THE RHEUMATOID FOOT & ANKLEcme.uthscsa.edu/Update/Presentations/Thursday/RHEUMATOID.pdf · 2008....

THE RHEUMATOID FOOT & ANKLE

Thomas J. Chang, DPM, FACFASRedwood Orthopedic Surgery Associates

EtiologyCause is unknown

Triggered by the exposure of an immunogenetically susceptible host to an arthritogenic microbial antigen

Continuing autoimmune reaction

4th Annual International External Fixation Symposium

December 11-14, 2008

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Theorized etiology

ImmunogeneticsRA is associated with a sequence motif (QR/KRAA) encoded by the HLA-DRB1 gene.Different HLA-DRB1 alleles confer disease susceptibility in different ethnic populations.65% - 80% of those who develop RA have HLA-DR4 or DRB1 genes.

Genetics – allows for susceptibility to RA

Theorized Etiology

Population Evidence Higher incidence in Native AmericansRA clusters in families and high rate of disease in monozygotic twins.1st degree relative of RA patient has 16 fold risk over the general population.



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Possible Antigenic Sources

Epstein-Barr virusRetrovirusParvovirusMycobacteriumBorreliaMycoplasma

(Cortran, 1999)

Laboratory ValuesRheumatoid Factor

Erythrocyte Sedimentation Rate

C-Reactive Protein

Synovial Fluid Analysis

Decreased Albumin

Increased plasma fibrinogen

Eosinophilia

Anemia of chronic disease



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Classification of rheumatoid arthritisAmerican Rheumatism Association -1987

Criterion Comment

1. Morning Stiffness Duration > 1 hour lasting > 6 weeks

2. Arthritis of at least 3 areas Soft tissue swelling or exudation lasting > 6 weeks

3. Arthritis of hand joints Wrist, MCP, PIP joints lasting > 6 weeks

4. Symmetrical arthritis At least one area, lasting > 6 weeks

5. Rheumatoid nodules Observed by a physician

6. Serum rheumatoid factor Assessed by a method positive < 5% of control subjects

7. Radiographic Changes Seen on anteroposterior films of wrists and hands

Clinical PresentationRigid digital deformity

Severe valgus deformity

Contracted lesser digits & adducted 5th

Skin atrophy & fragility

Rheumatologic nodules



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Radiographic EvaluationTarsal ankylosisDeformities and subluxations

HAV, dorsiflexion of PIPJ, subluxation of the metatarsal heads plantarlyCapsular contraction from long-term synovial inflammation and imbalance of tendons

Absence of bone formationLack of bone formation is a distinguishing feature of RA and differentiates from DJD and the seronegative spondyloarthropathiesWell-defined enthesophytes unlike other arthridities

Periarticular soft-tissue swellingEarly sign of synovitisPlantar faciitisNodules with eccentric soft tissue mass that are rarely calcified

Loredo, R., 1999

Stages of PathologyStage I

Smyth, C

•Proliferation and swelling

•Synovial Thickening

•Increased Joint Fluid

•Vascular abnormalities



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Stages of PathologyStage IV

• Destroyed articular cartilage

• Acellular fibrous restricts movement of the joint.

• Joint instability, subluxation and dislocation.

• Direct invasion of tendons.

Systemic ManifestationsCervical Spine

Airway Disease

Pulmonary

GI

Renal

Ocular

Cardiac

Skin

Bone Disease

Vascularities



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Goals of Treatment

Pain Relief

Suppression of inflammation

Prevention of Deformity

Education and Counseling

The Therapeutic Pyramid

Patient Education, Adjustment

NSAIDS � Salicylates

DMARDS, d-penicillamine, Chloroquine, azathioprine, gold

Long-Term Steroids

Experimental TherapyComplications:

(Surgery, Systemic

Manifestations)

Physical Medicine(Rest,

Physiotherapy)



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Pharmacologic Treatments

DMARDS

Leflunomide

Anti-Tumor Necrosis Factor Agents

Etanercept (Enbrel)

Infliximab (Remicade)

Adalimumab (Humira)

Conservative Treatment

Accommodative Shoe Gear

Orthotics

Custom Inserts

Extrinsic Modifications

Rocker sole

Metatarsal Bar

Full-length steel shank

(Trieb 2005)



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Conservative OutcomesFunctional, custom-designed and semirigid orthoses beneficialEDS effective but moreso when combined with orthosesPressure sub 2nd met most correlated with pain ratingsCMO with metatarsal dome was most effective for reducing painPlantar callous debridement < 1 wk relief

(Farrow et al 2005)

Surgical Risks

Increased Susceptibility for Infections

Delay in Wound Healing

Increase in Bleeding

General Anesthesia



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Goals of Surgery

Provide pain relief

Reduce any rigid deformities

Restore forefoot stability

Restore function and realignment of the digits.

