Rheumatoid Ankle Research Articles

A DOSE RESPONSE STUDY FOR THE ANTI ARTHRITIC EFFECT OF RESVERATROL IN A MODEL OF ADJUVANT ARTHRITIS IN RATS

The aim of this study was to investigate the effects of resveratrol (Res) on the clinical symptoms of rheumatoid arthritis in rats with adjuvant arthritis (AA). An AA model was established by injection of complete Freund’s adjuvant (CFA). Ankle diameter, paw volume, arthritic index, gait score as well as paw histopathological examination were assessed to determine the anti-arthritic effect of Res. Resveratrol, at dose 50 mg/kg, was able to significantly alleviate rheumatoid related paw swelling and ankle diameter and decrease both arthritic and gait scores. Besides, a significant reduction of inflammatory cell infiltration in the ankle joint tissue was shown by histopathological examination. These findings confirm the anti-rheumatic activity of Res which can be correlated to its anti-inflammatory activity.

Plantar pressure and surgical indication of toe arthroplasty for rheumatoid forefoot deformity

Objectives: The objective of this study is to clarify the surgical indication for rheumatoid forefoot deformity according to background characteristics and plantar pressure.Methods: Patients with rheumatoid arthritis were divided into a non-surgical group (group N) and a surgical group (group S). The former consisted of 225 ft, and the latter consisted of 88 ft. DAS28, Japanese Society for Surgery of the Foot rheumatoid arthritis foot and ankle scale (JSSF scale) and hallux valgus angle (HVA) were evaluated as background characteristics. Distribution of peak pressure as plantar pressure was measured in nine sections.Results: In groups N and S, the mean DAS28 was 3.6 and 3.0, the mean JSSF scale was 81.1 and 63.0, and the mean HVA was 19.9° and 35.3°, respectively. The mean peak pressure of group S at the first and third metatarsophalangeal joints was significantly higher compared with group N. Significant differences between the two groups were also seen in Δ pressure (the difference between the maximum and minimum peak pressure values). The cut-off values were 75.0 for JSSF scale, 24.9° for HVA and 3.94 kg/cm2 for Δ pressure.Conclusions: The combined assessment of HVA and Δ pressure was found to be useful as an indication for surgical treatment of the forefoot.

Short-term effect of ultrasound-guided low-molecular-weight hyaluronic acid injection on clinical outcomes and imaging changes in patients with rheumatoid arthritis of the ankle and foot joints. A randomized controlled pilot trial

To determine whether hyaluronic acid (HA) injection into rheumatoid arthritis ankles and feet can achieve improvement in foot function and reduce synovial hyper-vascularization. Forty-four patients with RA having unilateral or bilateral painful ankle and foot involvement (N = 75) were studied. All the patients were randomized to receive HA (N = 40) or lidocaine (LI) (N = 35) injection at 2-week intervals; Clinical assessments were performed using a visual analog scale (VAS) and foot function index (FFItotal) including subscales of pain (FFIpain) before injection at baseline, 4 weeks (first evaluation) and 12 weeks (secondary evaluation). Imaging evaluation based on color Doppler ultrasound (CDUS) and synovitis scores was performed simultaneously. HA injection improved the VAS score (p = .009), FFIpain (p = .041), and FFItotal (p = .032) considerably more than LI injections did at the first evaluation. The CDUS values at first evaluation (p = .005) and secondary evaluation (p < .001) decreased significantly compared with the base line values. HA injections reduced the CDUS values of more than half of the joints (54%, p = .042) while the control group exhibited no change (20%, p = .56). However, HA injection did not reduce the CDUS values more than LI injection did. Regarding the evaluation of synovial hypertrophy, no significant difference was observed between or within the groups in the synovitis scores. HA injection improved short-term foot function and pain reduction. HA injection may have a modest effect in reducing synovial hyper-vascularization. Further large-scale study is warranted to confirm this result.

