Tag Archive | rheumatoid arthritis

Outcomes of Joint-Preserving Surgery in RA-Affected Feet

Dramatic improvements in medical treatment of rheumatoid arthritis (RA) have led to marked reductions in joint damage and deformities. Consequently, surgical methods for treating RA-related foot problems have gradually evolved from joint-sacrificing to joint-preserving procedures. In a recent issue of The Journal of Bone & Joint Surgery, Yano et al. reported on outcomes of 105 feet in RA patients treated with joint-preserving methods followed up for a mean of 6 years.

What the Researchers Did:

  • Performed a proximal rotational closing-wedge osteotomy of the first metatarsal and modified shortening oblique osteotomies of the lesser metatarsals
  • Recorded Self-Administered Foot Evaluation Questionnaire (SAFE-Q) scores preoperatively and at latest follow-up
  • Measured hallux valgus angle (HVA), intermetatarsal angle (IMA), and medial sesamoid position before surgery, 3 months after surgery, and at the latest follow-up
  • Tracked delayed wound healing, hallux valgus recurrence, nonunion, and reoperations
  • Calculated Kaplan-Meier survivorship with reoperation as the endpoint

What the Researchers Found:

  • Surgery was associated with significantly improved median SAFE-Q scores, relative to preoperative values.
  • The average HVA, IMA, and grade of medial sesamoid positioning decreased significantly, compared with preoperative measurements.
  • Kaplan-Meier survivorship at 7 years was 89.5%.
  • Delayed wound healing was found in 20% of the feet (all wounds healed with nonoperative treatment), hallux valgus recurrence in 10.5% of the feet, and reoperation in 10.5% of the feet.

Yano et al. emphasize several advantages of joint-sparing over joint-sacrificing surgery: preserved range of motion, stability of the metatarsophalangeal joint, and improved plantar-pressure distribution. However, these advantages and the “satisfactory” long-term outcomes noted above come with substantial complications that foot-and-ankle surgeons will strive to address in the future.

JBJS 100: Juvenile Rheumatoid Arthritis, Tibial Fracture Healing

JBJS 100Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.

Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.

Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.

We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:

Changes in the Cervical Spine in Juvenile Rheumatoid Arthritis
R N Hensinger, P D DeVito, C G Ragsdale: JBJS, 1986 January; 68 (2): 189
This study of 121 patients with juvenile rheumatoid arthritis (RA) found that severe neck pain was not common, although neck stiffness and radiographic changes were commonly seen in the subset of patients with polyarticular-onset disease. The authors concluded that patients with juvenile RA who present with evidence of disease in the cervical spine should be examined carefully for involvement of multiple joints.

A Functional Below-the-Knee Cast for Tibial Fractures
A Sarmiento: JBJS, 1967 July; 49 (5): 855
In this report of 100 consecutive tibial shaft fractures, Gus Sarmiento encouraged early weight bearing in a skin-tight plaster cast that was molded proximally to contain the muscles of the leg. All 100 fractures healed, and healing occurred with minimal deformity or shortening. While most tibial shaft fractures are now treated with intramedullary nails, the principles developed by Dr. Sarmiento still apply, as the nail acts much like the fracture brace to maintain alignment during the weight-bearing healing process.

Stopping DMARDs Often Unnecessary for RA Patients Prior to Orthopaedic Surgery

Most patients with rheumatoid arthritis (RA) will undergo orthopaedic surgery during the course of their disease, and more than 80% of that cohort will be taking traditional or biologic disease-modifying antirheumatic drugs (DMARDs) at the time of their operations. That presents a dilemma, because stopping DMARDs can raise the risk of a rehab-hampering postoperative RA flare, while continuing the drugs is thought to increase the risk of postoperative infection.

A recent literature review in Seminars in Arthritis & Rheumatism suggests that surgeons should feel comfortable allowing patients to continue taking traditional DMARDs, such as sulfasalazine, as long as renal function is monitored. Emphasizing that more research is needed to pinpoint optimal start and stop dates for other DMARDs, review author Susan Goodman, MD, makes the following suggestions:

–Methotrexate: Continuing is recommended.

–Leflunomide: Discontinue for 1 week prior to surgery.

–Anti-TNF Alpha Drugs: Withhold therapy for 1.5 times the dosing interval.

–Tocilizumab: Exercise increased vigilance due to possible masking of signs of infection.

–Abatacept: Withhold for 2 to 3 weeks prior to surgery.

–Tofacitinib: Withhold for 2 days prior to surgery.

Dr. Goodman also observes that preoperative doses of corticosteroids, often used to cover RA flares in patients who’ve discontinued DMARDS, are often far higher than necessary, which could also increase infection risk.


Another Look at Bisphosphonates and Jaw Osteonecrosis

A recent study in the Journal of Clinical Endocrinology & Metabolism found that approximately one out of 200 Taiwanese who used oral alendronate long term for osteoporosis developed osteonecrosis of the jaw (ONJ). In comparison, among a group treated with raloxifene for osteoporosis, only one out of 1,882 developed ONJ. Risk factors for developing ONJ among alendronate users included diabetes, RA, and exposure to the drug for more than three years.

Although this study reinforces an association between oral bisphosphonates and jaw osteonecrosis, it also demonstrates that this adverse effect is uncommon. While the incidence of ONJ in this study was 7 times higher with alendronate than with raloxifene, the incidence rate of ONJ attributed to alendronate use was only 283 per 100,000 persons per year. The increased relative risk with alendronate is worth noting, but the absolute risk remains low, and for people with osteoporosis, the fracture risk-reduction benefits of bisphosphonates continue to outweigh the risk of jaw osteonecrosis.

RA Progression Rate Predicts Need for Future Surgery

UK epidemiologists presenting at the annual meeting of the British Society for Rheumatology recently reported that X-ray evidence of rapid rheumatoid arthritis (RA) progression during the first 12 months of the disease can help predict the need for later surgery of hand, foot, hip, and knee joints. Lewis Carpenter and colleagues analyzed data from the Early Rheumatoid Arthritis Study and found that a change in the Larsen radiographic score of four units during the first 12 months of RA was associated with an 80% increased risk of subsequent surgery on joints of the hand and foot, and a 50% increase in the risk of later hip or knee surgery. (The 0 to 5 Larsen score includes both joint-erosion and joint-space narrowing components.) Carpenter told MedPage Today that these findings help “build the case for early treatment in rheumatoid arthritis” and support the argument that a “therapeutic window of opportunity” exists with RA.