Search

An accurate assessment of the foot and ankle problem in elite athletes is the foundation of a treatment plan and prognosis. The special pressures of professional sports, where managers, agents, and lawyers may be involved, makes a thorough assessment especially critical for sound decision-making. Evaluation includes taking a history of the acute and chronic condition, including mechanism, physical sensation at injury, compensatory stresses, and general medical review. The athlete is assessed physically in several different ways, including comprehensive focal examination and alignment in static and dynamic nonweight-bearing and weight-bearing modes. This comprehensive process is essential to accurate assessment.

Polyfibromatosis syndrome is a rare disease entity that is characterized by various clinical features such as palmar, plantar, and penile fibromatoses, keloid formations of the skin, and erosive arthropathy. Its precise pathophysiology or etiology remains unclear. In addition to distinctive diverse skin manifestations, patients with polyfibromatosis have been previously reported to show erosive arthropathy with significant limitation of movement at affected joints. However, the presence of erosive polyarthropathy in polyfibromatosis has not emphasized in previous cases. Here, we report a case of polyfibromatosis syndrome combined with painless massive structural destruction of hand and foot joints, and review the characteristics of erosive arthropathy in previous cases.

Objectives: To evaluate a radiographic atlas for grading foot osteoarthritis (OA) in relation to the relative sensitivity of different radiographic and views and features, and to examine the relationship between radiographic OA and foot symptoms., Methods: Weightbearing dorso-plantar (DP) and lateral foot radiographs were obtained from 197 people (126 women and 71 men) aged 62-94 years (mean age 75.9, standard deviation [SD] 6.6). The prevalence of OA in five joints (the first metatarsophalangeal joint [1st MPJ], the first cuneo-metatarsal joint [1st CMJ], the second cuneo-metatarsal joint [2nd CMJ], the navicular-first cuneiform joint [N1st CJ] and the talo-navicular joint [TNJ]) was then determined using both views in combination (as recommended in the atlas), or by using either view in isolation. Associations between radiographic OA in individual foot joints and symptoms were then explored., Results: Joint-specific prevalence of OA using both DP and lateral views was 1st MPJ (42.4%), 1st CMJ (22.6%), 2nd CMJ (60.2%), N1st CJ (39.1%) and TNJ (32.7%). Using only the DP view detected almost all cases of 1st MPJ OA (94.6%), however, the sensitivity was lower for the other joints (31.0-60.7%). Using only the lateral view detected almost all cases of OA (83.8 to 86.9%), with the exception of the 1st MPJ and 1st CMJ (50.9% and 60.7%, respectively). Using either osteophytes (OP) alone or joint space narrowing (JSN) alone showed low sensitivity for all joints (14.3-63.0%), with the exception of OP alone in the DP view for the 1st MPJ and JSN in the lateral view for the 2nd CMJ (83.8% and 84.0%, respectively). Radiographic OA in individual foot joints and the total number of joints affected were both moderately associated with foot symptoms., Conclusion: Epidemiological and clinical studies should incorporate observation of both OP and JSN from both DP and lateral views to determine the presence of OA in the foot, as the number of cases detected is reduced if only one radiographic feature or view is used. Radiographic foot OA is common in older people and is moderately associated with foot symptoms.

Background: An accurate and consistent differentiation of foot type is needed to assess appropriate treatments and to examine potential risk factors for acute and overuse injuries., Materials and Methods: One hundred forty-seven members of the American Orthopaedic Foot and Ankle Society were asked to complete a questionnaire related to clinical assessments of foot type and to examine 30 photographs of healthy feet taken on the mirrored foot photo box (MFPB). Responders were asked to categorize each image into one of five categories (pes planus, low arch, normal, high arch, and pes cavus). Different static measurements were obtained from each image. Pearson correlations were calculated between the static foot measures and the clinical grade. Significantly correlated parameters were analyzed via regression analysis., Results: Clinical assessment was reported to be the most important tool in defining foot type (69.9%) followed by standing radiographs and foot print measurements. Clinicians stated that arch height (56.2%) was the most used physical characteristic, while the lateral talo-first metatarsal angle (64.4%) was the most used radiographic assessment. Foot measurements were correlated with the clinical grade (r = 0.511 to 0.780). Regression analysis revealed that rearfoot angle, foot print index and truncated arch index were significant predictors of clinically defined foot type. Rearfoot angle accounted for 78% of the variance in clinically assessed foot type., Conclusion: The results of this study indicate the need to measure multiple parameters to assess foot type. However, if only one parameter can be collected, it appears that rearfoot angle explains the majority of variance in the clinically assessed foot type.