Total ankle replacement in patients with bleeding disorders

Total ankle replacement (TAR) is a well-accepted treatment option in patients with end-stage ankle osteoarthritis. However, published literature on patients with bleeding disorders treated with TAR is limited. Therefore, we carried out this prospective study to analyze mid-term postoperative results in patients with bleeding disorders treated by TAR. A total of 34 patients with end-stage ankle osteoarthritis--14 patients with hemophilia type A and 20 patients with von Willebrand disease (VWD)--treated by TAR were included in this prospective study. The mean age of patients was 46.0 ± 9.0 years. Intraoperative and postoperative complications were recorded. The postoperative pain relief and functional results including range of motion (ROM) and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were assessed after a mean follow-up of 6.3 ± 3.4 years. Additionally, the quality of life was analyzed using the SF-36 questionnaire. The alignment of prosthesis components was assessed using weight-bearing conventional radiographs. The results were compared with those obtained in the control group, including 72 and 33 patients with post-traumatic and rheumatoid ankle osteoarthritis respectively. One patient sustained an intraoperative medial malleolar fracture. In total, three revision surgeries were necessary in our patient cohort. There was significant pain relief from 8.2 ± 0.8 to 0.9 ± 1.0, as assessed using a visual analog scale. All categories of the SF-36 score showed significant improvement. The average ROM increased from 20.1° ± 6.9° to 27.5° ± 7.4°. The AOFAS hindfoot score increased from 34.5 ± 10.0 to 82.4 ± 10.2 of a maximum of 100 points. Radiographic assessment showed the neutral alignment of prosthesis components in all patients. The postoperative clinical and radiographic outcomes were comparable in both patients with hemophilia and those with VWD. Patients with bleeding disorders had significantly higher pain relief and significantly lower ROM than the patients in the control group with ankle osteoarthritis of post-traumatic or rheumatoid etiology. Our prospective study revealed encouraging mid-term outcomes after TAR in patients with bleeding disorders. However, this surgery should be limited to highly experienced foot and ankle surgeons. Furthermore, this patient cohort requires a multidisciplinary approach to ensure a good outcome.

In vivo kinematics of three-component mobile-bearing total ankle replacement in rheumatoid ankle with talocalcaneal arthrodesis and spontaneous talocalcaneal fusion

Objective. It is often that patients with rheumatoid arthritis (RA) who require ankle surgeries already have the degeneration of talocalcaneal joints. When talocalcaneal joint was fused, whether operatively or spontaneously, ankle kinematics would be affected. The purpose of this paper was to study in vivo kinematics of mobile-bearing total ankle replacement (TAR) in rheumatoid ankle with concomitant talocalcaneal arthrodesis or with preexisting spontaneous talocalcaneal fusion.Methods. Thirteen TARs in ten patients with RA, in whom talocalcaneal joints had already been fused spontaneously or surgically, were studied. Fluoroscopic images were obtained while each patient was walking with full weightbearing on the implanted ankle. Thereafter tibio–talar motion was analyzed by 2D/3D registration technique.Results. Average tibio–talar motion was 4.0 ± 5.3° for plantarflexion and 6.6 ± 0.3° for dorsiflexion. Average range of internal/external rotation, inversion/eversion and AP translation was 3.8 ± 1.3°, 2.7 ± 1.0° and 1.6 ± 0.6 mm, respectively.Conclusions. Mobility of mobile-bearing TAR with talocalcaneal fusion was small during the stance phase of gait, but clinically measured ROM was mostly preserved. The movements of internal/external rotation and AP translation were allowed to a certain degree, but not of inversion/eversion. Even though the movement of inversion/eversion is limited, talocalcaneal arthrodesis could be accompanied with mobile-bearing TAR in rheumatoid ankles.

Rheumatoid Arthritis and Total Ankle Joint Replacement

Rheumatoid arthritis is a systemic autoimmune condition of unknown etiology which may present to the orthopedic surgeon with multi joint involvement. Rheumatoid arthritis can involve the ankle, hindfoot and forefoot. We review the historical surgical treatments for the rheumatoid ankle. We also discuss the results of the varying generations of total ankle replacement in rheumatoid arthritis. We conclude the results of the latest generation of ankle arthroplasties are limited in the rheumatoid population. This demands a frank discussion between patients and surgeons prior to embarking on surgery.

