Rheumatic Foot Research Articles

Rheumatism operations in a state of flux-"Foot"

Surgical management of rheumatic feet has dramatically changed over the last decades influenced by the development of new pharmacological drugs and tissue-preserving surgical procedures. It has switched from joint resection to joint-sparing procedures as the method of choice. Nevertheless, the surgical interventions commonly used for non-rheumatic patients cannot be applied to rheumatic patients without reflection: in addition to the basic treatment, comorbidities, degree of mobilization of the patient, orthopedic shoe engineering and orthotic treatment play amajor role. Due to the decreasing incidence of the classical rheumatic foot, it has become even more important for physicians, physiotherapists and ergotherapists to recognize the development of such a disease as early as possible and immediately start the appropriate treatment.

Rheumatic tendon pathologies

Rheumatoid arthritis is found in approximately 2 % of the total population in Europe and the peak incidence of the disease is during the fourth and fifth decades of life. In approximately 15 % the first symptoms of the disease occur at the level of the foot and ankle. If the early stage-dependent therapy with pharmaceuticals fails isolated surgery of the tendons (e.g. tenosynovectomy) and reconstructive surgery including the tendons (e.g. tendon transfer and tendon readaptation) are performed to keep the patient mobile. The aim of this article is to give an overview of the most commonly used interventions in the reconstruction of tendons in rheumatism patients and the corresponding indications. The conservative therapy options for rheumatic foot and ankle alterations with a special emphasis on tendon pathologies have a well-established importance and are also presented. A selective literature search was carried out for therapeutic options of rheumatic tendon pathologies. If possible attempts should be made to preserve functional qualities using tenosynovectomy, tendon sutures or tendon transfer operations. If joints are already destroyed or dislocated, tendon operations should be carried out only as combined interventions with arthrodesis, endoprostheses or resection arthroplasty. The time window in which these interventions are possible should not be missed. Orthotic devices, bandages or even orthopedic shoes provide external support and splinting but do not represent a causal therapy.

Association of hypermobility and ingrown nails

Ingrown nail (onychocryptosis) is a common condition with severe pain and various associated morbidities. Although some underlying factors are identified, its etiology remains largely unknown. Generalized joint hypermobility (GJH) is a common entity with clinical features that might prone affected individuals to ingrown nails. Herein, we investigated the incidence of GJH in patients with ingrown nails to determine possible association between hypermobility and ingrown nail formation. Patients 16-50years of age who were undergoing treatment for ingrown nails at the dermatology clinic were consecutively enrolled into the study. Patients with known rheumatic diseases or orthopedic foot disorders were excluded. All patients were in a pain-free period at the time of examination. The control group was comprised of age- and sex-matched healthy subjects without a history of ingrown nail. Assessment of GJH was made according to Beighton criteria. Local hypermobility was evaluated by measurement of range of motion using a goniometer. Thirty-nine patients (male/female, 17/22, mean age 31.9 ± 11.3years) and 32 healthy subjects (male/female 12/20, mean age 31.7 ± 10.4years) were included. Patients with ingrown toe nails were more likely to have GJH compared to healthy subjects (35.9 vs. 9.4%, p = 0.009). Toes with ingrown nails had significantly smaller maximum dorsiflexion angles (p < 0.001) compared to toes of healthy subjects. Ingrown nail formation may be associated with GJH. However, when examined locally, there is a limited range of motion in the affected toe rather than hypermobility, which could be due to the degenerative process facilitated by the hypermobility.

We should not forget the foot: relations between signs and symptoms, damage, and function in rheumatoid arthritis

We studied rheumatoid arthritis (RA) patients with foot complaints to address the associations between clinical signs and symptoms, radiographic changes, and function in connection with disease duration. Secondly, we describe the contribution of several foot segments to the clinical presentation and function. In 30 RA patients with complaints of their feet, attributed to either signs of arthritis and/or radiographic damage, we compared radiographic, ultrasound, clinical, and functional parameters of the feet and ankle. Pain and swelling of the ankle were correlated weakly but statistically significantly with limitation and disability (0.273 to 0.293) as measured on the 5-Foot Function Index (FFI). The clinical signs of the forefoot joints did not influence any of the functional outcome measures. Radiographic scores for both forefeet (SvdH) and hindfeet (Larsen) were correlated with the total Health Assessment Questionnaire Disability Index (HAQ DI) and the 5-FFI limitation subscale. Pain and disease duration, more than radiographic damage, influence the total HAQ DI significantly. With the progression of time, structural damage and function of the rheumatic foot worsen in RA patients. Pain and swelling of the ankle contribute more to disability than radiographic damage of the foot and ankle.

