Rheumatoid Ankle Research Articles

Tibiotalocalcaneal arthrodesis in rheumatoid arthritis using the Supracondylar nail

Abstract Our aim was to evaluate the outcome of tibiotalocalcaneal fusion in rheumatoid arthritis patients using the locked Supracondylar nail. Methods . Twenty-four patients (27 ankles) underwent this procedure. The mean follow up was 38.4 months. Seventeen cases had ankle debridement at the time of arthrodesis. This was aimed at correcting hindfoot deformity in addition to facilitating joint fusion. The Fries scoring system was used to assess the severity of rheumatoid disease. The rheumatoid ankle score (RAS) and modified American Orthopaedic Foot & Ankle Society Score were used to analyse functional outcome. Results . Patients with ankle debridement and intramedullary nailing had mean RAS of 80.5 and bony union in 87%. However, patients with in situ nailing without ankle debridement had mean RAS of 72 and no evidence of bony union. Conclusion . We recommend that, in patients with rheumatoid hindfoot arthritis intramedullary nail fusion is always performed with ankle debridement.

Percutaneous Arthrodesis in the Rheumatoid Ankle

Summary It has been generally accepted that residual cartilage and subchondral bone has to be removed to get bony fusion in arthrodeses. In 1998, we reported successful fusion of 11 rheumatoid ankles, all treated with percutaneous fixation only. This method is restricted for ankles with normal or at least functional alignment. Animal studies confirmed that it is possible to achieve arthrodesis without removal of cartilage and that synovial depletion is the possible mechanism behind cartilage disappearance. The stability of the fixation achieved at arthrodesis surgery is an important factor in determining success or failure. A good fit of the bone surfaces appears necessary. The results of our biomechanical studies indicate that the arch shape and the subchondral bone should be preserved performing ankle arthrodesis. The importance of this is likely to increase in weak rheumatoid bone. Overall, inserting the 2 screws at a 30° angle with respect to the long axis of the tibia and crossing them above the fusion site improves stability for ankle arthrodesis. In conclusion, the percutaneous technique is suitable for patients with rheumatoid arthritis and a painful ankle with complete loss of joint space but with no deformity to correct.

Arthrodesis by percutaneous fixation: patellofemoral arthrodesis in rabbits without debridement of the joint.

Arthrodesis is usually performed with joint resection or at least with removal of cartilage. Our recent experience with successful fusion in all 11 rheumatoid ankles treated only with percutaneous fixation questions the necessity of debridement of the joint before arthrodesis. In this rabbit study we tested the hypothesis that joints fuse because of rigid fixation. 9 skeletally mature loop-ear dwarf female rabbits were operated on. With the knee in about 45 degrees of flexion, two 1.5 mm cortical screws were inserted through the patellofemoral joint in an anterior-posterior direction with the lag screw technique. 3 rabbits were excluded due to technical problems. Of the remaining 6 rabbits, 5 underwent bony fusion and 1 fibrous healing. Fusion was confirmed with Micro-CT in 2 cases and by histological examination in all 5 cases. In those 5 cases, bony fusion was seen in almost all areas with close contact. Therefore, fusion occurred not only in relation to the screws, but also between the screws and in the periphery of the patella. Our findings show that bony fusion can occur in a healthy joint without joint resection or debridement.

Why do ankle arthrodeses fail in patients with rheumatic disease?

Solid and painless fusion was achieved in 117/130 patients (90%) with rheumatic diseases after primary ankle arthrodesis at the authors' institution. Operations were performed using internal fixation according to the Adams technique. Critical retrospective analysis of failures in 13 patients (11 nonunions, one postoperative low-grade infection, and one painful arthrodesis) revealed errors in the primary operative technique in 10/13 ankles (77%), resulting typically from the surgeon's attempt to overcompensate a malaligned ankle while ignoring correction of the hindfoot deformity (subtalar complex). The optimum of 0-5 degrees of valgus was found in only 5/13 patients (38%). All four patients with varus alignment presented with malleolar pain. Bone grafting was adequate even in those patients with failure, whereas immobilization time was suboptimal in one patient (eight weeks). Patient satisfaction was lowered in every case of nonunion. Revision arthrodesis of failed primary fusion was successful in 10/13 patients (77%), however three additional stress fractures, two painful ankles without nonunions, and one superficial wound infection were detected. Ankle arthrodesis is a demanding procedure, and the operation should always be performed by an experienced surgeon, taking into account the alignment, ligament, and muscle balance of the rheumatoid ankle and hindfoot. Correction and rebalancing of these factors and the use of bone grafts are of crucial importance when considering the optimal conditions for fusion. Nonunions, infections, and stress fractures occurring after the primary arthrodesis are severe complications, leading eventually to revision operations and problems with osteoporotic bone, fragile soft tissues, and skin.

Treatment of the ankle joint in rheumatoid arthritis with surgical and radiation synovectomy

Results of surgical synovectomy and radiation synovectomy (radiosynoviorthesis) of the tibiotalar joint in rheumatoid patients are reported. The staged concept for management of the rheumatoid ankle joint is presented which is based on the radiographic appearance of disease progression. Results of 16 rheumatoid patients with disease to the ankle joint suggest that pain and walking capability is positively influenced by synovectomy and radiosynoviorthesis. Follow-up of 30 months revealed no deterioration of postoperative clinical improvement. In the absence of contraindications to radiosynoviorthesis it is suggested to combine arthroscopic synovectomy with radiosynoviorthesis for the treatment of early stages of rheumatoid disease of the ankle joint. Open synovectomy is preferred to arthroscopic synovectomy, if tenosynovectomy is simultaneously required.