AB0354 In vivo kinematics of three-component mobile-bearing total ankle replacement for rheumatoid arthritis during gait.

BackgroundThe standard treatment for end-stage arthritis of ankle joint due to rheumatoid arthritis (RA) has been arthrodesis. It is often that patients with RA who require ankle surgery already have...

AB0353 In vivo kinematics of three-component mobile-bearing total ankle replacement for rheumatoid arthritis during non-weightbearing plantarflexion/dorsiflexion.

BackgroundTotal ankle replacement (TAR) that can relieve pain while retaining ankle movement is a useful surgical option for patients with rheumatoid arthritis (RA). However, high complication rates and low survivorship...

Perioperative Care for Rheumatoid Foot and Ankle Surgery Patients

tating and leads to progressive joint inflammation and destruction, with subsequent functional impairment. The hands and legs are most commonly involved, with women more frequently affected than men, and the most common age groups affected lie between 40 and 60 years. Juvenile RA is the most common form of childhood arthritis, yet its clinical pattern usually differs from that of adult RA. The exact cause of RA is unknown but research points toward a genetic predisposition with certain infections or environmental factors that might trigger the activation of the immune system in susceptible individuals. Immune cells, called lymphocytes, are activated and cytokines, such as tumor necrosis factor (TNF) and interleukins 1 and 6 are expressed in the inflamed areas leading to articular effusions. Synovial hypertrophy contributes to the formation of synovial pannus, which selectively causes destruction to periarticular structures, cartilage, and bone. RA can affect any joint including the hand, wrist, elbow, shoulders, hip, knee, foot, ankle, and cervical spine. Nearly 100% of patients report foot problems within 10 years of RA onset. 3–5 Sites of involvement often coincide with the duration of the disease, with forefoot involvement occurring much earlier

Mid-term results of joint-preserving procedures by a modified Mann method for big toe deformities in rheumatoid patients undergoing forefoot surgeries

This study aimed to evaluate joint-preserving procedures by a modified Mann method for rheumatoid forefoot deformities and their functional outcomes in the mid-term. Eleven feet in seven patients underwent forefoot surgery using a modified Mann method for the big toe, combined with offset osteotomy or resection arthroplasty of the lesser toes. The mean follow-up period was 3.6 years. The mean score on the Japanese Society for Surgery of the Foot scale for rheumatoid arthritis foot and ankle joints improved from 44.0 to 72.0. The mean hallux valgus angle improved from 39.4° to 20.5° and the mean M1M5 angle improved from 31.1° to 25.8°. However, deformities involving a hallux valgus angle of more than 25.0° recurred in three feet at the latest follow-up, although the patients did not complain of any symptoms from the recurrence. Improvement in the Sharp score for joint space narrowing was observed in the big toe, indicating better congruity of the metatarsophalangeal joint. For restraint of rheumatoid forefoot deformities, a modified Mann method, combined with offset osteotomy or resection arthroplasty, was satisfactory for not only improving the foot function, but also preserving the metatarsophalangeal joint mobility.

Rheumatoid Foot and Ankle Surgery

Rheumatoid arthritis is a common and disabling condition which can be effectively managed through a multidisciplinary approach. A review of the etiology, pathophysiology, clinical presentation, diagnosis and treatment is presented, followed by a discussion focused on the disease presentation and management in the foot and ankle. Conservative care options, perioperative considerations and surgical treatment options for rheumatoid deformity in the foot and ankle are discussed.