Background: Ultrasonography is an emerging imaging modality which affords dynamic, real-time, cost-effective and surgeon controlled visualization of the foot and ankle. The purpose of this study was to evaluate the accuracy of ultrasound guided injections for common injection sites in the foot and ankle., Materials and Methods: In 10 fresh cadaver feet, ultrasound guidance was utilized to inject a methylene blue-saline mixture into (1) the first MTP joint, (2) the second MTP joint, (3) the tibiotalar joint, (4) the Achilles peritendinous space, (5) the flexor hallucis longus sheath, (6) the posterior tibial tendon sheath, and (7) the subtalar joint. Dissection was then undertaken to assess injection accuracy., Results: Ultrasound guidance allowed the avoidance of intervening neurovascular and tendinous structures. Ultrasound guided MTP, ankle, Achilles, PTT and FHL peritendinous injections were 100% accurate. Ultrasound guided subtalar injection was 90% accurate., Conclusion: Ultrasound appears to be a highly accurate method of localizing injections into a variety of locations in the foot and ankle., Clinical Relevance: Ultrasound's ability to display soft-tissue structures may be an advantage over blind injection and fluoroscopic injection techniques.

The controversy regarding the radiographic parameter which best represents the various deformities of clubfoot continues. The aim of our study was to clear up this controversy. Fifty surgically treated (soft-tissue release) congenital clubfeet were studied clinically using Laaveg and Ponseti score and radiologically using twelve different radiographic parameters in weight-bearing AP and lateral views. The talo-calcaneal angle (TCA) in AP and lateral view showed statistically significant correlation with the functional rating, but significant variation in the dimension of the angles among the different functional groups was found with AP angle only. The talo-first metatarsal angle in AP and lateral view averaged 10 degrees and 19 degrees respectively, and showed significant correlation with the functional rating. The talo-navicular subluxation in AP, the calcaneo-fifth metatarsal angle and the first-fifth metatarsal angle in lateral view did not show any significant correlation with function. Talo-calcaneal index averaged 44 degrees in the clubfeet and showed significant correlation. The wide range of parameters representing each of the deformities gives a better radiological assessment of the clubfoot than any single parameter.

Introduction: The outcome of displaced intra-articular fractures of the calcaneus is affected by many factors such as fracture type and age. The restoration and maintenance of the posterior facet is a priority and has a strong correlation with improved outcome. The fracture occasionally extends anteriorly to the calcaneocuboid joint (CCJ). Currently there is little literature discussing pain, functional or radiographic information about calcaneal fractures, which involve the CCJ or those that do not. The aim of this study was to compare pain and functional outcome measurements in a cohort of calcaneal fractures treated operatively and non-operatively to determine whether CCJ involvement was important., Patients and Methods: A prospective database of calcaneal fractures managed by a single surgeon was reviewed. CT images allowed us to assess the degree of CCJ involvement before and after surgery. Final outcome was determined by pain (validated visual analogue score) and functional outcomes (SF-36) taken 2 years after injury with further CT imaging used to determine the presence of arthritic change at the CCJ. 59 patients with 64 intra-articular calcaneal fractures were identified who also had 35 fractures that extended to the CCJ. Pre-operative CT imaging identified 3 levels of CCJ involvement: Undisplaced fracture line (n=27); fractures that involved <50% of the CCJ (n=4) and fractures that involved >50% of the CCJ with joint subluxation (n=4)., Results: Pain and functional scores were comparable between fractures that involved the CCJ and those that did not. All fractures that involved >50% of the CCJ demonstrated arthritic change 2-years after injury., Discussion: Displaced intra-articular fractures of the calcaneus will often have a fracture line extending into the CCJ. This is commonly undisplaced and does not appear to predict continued pain, dysfunction on radiographic appearance using generalised outcome measurements.

Charcot neuroarthropathy is often a devastating diabetic foot complication that poses a great risk for limb loss and can have a significant impact on a patient's quality of life in the presence of multiple existing comorbidities. It is a progressive and debilitating condition characterized by joint dislocation, pathologic fracture(s), and extensive destruction of the foot or ankle architecture secondary to dense peripheral neuropathy. This pathologic process can be idiopathic, secondary to acute trauma or previous surgery, or attributable to repetitive "microinjury." Once the Charcot process has been initiated, continued ambulation results in progressive collapse and deformity. Severe deformities can have an impact on the patient's ambulatory status, and when associated with instability, ulceration, or infection, there is greater risk for a major limb amputation.

Background: The prevalence of foot and ankle conditions varies among different ethnic groups. It is not known if this difference is due to any distinctive skeletal morphological characteristics of the foot. The purpose of this study was to determine if ethnic differences exist in the morphometric measurements on radiographs of the weightbearing foot., Materials and Methods: A morphometric study of weightbearing radiographs of feet was performed prospectively. Radiographic parameters were measured on digital monitors using digital tools. These were the hallux valgus angle (HVA), intermetatarsal angle (IMA), talonavicular angle (TNA), talonavicular coverage angle (TNCovA), metatarsal span (MS) on anteroposterior (AP) radiographs and talo-first metatarsal angle (T-1(st)MTA), calcaneal pitch (CP), and lateral talocalcaneal angle (LTCA) on lateral radiographs., Results: A total of 237 feet in 126 patients (45 African Americans, 59 Caucasians, and 22 Hispanics) were studied. Statistically significant differences were found in the CP, LTCA, and MS. African Americans have significantly lower CP than Caucasians (p < 0.0001). African Americans have significantly lower CP than Hispanics (p < 0.0016). Caucasians have significantly higher TCA than African Americans (p < 0.0004). Males have a larger MS than females (p < 0.0001)., Conclusion: There are differences in the radiographic morphology of feet among different ethnic groups. A larger prospective community-based study of morphological differences is needed for better understanding of the genetic and environmental factors influencing the prevalence of foot and ankle conditions., Clinical Relevance: The clinical relevance between having a lower CP angle and a higher incidence of flat feet in African Americans warrants further investigation. It is not known if there is a relationship between posterior tibialis insufficiency and low CP.

