Background The treatment aim of rheumatoid arthritis (RA) is achieving and maintaining remission (REM) or low disease activity (LDA) via tight medical control1). However, despite remarkable advances in medication, progressive deterioration and deformity of the forefoot sometimes occur if adequate medication is not administered in the early stage. Surgical reconstruction is still required in patients with painful callosity and footwear problems caused by typical forefoot deformity. Recently, patients have expressed a desire to achieve functional REM with a higher quality of life (QOL) and improved mental wellness.
Objectives The objective of this study was to clarify the systemic effects of forefoot reconstruction on the impaired foot, even in patients who have achieved REM or LDA.
Methods A prospective cohort study was performed for 63 feet of 50 patients (males: 6, females: 44) with RA who underwent primary elective surgery between October 2012 and September 2014. Both feet underwent surgery on the same day in 13 patients. The average (range) age was 64 (42–89) years, and the average (range) disease duration was 20 (2–36) years. The procedures performed included shortening oblique osteotomy at the metatarsal neck of the lessor toes in 47 feet, first metatarsophalangeal joint arthroplasty (Swanson) in 44 feet, correction shortening osteotomy (modified Mitchell) at the first metatarsal in 4 feet, and fusion at the first interphalangeal joint in 7 feet, among others. A total of 30 feet in 27 patients (males: 5, females: 22) had a disease activity of REM or LDA just before surgery. The patient-reported outcomes (PROs) were assessed using the Health Assessment Questionnaire-Disability Index (HAQ-DI), EuroQol-5 Dimensions (EQ-5D), Beck Depression Inventory-II (BDI-II), and Patient's General Health using a visual analogue scale of 100 mm (Pt-GH). The 28-joint Disease Activity Score using C reactive protein (DAS28-CRP), the Japanese Society of Surgery of the Foot (JSSF) standard rating system (JSSF) for the RA foot and ankle scale2), and the Time Up&Go test (TUG) were also evaluated. All of these items were investigated just before surgery (baseline) and again at 6 and 12 months after surgery.
Results Overall, the physical function (JSSF, TUG), QOL (EQ-5D), and mental wellness (depression) (BDI-II) were significantly improved at 6 and 12 months after surgery compared to the baseline values (p<0.05). In the REM/LDA group, significant improvement was noted in the physical function (JSSF), QOL (EQ-5D) both at 6 and 12 months after surgery; however, we did not observe any significant changes in the Pt-GH or DAS28-CRP (Table 1).
Conclusions Achieving REM or LDA is not the ultimate goal of treatment for patients with painful callosity and footwear problem functional loss. A higher QOL and improved function can be achieved by surgical intervention in the deformed forefoot.
Smolen JS, Breedveld FC, Burmester GR, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis. 2016;75(1):3–15.
Niki H, Aoki H, Inokuchi S, et al. Development and reliability of a standard rating system for outcome measurement of foot and ankle disorders I: development of standard rating system. J Orthop Sci. 2005:10:457–465.
Disclosure of Interest None declared