Mid-term results of joint-preserving procedures by a modified Mann method for big toe deformities in rheumatoid patients undergoing forefoot surgeries

This study aimed to evaluate joint-preserving procedures by a modified Mann method for rheumatoid forefoot deformities and their functional outcomes in the mid-term. Eleven feet in seven patients underwent forefoot surgery using a modified Mann method for the big toe, combined with offset osteotomy or resection arthroplasty of the lesser toes. The mean follow-up period was 3.6 years. The mean score on the Japanese Society for Surgery of the Foot scale for rheumatoid arthritis foot and ankle joints improved from 44.0 to 72.0. The mean hallux valgus angle improved from 39.4 degrees to 20.5 degrees and the mean M1M5 angle improved from 31.1 degrees to 25.8 degrees . However, deformities involving a hallux valgus angle of more than 25.0 degrees recurred in three feet at the latest follow-up, although the patients did not complain of any symptoms from the recurrence. Improvement in the Sharp score for joint space narrowing was observed in the big toe, indicating better congruity of the metatarsophalangeal joint. For restraint of rheumatoid forefoot deformities, a modified Mann method, combined with offset osteotomy or resection arthroplasty, was satisfactory for not only improving the foot function, but also preserving the metatarsophalangeal joint mobility.

Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor

The aim of this study was to characterize the pathological conditions of symptomatic ankles in patients with rheumatoid arthritis (RA) using power Doppler sonography (PDS). We analyzed 17 consecutive ultrasonography (US) records of RA patients with symptomatic ankles who underwent B-mode ultrasonography (BUS) combined with PDS of their ankles in our department because of clinical need. Correlations between US findings and clinical and serological data were assessed. The diagnostic capabilities of BUS and PDS were also compared. Common US findings were talocrural synovitis (76%), subtalar synovitis (71%), and talonavicular synovitis (59%). Tenosynovitis around the ankle was detected in ten patients (59%), including several cases of tenosynovitis of tibialis posterior (41%) and tenosynovitis of peroneus longus and brevis (35%). Achilles tendon enthesitis was detected in six patients, and retrocalcaneal bursitis was detected in five. Compared with BUS, PDS offers demonstrably superior diagnostic capability for the detection of rheumatoid ankle diseases, especially subtalar joint synovitis and peroneal tenosynovitis. Rheumatoid factor (RF) levels were significantly higher in patients with tenosynovitis than in patients without tenosynovitis. PDS is an excellent modality for diagnosing both intra- and extracapsular synovitis in rheumatoid ankles. Using PDS, we found positive association between ankle tenosynovitis and RF levels in RA patients.

Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor

The aim of this study was to characterize the pathological conditions of symptomatic ankles in patients with rheumatoid arthritis (RA) using power Doppler sonography (PDS). We analyzed 17 consecutive ultrasonography (US) records of RA patients with symptomatic ankles who underwent B-mode ultrasonography (BUS) combined with PDS of their ankles in our department because of clinical need. Correlations between US findings and clinical and serological data were assessed. The diagnostic capabilities of BUS and PDS were also compared. Common US findings were talocrural synovitis (76%), subtalar synovitis (71%), and talonavicular synovitis (59%). Tenosynovitis around the ankle was detected in ten patients (59%), including several cases of tenosynovitis of tibialis posterior (41%) and tenosynovitis of peroneus longus and brevis (35%). Achilles tendon enthesitis was detected in six patients, and retrocalcaneal bursitis was detected in five. Compared with BUS, PDS offers demonstrably superior diagnostic capability for the detection of rheumatoid ankle diseases, especially subtalar joint synovitis and peroneal tenosynovitis. Rheumatoid factor (RF) levels were significantly higher in patients with tenosynovitis than in patients without tenosynovitis. PDS is an excellent modality for diagnosing both intra- and extracapsular synovitis in rheumatoid ankles. Using PDS, we found positive association between ankle tenosynovitis and RF levels in RA patients.

Zur Effektivität der arthroskopischen Synovektomie bei rheumatoider Arthritis

Arthroscopic synovectomy in rheumatoid arthritis has proven beneficial in terms of pain relief and joint function, both for upper limb joints (shoulder, elbow, wrist) and the knee. The clinical long-term improvement, such as pain reduction and improved joint mobility, seems more distinct in joints with no or mild joint destruction (early synovectomy) compared to advanced joint damage (late synovectomy). Late-stage elbow arthritis, synovitis of the metacarpophalangeal and proximal interphalangeal joints and the rheumatoid ankle can better be addressed by an open approach. Although a real joint-preserving effect has not been demonstrated, pain reduction and improvement in joint function recommend arthroscopic synovectomy as a substantial treatment option in patients with rheumatoid arthritis.

