Bilateral flatfoot before Surgery and  Bilateral flatfoot after Surgery
Ankle Arthroscopy and Subtalar Arthroscopy
Ankle Arthritis in Rhuematoid patient and Ankle Replacement in Rhuematoid Arthritis
Diabetic foot before Surgery and Diabetic foot after Surgery
Claw toe deformity in Rhuematoid patient and Claw toe deformity in Rhuematoid patient after surgery
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Rheumatoid Arthritis in India


Rheumatoid Arthritis of the Foot and Ankle

What is Rheumatoid Arthritis?

Rheumatoid arthritis is a systemic disease that attacks multiple joints throughout the body. It most often starts in the small joints of the hands and feet, and usually affects the same joints on both sides of the body. More than 90% people of arthritis (RA) develop pain and deformities in the foot and ankle.

  Bilateral forefoot deformities in Rheumatoid Arthritis patient      
 
         

Why joint problems occur in Rhuematoid Arthritis?How do you get Rhuematoid Arthritis?

The joints of your body are covered with a lining — called synovium — that lubricates the joint and makes it easier to move.

   Joint problems in Rheumatoid Arthritis      
 
         

In Rheumatoid arthritis this lining becomes overactive and abnormal. It swells, becomes inflamed and secrete toxic substances which destroy the cartilage of joint, as well as the ligaments and other tissues that support it. Weakened ligaments can lead to joint deformities — such as claw toe or hammer toe. Pain and swelling decreases the activities of the patient. This along with the disease process results in softening of the bone (osteopenia) and can result in stress fractures and collapse of bone.

Rheumatoid arthritis is not an isolated disease of the bones and joints. It affects tissues throughout the body, causing damage to the blood vessels, nerves, and tendons. Deformities of the hands and feet are the more obvious signs of RA. In about 20% of patients, foot and ankle symptoms are the first signs of the disease.

How common is Rhuematoid Arthritis?

Rheumatoid arthritis affects approximately 1% of the population. Women are affected more often than men.Symptoms most commonly develop between the ages of 40 and 60.

What problems are faced by patients of Rheumatoid Arthritis?

The most common problems are pain, swelling, and stiffness of joints. Unlike osteoarthritis, which typically affects one specific joint, symptoms of RA usually appear in both feet, affecting the same joints on each foot.

Problems faced by patients can be divided depending upon the area of foot affected. Foot and ankle can be divided broadly into:-

1. Ankle
2. Hindfoot
3. Midfoot
4. Forefoot

  Parts of foot      
 
         

Ankle

Pain in the Ankle and discomfort climbing inclines and stairs is the early feature of ankle involvement. As the disease progresses, simple walking and standing can become painful.

Hindfoot (Heel Region of the Foot)

Pain in the heel and discomfort walking on uneven ground, grass, or gravel are the initial signs. Pain is common just beneath the fibula (the smaller lower leg bone) on the outside of the foot.

As the disease progresses, the alignment of the foot may change as the bones move out of their normal positions. This can result in a flatfoot deformity. Pain and discomfort may be felt along the posterior tibial tendon on the inside of the ankle, or on the outside of the ankle beneath the fibula.

  Bilateral forefoot and hindfoot deformities in Rheumatoid Arthritis patient      
 
         

Midfoot (Top of the Foot)

With RA, the ligaments that support the midfoot become weakened and the arch collapses. With loss of the arch, the foot becomes flat and the front of the foot points outward. RA also damages the cartilage, causing arthritic pain. Over time, the shape of the foot can change because the structures that support it degenerate. This can create a large bony prominence (bump) on the arch. All of these changes in the shape of the foot can make it very difficult to wear shoes and walk.

  X Ray Midfoot Rheumatoid Arthritis XRay of Midfoot Rheumatoid Arthritis  
  flat foot due to Midfoot Rheumatoid Arthritis      

This x-ray shows signs of RA of the midfoot. Note that the front of the foot points outward and there is a large swelling(lump) on the inside and bottom of the foot.

         

Forefoot (Toes and Ball of the Foot)

Pain in the foot and swollen feet are common in RA.The changes that occur to the front of the foot are unique to patients with RA. These problems include bunions, claw toes, and pain under the ball of the foot (metatarsalgia). Although, each individual deformity is common, it is the combination of deformities that compounds the problem.

The bunion is typically severe and the big toe commonly crosses over the second toe.

  Cross Over Toe deformity in Rheumatoid Arthritis      
 
         

There can also be very painful bumps on the ball of the foot, creating calluses. The bumps develop when bones in the middle of the foot (midfoot) are pushed down from joint dislocations in the toes. The dislocations of the lesser toes (toes two through five) cause them to become very prominent on the top of the foot. This creates clawtoes and makes it very difficult to wear shoes. In severe situations, ulcers can form from the abnormal pressure.

  Forefoot deformities in Rheumatoid Arthritis   Sole deformities in Rheumatoid Arthritis  
 
         

People with RA can experience a combination of common foot problems, such as bunions and clawtoe. Severe claw toes can become fixed and rigid. They do not move when in a shoe. The extra pressure from the top of the shoe can cause severe pain and can damage the skin.