High failure with the dowel technique for fusion of rheumatoid ankles

Twelve patients (12 ankles) with rheumatoid arthritis were treated with arthrodesis using the dowel technique described by Baciu. Only five of 12 ankles obtained bony fusion. The technique is unsuitable for patients with rheumatoid arthritis.

Distal fibular notch: a frequent manifestation of the rheumatoid ankle.

To describe the distal fibular notch, an infrequently described manifestation of rheumatoid arthritis, and to speculate on its etiology through gross dissection, histologic correlation and MR imaging. One hundred and twenty-one conventional ankle radiographs were obtained and reviewed in 76 patients with clinically diagnosed rheumatoid arthritis. Additional imaging of three ankles was obtained utilizing CT and MR imaging. In addition to evaluating erosive changes, note was made of the presence and location of a well-defined scalloped defect along the medial border of the distal fibula. Ankle specimen dissection and histoanatomic examination was performed in an attempt to determine the exact pathogenesis of this fibular notch. The distal fibular notch was identified in 52 of 121 ankles (43%). Seventy-five percent of notches were syndesmotic and extended down to the horizontal ankle joint level, while 25% of notches were syndesmotic with extension below the joint. The majority of ankles (79%) demonstrated coexistent marginal erosions and/or joint narrowing. Ankle specimen dissection revealed a single-celled synovial fold within the distal tibiofibular syndesmotic recess without underlying articular cartilage extension. The fibular notch within the distal tibiofibular syndesmosis is a frequent manifestation of rheumatoid arthritis and appears to result from synovial proliferation rather than from mechanical instability.

Compression arthrodesis of the rheumatoid ankle and hindfoot.

The reported frequency of involvement of the rheumatoid ankle and hindfoot varies between 9% and 70%. Fusion of the ankle joint, the subtalar, talonavicular, or calcaneocuboidal joint (Chopart's joint) or all of them is the preferred method of treatment for severe rheumatoid involvement causing pain, instability, and/or severe deformity. Ankle arthroplasty is indicated rarely. Pantalar arthrodesis is performed more frequently than talonavicular fusion or ankle fusion. Reported rates of fusion after compression arthrodesis of the ankle joint vary from 65% to 90%, averaging 80% to 85%. Higher success rates of as high as 95% were obtained with internal lag screw fixation as proposed by Wagner. The result of various combinations of arthrodesis (n = 54) of the ankle joint, the subtalar joint, and Chopart's joint in 43 patients with rheumatoid arthritis operated on in a 10-year period from 1984 through 1993 are presented. In all cases internal fixation by lag screws according to Wagner was used with a modified lateral approach incorporating osteotomy of the distal fibula. The technique is described in detail. Solid fusion was obtained in 21% of the cases after 8 weeks, in 9% of the cases after 12 weeks, and in 92% of the cases after 16 weeks. In 8% (3 patients) revision because of delayed union or nonunion eventually led to bony fusion. Postoperative pain, walking capacity, gait, and the subjective outcome were assessed. Complications occurred in 16%, revision was performed in 11.6% of the cases; in all cases healing was obtained. Overall patient satisfaction was 93%.

The long-term results of ankle joint synovectomy for rheumatoid arthritis

The clinical and radiological results of synovectomy for rheumatoid arthritis in the ankle joint were investigated in 20 ankles of 15 patients. The average follow-up period after synovectomy was 15 years, ranging from 10 to 25 years. The clinical evaluation at the time of follow-up, found that only two ankles showed recurrence of synovitis, and no patient complained of severe ankle pain disturbing the activities of daily life. During the period between the synovectomy and our investigation, no patients required further surgical procedures for their ankle joints. The radiological evaluation found that in approximately two-thirds of the cases, deterioration of the radiological grade, evaluated with Larsen's criteria, had continued after synovectomy. There was no considerable radiological deterioration in the less-erosive subset patients, classified according to Ochi's criteria (1). In the unilateral synovectomized cases, using the non-operated ankles as the natural-course control, osteoarthritic changes were predominant in the operated ankle joint, and the non-operated ankle demonstrated inflammatory disease changes. These results indicate that: (1) synovectomy for a rheumatoid ankle is still a preferred treatment, lessening the clinical symptom of persistent, marked synovial proliferation resistant to medical treatment. (2) Radiological deterioration continues after synovectomy in many cases. However, a radiogram demonstrates predominant osteoarthritic destruction, which indicates the natural course of rheumatoid destruction in the operated site could be altered by synovectomy.

Management of the rheumatoid ankle and hindfoot

Management of the rheumatoid ankle and hindfoot

Dowel arthrodesis of the ankle joint in rheumatoid arthritis

Surgical Principles Dowel arthrodesis of the ankle is a simple, safe and effective form of arthrodesis for the rheumatoid ankle joint in those cases where there is no significant deformity. The basic technique of the operation is similar to that used for anterior interbody fusion of the spine and uses similar instruments [1].

Ankle arthrodesis in rheumatoid arthritis: 30 cases followed for 5 years

We have reviewed the results of 30 ankle arthrodeses performed on 26 patients with rheumatoid arthritis. This procedure was associated with a high morbidity, with wound breakdown and infection occurring in 12 cases. Eighteen ankles had fused, six had pain-free fibrous union, and six required further surgery for nonunion. Clinical evaluation, at an average follow-up of 5 years, was based on a modified ankle-grading system with good or excellent results in 14, fair results in nine, and poor in two. Only 4 patients had some residual pain in the ankle, and so, despite the high complication rate, arthrodesis is an effective method of treating the painful, rheumatoid ankle.

重度ＲＡ足関節病変に対する外科的治療について

重度ＲＡ足関節病変に対する外科的治療について