The implications of biologic therapy for elective foot and ankle surgery in patients with rheumatoid arthritis.

INTRODUCTION: Rheumatoid arthritis (RA) is one of a number of inflammatory arthropathies resulting in foot pain and deformity. Patients with this disease may require surgical intervention as part of their management. Many of these patients are now taking biologic agents which pose several risks to patients in the perioperative phase. The surgical team therefore need to be aware of these associated complications and how to manage these cases. AIM: This paper aims to review the current literature about perioperative needs (foot and ankle surgery) associated with patients with rheumatoid arthritis receiving biologic therapy. MAIN FINDINGS: The majority of the literature discusses the perioperative complications associated with patients on anti-TNFα therapy with few studies investigating the other biologics in common use. There is conflicting evidence as to the safety of continuing or stopping biologic drug therapy prior to orthopaedic procedures. The British Society for Rheumatology (BSR) have produced guidelines for the management of patients on anti-TNFα therapy or the biologic agent Tocilizumab. These recommendations suggest the risks of post-operative infection need to be balanced against the risk of a post-operative disease flare. In essence, it is suggested anti-TNFα therapy is stopped 3-5 times the half-life of the drug whilst Tocilizumab is stopped 4 weeks prior to surgery. CONCLUSION: Good communication is needed between the surgical team and the local Rheumatology department managing the patient's disease in order to optimise perioperative care. Local pathways may vary from the BSR recommendations to determine the most suitable course of action with regards to continuing or stopping biologic therapy prior to foot and ankle surgery.

Case study: a case of debilitating gout in the 1st metatarsophalangeal joint.

Gout is a painful arthritic condition that affects many people worldwide. The disease has been associated with hyperuricaemia and life style risk factors such as obesity, alcohol intake, meat and seafood consumption. We present a case of a 67-year-old male with a history of gout, who attended the clinic with a painful 1st metatarsophalangeal joint, which had progressively worsened in pain, mobility and deformity in the last 20 years. Although lifestyle changes had been advised by the GP some years earlier such as a low purine based diet, management had only consisted of NSAID's, which had not significantly improved symptoms. Surgical excision of chalky white material from around the 1st metatarsophalangeal joint rendered the patient symptom free with increased mobility after 6 weeks. Histopathology confirmed the excised tissue as gouty tophus. Following this, the patient was placed on allopurinol, a xanthine oxidase inhibitor to prevent recurrent attacks. This case study highlights the importance of early recognition and prophylactic management in gout sufferers. In joints where the disease process is well-established surgical excision of the gouty tophus may help mitigate further disease progression, and restore quality of life to individuals.

The reliability of measurements taken from radiographs in the assessment of paediatric flat foot deformity.

BACKGROUND: Radiographic charted values are widely applied in the assessment of paediatric flat foot and as quantitative markers of intervention success. Nearly all literature pertaining to the reliability of these measures relates to the adult foot. In view of the importance placed on these charted values we assessed the inter and intra-rater reliability of 10 key radiographic measures in children aged 7-14 years. METHODS: We present the reliability of these measures in terms of intra class correlation and standard error based on repeated measures of 50 radiographs across five independent trained observers. Two new detailed methods are presented for the calculation of lateral and dorso-plantar talo-calcaneal overlap in an attempt to better define the talo-calcaneal inter-relationship. RESULTS: The results demonstrate wide variation of measurement reliability, with some measures being highly reproducible and others showing poor reproducibility. A strong negative correlation between reliability and the number of steps required for the measurement was demonstrated. Consistent with other studies intra-rater reliability tended to be higher than that of inter-rater reliability. CONCLUSION: In conclusion, we have provided evidence as to which radiographic charted measures may be reliably used in evaluating the paediatric flat foot in children aged 7-14 years, and which measures are not reliable and we advise against their application.

A longitudinal study of hallux valgus surgical outcomes using a validated patient centred outcome measure.

