Radiographic factors associated with painful callosities after forefoot surgery in patients with rheumatoid arthritis.

OBJECTIVES: Operative procedures for rheumatoid forefoot deformities have gradually changed from arthrodesis or resection arthroplasty to joint-preserving surgery. Although joint-preserving arthroplasty has yielded good outcomes, painful plantar callosities may occur post-operatively. This study aimed to reveal the radiographic factors associated with painful callosities after joint-preserving surgery for forefoot deformities in patients with rheumatoid arthritis (RA). METHODS: We retrospectively evaluated 166 feet in 133 patients with RA who underwent forefoot joint-preserving arthroplasty, including proximal rotational closing-wedge osteotomies of the first metatarsal, between January 2012 and December 2015. Logistic regression analysis was performed with the objective variable set as the presence/absence of painful plantar callosities at the final observation and the explanatory variables set as several radiographic factors, including post-operative relative first metatarsal length (RML), amount of dorsal dislocation of the fifth metatarsal (5DD), and arc failure of the lesser toes. RESULTS: At the final follow-up, 42 of the 166 feet (25.3%) had painful callosities under the metatarsal heads post-operatively. Logistic regression analysis showed that the RML, 5DD, and lesser toes' arc failure were significantly associated with painful callosities. CONCLUSIONS: We identified that RML, 5DD, and arc failure of the lesser toes were associated with painful plantar callosities after the surgery.

How reliable is assessment of joint swelling and tenderness over socks or stockings in patients with established rheumatoid arthritis?

OBJECTIVES: Physicians tend to omit examinations of the foot and ankle in routine practice because it consumes a lot of time when working within tight time constraints. Although barefoot examination is critical to assess disease activity of rheumatoid arthritis (RA), we think occasional examination of foot over socks or stockings is better than not examining foot at all. The aim of this study was to assess the accuracy of foot examinations over socks or stockings in patients with RA. METHODS: Sixty patients with RA were enrolled in this study. A rheumatologist and a senior resident performed foot examinations on each patient over socks, over stockings, and on bare foot to assess swelling and tenderness. Concordance rates between the barefoot examination and the examinations over socks or stockings by each examiner were investigated. RESULTS: The rheumatologist had a concordance rate of 94.4% over socks and 98.8% over stockings. The senior resident had a concordance rate of 95.6% over socks and 98.5% over stockings. CONCLUSIONS: Foot examinations over socks and stockings had high concordance rates with the barefoot examination, and it may be an option for decreasing foot and ankle examination time in RA patients.

Joint-Preserving Surgery for Forefoot Deformities in Patients with Rheumatoid Arthritis: A Literature Review.

The combination of first metatarsophalangeal joint arthrodesis and resection arthroplasty of all lesser metatarsal heads has been historically considered the golden standard treatment for rheumatoid forefoot deformities. However, as recent improved management of rheumatoid arthritis have reduced progression of joint destruction, the surgical treatments for rheumatoid forefoot deformities have gradually changed from joint-sacrificing surgery, such as arthrodesis and resection arthroplasty, to joint-preserving surgery. The aim of this literature review was to provide current evidence for joint-preserving surgery for rheumatoid forefoot deformities. We focused on the indications, specific outcomes, and postsurgical complications of joint-preserving surgery in this review.

Patient-Reported and Radiographic Outcomes of Joint-Preserving Surgery for Rheumatoid Forefoot Deformities: A Retrospective Case Series with Mean Follow-up of 6 Years.

