Rheumatoid Arthritis
Rheumatoid Arthritis can have significant
effects on the feet and the ankle. These range from swelling of the
toe joints to severe destruction of the joints of the foot and the
ankle. The process of joint inflammation begins with an inflammation
of the lining of the joints called the capsule. As the capsule becomes
inflamed, the joint fills with fluid and becomes painful. The cartilage
lining of the joint may wear out.
The joint space becomes narrow and bone begins to rub on bone, leading
to painful arthritis. In addition, deformities may occur as a result
of loosening of the ligaments and capsule lining of the joint. If
the housing of the joint (the capsule) loosens up significantly, the
joints (particularly in front of the foot) may dislocate. This can
cause painful swelling on the bottom of the ball of the foot that
can make walking terribly uncomfortable. In addition to the dislocation
of the joints, the big toe begins to deviate and bunions may form
on the inside of the big toe.
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A large bunion with deformity of the
big toe is associated with deformities of all of the toes. This
is a typical appearance of rheumatoid arthritis. |
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The treatment of this condition is two fold. The first goal is to
keep the foot as stable as possible and prevent further deterioration
of the joints and increasing deformity of the foot. The second goal
is to obtain relief in walking and make it easier to wear shoes. Unfortunately,
as the deformity (particularly of the toes) worsens, it becomes very
difficult to proceed without surgery.
Surgery on the toes, particularly the knuckle joints of the toes (metatarso-phalangeal
joints), needs to be performed as soon as possible. This will prevent
some of the destructive changes of the joints from occurring. Although
we are able to treat even the most severe deformities of the toes,
it is always preferable to try to maintain the toe function and the
toe movement. Surgery of the toes is divided into those of the big
toe (the hallux) and those of the little toes and their joints (the
lesser metatarso-phalangeal joints). As the deformity of the big toe
worsens, the most reliable procedure for correction is to fuse the
joint. This straightens the toe, provides a permanent correction to
the deformity and prevents any recurrent deformity or pain from arthritis.
It is however, possible to correct the big toe joint without a fusion,
particularly if the deformity can be addressed earlier on in the course
of events.
The same applies to the lesser metatarsal phalangeal joints. If the
joints are severely dislocated and bone changes are present, the most
reliable procedure is to remove all of the metatarsals (the knuckles
of the front of the foot). This straightens the toes, relieves the
curling or clawing of the toes and relieves all of the terrible pressure
under the ball of front of the foot. It is preferable to try to maintain
the joints without removing the knuckles. This can be done with bone
cuts (called osteotomies) of the metatarsals. These osteotomies need
to be performed early on in the disease process.
Rheumatoid arthritis also affects the back of the foot and the ankle
joint. Arthritis of these joints is often associated with flattening
of the arch of the foot. The ideal treatment would be to prevent these
severe deformities from occurring by performing surgery in the early
stages of the condition. As the deformity worsens, it becomes increasingly
difficult to obtain a normally aligned foot. Even with severe deformities,
however, surgery can still be performed. The foot is straightened
with fusion of the joints of the back of the foot. When rheumatoid
arthritis involves the ankle joint, the ideal surgical treatment is
total ankle replacement. Although a fusion of the ankle joint is possible
and sometimes necessary, the majority of patients with rheumatoid
arthritis that involves the ankle joint do better with a total ankle
replacement then with a fusion. This is because the ankle joint is
not the only joint involved. Other joints of the back of the foot
are also involved. For this reason, it is preferable to maintain movement
of the foot and ankle whenever possible and avoid arthrodesis.
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