Introduction: Undifferentiated arthritis (UA) has a variable disease course; 40 to 50% of UA patients remit spontaneously, while 30% develop rheumatoid arthritis (RA). Identifying the UA patients who will develop RA is essential to initiate early disease-modifying anti-rheumatic drug (DMARD) therapy. Although the presence of bone erosions at baseline is predictive for a severe destructive disease course in RA, the prognostic importance of erosive joints for disease outcome in UA is unknown. This study evaluates the predictive value of erosive joints for the disease outcome in UA as measured by RA development and disease persistency., Methods: Baseline hands and feet radiographs of 518 UA patients were evaluated for erosions using a clinical definition as well as the Sharp/van der Heijde method. After 1 year follow-up, patients were re-assessed for the fulfillment of the 1987 ACR classification criteria for RA. Disease persistency was defined as the absence of sustained remission during all available follow-up (mean 8 +/- 3 years)., Results: At baseline, 28.6% of UA patients had erosive joints. Presence of > or = 2 erosive joints showed a positive predictive value for RA development of 53% and for persistent disease of 68%. Patients with erosions that did not develop RA were less often anticyclic citrullinated peptide antibody (ACPA)+ve, rheumatoid factor (RF)+ve and had lower C-reactive protein (CRP), erythrocytic sedimentation rate (ESR) and number of swollen joints compared to those who developed RA. Feet erosions are equally predictive compared to erosions at hands., Conclusions: Presence of > or = 2 erosive joints at baseline in UA patients gives a risk for RA development of 53% and for persistent disease of 68%, indicating that erosions in UA are not always predictive for unfavorable disease outcomes.

The aim of this study was to establish normal reference values of anatomic and mechanical joint angles of the tibia in sheep at different age groups. Eighteen clinically healthy Santa Ines sheep were used. The animals were divided into three equal groups according to age: Group I - from six- to eight-months-old, Group II - 2-years-old, Group III - from three- to five-years-old. Anatomic medial proximal and lateral distal tibial angles, mechanical proximal and distal tibial angles, and anatomic caudal proximal and anatomic cranial distal tibial angles were measured from tibiae radiographs (n = 36). In the craniocaudal view, the mean values of the anatomic medial proximal, anatomic lateral distal, mechanical medial proximal, and mechanical lateral distal tibial joint angles were 89.6 masculine, 86.6 masculine, 91.4 masculine, and 85.19 masculine respectively. In mediolateral view, the mean values of the anatomic caudal proximal and anatomic cranial distal tibial angles were 64.55 masculine and 105.69 masculine, respectively. The joint orientation angles of the tibia in sheep showed similar values regardless of animal age for both anatomic and mechanical axes.

It was our aim to describe a CT-guided robotically-assisted infiltration technique for diagnostic injections in foot and ankle orthopaedics. CT-guided mechatronically-assisted joint infiltration was performed on 16 patients referred to the orthopaedic department for diagnostic foot and ankle assessment. All interventions were performed using an INNOMOTION-assistance device on a multislice CT scanner in an image-guided therapy suite. Successful infiltration was defined as CT localization of contrast media in the target joint. Additionally, pre- and post-interventional VAS pain scores were assessed. All injections (16/16 joints) were technically successful. Contrast media deposit was documented in all targeted joints. Significant relief of pain was noted by all 16 patients (p<0.01). CT-guided robotically-assisted intervention is an exact, reliable and safe application method for diagnostic infiltration of midfoot and hindfoot joints. The high accuracy and feasibility in a clinical environment make it a viable alternative to the commonly used fluoroscopic-guided procedures.