BACKGROUND: Rheumatoid arthritis (RA) is an autoimmune disorder and a chronic inflammatory disease that can damage joints throughout the body. As dramatic improvements in medical treatment have contributed to reduced progression of joint destruction, surgical methods for the treatment of RA-related forefoot deformities have gradually changed from joint-sacrificing to joint-preserving. The aim of this study was to assess the long-term outcomes, including patient-reported outcomes, of joint-preserving surgery for forefoot deformities associated with RA. METHODS: This retrospective study included 105 feet in 89 patients with RA who were treated during the period of January 2012 to May 2015 and had a minimum of 5 years of follow-up (mean, 6.0 ± 0.9 years). The patient-reported outcome measure used was the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), which was completed preoperatively and at the latest follow-up (n = 53 feet). The hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the position of the medial sesamoid were measured preoperatively, at 3 months postoperatively, and at the latest follow-up. Cases of delayed wound-healing, hallux valgus recurrence, nonunion at the osteotomy sites, and reoperation were recorded. Kaplan-Meier survival curves were used to determine the estimated survivorship, with reoperation as the end point. RESULTS: Scores of all 5 subscales of the SAFE-Q demonstrated significant improvement at the latest follow-up. The average HVA and IMA decreased significantly 3 months postoperatively, and these measurements remained significantly lower than the preoperative values (p < 0.01). The position of the medial sesamoid at the latest follow-up improved significantly (p < 0.01). Delayed wound-healing was found at the site of surgery in 21 (20.0%) of the 105 feet. Recurrence of hallux valgus was observed in 11 (10.5%) of the feet. There was no case of nonunion at any osteotomy site. Eleven (10.5%) of the feet required reoperation. The estimated survivorship of the studied joint-preserving surgery at 7 years, with reoperation as the end point, was 89.5%. CONCLUSIONS: Satisfactory long-term patient-reported and radiographic outcomes after joint-preserving surgery for forefoot deformities associated with RA can be achieved. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Triple osteotomy for erosive first metatarsal in a patient with rheumatoid arthritis: a case report.

Recently, over the half of the patients with rheumatoid arthritis achieved clinical remission with beneficial effects of disease modifying anti-rheumatic drugs, including biological disease modifying anti-rheumatic drugs. Because the patients in remission should have no/reduced progression of joint damage, there is a trend towards joint-preserving surgery in the treatment of rheumatoid forefoot deformities. Here we report a 76-year-old woman with rheumatoid arthritis developed a severe forefoot deformity including a large bony erosion of the first metatarsal head. She showed near remission for rheumatoid arthritis without having clinically active synovitis in her MTP joints. To preserving her metatarsophalangeal joint, a double first metatarsal osteotomy was planned to remove the bony erosion and simultaneously correct the hallux valgus. Thirty-month follow-up demonstrated excellent radiographical and patient-reported outcomes. To the best of our knowledge, this is the first case of a double first metatarsal osteotomy to remove the bony erosion and simultaneously correct the hallux valgus in a patient with rheumatoid arthritis with a large erosion of the first metatarsal head.

Nontraumatic Perforation of the Metacarpal by the Stem of a Flexible Silicone Implant in a Patient with Rheumatoid Arthritis.

A 49-year-old woman with rheumatoid arthritis who underwent replacement arthroplasty of second to fifth left metacarpophalangeal joints with silastic implant seven years ago presented with a complaint of mild pain and discomfort on the replaced joint of index finger. Ulnar deviation had relapsed, with severe swan neck deformities. Computed tomography examination demonstrated that the tip of the stem of the silicon implant penetrated the second metacarpal. We confirmed that finding surgically, and we performed a revision surgery successfully with autogenous bone grafting from distal radius. As the patient had undergone finger joint replacement surgery with silastic implant, nontraumatic perforation of the bone cortex by the implant could happen in a long-term process. On long-term follow up of silastic arthroplasty of finger joint, the possibility of nontraumatic perforation of the finger bone by the prosthesis should be considered, especially in the coexistence of severe finger deformities such as swan neck deformity.

Recurrent volar dislocation of the metacarpophalangeal joint of the thumb with radial collateral ligament injury: A case report.

