Lollo Gröndal

The foot: still the most important reason for walking incapacity in rheumatoid arthritis: Distribution of symptomatic joints in 1,000 RA patients

Background and purpose Our knowledge of frequency of foot involvement in rheumatoid arthritis (RA) is still often based on a study from Finland in 1956. Great changes in the treatment of RA may have led to a different situation. We investigated the distribution of joint involvement in RA patients today, with special attention given to the feet and subjective walking ability. Methods 1,000 RA patients answered a questionnaire concerning joints affected, joint surgery, foot problems, and subjectively experienced reasons for walking incapacity. Results In 45% of the patients, the forefoot was involved at the start of the disease. In 17%, the hindfoot/ankle was involved at the start. Only hand symptoms were commoner. 80% of patients reported current foot problems, 86% in the forefoot and 52% in the hindfoot/ankle. Difficulty in walking due to the feet was reported by 71%. For 41% of patients, the foot was the most important part of the lower extremity causing reduced walking capacity, and for 32% it was the only part. Interpretation After the hand, the foot was the most frequently symptomatic joint complex at the start of the disease, but also during active medical treatment. The foot caused walking disability in three-quarters of the cases and—4 times as often as the knee or the hip—it was the only joint to subjectively impair gait.

Gait pattern in rheumatoid arthritis

The purpose of this study was to analyse kinematic and kinetic gait changes in rheumatoid arthritis (RA) patients in comparison to healthy controls and to examine whether levels of functional disability (Health Assessment Questionnaire (HAQ)-scores) were associated with gait parameters. Using a three-dimensional motion analysis system, kinematic and kinetic gait parameters were measured in 50 RA patients and 37 healthy controls. There was a significant reduction in joint motions, joint moments and work in the RA cohort compared with healthy controls. The following joint motions were decreased: hip flexion-extension range (Delta6 degrees ), hip abduction (Delta4 degrees ), knee flexion-extension range (Delta8 degrees ) and ankle plantarflexion (Delta10 degrees ). The following joint moments were reduced: hip extensor (Delta0.30Nm/kg) and flexor (Delta0.20Nm/kg), knee extensor (Delta0.11Nm/kg) and flexor (Delta0.13Nm/kg), and ankle plantarflexor (Delta0.44Nm/kg). Work was lower in hip positive work (Delta0.07J/kg), knee negative work (Delta0.08J/kg) and ankle positive work (Delta0.15J/kg). Correlations were fair although significant between HAQ and hip flexion-extension range, hip abduction, knee flexion-extension range, hip abductor moment, stride length, step length and single support (r=-0.30 to -0.38, p<0.05). Our findings suggest that RA patients have overall less joint movement and specifically restricted joint moments and work across the large joints of the lower limbs during walking than healthy controls. There were only fair associations between levels of functional disability and gait parameters. The findings of this study help to improve the understanding how RA affects gait changes in the lower limbs.

Arthrodesis versus Mayo resection: THE MANAGEMENT OF THE FIRST METATARSOPHALANGEAL JOINT IN RECONSTRUCTION OF THE RHEUMATOID FOREFOOT

In a prospective randomised study 31 patients were allocated to either arthrodesis or Mayo resection of the first metatarsophalangeal joint as part of a total reconstruction of the rheumatoid forefoot. Of these, 29 were re-examined after a mean of 72 months (57 to 80), the Foot Function Index was scored and any deformity measured. Load distribution was analysed using a Fscan mat in 14 cases, and time and distance were measured in 12 of these patients using a 3D Motion system. We found excellent patient satisfaction and a significant, lasting reduction of the Foot Function Index, with no statistically significant differences between the groups. There were no significant differences in recurrence of the deformity, the need for special shoes, gait velocity, step length, plantar moment, mean pressure or the position of the centre of force under the forefoot. The cadence was higher and the stance phase shorter in the fusion group. These results suggest that a Mayo resection may be an equally good option for managing the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot.

Urinary tract infection in patients with hip fractures

We found that 23% of 435 patients treated for a femoral neck fracture in our department also were treated for a urinary tract infection during their hospital stay. The most common pathogen was Escherichia coli, sensitive for mecillinam in 98% of the cases. The most frequently used antimicrobial agent was a broad-spectrum antibiotic, fluoroquinolon, although the most reasonable choice would have been a non broad-spectrum agent such as mecillinam. Catheterization was not a predisposing factor for urinary tract infection, but a poor medical condition and female sex were. We did not find a higher mortality rate among patients with a urinary tract infection.

Serum albumin and deep infection in femoral neck fractures. A study of 437 cases followed for one year.

Summary.Four hundred and thirty-seven patients with femoral neck fractures were studied to determine the value of serum albumin estimations on admission. Serum albumin is a good predictor of mortality, and patients with low levels should be given additional nutritional support. We found that the serum albumin level is not useful in predicting deep wound infection. The infection rate of 3% does not justify the use of antibiotic prophylaxis in general.Résumé.Nous avons étudié rétrospectivement 437 patients avec des fractures du col fémoral pour re- trouver la présence des infections profondes et des facteurs prédictifs de línfection postoperative et de la mortalité. Le nombre de cas d’infection se montant à 3% ne motive pas un traitment antibiotique prophylactique en général. Le tauxe de sérum-albumine prédit bien la mortalité mais pas les infections postoperatoires.