Objectives: The aim of this pilot study was to compare clinical examination (CE) and ultrasound (US) with high field MRI (as the reference standard) for the detection of rearfoot and midtarsal joint synovitis and secondly tenosynovitis of the ankle tendons in patients with established rheumatoid arthritis (RA)., Methods: Patients with RA (as determined by the modified American College of Rheumatology (ACR) criteria) with symptoms of midfoot and rearfoot disease were recruited. Demographic data were collected. All underwent CE, US and high field MRI (with intravenous gadolinium contrast) of their right foot. Percentage exact agreement (PEA), sensitivity and specificity were calculated for CE and US when compared to MRI. Inter-reader reliability for CE and US was also assessed., Results: Compared to the gold standard of MRI, for CE (joint synovitis) the ranges for sensitivity, specificity and PEA were 55-83%, 23-46% and 46-60%, and for US were 64-89%, 60-80% and 64-78%, respectively. Compared to the gold standard of MRI, for CE (tenosynovitis) the ranges for sensitivity, specificity and PEA were 0-100%, 20-91% and 55-91%, and for US were 0-67%, 86-100% and 59-86%, respectively., Conclusion: CE was sensitive but US more specific in identifying hindfoot pathology in RA when compared to the reference standard of MRI. There was poor interobserver variability between ultrasonographers suggesting a need for standardisation of acquisition and interpretation of US images of the hindfoot.

Pes cavus is a multiplanar deformity that involves the 3 foot-joint complexes. Description of the deformity is not well standardized and the surgical management does not have a comprehensive algorithm to follow. Treatment should be tailored to the patient's requirements, foot condition, and the potential for future progression of the deformity. This study describes a heterogeneous group of patients treated surgically and followed for 5 to 28 years. The benefits and risks are discussed, together with pitfalls encountered.

Unlabelled: The best procedure for surgical correction of stage II posterior tibial tendon dysfunction has long been a source of debate among foot and ankle surgeons. A combination of endoscopic gastrocnemius recession, subtalar joint arthroereisis, and flexor digitorum longus tendon transfer has been used in an attempt to avoid some of the complications seen with calcaneal osteotomies, and to allow an earlier return to function and weight bearing. A retrospective analysis of preoperative and postoperative radiographic changes in 10 patients for whom surgical correction of the deformity was performed between 2003 and 2006 is presented as a pilot study. Seven radiographic variables considered standard for the radiographic assessment of posterior tibial tendon dysfunction were measured. The outcome measure of interest was the return of radiographic variables to normal ranges following surgical correction of the deformity. In addition, preoperative and postoperative clinical outcomes were assessed to evaluate the long-term clinical benefits of this trio of procedures. Radiographic values were noted to return to normal ranges in all cases following this trio of surgical procedures; these changes were statistically significant (P < or = .05). These preliminary results suggest that this surgical combination provides satisfactory correction of deformity in patients presenting with stage II posterior tibial tendon dysfunction., Level of Clinical Evidence: 4.

Background: Many studies have examined the relationship between long-term radiographic damage and physical function. However, it is not known if short-term radiographic progression is also associated with physical function., Aim: To investigate the longitudinal relationship between physical function and both the level of radiographic damage and the radiographic progression rate in patients with early or advanced active rheumatoid arthritis., Methods: The database for the 2-year Trial of Etanercept and Methotrexate with Radiographic Patient Outcomes (TEMPO) was used for this study. Physical function was measured by the Health Assessment Questionnaire (HAQ) score at baseline, 6 months and 1 and 2 years. Radiographs of the hands and feet, taken at the same time points, were scored by the van der Heijde-modified Total Sharp Score (TSS). The HAQ score was modelled using generalised mixed linear modelling by TSS or progression in TSS (interval 0-1 year and 1-2 years) adjusted for age, sex, treatment and disease activity., Results: After adjustment for age, sex and disease activity, both TSS and the change in TSS (progression rate) were significant determinants of the HAQ score. When radiographic progression was divided into four categories (negative, zero, minor and greater progression), results showed that HAQ scores tended to be higher with a higher rate of progression. Patients with negative progression scores had lower HAQ scores than patients with positive progression scores., Conclusions: Patients with greater radiographic damage, and those with recent radiographic progression, have a higher degree of disability.

Objective: Assess the effect of abatacept on progression of structural damage over 2 years in patients with rheumatoid arthritis who had an inadequate response to methotrexate., Methods: 539 patients entered an open-label extension of the AIM (Abatacept in Inadequate responders to Methotrexate) trial and received abatacept. Radiographic assessment of the hands and feet was performed at baseline, year 1 and year 2. At year 2, each patient's radiographs were scored for progression blinded to sequence and treatment allocation., Results: In patients treated with abatacept for 2 years, greater reduction in progression of structural damage was observed in year 2 than in year 1. The mean change in total Genant-modified Sharp scores was reduced from 1.07 units in year 1 to 0.46 units in year 2. Similar reductions were observed in erosion and joint space narrowing scores. Following 2 years of treatment with abatacept, 50% of patients had no progression of structural damage as defined by a change in the total score of < or =0 compared with baseline. 56% of patients treated with abatacept had no progression during the first year compared with 45% of patients treated with placebo. In their second year of treatment with abatacept, more patients had no progression than in the first year (66% vs 56%)., Conclusions: Abatacept has a sustained effect that inhibits progression of structural damage. Furthermore, the mean change in radiographic progression in patients treated with abatacept for 2 years was significantly lower in year 2 versus year 1, suggesting that abatacept may have an increasing disease-modifying effect on structural damage over time.