INTRODUCTION: A volar dislocation of the metacarpophalangeal (MCP) joint of the thumb is a rare trauma, and in combination with a radial collateral ligament (RCL) injury is much rarer. We present a surgical case with a recurrent volar dislocation of the MCP joint of the thumb with RCL injury. PRESENTATION OF CASE: A 47-year-old man was referred to our hospital in the subacute phase. Open reduction was performed through a dorsal incision and the RCL was repaired. X-rays taken six weeks later revealed a recurrent dislocation of the MCP joint. At the revision surgery, the extensor pollicis brevis (EPB) was detached from the proximal phalanx. As there was volar tightness, the volar plate was incised horizontally and the EPB was attached to the proximal phalanx. The final X-rays six months post-operatively revealed that the MCP joint was slightly subluxated but there was no pain on motion. DISCUSSION: This case revealed that it is not enough only to repair the RCL to reduce a volar dislocation of the MCP joint of the thumb with an RCL injury. It revealed that re-attachment of the extensor tendons and the volar procedure are also important for a perfect reduction of a recurrent volar dislocation of the MCP joint of the thumb. CONCLUSION: For a volar dislocation of the MCP joint of the thumb with RCL injury, it is important not only to repair the RCL, but also to perform arthroplasty with the extensor tendons and a volar procedure to prevent recurrent dislocation after surgery.

The impact of hindfoot deformities for the recurrence of hallux valgus after joint-preserving surgeries for rheumatoid forefoot deformities.

BACKGROUND: Recurrence of hallux valgus (HV) is a common complication after forefoot surgery for rheumatoid forefoot deformities. The aim of this study is to evaluate the impact of hindfoot malalignment on recurrence. METHODS: This was a retrospective observational study designed to analyze the radiographic outcomes of 87 feet in 64 patients with rheumatoid arthritis treated with a joint-preserving surgery for HV deformity. Differences in hindfoot alignment preoperatively between the recurrence and nonrecurrence groups was compared. RESULTS: There were no significant differences in hindfoot alignment preoperatively between groups. To estimate the impact of technical problems, the HV and intermetatarsal angles measured from radiographs 3 months postoperatively were compared between groups. The HV angles in the recurrence group were significantly larger than those in the nonrecurrence group (p=0.02). CONCLUSIONS: There were no significant differences between preoperative hindfoot malalignment and postoperative recurrence of HV in rheumatoid forefoot surgeries.

Features of patients with rheumatoid arthritis whose debut joint is a foot or ankle joint: A 5,479-case study from the IORRA cohort.

BACKGROUND: Foot and ankle joint disorders are serious issues for patients with rheumatoid arthritis (RA). We compared the differences between patients with RA whose first symptom involved a foot or ankle joint (FOOT group) versus other joints (non-FOOT group) within the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) cohort in our institute. PATIENTS AND METHODS: In the IORRA survey conducted in April 2016, patients were invited to complete six questionnaires about their first symptom at RA onset, current foot or ankle symptoms, daily living activities, and mental health. Disease activity, clinical laboratory variables, functional disability, quality of life, use and ratio of anti-inflammatory and antirheumatic drugs, daily living activities and mental health were compared between the two groups. RESULTS: Among 5,637 Japanese patients with RA who participated in the IORRA survey on April 2016, 5,479 (97.2%) responded to the questionnaire regarding their debut joint. Of these patients, 2,402 (43.8%) reported that their first symptom of RA involved a foot or ankle joint. The FOOT group (n = 2,164) had higher disease activity, higher disabilities, lower quality of life, lower activities of daily living, and poorer mental health and used anti-inflammatory drugs at a higher rate and at higher doses compared with the non-FOOT group (n = 2,164). On the other hand, the use of medications to suppress the disease activity of RA was similar between the groups. CONCLUSION: Clinicians should pay more attention to foot and ankle joints in daily practice so as not to underestimate the disease activity of RA.

Tocilizumab treatment in patients with rheumatoid arthritis is associated with reduced fibrinogen levels and increased blood loss after total knee arthroplasty.

OBJECTIVE: Since IL-6 has been associated with activation of the coagulation cascade and upregulation of fibrinogen transcription, we retrospectively tested the hypothesis that patients with rheumatoid arthritis (RA) treated with tocilizumab (TCZ) may lose more blood when undergoing total knee arthroplasty (TKA). METHODS: This study included 115 RA patients who underwent primary TKA and were preoperatively tested for fibrinogen levels. The blood volume of each patient was calculated using the Nadler formula, and estimated blood loss after TKA was calculated as the change between pre-operative and post-operative hematocrits. If salvaged blood was reinfused, the volume was measured and added to the volume of the estimated blood loss. RESULTS: We observed that patients treated with TCZ had significantly lower pre-operative fibrinogen levels than those not treated with TCZ (190.0 mg/dL versus 347.0 mg/dL, respectively; p = .00018). We also observed a statistically significant increase in mean total volume of estimated blood loss after TKA in RA patients who had been treated with TCZ compared with those not treated with TCZ (797.1 mL versus 511.4 mL, respectively; p = .0039). CONCLUSION: TCZ treatment in patients with RA may increase the risk of blood loss after TKA because of decreased fibrinogen levels.