Führungsplatte zur exakten Ausrichtung der Arthrodese im ersten Metatarsophalangealgelenk

ZusammenfassungOperationszielExakte Positionierung der Arthrodese im ersten Metatarsophalangealgelenk mit Hilfe einer speziellen Führungsplatte.IndikationenSchmerzhafte, degenerativ veränderte Großzehengrundgelenke infolge rheumatoider Arthritis, Hallux rigidus oder eines ausgeprägten Hallux valgus. Die Operationsmethode wird für isolierte Probleme an der Großzehe, aber auch im Rahmen einer Vorfußkorrektur bei rheumatoider Arthritis empfohlen.KontraindikationenZusätzliche rheumatische Veränderungen des Interphalangealgelenks der Großzehe.Hallux-valgus-Deformität aufgrund einer Fehlstellung im Mittel- oder Rückfuß, die primär korrigiert werden muss.OperationstechnikÜber eine gerade mediale Inzision werden die Gelenkflächen dargestellt. Abtragen der medialen Exostose und des verbleibenden Knorpels mit einer oszillierenden Säge und Einbohren eines 1,4-mm-Kirschner-Drahts zentral in das Köpfchen des ersten Os metatarsale. Über diesen Führungsstift wird eine Coughlin-Metatarsale-Kopffräse der Größe 18 mm aufgesetzt und eine konvexe Oberfläche aus dem Knochen gefräst. Das Verfahren wird an der Basis der proximalen Phalanx mit der reziproken konkaven Fräse in gleicher Weise wiederholt. So entstehen zwei gut ineinander passende knöcherne Oberflächen, die mit gutem Knochenkontakt in jedem Winkel zueinander eingestellt werden können.Anlegen der Führungsplatte entlang der plantaren und medialen Kante des Fußes und Einstellen des Gelenks in der gewünschten Position. Temporäre Transfixation des Gelenks mit zwei gekreuzten Kirschner-Drähten. Nach der endgültigen Positionierung werden die Drähte durch zwei 2,7-mm-Kortikaliszugschrauben ersetzt.ErgebnisseSieben Frauen und drei Männer in einem Durchschnittsalter von 52 Jahren (31–66 Jahre) mit rheumatoider Arthritis wurden in der angegebenen Weise operiert. Der durchschnittliche postoperative Hallux-valgus-Winkel betrug 14° (2–29°) und die Dorsalextension 12° (6–19°). Bei einem starken Raucher war eine Pseudarthrose zu verzeichnen.AbstractObjectiveAccurate positioning of the first metatarsophalangeal joint during fusion with the help of a special guide plate.IndicationsPainful and deformed first metatarsophalangeal joint, due to rheumatoid arthritis, hallux rigidus or severe hallux valgus. The method may be used either in isolation or as part of a forefoot reconstruction in rheumatoid arthritis.ContraindicationsRheumatoid involvement of the interphalangeal joint of the great toe.A valgus position of the hindfoot might need to be addressed first.Surgical TechniqueThrough a straight medial incision, the joint surfaces are freed. The medial exostosis and any remaining cartilage are removed with a small power saw. A 1.4-mm Kirschner wire is introduced centrally in the first metatarsal head. A Coughlin metatarsal head joint reamer of 18 mm diameter connected to a power drill is passed over the wire. A spherical surface of cancellous bone is shaped. The procedure is repeated on the base of the proximal phalanx with the reciprocal part of the reamer, resulting in two nicely fitting bony surfaces. They can be positioned in any angle without sacrificing good bone contact.The guide plate is applied along the plantar and medial border of the foot and the joint positioned in the desired angles. The joint is temporarily transfixed with two crossed Kirschner wires. After a final assessment of the position, including rotation, they are replaced by two 2.7-mm corti-cal screws inserted using the lag screw principle.ResultsTen patients, seven women and three men, median age 52 years (31–66 years), all suffering from rheumatoid arthritis were operated with this technique. The mean postoperative hallux valgus angle was 14° (2–29°) and the dorsiflexion position 12° (6–19°), measured as angle of inclination from the floor. One pseudarthrosis occurred in a heavy smoker.

Arthrodesis versus Mayo resection

In a prospective randomised study 31 patients were allocated to either arthrodesis or Mayo resection of the first metatarsophalangeal joint as part of a total reconstruction of the rheumatoid forefoot. Of these, 29 were re-examined after a mean of 72 months (57 to 80), the Foot Function Index was scored and any deformity measured. Load distribution was analysed using a Fscan mat in 14 cases, and time and distance were measured in 12 of these patients using a 3D Motion system. We found excellent patient satisfaction and a significant, lasting reduction of the Foot Function Index, with no statistically significant differences between the groups. There were no significant differences in recurrence of the deformity, the need for special shoes, gait velocity, step length, plantar moment, mean pressure or the position of the centre of force under the forefoot. The cadence was higher and the stance phase shorter in the fusion group. These results suggest that a Mayo resection may be an equally good option for managing the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot.

Arthrodesis versus Mayo resection : the management of the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot

In a prospective randomised study 31 patients were allocated to either arthrodesis or Mayo resection of the first metatarsophalangeal joint as part of a total reconstruction of the rheumatoid forefoot. Of these, 29 were re-examined after a mean of 72 months (57 to 80), the Foot Function Index was scored and any deformity measured. Load distribution was analysed using a Fscan mat in 14 cases, and time and distance were measured in 12 of these patients using a 3D Motion system. We found excellent patient satisfaction and a significant, lasting reduction of the Foot Function Index, with no statistically significant differences between the groups. There were no significant differences in recurrence of the deformity, the need for special shoes, gait velocity, step length, plantar moment, mean pressure or the position of the centre of force under the forefoot. The cadence was higher and the stance phase shorter in the fusion group. These results suggest that a Mayo resection may be an equally good option for managing the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot.