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
1
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.
4th Annual International External Fixation Symposium
December 11-14, 2008
2
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
4th Annual International External Fixation Symposium
December 11-14, 2008
3
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
4th Annual International External Fixation Symposium
December 11-14, 2008
4
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
4th Annual International External Fixation Symposium
December 11-14, 2008
5
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
4th Annual International External Fixation Symposium
December 11-14, 2008
6
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)
4th Annual International External Fixation Symposium
December 11-14, 2008
7
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)
4th Annual International External Fixation Symposium
December 11-14, 2008
8
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
4th Annual International External Fixation Symposium
December 11-14, 2008
9
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
4th Annual International External Fixation Symposium
December 11-14, 2008
10
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
4th Annual International External Fixation Symposium
December 11-14, 2008
11
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)
4th Annual International External Fixation Symposium
December 11-14, 2008
12
Procedures of the ForefootPan Metatarsal Head Resection
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)
4th Annual International External Fixation Symposium
December 11-14, 2008
13
Procedures of the Forefoot1st MTPJ Procedures
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
Procedures of the Forefoot1st MTPJ Procedures
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
4th Annual International External Fixation Symposium
December 11-14, 2008
14
Young Tom Zgonis
Rheumatoid Arthritis
of the Ankle and Hindfoot
Cimino and O’Malley, Clin Pod Med and Surg, 1999
4th Annual International External Fixation Symposium
December 11-14, 2008
15
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
4th Annual International External Fixation Symposium
December 11-14, 2008
16
Rearfoot Procedures
Arthrodesis of the Talonavicular Joint
Subtalar and Triple Arthrodesis
4th Annual International External Fixation Symposium
December 11-14, 2008
17
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
4th Annual International External Fixation Symposium
December 11-14, 2008
18
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
4th Annual International External Fixation Symposium
December 11-14, 2008
19
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)
4th Annual International External Fixation Symposium
December 11-14, 2008
20
SUBTALAR FUSION
4th Annual International External Fixation Symposium
December 11-14, 2008
21
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
4th Annual International External Fixation Symposium
December 11-14, 2008
22
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.
4th Annual International External Fixation Symposium
December 11-14, 2008
23
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
Procedures of the ForefootPan Metatarsal Head Resection
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)
4th Annual International External Fixation Symposium
December 11-14, 2008
24