The objective of our study was to investigate the role of musculoskeletal ultrasound (US) in the assessment of hand and foot small joints in psoriatic arthritis (PsA). Thirteen consecutive patients with PsA of hands or feet underwent B-mode US using a 9- to 13-MHz transducer and simultaneous magnetic resonance imaging (MRI), bone scintigraphy and radiography. US findings were compared with radiography, MRI and scintigraphy in 190, 182 and 109 joints, respectively. To assess the sensitivity and specificity of US, radiography was considered as gold standard for the detection of erosions and osteoproliferations and MRI as gold standard for the detection of joint effusion and synovitis. US, MRI and scintigraphy had a higher sensitivity in the detection of overall joint pathology than radiography in painful and/or swollen joints (71%, 72%, 82% vs 32%) and clinically unaffected joints (17%, 21%, 9% vs 2%). US and radiography detected more erosions and osteoproliferations than MRI, with low agreement between the methods in the detection of erosions. Radiography was superior to US in the visualisation of osteoproliferations. Joint effusions and/or synovitis were more frequently detected by MRI than US. Agreement between both imaging methods was better in carpal joints, carpometacarpal joint I, metacarpophalangeal (MCP)/metatarsophalangeal (MTP) joint I, II and V than in MCP/MTP III, IV, PIP and DIP joints. Compared with MRI, radiography and scintigraphy, the specificity of US ranges between 0.84 and 0.94, depending on the joint pathology. In conclusion, the diagnostic sensitivity of US in the detection of PsA-related synovitis of hands and feet is lower than MRI and depends on the joint region. However, the low cost and the acceptable specificity suggest that US is a useful imaging method in addition to radiography in PsA of hands and feet.

Objective: Comparison of performances of 5 (semi)automated methods in measuring joint space width (JSW) in rheumatoid arthritis., Methods: Change in JSW was determined by 5 measurement methods on 4 radiographs per patient from 107 patients included in the COBRA trial (comparing sulfasalazine alone or in combination with methotrexate and corticosteroids). For each method the number of patients with sufficient available results was assessed (efficiency). An independent repeated measurement was carried out on a random sample of 30 patients' baseline and 1-year radiographs, to evaluate within-method reliability of change scores. Discriminatory ability (DA) of the measurement methods (between the 2 treatment arms) was compared with the DA of the Sharp-van der Heijde score (SHS) and its 2 components (erosion and JSW scores)., Results: The overall success rate varied widely between methods. Applying the chosen threshold of a minimum of 50% available joints with a change score per patient resulted in a success rate > 92% in 4/5 methods. Repeatability of measurements was good for most methods (intraclass correlation coefficient > or = 0.80 in 4/5 methods). Almost all measurement methods in 3 followup periods (12/14) showed a lower mean loss of JSW in patients from the intensive treatment group, although this was rarely statistically significant, confirming the known difference in structural damage. JSW as measured by the (semi)automated systems often showed higher DA than the JSW score of the SHS, but was lower than the total SHS and erosion scores., Conclusion: Although efficiency of the methods should be improved further, results already show good reliability and encouraging DA of most methods. Optimal information may be obtained with a combination of scoring of erosions and (semi)automated measurement of JSW.

Objective: Treating early active rheumatoid arthritis (RA) with disease modifying antirheumatic drug (DMARD) monotherapy achieves incomplete outcomes and intensive treatment seems preferable. As the relative benefits of combining two DMARDs, one DMARD with glucocorticoids and two DMARDs with glucocorticoids are uncertain we defined them in a factorial trial., Methods: A 2-year randomised double-blind factorial trial in patients with RA within 2 years of diagnosis treated with methotrexate studied the benefits of added ciclosporin, 9 months intensive prednisolone or both (triple therapy). The primary outcome was the number of patients with new erosions. Secondary outcomes included Larsen's x-ray scores, disability, quality of life and adverse events., Findings: 1391 patients were screened and 467 randomised. Over 2 years 132 (28%) changed therapy and 88 (19%) were lost to follow-up. The number of patients with new erosions was reduced by nearly half by adding ciclosporin or prednisolone (p = 0.01 and 0.03); both treatments reduced increases in Larsen's x-ray scores by over 2 units (p = 0.008 and 0.003). A further reduction in erosive damage was seen with combined use of both treatments. Their effects on erosive damage appeared independent. Triple therapy reduced disability and improved quality of life compared with methotrexate; ciclosporin and prednisolone acted synergistically. More patients withdrew because of adverse events with triple therapy, without an increase in serious adverse effects., Conclusions: This study confirms the existence of a "window of opportunity" in early RA, when intensive combination therapy produces sustained benefits on damage and disability. Although methotrexate-prednisolone combinations reduce erosive damage, the synergistic effect of two DMARDs is needed to improve quality of life.

