposition can occur in people with asymptomatic hyperuricaemia, these deposits occur more frequently and at higher volumes in those with symptomatic gout. These data suggest that a threshold of urate crystal volume may be required before symptomatic disease occurs.

The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: cross-sectional findings from the clinical assessment study of the foot

OBJECTIVES

To estimate the population prevalence of symptomatic radiographic osteoarthritis (OA) affecting the 1st metatarsophalangeal joint (MTPJ), 1st and 2nd cuneometatarsal joints (CMJs), navicular first cuneiform joint (NCJ) and talonavicular joint (TNJ) in community-dwelling older adults.

METHODS

9334 adults aged ≥50 years registered with four general practices were mailed a health survey. Responders reporting foot pain within the last 12 months were invited to undergo weight-bearing dorso-plantar and lateral radiographs of both feet. OA at the 1st MTPJ, 1st and 2nd CMJs, NCJ and TNJ was graded using a validated atlas. Population prevalence estimates for symptomatic radiographic foot OA overall and for each joint were calculated using multiple imputation and weighted logistic regression modelling to account for missing data and non-response.

RESULTS

5109 health surveys were received (adjusted response 56%). Radiographs were obtained on 557 participants. Overall population prevalence of symptomatic radiographic OA was 16.7% (95% CI 15.3% to 18.0%), 1st MTPJ 7.8% (6.7% to 8.9%), 1st CMJ 3.9% (2.9% to 4.9%), 2nd CMJ 6.8% (5.7% to 7.8%), NCJ 5.2% (4.0% to 6.4%) and TNJ 5.8% (4.8% to 6.9%). With the exception of the 1st CMJ, prevalence was greater in females than males, increased with age and was higher in lower socioeconomic classes. Three-quarters of those with symptomatic radiographic OA reported disabling foot symptoms.

CONCLUSIONS

While cautious interpretation due to non-response is warranted, our study suggests that symptomatic radiographic foot OA affects one in six older adults and the majority report associated disability. Clinicians should consider OA as a possible cause of chronic foot pain in older people.

Imaging of the Lisfranc injury

Lisfranc ligament and joint injuries are relatively uncommon but can result from a variety of low- and high-impact trauma. Up to 20% of Lisfranc fracture-dislocations are misdiagnosed or missed during the initial evaluation. Timely and accurate diagnosis of the injury and early anatomical reduction and stabilization of the Lisfranc joint are crucial to avoid long-term sequelae and functional impairment. Magnetic resonance imaging (MRI) is a sensitive and specific imaging modality and should be considered in injuries with equivocal physical and radiographic findings. In this article, the mechanism and the classification of the Lisfranc joint and ligament injuries are outlined, and imaging findings of different modalities are discussed with the emphasis on MRI.

A genetic variant in the region of MMP-9 is associated with serum levels and progression of joint damage in rheumatoid arthritis

OBJECTIVES

The severity of joint destruction is highly variable between rheumatoid arthritis (RA) patients. The majority of its heritability is still unexplained. Several autoimmune diseases share genetic risk variants that may also influence disease progression. We aimed to identify genetic risk factors for the severity of joint damage in RA by studying genetic susceptibility loci of several autoimmune diseases.

METHODS

In phase 1, 3143 sets of x-rays of 646 Dutch RA patients taken over 7 years (Sharp van der Heijde (SHS) scored) were studied. Genotyping was done by Immunochip. Associations of single-nucleotide polymorphisms (SNPs) with minor allele frequency (MAF) >0.01 and joint destruction were analysed. In phase 2, 686 North American RA patients with 926 SHS-scored x-rays over 15 years of follow-up were evaluated. In both phases multiple testing corrections were done for the number of uncorrelated SNPs; the thresholds for significance were p<1.1×10(-6) and p<0.0036. Matrix metalloproteinase 9 (MMP-9) levels were measured with ELISA in baseline serum samples.

RESULTS

In phase 1, 109 SNPs associated significantly with joint destruction (p<1.1×10(-6)). Of these, 76 were located in the HLA region; the 33 non-HLA variants were studied in phase 2. Here two variants were associated with the severity of joint destruction: rs451066 on chromosome 14 (p=0.002, MAF=0.20) and rs11908352 on chromosome 20 (p=0.002, MAF=0.21). Rs11908352 is located near the gene encoding MMP-9. Serum levels of MMP-9 were significantly associated with the rs11908352 genotypes (p=0.007).

