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Rheumatoid Arthritis and the Surgical Management of the Rheumatoid Foot

By Kelvin A. Barry, Sr., DPM

Rheumatoid Arthritis
Rheumatoid arthritis is an auto immune disease which eventually leads to hypertrophy of the synovium into something called a pannus. This ultimately erodes the articular surface and causes ligaments to come loose from their attachments, which leads to joint subluxation and dislocations. As podiatrists, what we deal with is the end results of this process of degeneration.

Normal vs. Rheumatic Joint


In A Normal Joint Synovium is continuous and contiguous with the joint capsule Synovium does not cover the joint surface In A Rheumatoid Joint Due to autoimmune process p thickening of the synovium Inflammatory mass of tissue p pannus Elaboration of destructive enzymes Erosion of the cartilaginous surface of the joint Synovium does not extend across the joint, but heavily thrown into folds in deep recesses, that are periarticular Erosive changes will appear first where the synovium is the thickest

Clinical Findings in RA
Stiffness in the morning more than 30 minutes ( poststatic diskenisia)
Less then 30 minutes is usually Osteoarthritis

Occurs mostly in women Involves small joints Bilateral & Symmetrical

Process of the erosion


Synovium does not extend across the cartilage The pannus becomes thicker and more inflamed, and starts leaching calcium out of the bone First radiographic finding is juxtaarticular osteoporosis As the pannus thickens p more erosion p erosion of the side of the joint ("marginal erosion") As erosions become deeper p tendons and ligaments inserting in the periarticular area lose their attachments because the bone is so weak p they pull free and that allows the toes and the rest of the joint to sublux and dislocate p deformities

Earliest site of RA changes in the foot


Metatarsal phalangeal joints 5th MTPJ joint tends to show the changes of RA earlier than the other MTPJs The joint is osteopenic (less calcium) on the Xray. Patients not only suffer from pain in the joint, but also suffer from the deformity of the toes and have problems wearing shoes etc. Since RA is a connective tissue disease, it will affect other systems within the body

Extraarticular manifestations of RA
Vasculitis Autoimmune reaction against your own blood vessels If the blood vessels that are affected are very large, can lead to gangrene and loss of healthy tissue. If the blood vessels are small p petechia-like changes within the skin will develop
don't blanche when pressure is applied

Extraarticular manifestations of RA
Rheumatoid nodules or cysts Rheumatoid nodules should not be operated on as they are non-inflammatory. Fade when you push on them. They usually occur at sites of compression. Rheumatoid cysts can be operated on.

Clinical or Pharmacological Concerns in RA patients


Usually dependent on a regimen prescribed by their Rheumatologist
Non-steroidal anti-inflammatory drugs Rest Therapeutic exercise Exogenous corticosteroids

Some of these will have an effect on your pre-, peri-, and postoperative care
Example: If a pt takes NSAIDs such as Aspirin, take into consideration
Increase in the bleeding. time aspirin has an irreversible affect on platelets discontinue the aspirin for 2 weeks pre-op. get the patient on another non-steroidal drug with more reversible effects.

Clinical or Pharmacological Concerns in RA patients


During a flare-up you don't operate Time on the operating table p patients stiffen up no matter how good the surgery is going. Exogenous corticosteroids These pts may be on one of them example "prednisone" Suppresses the pituitary -adrenal Axis If you take 1.5 mg a day for a week thats enough to shut the Axis down for up to a

Surgical options for a painful Joint


Eliminating the joint, either part of it or all of it Sometimes artificial joints can be used in place Sometimes you do an arthrodesis (fusion) Digital deformities Arthroplasty Digital fusion or arthrodesis

Surgical options for a painful Joint


Isolated lesser MTPJ deformities Partial met head resection Total met head resection Rarely fused this joints Implants usually fail First MPJ deformities Partial met head resection Total met head resection Keller Arthrodesis Total 1st MPJ implants

Pan Metatarsal Head Resection


Indication
Pain with motion -- the most important Dislocation Joint destruction Progressing arthritis

Surgical approaches
Hoffman
Transverse plantar incision. Cut plantarly on all the met heads p pop out and cut off the heads in an even met parabola.

Clayton
Transverse dorsal incision

Problem with any transverse incision is that there are important structures that one risks destroying
lymphatics get interrupted Neurovascular structures might get interrupted also-- BE CAREFUL Chronic swelling and numbness are the complications.

Complications
Infections (staph, strep)
Preoperatively order, Ancef IV . 1 g 30 before the surgery

Delayed wound healing


Leave the sutures in longer or use Steri-Strips

Skin slough
Local wound care post-op

Recurrent deformity
You have not cured RA. You have only relieved the symptoms

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