The aim of this article was to review the current status of ultrasound imaging of patients with rheumatological disorders of the hands and feet. Ultrasound machines with high-resolution surface probes are readily available in most radiology departments and can be used to address important clinical questions posed by the rheumatologist and sports and rehabilitation physician. There is increasing evidence that ultrasound detects synovitis that is silent to clinical examination. Detection and classification of synovitis and the early detection of bone erosions are important in clinical decision making. Ultrasound has many advantages over other imaging techniques with which it is compared, particularly magnetic resonance. The ability to carry out a rapid assessment of many widely spaced joints, coupled with clinical correlation, the ability to move and stress musculoskeletal structures and the use of ultrasound to guide therapy accurately are principal amongst these. The use of colour flow Doppler studies provides a measure of neovascularisation within the synovial lining of joints and tendons, and within tendons themselves, that is not available with other imaging techniques. Disadvantages compared to MRI include small field of view, poor image presentation, and difficulty in demonstrating cartilage and deep joints in their entirety. Contrast-enhanced magnetic resonance provides a better measure of capillary permeability and extracellular fluid than does ultrasound. The ability to image simultaneously multiple small joints in the hands and feet and their enhancement characteristics cannot be matched with ultrasound, though future developments in 3-D ultrasound may narrow this gap. Magnetic resonance provides a more uniform and reproducible image for long-term follow-up studies.

The anti-TNF-alpha chimeric monoclonal antibody infliximab is the first biologic to be approved for rheumatoid arthritis (RA) in Japan, and post-marketing surveillance of all of the Japanese cases treated with infliximab has been conducted to explore the safety of infliximab therapy. In addition, a retrospective clinical study on the notable efficacy and related factors of infliximab therapy in an RA management group in Japan (RECONFIRM and RECONFIRM-2) has demonstrated clinical responses. However, information on the effect of infliximab on joint destruction in Japanese RA patients remains insufficient. In this study, we retrospectively analyzed X-ray data from 67 patients in whom both hand and foot X-rays at baseline and at 54 weeks had been available among the 410 cases in the RECONFIRM-2 study. By scoring the X-rays according to the modified van der Heijde (vdH)-Sharp method, we found that the total vdH-Sharp score in the RA patients before infliximab therapy was 104.40+/-87.34 and the yearly progression was 21.33, indicating relatively rapid progression. After infliximab therapy for 54 weeks, the total vdH-Sharp score at 54 weeks was 104.37+/-86.87 and the estimated yearly progression was -0.03, indicating the almost complete inhibition of progression. The RECONFIRM-2J study confirmed the significant ability of infliximab to halt joint destruction in Japanese RA patients, and showed that joint destruction was significantly associated with disease activity and the dose of MTX in the patients with moderate and advanced disease durations, respectively, before infliximab therapy.

Aim: To estimate potentialities of early diagnosis of rheumatoid arthritis (RA) diagnosis in clinical practice in the course of the RADICAL program., Material and Methods: Of 366 patients participating in the trial 61 (16.7%) were males and 305 (83.3%) were females at the age of 47.76 +/- 14.1 years. The longest duration of the symptoms before consulting a doctor was 51 weeks, mean duration--5.7 weeks, 55% patients had the symptoms for 3 weeks. All the patients have undergone laboratory examination including leukocyte count, platelet count, estimation of ESR, concentration of C-reactive protein (CRP), rheumatoid factor (RF) and antibodies to a cyclic citrullated peptide (ACCP); roentgenography of the wrists and feet. On demand, antinuclear factor (ANF) and HLA-B27 were investigated. RA was diagnosed on the basis of ACR classification criteria. If the criteria were not complete at the moment of the study, the patient was referred to the group of "undifferentiated arthritis" (UA). The patients were examined before the treatment, 6 and 12 months later. The treatment was made according to Russian clinical recommendations., Results: Prior to admission to hospital, 58% patients were suspected for RA, 18.3%--osteoarthrosis (OA), 14%--reactive arthritis. 18.9% were not diagnosed, other diagnoses were considered in 12.6% patients. At primary examination RA was diagnosed in 212 (57.9%) patients, UA was in 133 (36.3%) patients, 21 (5.7%) patients had other diagnoses. Twelve months later RA, UA and other diseases were diagnosed in 256 (69.9%), 70 (19.1%) and 40 (10.9%) patients, respectively., Conclusion: A 3-stage algorithm of early RA diagnosis is proposed. At the stage of the first contact with the patient in an outpatient clinic a valid RA suspition with consideration of modified EULAR criteria must be formulated. At the second stage a district rheumatologist must examine the patient outpatiently with determination of ACR classification criteria. In diagnosis verification the treatment must be started according to APP and EULAR clinical recommendations. If RA diagnosis can not be verified or rejected, the patient must be refered to hospital (stage 3). If verification of RA diagnosis is impossible, the diagnosis should be formulated as UA.