Steroid UsePreoperative

ConsiderationsImmunocompromised Patient

Corticotrophin Stimulation Test

Surgical Prophylaxis



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Procedures of the Forefoot

Digital Procedures

Digital Arthroplasty

Basal Hemiphalangectomy

PIPJ Arthrodesis

Synovectomy

Tenosynovectomy

Procedures of the ForefootPan Metatarsal Head Resection

Hodor & Dobbs

Kates

LarmonFowler



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STAGE III

Procedures of the Forefoot1st MTPJ Procedures

Arthrodesis

11 patients with 18 feet arthrodesis of the 1st MTPJ and excision of

all lesser met headsexcellent results were noted 14 feet, good

2, and fair 2 No poor results obtained and fusion was

achieved in all but one foot. The fibrous anklylosis was not symptomatic

(Mann and Thompson, Foot and Ankle International, Feb 1997)



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Clinical Outcomes•In 11 patients with 18 feet who underwent arthrodesis of the 1stMTPJ and excision of all lesser met heads, excellent results were noted in 14 feet, good in 2, and fair in 2. •No poor results obtained and fusion was achieved in all but one foot. The fibrous anklylosis was not symptomatic(Mann and Thompson, Foot and Ankle International, Feb 1997)



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11 of 16 pts with Keller and Pan Met Recurrence of HAV and one spontaneous fusionRecommend arthrodeses 1stMPJ

(Belt, 1997)

29 pts with 49 ftRecurrence 53% HAV Forefoot instability 27%20% metatarsalgia

(McGarvey, 1986)

Arthroplasty


29 pts, 60 ft flexible hinge toe implant arthroplasty 1st MPJ combined with shortening oblique osteotomy at metatarsal neck in lateral toes9 implant fractures4 removed due to infectionWith revision, 93% implant survival at 10 yrsWith implant fracture, 87% implant survival at 10 yrs

(Hanyu, J Ortho Sci, 2001)

Implant Arthroplasty



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Young Tom Zgonis

Rheumatoid Arthritis

of the Ankle and Hindfoot

Cimino and O’Malley, Clin Pod Med and Surg, 1999



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Sequential Surgical Management

Multiple Lower Extremity Involvement

Forefoot, hindfoot, ankle, and knee

TKA

Pantalar arthrodesis

Hip Involved

THA

Talonavicular or triple arthrodesis

Forefoot reconstruction

Ankle arthrodesis (or

total ankle)

Arthrodesis in the Management of

Rheumatoid Arthritis of the Foot

and AnkleBrodsky and Hong, Foot and Ankle Clinics, 1996



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Rearfoot Procedures

Arthrodesis of the Talonavicular Joint

Subtalar and Triple Arthrodesis



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Rearfoot Procedures

• Review of 43 pts and 57 various procedures that fused every combination of the ankle, subtalar, calcaneocuboid, and talonavicular joints• 92% of the procedures had complete radiological fusion after 16 weeks• Pain was resolved in 89% and walking capacity was good in 89%.

(Miehlke et al., CORR 1997)

Hindfoot Arthrodesis

Management of the Rheumatoid Hindfoot

with Special Reference to TaloNavicular

Arthrodesis

Kindsfater et al, Clin Orth and Rel Res, 1997



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Kindsfater et al

104 Talonavicular Fusions95% Good to Excellent Results12 Months to 16 years ( 4.5 years)

Delayed and Non-unions attributed to no fixation



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Rearfoot Procedures

Of 35 talonavicular fusions, 75% were pain free at 5 years

(Elbaor, M, Orthatpeadic Clinics of North America 1976)

20 tarsal arthrodesis of medial and lateral column with 75% good or excellent result objectively and 81% patient satisfaction.

(Clain and Baxter, J. of Bone and Joint Surgery March 2000).

Arthrodesis of the Talonavicular Joint

Rearfoot ProceduresSubtalar and Triple Arthrodesis

• 40 pts with 49 STJ procedures• RF was aligned at the average of 5 degrees valgus• 8 feet had a valgus angle > 10 degrees • 5 of the 8 cases having pain and 3 of the 5 requiring pantalar arthrodesis• overall satisfaction was 90% with 94% having diminished pain and 85% able to increase their activity after 5 years.

(Figgie et al., CORR, 1993)



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SUBTALAR FUSION



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Tibiotalar Joint Arthrodesis for the

Treatment of Severe Ankle Joint

Degeneration Secondary to Rheumatoid Arthritis

Caron et al, Clin Pod Med and Surg, 1999

Ankle Procedures

Ankle Arthrodesis

Ankle Joint Implants



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Stages of PathologyStage II

• Proliferation of cell lining with hyperplasia and hypertrophy ( 6 cell layers ).

• Monocytes and macrophages surround small blood vessels in a normally acellular layer.

Stages of PathologyStage III

•Develop slender villous projections into joint cavity.

•Inflammatory tissue invades the cartilage.

•Pannus begins to replace bone.

•Active synovitis

•Granular layer forms with chronic inflammatory cells and giant cells.

•Inflammatory changes to the vessels cause intimal proliferation.



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Radiographic EvaluationBilateral and symmetrical distribution

Exception: symmetrical groups of joints without involvement of identical joints

Periarticular osteoporosis that progresses to generalized osteoporosis

Occurs secondary to hyperemia induced by the synovial inflammationIncreased risk for stress fracture and ischemic necrosis

Uniform loss of joint spaceInitially, the joint is wider secondary to joint effusion but as cartilage is destroyed, the joint space becomes narrowedAdvanced disease results in anklylosis Loredo, R., 1999


Clinical Outcome• 27 patients with RA and diabetes had recurrent plantar ulceration that failed conservative offloading. •Pan met head resection was performed with 25% of RA and 28% of the diabetic patients reulcerated. •The ulcers recurred on an average of 4 years post-op with the earliest at 6 months. •They attributed the high recurrence rate to bony regeneration of the metatarsal heads.

(Petrov et al., Journal of Foot and ankle, Nov 1996)



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