Medial Malleolar Osteotomy for the Correction of Varus Deformity During Total Ankle Arthroplasty: Results in 15 Ankles

Preoperative deformity in the frontal plane in the arthritic ankle is a risk factor for failure after total ankle arthroplasty. Medial malleolar lengthening osteotomy was developed to correct varus malalignment. From 1998 to 2005 total ankle arthroplasty combined with medial malleolar lengthening osteotomy was done in 15 ankles (13 patients) with a mean preoperative varus deformity of 14.9 (SD, 7.8) degrees. Diagnosis was arthritis with instability in 11 ankles (9 patients) and inflammatory joint disease in 4 ankles. Two mobile-bearing designs were used. Osteosynthesis of the osteotomy was done in 2 ankles; for the remaining 13 osteotomies, no fixation was used. Followup was 5 (range 2 to 8) years. Neutral alignment was obtained in all ankles. In 3 patients residual hindfoot varus remained, for which a second-stage hindfoot correction was done. Two rheumatoid ankles developed a symptom-free nonunion of the medial malleolus, all other malleolar osteotomies united. One tibial component, implanted with too much anterior slope, developed early aseptic loosening and was revised. Debridement for talar-malleolar arthritis was done in two ankles. Of the 14 ankles in followup, 12 were rated as excellent or good, one as fair. One ankle with subsidence of the talar component was rated as unsatisfactory. AOFAS score increased from 30.8 preoperative to 81.0 at followup (p < 0.01). Medial malleolar lengthening osteotomy is an easy technique for the realignment of the varus ankle at the time of total ankle arthroplasty, and served as an alternative to medial ligament release or lateral ligament reconstruction.

Use of the Versa nail and anterior ankle arthrotomy to achieve primary tibiotalocalcaneal arthrodesis in rheumatoid arthritis

Background Surgical treatment of rheumatoid ankle can be challenging. Tibiotalocalcaneal arthrodesis is one such treatment and has been performed using various methods and tools including different types of nails. Objective To evaluate the clinical outcome of primary tibiotalocalcaneal arthrodesis in rheumatoid arthritis using anterior ankle arthrotomy and Versa nail, an intramedullary nail designed specifically for tibiotalocalcaneal arthrodesis. Methods Review of case records, radiographs and telephonic interview of 11 rheumatoid patients who had undergone primary tibiotalocalcaneal fusion using the Versa nail between March 2004 and May 2005. Results Arthrodesis was achieved in nine cases. Complications seen in four patients included a non-union, fractured tibia, ulceration and cellulitis. All complications resolved with conservative treatment and none affected the long-term outcome. There was a highly significant improvement in the modified AOFAS score from 18 before surgery to 72 afterwards [ p < .0001]. Conclusion Tibiotalocalcaneal arthrodesis using Versa nail and anterior approach is an effective procedure in rheumatoid arthritis. Anterior approach preserves the malleoli and therefore rotational stability, making it possible to avoid the use of proximal screws. Our study suggests that, in the presence of very osteopenic bone and atrophic skin, it is safe to avoid using screws and to allow weight bearing without compromising the final outcome.