BACKGROUND: Hallux valgus is a common chronic condition affecting up to a third of the population. Progressive disruption to the complex anatomy of the first ray involving metatarsal, sesamoids and hallux impose both structural and functional alteration to the foot which underpin the secondary pathologies associated with this condition. It is common for patients to seek correction of the deformity in order to alleviate pain and improve footwear tolerance. Surgical intervention remains the only viable means to restore osseous alignments. To date there remains no universally accepted standards for procedure selection. METHODS: A total of 179 consecutive participants were recruited into the study. Ethical approval was obtained and all participants consented to participate in the study, in accordance with the Helsinki Declaration. All patients attending the Department of Podiatric Surgery, between July 2004 and October 2007 for the surgical management of hallux valgus were invited to complete a Foot Health Status Questionnaire. Pre-operative data collection on all participants was undertaken on the day of admission, using the validated Foot Health Status Questionnaire measurement tool as with previous studies. RESULTS: A total of 179 complete data sets were recorded in this longitudinal study with an average participant age of 49.4 years (SD 14.5). The group comprised 164 females and 15 males. The mean days for administration of the Foot Health Status Questionnaire post operative follow up was 1045 days (149 weeks or 2.9 years). The results demonstrated that within all four foot specific domains, the minimal important differences were achieved by the majority of the group. Meanwhile, in domains relating to general health, physical activity, vigour and social capacity, the majority of participants failed to attain the calculated minimal important difference (94 [53%], 96 [54%], 93 [52%], 93 [52%], respectively). CONCLUSIONS: The authors have presented for the first time minimal important difference for all eight domains for the Foot Health Status Questionnaire quality of life tool in respect to hallux valgus surgery. Results demonstrate that surgical correction of hallux valgus undertaken under local anaesthetic as a Day Case procedure is an effective intervention directly benefiting patients by reducing perceived foot pain, improving foot function and general foot health for the majority of patients.

Critically evaluating the role of diagnostic imaging in osteomyelitis.

Early diagnosis, essential for timely appropriate treatment and reduction of complications, can be difficult. This article aims to give an overview of the role that different imaging modalities have to play in the diagnosis of osteomyelitis. Osteomyelitis is a heterogeneous disease in its pathophysiology, clinical presentation, and management. It infers inflammation of bone and marrow, whereas osteitis is inflammation of the bone only. Thus, a soft-tissue infection that reaches the bone surface but has not infected the marrow is osteitis and not osteomyelitis. Chronic osteomyelitis is divided into active and inactive forms. Newly appearing periosteal reaction or bone destruction within the chronic involucrum are indicators of activation. Imaging modalities represent different underlying pathophysiological processes that may be represented in differing types and differing phases of osteomyelitis. Sequential selection of appropriate imaging modalities requires a thorough understanding of the disease processes and the process by which each modality visualizes this dynamic disease process.

Subtalar joint arthroereisis in the management of pediatric flexible flatfoot: a critical review of the literature.

BACKGROUND: Pediatric flexible flatfoot is a common deformity for which a small, but significant number undergo corrective surgery. Arthroereisis is a technique for treating flexible flatfoot by means of inserting a prosthesis into the sinus tarsi. The procedure divides opinion in respect of both its effectiveness and safety. METHODS: A database search up until 2010 was used to find articles regarding arthroereisis in pediatric patients. We summarized the findings of this study. RESULTS: Seventy-six studies were identified. Eight of the nine radiographic parameters reported show significant improvement following arthroereisis reflecting both increased static arch height and joint congruency. Calcaneal inclination angle demonstrated the least change with only small increases following arthroereisis. Arthroereisis remains associated with a number of complications including sinus tarsi pain, device extrusion, and under-correction. Complication rates range between 4.8% and 18.6% with unplanned removal rates between 7.1% and 19.3% across all device types. CONCLUSION: Current evidence is limited to consecutive case series or ad hoc case reports. Limited evidence exists to suggest that devices may have a more complex mode of action than simple motion blocking or axis altering effects. The interplay between osseous alignment and dynamic stability within the foot may contribute to the effectiveness of this procedure. Although literature suggests patient satisfaction rates of between 79% to 100%, qualitative outcome data based on disease specific, validated outcome tools may improve current evidence and permit comparison of future study data.

Liquid silicone to mitigate plantar pedal pressure: a literature review.