CONCLUSIONS

These data indicate that two loci that confer risk to other autoimmune diseases also affect the severity of joint destruction in RA. Rs11908352 may influence joint destruction via MMP-9 production.

Systemic staging for urate crystal deposits with dual-energy CT and ultrasound in patients with suspected gout

Objective of the study is to compare the diagnostic accuracy for detecting monosodium urate crystal deposits between dual-energy CT (DECT) and ultrasound (US). Sixty consecutive patients (49 men, mean age 62 years) with clinically suspected gout were included in this case-control study. DECT and US of feet, knees, hands and elbows were performed in all patients. Polarisation microscopy of synovial fluid or a score incorporating serum uric acid level, first MTP joint involvement, gender, previous patient-reported arthritis attack, cardiovascular diseases, joint redness and onset within 1 day was used as standard of reference. Standard of reference classified 39 patients as gout positive. Sixteen patients had gout and a concomitant rheumatic disease. Sensitivities for diagnosis of gout disease were 84.6 % (33/39) for DECT and 100 % (39/39) for US. Specificities were 85.7 % (18/21) for DECT and 76.2 % (16/21) for US. Positive and negative predictive values were 91.7 % (33/36) and 75.0 % (18/24) for DECT, 88.6 % (39/44) and 100 % (16/16) for US, respectively. Urate crystals were detected most frequently in MTP1 joints (DECT 20/78, US 58/78), any other toe joints (DECT 25/78, US 62/78) and knees (DECT 41/78, US 31/78). The volumetry of DECT computed a mean urate crystal deposit load of 2.1 cm(3) (SD 9.6 cm(3)). A mean effective dose of ≤0.5 mSv was estimated. DECT is more specific for the diagnosis of gout than US. However, it fails to detect small urate crystal deposits. It might be particularly useful for patients with ambivalent findings, concomitant rheumatic diseases and with non-conclusive joint aspiration.

Modified Lapidus arthrodesis with plantar plate and compression screw for treatment of hallux valgus with hypermobility of the first ray: a preliminary report

BACKGROUND

TMT-1 arthrodesis is an established method in hallux valgus surgery, but it is technically demanding and typically calls for a period of postoperative immobilization.

METHODS

In this cohort study, initial experience with a plantar plate is described. 58 patients (59 arthrodesis) were included.

RESULTS

The mean duration of protected full weight bearing was 7 weeks. 94.12% patients were satisfied with the results, bony union was achieved in 98.31%. The Foot Function Index improved by 33 to a mean of 8 (p<.001). The postoperative Mayo Clinic Forefoot Score was excellent in 47.04 and good in 47.04%. The mean hallux valgus angle improved by 24.4-13.2° (p<.001). The mean first intermetatarsal angle improved by 11.2-5.2° (p<.001).

CONCLUSION

Initial experience with this form of fixation appears to provide suitable stability, allow early-protected weight bearing, with an acceptable level of complications.

Usefulness of US to show subclinical joint abnormalities in asymptomatic feet of RA patients compared to healthy controls

OBJECTIVES

The aim of the present study was to demonstrate the utility of ultrasound to show subclinical feet disease in RA.

METHODS

The foot joints (talocrural, talocalcaneal, talonavicular, naviculocuneiform, calcaneocuboid, 5th tarsometatarsal and 1st to 5th metatarsophalangeal [MTP] joints) of 50 healthy subjects and 50 RA patients, with asymptomatic feet, were compared bilaterally. Statistical significance was set at 5%.