Magnetic Resonance Imaging of the Rheumatic Foot According to the RAMRIS System Is Reliable

In rheumatology, magnetic resonance imaging (MRI) is predominantly applied in the assessment and outcome measurement of rheumatoid arthritis (RA) in hands and wrists, leading to the development of the RAMRIS (RA-MRI-Scoring) system. It was initiated by the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT). The RAMRIS system has not been applied widely in the measurement of feet. We investigated the interreader and intrareader agreement of the RAMRIS scoring system in the assessment of feet in RA. Twenty-nine patients with RA who had radiological damage and/or arthritis underwent MRI. Two experienced readers independently read both complete sets. One reader read 6 random sets after the initial session, in order to assess the intrareader agreement. For evaluation of the intrareader and interreader reliability, quadratic-weighted κ scores were calculated per joint and lesion. For the forefeet, interreader scores were excellent, ranging from 0.77 (bone edema) to 0.95 (bone erosion). Hindfoot interreader agreement scores were highest for erosion (0.90) and synovitis global score (0.88), but edema and synovial thickness agreement were also acceptable (0.83 and 0.86). Intrareader scores were on the whole slightly lower, but excellent. Reliability (interreader and intrareader agreement) in the assessment of the rheumatoid foot according to the RAMRIS method is excellent.

The Use of Foot Orthoses in the Management of the Rheumatoid Arthritis Patient

Rheumatoid arthritis is a systemic inflammatory autoimmune condition of unclear aetiology. Foot problems, including pain, deformity and functional limitation, are common amongst patients. Despite orthotic intervention being common in rheumatoid arthritis, there is reportedly limited and conflicting evidence for its effectiveness. The aim of this review is to identify and evaluate the evidence for the effectiveness of foot orthoses in the management of adult patients with rheumatoid arthritis. A systematic literature review was conducted to identify relevant literature pertaining to the use of orthoses in the management of the rheumatic foot. Fifteen articles, comprising both primary and secondary evidence, were identified that met the inclusion criteria. Their methodological quality varied, but was generally good. Most interventions described reported beneficial effects on pain and function, using pre- and post-intervention measures or through comparisons with placebos. There were few studies that directly compared the effectiveness of different foot orthoses interventions (such as hard, soft, semi-rigid) in the management of rheumatoid arthritis of the foot. Clinical recommendations are difficult to make without this comparative data. The most appropriate foot orthoses may also be dependent on the type and level of foot deformity present from rheumatoid arthritis. Further research is recommended to identify appropriate orthotic interventions for different clinical scenarios.

Sehnenrupturen beim Rheumatiker

In the course of rheumatoid arthritis, changes to tendons occur in different areas. This can lead to rupture if not prevented at an early stage. In particular, regions with extreme joint thickness, high mechanical wear and tear and narrow regions present a higher risk of synovitis. This primarily affects the tendons of the hand, where the extensor digitorum minimus tendon and the extensor and flexor pollicis tendons are most at risk. There is a high possibility of rotator cuff lesion in the shoulder area during the course of a secondary synovitis dependent raised shoulder, or by bursitis or tendonitis. A rupture of the biceps tendon is also increased by omarthritis or synovitis in the sulcus. For the foot, the posterior tibial tendon is most commonly effected, which if primarily or secondarily damaged can lead to a rheumatic flat foot. In addition, there can be partial or complete destruction in the Achilles tendon area, which is definitely pathognomonic. The narrow syndrome in the flexor hallucis and the extensor digitorum tendons are less common.

3-Dimensional motion analysis of the rheumatic foot—development of a foot model

3-Dimensional motion analysis of the rheumatic foot—development of a foot model

Progression of foot deformities in rheumatoid arthritis--a radiologic follow-up study over 5 years

The typical changes of the foot in patients with rheumatoid arthritis (RA) are the rear foot valgus and the flattening of the longitudinal arch as well as the splayfoot with hallux valgus and little toe deformities. These foot deformities are not so much a cosmetic problem, but are very painful and limit the patient's mobility. The progression of rheumatic foot deformities with a follow-up of five years was described in 36 patients (70 feet) with RA and an average duration of the disease of 19.2 years (+/- 9.8 years). The analysis was based on standardized X-rays of the feet using the index of Larsen, Dale, and Eek. The number of affected joints and their predominant locations were evaluated. In the course of the follow-up, the first MTP joint was affected most frequently in 57%. Especially the tarsometatarsal joints of the Lisfranc-joint-line showed progressive changes. Altogether, a radiological progression of arthritic changes and a worsening of the foot statics were observed in 97% of the patients. In view of the rapid progression of rheumatic foot disorders, there is need not only for a consequent pharmacotherapy but also for strict clinical controls and a disease stage oriented local therapy.