TOTAL ANKLE ARTHROPLASTY IN INFLAMMATORY JOINT DISEASE WITH USE OF TWO MOBILE-BEARING DESIGNS

Background: Interest in mobile-bearing total ankle arthroplasty has increased in recent years. However, to our knowledge, no study has focused exclusively on patients with the diagnosis of inflammatory joint disease or has provided a detailed analysis of the risk factors for failure. Methods: A prospective observational study of the results of cementless mobile-bearing total ankle arthroplasty in patients with inflammatory joint disease (mainly rheumatoid arthritis) was conducted at two centers. Ninety-three total ankle arthroplasties were performed. The LCS (low contact stress) prosthesis was used initially, in nineteen ankles, between 1988 and 1992, and a modification of the LCS prosthesis, the Buechel-Pappas design, was used in seventy-four ankles between 1993 and 1999. Clinical and radiographic follow-up was performed at yearly intervals. Three clinical scoring systems were used, and any complication was recorded throughout follow-up. Actuarial survival (with revision as the end point), multivariate analysis, and a competing risk approach were used to describe the long-term outcome. Results: The clinical result at one year after surgery showed a significant improvement in the scores on all three scoring systems (p < 0.05). Ankle dorsiflexion (mean, 7°) also improved significantly (p < 0.05) compared with the preoperative state. The most frequent complication was a malleolar fracture, which occurred in twenty ankles. Only when it occurred in combination with a deformity in the frontal plane did this complication have an adverse effect on the end result. At a mean follow-up of eight years, seventeen patients (twenty-one ankles) had died and fifteen ankles had been revised because of aseptic loosening (six ankles), primary or secondary axial deformity with edge-loading (six ankles), deep infection (two ankles), and a severe wound-healing problem (one ankle), leaving fifty-seven ankles (61%) that were evaluated. The mean overall survival rate at eight years was 84%. An increased failure rate was encountered in ankles with a preoperative deformity in the frontal plane of >10° (p = 0.03) and in ankles in which an undersized tibial component had been implanted (p = 0.02). Conclusions: Mobile-bearing total ankle arthroplasty is a valid treatment option for the rheumatoid ankle if proper indications are used. Aseptic loosening and persistent deformity are the most important modes of failure. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Total Ankle Arthroplasty in Inflammatory Joint Disease with Use of Two Mobile-Bearing Designs

Interest in mobile-bearing total ankle arthroplasty has increased in recent years. However, to our knowledge, no study has focused exclusively on patients with the diagnosis of inflammatory joint disease or has provided a detailed analysis of the risk factors for failure. A prospective observational study of the results of cementless mobile-bearing total ankle arthroplasty in patients with inflammatory joint disease (mainly rheumatoid arthritis) was conducted at two centers. Ninety-three total ankle arthroplasties were performed. The LCS (low contact stress) prosthesis was used initially, in nineteen ankles, between 1988 and 1992, and a modification of the LCS prosthesis, the Buechel-Pappas design, was used in seventy-four ankles between 1993 and 1999. Clinical and radiographic follow-up was performed at yearly intervals. Three clinical scoring systems were used, and any complication was recorded throughout follow-up. Actuarial survival (with revision as the end point), multivariate analysis, and a competing risk approach were used to describe the long-term outcome. The clinical result at one year after surgery showed a significant improvement in the scores on all three scoring systems (p < 0.05). Ankle dorsiflexion (mean, 7 degrees ) also improved significantly (p < 0.05) compared with the preoperative state. The most frequent complication was a malleolar fracture, which occurred in twenty ankles. Only when it occurred in combination with a deformity in the frontal plane did this complication have an adverse effect on the end result. At a mean follow-up of eight years, seventeen patients (twenty-one ankles) had died and fifteen ankles had been revised because of aseptic loosening (six ankles), primary or secondary axial deformity with edge-loading (six ankles), deep infection (two ankles), and a severe wound-healing problem (one ankle), leaving fifty-seven ankles (61%) that were evaluated. The mean overall survival rate at eight years was 84%. An increased failure rate was encountered in ankles with a preoperative deformity in the frontal plane of >10 degrees (p = 0.03) and in ankles in which an undersized tibial component had been implanted (p = 0.02). Mobile-bearing total ankle arthroplasty is a valid treatment option for the rheumatoid ankle if proper indications are used. Aseptic loosening and persistent deformity are the most important modes of failure.

Chaussage et orthèses plantaires dans la polyarthrite rhumatoïde

Chaussage et orthèses plantaires dans la polyarthrite rhumatoïde