Background: This study compared the effects of lateral column lengthening and medial translational calcaneal osteotomy on pedal realignment and degeneration of adjacent hindfoot joints noted on radiographs., Methods: Forty patients who had either a lateral column lengthening (25 feet) or calcaneal osteotomy (17 feet) to reconstruct a flatfoot were retrospectively reviewed as two groups. Six parameters of foot alignment were measured from weightbearing preoperative, early postoperative, and latest followup radiographs. The magnitude of realignment achieved initially and preserved at latest followup was determined for each group. The talonavicular and subtalar joints were graded for radiographic evidence of arthritis before the reconstruction and at latest followup. Demographic information, complication rate, and reoperation associated with each group also were determined by chart review., Results: The group that received a lateral column lengthening demonstrated a greater initial realignment than the group treated with a calcaneal osteotomy. The lengthening group also demonstrated greater realignment than the osteotomized group when they were compared at their respective latest followup. The lengthening group had a higher number of adjacent joints with progression of arthritis. The rate of nonunion was higher with a lateral column lengthening; however, the rate of reoperation after an osteotomy was more than twice that observed after a lateral column lengthening., Conclusions: The lateral column lengthening group achieved greater realignment initially and maintained correction better over time than the calcaneal osteotomy group while having a lower reoperation rate despite a higher incidence of nonunion and radiographic progression of adjacent joint arthritis.

Objective: To study interleukin (IL)-1beta levels in recent onset RA patients treated either with combination DMARD therapy (sulfasalazine, methotrexate, hydroxychloroquine) or a single DMARD therapy., Methods: Serum IL-1beta levels were measured before the treatment and 6 months after the institution of either single or combination DMARD therapy using a high sensitivity ELISA method. Radiographic evaluation of the hands and feet was performed at 0 and 24 months., Results: Significant correlations (r = 0.28, 95% CI 0.10-0.45) were found between IL-1beta levels measured at 0 and 6 months. The IL-1beta levels at 0 months correlated significantly (r = 0.23, 95% CI 0.03-0.4, p= 0.021) with the baseline number of eroded joints at 0 months but not with radiographic joint damage at 24 months. The baseline level of IL-1beta was a better indicator for the presence of eroded joints than the baseline level of serum CRP. No significant changes in IL-1beta levels were observed during the first 6 months of anti-rheumatic treatment in either group. No statistically significant difference between IL-1beta levels in the patients with or without the shared epitope could be observed., Conclusions: The serum IL-1beta level is significantly associated with the presence of erosions at the onset of RA but its predictive value is attenuated or lost when single or combination DMARD medication is instituted. Measuring IL-1beta at the time of diagnosis in a single patient cannot be used to estimate the erosive nature of the disease or the prognosis.

Objective: To evaluate the ability of tocilizumab (a humanised anti-IL-6 receptor antibody) monotherapy to inhibit progression of structural joint damage in patients with RA., Methods: In a multi-centre, x ray reader-blinded, randomised, controlled trial, 306 patients with active RA of <5 years' duration were allocated to receive either tocilizumab monotherapy at 8 mg/kg intravenously every 4 weeks or conventional disease-modifying antirheumatic drugs (DMARDs) for 52 weeks. Radiographs of hands and forefeet were scored by the van der Heijde modified Sharp method., Results: Patients had a mean disease duration of 2.3 years and a disease activity score in 28 joints of 6.5 at baseline. Mean total modified Sharp score (TSS) was 29.4, which was very high despite the relatively short disease duration. At week 52, the tocilizumab group showed statistically significantly less radiographic change in TSS (mean 2.3; 95% CI 1.5 to 3.2) than the DMARD group (mean 6.1; 95% CI 4.2 to 8.0; p<0.01). Tocilizumab monotherapy also improved signs and symptoms. The overall incidences of AEs were 89% and 82% (serious AEs: 18% and 13%; serious infections: 7.6% and 4.1%) in the tocilizumab and DMARD groups, respectively., Conclusion: Tocilizumab monotherapy was generally well tolerated and provided radiographic benefit in patients with RA.

Background: Smoking is a well-established environmental risk factor for the development of rheumatoid arthritis (RA). However, it remains unclear whether smoking influences RA disease progression and whether smokers have more radiographic damage progression than non-smokers over time., Objective: To compare the rates of radiographic damage progression in current smokers and non-smokers in a large prospective RA cohort., Methods: The SCQM-RA is a population-based registry monitoring disease activity, radiographic damage and symptoms at regular intervals. All patients in the SCQM-RA database with sequential plain radiographs were included. Joint erosions were assessed in 38 hand and foot joints with a validated scoring method. The rate of erosion progression was analysed using multivariate longitudinal regression models and adjusted for potential confounders., Results: 2004 RA patients with a mean of 3.6 sequential radiographs and 3.1 years of follow-up were included. The 545 (27%) current smokers smoked on average 16 cigarettes per day and had a mean past smoking exposure of 20.6 pack-years. Radiographic joint damage progressed at a similar rate in current smokers and non-smokers (p = 0.26). However, smoking intensity was associated with a significant inverse dose-response; heavy smokers (>1 pack-day) progressed significantly less than non-smokers or moderate smokers (p<0.001)., Conclusion: Radiographic joint damage progressed at an equivalent rate in smokers and non-smokers. Furthermore, a significant trend was observed for reduced radiographic progression and generally more favourable functional scores among heavy smokers, suggesting that cigarette smoke does not accelerate RA disease progression.