RESULTS

Twenty-two joints were examined per individual (2200 in the entire sample). Significantly higher values were found in the RA group regarding quantitative synovitis in all joints recesses (p<0.003), the presence of synovitis (p<0.035) (except the 5thtarsometatarsal and 3rdMTP joint), power Doppler (PD) signals (p<0.029) (talocalcaneal, talonavicular, 1st, 2nd, 3rd and 4thMTP joints) and bone erosion (p<0.003) (except for the talocrural and talocalcaneal joints). Synovitis, PD signals and erosion were observed in 18.3% and 3.05% (p<0.001), 5.77% and 0.22% (p<0.001) and 34.45% and 2.85% (p<0.001) of the RA group and control group, respectively. Greater DAS-28, HAQ and FFI values were associated with ultrasound findings in only some joints (p<0.046). Interobserver agreement was ≤0.686 for semi-quantitative synovitis, ≤0.641 for quantitative synovitis, ≤0.474 for PD signals and ≤1.000 for erosion. Low Cohen Kappa values were found in the correlation between radiography and ultrasound (0.084-0.400). CONCLUSIONS. Ultrasound on RA asymptomatic feet demonstrated a significantly greater number of inflammatory changes in current activity (synovitis, PD signals) and sequelae (erosion) in comparison to control subjects. In the midfoot, the talonavicular joint has the greatest number of ultrasound findings.

Association of joint space narrowing with impairment of physical function and work ability in patients with early rheumatoid arthritis: protection beyond disease control by adalimumab plus methotrexate

OBJECTIVES

Tumour necrosis factor inhibition plus methotrexate is believed to inhibit radiographic progression independent of inflammation. This analysis assessed whether these protective effects are exerted on bone (joint erosion; JE) and/or cartilage (joint space narrowing; JSN), and what the independent effects of JE/JSN progression are on longer-term patient-reported outcomes.

METHODS

PREMIER was a 2-year, randomised, controlled trial of adalimumab plus methotrexate (ADA+MTX) versus the monotherapies. The impact of treatment on the relationships between time-averaged disease activity (TA-DAS28(CRP)) and changes in JE/JSN and associations of JE/JSN with the disability index of the health assessment questionnaire (HAQ-DI) at baseline and weeks 52 and 104 were assessed through non-parametric approaches of analysis of variance and quantile regression. JE/JSN association with employment status was evaluated at baseline and weeks 52 and 104 through logistic regression.

RESULTS

Increasing tertiles of TA-DAS28(CRP) were associated with JE and JSN progression in the monotherapy groups, a phenomenon largely absent in ADA+MTX-treated patients. Although JSN was not associated with HAQ-DI at baseline, it was at 52 and 104 weeks. In contrast, JE was not associated with HAQ-DI at any time point examined. Odds of being employed at baseline, 52 weeks and 104 weeks were significantly associated with lower JSN, but not JE, scores.

CONCLUSIONS

ADA+MTX inhibited both JE and JSN progression independently of disease activity. JSN played a more prominent role in patient-reported outcomes than JE. Preventing the onset or worsening of JSN probably represents a critical aspect of effective disease management of early rheumatoid arthritis patients.

Concomitant osteomyelitis and avascular necrosis of the talus treated with talectomy and tibiocalcaneal arthrodesis

The goal with Lisfranc fracture-dislocations is to regain joint congruity and reestablish midfoot stability to avoid debilitating posttraumatic arthrosis and chronic pain in the sensate patient. In the diabetic population, dense peripheral neuropathy and/or vascular disease are equally important and may alter the surgical approach to traumatic tarsometatarsal injuries. The initial diagnosis in the diabetic population may be delayed due to subtle radiographic findings and/or patient unawareness of trauma in the insensate foot. Failure to initiate treatment in the early stages of acute diabetic neuropathic Lisfranc injuries can predispose the patient to midfoot instability, potential ulceration, infection, and Charcot neuroarthropathy.

Osteoarthritis of the foot: a review of the current state of knowledge

Foot osteoarthritis(OA)is very common disease that mainly affects older people deeply influencing their quality of life.The join most frequently involved in the articular degenerative process is the first metatarsophalangeal joint. Its severe impairment may lead to a specific clinical pattern known as hallux rigidus that often requires surgical treatment.Currently conventional radiograms of feet associated with an accurate clinical examination should be performed in order to diagnose foot OA.However, new imaging modalities as ultrasonography and magnetic resonance imaging are emerging as valuable tools to assess foot OA.Therapeutic options for foot OA consist of conservative strategies, including life-style modification and pharmacological treatment, options that are usually adopted in early-stage disease and in invasive surgical procedures reserved to late-stage conditions. At the present time there is a lack of evidence in international literature specifically dealing with foot OA, so further investigation on this topic is required to clarify its pathogenesis, the diagnostic pathway and the best clinical management.