Disruption of the body's plantar fat pad can occur as a result of one of three mechanisms: simple fat pad atrophy associated with age-related degeneration, steroid use, or collagen vascular disease. Actual or relative displacement in to the underlying osseous prominences may be seen in association with structural deformity of the foot. Disease states such as diabetes may alter the normal structural integrity of soft tissues through nonenzymatic glycation leading to increased stiffness and thus reduced attenuating capacity. Fat pad atrophy, regardless of the cause, is often associated with substantial emotional, physical, productivity, and financial losses. In situations where the patient is sensate, the resultant skin on bone situation is extremely painful, especially when walking.

A report of UK experience in 917 cases of day care foot surgery using a validated outcome tool.

BACKGROUND: Day case surgery is an increasingly important treatment modality and one that foot surgery is particularly well suited to. OBJECTIVES: This article presents an in depth evaluation of the outcomes of day case foot surgery undertaken in the primary care setting. METHOD: 917 consecutive day surgery cases were evaluated with the Foot Health Status Questionnaire (FHSQ), patient satisfaction questionnaires and complication audits. RESULTS: 917 separate day care admissions were audited (696 females and 221 males). The average age at time of surgery was 50 years (range 14-100, S.D. 11). Post-operative follow up was usually complete by 26 weeks (range 21-218 weeks, S.D. 145). A total of 2772 individual procedures with patients receiving between one and five procedures per admission. The majority of patients (81%, N=743) opted for local anaesthesia. The FHSQ scores for foot pain, foot function, foot health, shoe fitting, general health, physical activity, social capacity and vigour improved. Patient satisfaction results were favourable and complication rates were within acceptable limits. CONCLUSIONS: Podiatric surgery is well placed to meet both the demands of government and patients in delivering a high quality, safe and efficient treatment for patients requesting elective surgical intervention for foot deformity.

Midfoot fusion using a locking plate system: a case report.

BACKGROUND: Midfoot osteoarthrosis can impede daily activity and affect lifestyle, due to pain and footwear restrictions. A case is presented of an arthrodesis of the 2nd and 3rd metatarsocuneiform joints (MCJs), undertaken using a locking plate system, to treat painful degenerative changes that had been symptomatic for 6 months. CONCLUSION: Arthrodesis of the 2nd and 3rd MCJs using a locking plate system achieved adequate fusion and the presenting complaint was resolved. The patient was delighted with the surgical outcome.

Local anaesthetic toxicity.

BACKGROUND: Local anaesthesia has been used by British podiatrists since the early 1960s. The use of local anaesthesia has allowed for the advancement of scope of practice and the development of podiatric surgery. Local anaesthesia is however associated with potential risks and adverse reactions including toxicity. OBJECTIVES: To review the current literature on the subject of local anaesthetic toxicity and to consider recent developments in the management of acute toxicity. CONCLUSIONS: Local anaesthesia although safe has the potential to cause serious harm in the event of toxicity. Appropriate steps should be taken to minimise the risk of toxicity and should it occur measures should be applied to minimise the consequences of toxicity. Such measures may include the use of Intralipid for resuscitation.

A review of surgical outcomes of the Lapidus procedure for treatment of hallux abductovalgus and degenerative joint disease of the first MCJ.

BACKGROUND: The modified Lapidus procedure has been used to treat hallux abducto valgus and degenerative joint disease of the first metatarsocuneiform joint for many years. Historically, the Lapidus has been associated with poor satisfaction due to complications such as non-union. The aim of this study was to review the surgical outcomes of 18 patients using the validated Foot Health Status Questionnaire (FHSQ). The four domains within the FHSQ were all investigated. Pre and post operative angular measurements were also reviewed. RESULTS: The results of the FHSQ were positive for all four domains, with foot pain having the greatest change. Only two complications were recorded: one poor pain control and one post operative bleed and all 18 patients went to osseous union. Radiographically the mean intermetatarsal angle improved by 7.8 degrees and HAV angle by 22.9. A positive association was also demonstrated between validated 'Minimal Important Difference' (MID) scores. CONCLUSION: The Lapidus is a valuable procedure that can have few complications and high levels of patient satisfaction.