Multiple Tophaceous Gout of Hand with Extensor Tendon Rupture.

A 45-year-old man presented with painless subcutaneous masses bilaterally on his hands and loss of motion or contracture of the fingers. Initially, drug therapy to reduce the serum uric acid was administered and was expected to reduce the tophi. However, during observation at the clinic, spontaneous rupture of an extensor tendon occurred, and surgical repair of the tendon and resection of the masses were performed. Surgical exploration of the right hand showed hypertrophic white-colored crystal deposits that both surrounded and invaded the extensor digitorum communis of the index finger, which was ruptured. Histopathologic examination of the specimen demonstrated findings consistent with gouty tophi. Tophaceous gout can induce a rupture of tendons during clinical observation, and surgical resection of the tophi might be needed to prevent ruptures.

The efficacy of home-based muscle training for the elderly osteoporotic women: the effects of daily muscle training on quality of life (QoL).

There is little evidence that home-based muscle training through exercise improves the muscle strength and QoL of elderly osteoporotic women. The efficacy of home-based daily exercise on muscle strength of the upper and lower extremities and QoL were examined in elderly osteoporotic women by means of a case-controlled study that was designed and conducted between 2005 and 2006. Sixty-three osteoporotic women over 60 years of age were randomly assigned to 12 months of muscle exercise or to no intervention. The outcomes were changes in muscle strength and quality of life (QoL). Ultimately, sixty-two participants completed the 12 months program. Before the start of home-exercise training, the lumbar spine bone mineral density (BMD) and femoral neck BMD values in the intervention group were significantly lower than those in the control group (p<0.05). Grip strength and maximum walking speed increased significantly in the intervention group (p<0.05). In terms of QoL, physical functioning was improved by home-based exercise in the intervention group (p=0.05), while there were no improvements in any of the categories of Short-Form 36 in the control group. Our results suggest that home-based training is effective for elderly osteoporotic women in improving not only muscle strength in upper and lower extremities but also physical functioning in QoL.

Preparation and characterization of microporous layers on titanium.

Microporous layers on titanium (Ti) are formed by chemical treatment in highly concentrated alkaline media, and their properties and growth mechanism are examined using electrochemical techniques, in situ resistometry, scanning electron microscopy (SEM), grazing-incident X-ray diffraction (GIXRD), and glow discharge optical emission spectroscopy (GD-OES). Chemical treatment in a 5 M aqueous KOH solution yields results superior to those from the same treatment in a 5 M aqueous NaOH solution, while a 3 M aqueous LiOH solution does not produce porous layers. The cation constituting the solution plays a vital role in the process. An SEM analysis reveals that the KOH solution is the most effective in forming microporosity and that the longer the treatment time, the more porous the near-surface layer. The results of GIXRD analysis show the presence of Na(2)Ti(5)O(11) and K(2)Ti(6)O(13) in the layers formed in the NaOH and KOH solutions, respectively; in the case of the LiOH solution, TiO(2) is formed. Chemical treatment in the NaOH and KOH solutions resembles a general corrosion process with the existence of local cathodic and anodic sites. The reduction reaction produces H(2), some of which becomes absorbed in the near-surface region of Ti, while the oxidation reaction produces the above-mentioned compounds and/or an oxide layer. The presence of hydrogen (H) within the solid is detected using GD-OES. The H-containing near-surface layer partially dissolves, yielding a microporous structure. The development and dissolution of the H-containing near-surface layer of Ti upon chemical treatment in the NaOH and KOH solutions are confirmed by resistometry measurements. They point to the formation of a compact passive layer on Ti upon exposure to the LiOH solution.