Treatment

Although there is no cure for RA, there are many treatment options available to help people manage pain, stay active, and live fulfilling lives.

Although orthopaedic treatment may relieve symptoms, it will not stop the progression of the disease. Specific medicines called disease-modifying anti-rheumatic drugs are designed to stop the immune system from destroying the joints. The appropriate use of these medications is directed by a rheumatologists and physicians.Orthopaedic treatment of Rheumatoid Arthritis depends on the location of the pain and the extent of cartilage damage. Many patients will have some symptom relief with appropriate nonsurgical treatment.

Rest

Limiting or stopping activities that make the pain worse is the first step in minimizing the pain. Biking, elliptical training machines, or swimming are exercise activities that allow patients to maintain their health without placing a large impact load on the foot.

Ice

Placing ice on the most painful area of the foot for 20 minutes is effective. This can be done 3 or 4 times a day. Ice application is best done right after you are done with a physical activity. Do not apply ice directly to your skin.

Nonsteroidal Anti-inflammatory Medication

Drugs, such as ibuprofen or naproxen, reduce pain and inflammation. In patients with RA, the use of these types of medications should be reviewed with your rheumatologist or medical doctor.

Orthotics

An orthotic (shoe insert) is a very effective tool to minimize the pressure from prominent bones in the foot. The orthotic will not be able to correct the shape of your foot. The primary goal is to minimize the pressure and decrease the pain and callous formation. This is more effective for deformity in the front and middle of the foot.

  Orthotics      

 

A custom made soft orthotic can be effective in minimizing the pain and discomfort from flat footFor people with RA, hard or rigid orthotics generally cause too much pressure on the bone prominences, creating more pain. A custom orthotic is generally made of softer material and relieves pressure on the foot.

Braces

A lace-up ankle brace can be an effective treatment for mild to moderate pain in the back of the foot and the ankle. The brace supports the joints of the back of the foot and ankle. In patients with a severe flatfoot or a very stiff arthritic ankle, a custom-molded plastic or leather brace is needed. The brace can be a very effective device for some patients, allowing them to avoid surgery.

  Hindfoot Brace      
 

A custom-molded leather brace can be effective in minimizing the pain and discomfort from ankle and hindfoot arthritis.

Steroid Injection

An injection of cortisone into the affected joint can help in the early stages of the disease. In many cases, a rheumatologist or medical doctor may also perform these injections. The steroid helps to reduce inflammation within the joint. The steroid injection is normally a temporary measure and will not stop the progression of the disease.

Surgery for Rheumatoid Arthritis Problems

Surgery depends upon how badly the joint cartilage is damaged and what is your response to non-surgical options?

Joint Fusion

Fusion of the affected joints is the most common type of surgery performed for RA. Fusion takes the two bones that form a joint and fuses them together to make one bone.

During the surgery, the joints are exposed and the remaining cartilage is removed. The two bones are then held together with screws or a combination of screws and plates. This prevents the bones from moving. During the healing process, the body grows new bone between the bones in these joints.

Fusion reliably relieves pain and improves walking. However it does limit joint movement. This may or may not be felt by the patient depending upon which joint has been fused. For example midfoot and hindfoot joints have very little movement to begin with and fusion of these joints does not create any extra noticeable stiffness but ankle joint is very mobile and hence fusion of this joint does cause noticeable stiffness. Additionally if the movements are already severely compromised because of underlying arthritis fusion may not create any perceivable change to the patients walking but if the joint is very mobile it change in movement is expected.

Other surgeries

Forefoot problems can be treated by joint sparing operations to correct the bunion and hammertoes in some patients. This all depends upon the severity of underlying damage.

Ankle

Ankle fusion and total ankle replacement are the two primary surgical options for treating RA of the ankle. Both treatment options can be successful in minimizing the pain and discomfort in the ankle. The appropriate surgery is based upon multiple factors and is individualized for every patient.

  Ankle Replacement in Rheumatoid Arthritis      
 

The patient shown in these x-rays had arthritis of the hindfoot. It was treated by fusing all three joints of the hindfoot (triple fusion). 6 years later she developed arthritis and pain in ankle and an ankle replacement was done in order to improve mobility and avoid the severe stiffness that would result from ankle fusion. The ankle replacement implants can be seen here from the front and the side.

Patients with severe involvement of other joints around the heel or patients who have previously undergone a fusion on the other leg, may be more suited for ankle replacement. In addition, patients who have fusions within the same foot may be more suited for an ankle replacement.

Newer generation ankle replacement implants have shown promising early results.

 
X-ray showing Ankle Arthritis in Rheumatoid Arthritis patient
 
Ankle Fusion  in Rheumatoid Arthritis
 

These x-rays show an ankle fusion from the front and the side. The number and placement of screws or the use of a plate are dependent upon the surgeon's technique.

