Rheumatoid arthritis (RA)

• Joint pain
• Swelling
• Morning stiffness
• Rheumatoid nodules at sites exposed to pressure and loading
• Restricted joint movement and mobility
• Joint tenderness on pressure

The most common associated symptoms of RA in the ankle and foot are:

• Hallux valgus
• Hammer toes
• Subluxations and dislocations of the metatarsophalangeal joints
• Flatfoot (lowering of the foot’s natural arch)
• Valgus alignment of the hindfoot

These changes reduce loading of the front of the foot and shorten the stride.

Diagnosis

The diagnosis is based on criteria published by the American College of Rheumatology, the organisation that sets global standards for rheumatic disease management.

Treatment of rheumatoid arthritis (RA)

Treatment goals:

• Reduce pain
• Control inflammation
• Prevent deformities
• Correct deformities
• Preserve musculoskeletal function
• Restore musculoskeletal function

Conservative treatment of RA is provided in rheumatology clinics.

Surgical treatment of rheumatoid arthritis (RA)

Procedures used to treat changes in the feet and ankle caused by RA are usually divided into preventive, corrective and reconstructive procedures.

1. Preventive procedures in rheumatoid arthritis (RA)

They aim to limit disease progression and thereby prevent further deformities and functional disorders.

These include:

• Synovectomy – excision of inflamed synovium from a diseased joint.

The procedure can be performed open or arthroscopically.

2. Corrective procedures in rheumatoid arthritis (RA)

They aim to correct deformities caused by the disease and improve foot function and patients’ quality of life.

These include:

• Arthrodesis, or permanent joint fusion, can be performed in the forefoot or hindfoot. Adjacent joints take over the function of the fused joint. Arthrodesis corrects deformity, reduces pain and improves mobility.

Arthrodesis in rheumatoid arthritis is most often performed for the following forefoot deformities:

• hallux valgus
• Hallux rigidus
• Hammer toe
• Mallet toe
• Claw toe

For hindfoot changes, arthrodesis may involve one or several joints. Its extent depends on the severity of the hindfoot deformity and coexisting changes elsewhere in the foot.

 Arthrodesis is most commonly performed at the following joints:

• Subtalar joint
• Talonavicular joint
• Calcaneocuboid joint

Other procedures:

• Partial or total resection of metatarsal heads II–V
• Removal of rheumatoid nodules
• Soft-tissue procedures

3. Reconstructive procedures in rheumatoid arthritis (RA)

They aim to restore the function of the damaged joint and reduce pain.

These include:

• Arthroplasty of metatarsophalangeal joints II–V
• Arthroplasty of the big-toe metatarsophalangeal joint should not be used because of the very high number of complications.
• Ankle arthroplasty

The correct order of surgical treatment is also important. If RA affects several joints of the lower limbs, deformities of the feet should be corrected first. Hip surgery follows, and knee surgery is performed last.

Rehabilitation is an important element supporting rapid recovery after surgery for rheumatoid foot. To be effective, it should be based on the following principles:

• the patient’s condition should be assessed
• Individual recommendations should be prepared during treatment
• therapy should be adapted to the patient’s abilities

Individual exercises with the patient aim to:

• improve the range of motion in the joints of the operated lower limb
• improve proprioception
• Work on improving neuromuscular coordination
• Reduction of swelling (soft-tissue work, lymphatic massage, kinesiotaping)
• correct gait and faulty movement habits
• physiotherapy

In foot surgery, ensuring a pain-free operation and minimising postoperative pain have always been major challenges.

It is commonly believed that recovery after foot surgery, especially hallux surgery, is very painful.

There are many options for anaesthesia during procedures on the foot.

Modern anaesthesiology aims, wherever possible, to use regional anaesthesia techniques – from central blocks such as spinal and epidural anaesthesia, commonly known as lumbar anaesthesia, to peripheral nerve blocks at various levels performed under ultrasound guidance, especially when operating on one foot.

The possibility of using a particular type of anaesthesia depends mainly on the extent of surgery and any coexisting conditions.

The final choice of anaesthesia is agreed with the patient during the preoperative assessment interview.

Using ultrasound in anaesthesiology to perform peripheral nerve blocks has enabled highly precise regional anaesthesia.

Our many years of experience have changed our perioperative approach, both to anaesthesia itself and to the postoperative period.

For foot surgery, peripheral nerve anaesthesia, known as an ankle block, means injecting a local anaesthetic around the nerves at the appropriate level.

These anaesthetics are highly precise because the nerves responsible for pain sensation are clearly visible on ultrasound and medication delivery is fully controlled.

This can substantially reduce or even eliminate the need for pain medication early after surgery.

For many patients, one of the most important advantages is that sensation above the knee is preserved in the operated leg and, most importantly, lumbar anaesthesia is avoided, which patients do not always accept.

Another important advantage is that walking can begin very soon after the procedure.

During the postoperative period, administering pain medication at regular intervals under ultrasound guidance around the nerves responsible for pain enables patients to pass through this period as comfortably and painlessly as possible.