Following ankle fusion, there is a loss of the up and down motion of the ankle. The up and down motion is transferred to the joints near the ankle. Patients are able to walk in shoes on flat, level ground without much difficulty after an ankle fusion, despite the loss of ankle motion. The joints in the foot next to the ankle joint allow for motion similar to the ankle joint, and help patients with fused ankle joints walk more normally.

 
Subtalar Arthritis following ankle fusion
   

Over time, the increased stress that is placed on the rest of the foot after an ankle fusion can lead to arthritis of the joints surrounding the ankle. This patient had pain in the subtalar joint (arrow) and required an additional fusion of that joint to minimize the pain. Increased stress on other joints is the most concerning problem following ankle fusion.

Hindfoot (Heel Region of the Foot)

A fusion of the affected joints of the hindfoot is the most common surgery used to treat patients with flatfoot or arthritis of the hindfoot. A triple arthrodesis is a fusion that involves all three joints in the back of the foot. This type of fusion eliminates the side-to-side motion of the foot, while preserving most of the up and down movement.

If RA is only in one joint, then a fusion of just that affected joint may be all that is needed.

 
Hind foot Arthritis in Rheumatoid Patient
 
Triple fusion in Ankle Rheumatoid Arthritis
 

In this x-ray, patient has arthritis of subtalar and talonavicular joint and all three joints in the hindfoot have been fused. 

Any fusion of the hindfoot will limit side-to-side motion of the foot.

Midfoot (Middle of the Foot)

Fusion is the most reliable surgical method to treat RA of the midfoot joints. If the shape of the foot is not normal, surgery is designed to help restore the arch and minimize the prominences on the foot.

Although the foot cannot be returned to a normal shape, the goals are to reduce pain in the foot and improve the potential for the patient to wear more normal shoes.

 
Midfoot arthritis Leading to flat foot
 
Surgical correction of flat foot
 

(Left) This x-ray shows RA of the midfoot that has collapsed the arch.(Right) The surgical reconstruction involved a fusion of the middle of the foot with plates and screws.

Forefoot (Toes and Ball of the Foot)

The choice of treatment for patients with a bunion or lesser toe deformities (hammer or claw toes) depends on a number of factors.

Joint preserving operation-

If the disease is very mild, joint-sparing procedures that preserve motion can be considered. The decision is dependent on the amount of damaged cartilage that is present. This operation involves complex reconstructive osteotomies to your big and lesser toes. This however is not always possible, and the joint may have to be removed.

 
Forefoot deformities before and after surgery
 
 

(Left) This x-ray shows RA of the midfoot that has collapsed the arch.(Right) The surgical reconstruction involved a fusion of the middle of the foot with plates and screws.

Joint sacrificing operation

If the RA has progressed and the lesser toes (two through five) have dislocated, a complex operation to minimize the pain and restore the shape of the foot may be recommended. The operation involves fusion of the big toe and removing a portion of bone of each of the metatarsals. This surgery removes the prominent bone on the bottom of the foot that is a source of the pain and allows the toes to re-align into a better position.

 
X-ray showing Forefoot deformities before joint sacrificing surgery
 
X-ray showing Forefoot deformities after joint sacrificing surgery
 

(Left) RA of the forefoot. The big toe is deviated and crosses over the second toe, a typical appearance of a bunion. The lesser toes (two through five) are dislocated, resulting in painful and severe claw toes. (Right) This x-ray taken immediately after fusion of the big toe shows that the prominent bones on the ball of the foot were removed and the claw toes were corrected. The pins hold the toes in place while the soft tissues heal. The pins are removed in the office after 4 to 6 weeks with minimal discomfort. Please look at the pictures below showing deformity and correction after surgery.

 
Forefoot Deformities as seen from top
 
Forefoot Deformities as seen from sole
 
         
 
 Forefoot Deformities correction after surgery as seen from top
  Forefoot Deformities correction after surgery as seen from sole  

To fix the bend in the lesser toes operation involves removing a small portion of bone of the toes to allow them to straighten. Pins that stick out of the foot are temporarily required and will be removed in the office after healing takes place.
 This operation is very successful in giving patient with a high level of function, comfortable walking and the ability to enjoy a wider variety of shoewear.

 
X-ray of a patient showing Forefoot deformities after joint sacrificing surgery
 
forefoot rhuematoid surgery patient wearing sandals
forefoot rhuematoid surgery patient wearing normal footwear

Reconstruction of the foot does not mean that a patient will be required to wear bulky and unappealing shoes every day. The patient shown here had both feet reconstructed. She is able to wear sandals and mild heels without difficulty.

Preparing for Surgery

Many of the medications that help with RA also affect the ability of the body to heal wounds and fight infection. Dr Bhargava will work out after reviewing your medication which of these will need to be stopped prior to surgery. Once the wounds are healed, the medication is typically resumed.

This period of time can be very difficult for patients with other areas of the body that are affected by RA. Many fusions require at least 6 weeks of time where no pressure can be placed on the foot. Making appropriate preparations to ensure you have help at home is crucial for success after surgery.