Objective: To investigate the predictive value of the distribution of inflamed joints at first presentation for the severity of the disease course in rheumatoid arthritis (RA)., Methods: Of the 1009 consecutive patients included in the Leiden Early Arthritis Clinic (Leiden, The Netherlands), 285 patients fulfilled the American College of Rheumatology criteria for RA within 1 year of follow-up. Of these, 28 patients achieved remission. Radiographs of hands and feet were scored according to the Sharp-van der Heijde method, and the 28 patients with the most destructive disease were selected. The distribution of inflamed joints of the patients with the extreme disease courses was compared. The association between the distribution of inflamed joints and the level of destruction of the joints of hands and feet in the whole group of patients with RA was assessed using regression analysis., Results: Comparison of patients with extreme disease courses using univariate and logistic regression analyses showed that arthritis of the large joints - in particular, the knee - was associated with severe RA. In the whole group of patients with RA, the total number of swollen joints and the presence of knee arthritis were associated independently with the level of destruction of the small joints. Patients with RA with knee arthritis had higher C reactive protein (CRP) levels than patients without knee arthritis, and investigating the distribution of inflamed joints together with other variables yielded the number of swollen joints, CRP, presence of anti-cyclic citrullinated peptide antibodies and symptom duration as predictors for severity of RA., Conclusion: Arthritis of large joints - in particular, the knee - at first presentation is associated with a destructive course of RA.

Background: Because an increasing number of clinical trials evaluating disease-modifying antirheumatic drugs in rheumatoid arthritis (RA) emphasise radiographic outcomes as a primary outcome, using a reproducible radiographic measure should be placed at a premium., Aim: To evaluate the reporting of radiographic methods in randomised trials assessing radiographic outcomes in RA., Methods: Medline was searched for randomised controlled trials assessing radiographic outcomes published between January 1994 and December 2005 in general medical and specialty journals with a high impact factor. One reader extracted data (radiographic acquisition, assessment and reproducibility) using a standardised form., Results: A total of 46 reports were included in the analysis. The mean (SD) methodological quality scores on the Jadad scale (range 0-5) and the Delphi list (0-9) were 2.9 (1.2) and 6.4 (1.3), respectively. Use of a standardised procedure for the acquisition of the radiographs was reported in 2 (4.3%) articles. 2 (4.3%) reports indicated that the quality of the radiographs was evaluated. In 65.2% of the reports, > or = 2 radiographic scores were used. Reporting of radiographic assessment was well detailed for number of readers (91.3%), information on readers (71.7%), blinding (91.4%) and how films were viewed (74.0%). The reproducibility of the reading was reported in 39.1% of the articles., Conclusion: The reporting of results of randomised controlled trials of radiographic outcomes in RA shows great variability in radiographic scores used. Reporting of radiographic methods could be improved upon, especially the acquisition procedure and the reproducibility of the reading.

Background: Increasing age at onset has been associated with worse outcome in rheumatoid arthritis, although there are few data from unselected inception cohorts., Hypothesis: Increasing age is associated with a higher risk of erosions at presentation, and this increase is not explained by age-related disease confounders., Subjects and Methods: 222 subjects (median onset age 59 years) were studied from a primary-care-based register of new-onset inflammatory polyarthritis. Patients had hand and feet radiographs taken within 12 months from symptom onset. Films were scored by two readers using the Larsen score. The risk of erosions in those aged 50-69 and >or=70 years at onset was compared with the risk in those aged <50 years both before and after adjustment for possible age-related disease confounders., Result: The prevalences of erosions were 22%, 52% and 71% in those aged <50, 50-69 and >or=70 years at onset equivalent to odds ratios (ORs) (95% confidence intervals (CIs)) of 3.5 (2.2 to 5.7) and 7.4 (4.5 to 12.1), respectively, in the two older age groups. Excluding those with proximal interphalangeal (PIP) erosions alone (due to possible osteoarthritis) did not alter these findings. Adjustments for disease characteristics using logistic regression did not attenuate these findings: adjusted ORs (95% CIs) 3.6 (2.1 to 6.1) and 6.9 (3.8 to 12.2) for age groups 50-69 and >or=70 years, respectively. The influence of age was stronger than most of the disease-related variables in predicting erosions in this cohort., Conclusion: Increasing age at symptom onset is strongly associated with higher occurrence of erosions within the first year unexplained by greater disease severity.

The objective of the present study was to test the hypothesis that experts recognize repair of erosions and, if so, to determine which, if any, morphologic features permitted them to recognize the repair. We also tested whether scoring by a standard method detected repair. Seven experienced readers of radiographs in rheumatoid arthritis were presented with 64 sets of single joints-of-interest at two time points, randomized and blinded for the correct sequence. The readers assessed which joint was better, and recorded whether any of six specific features were seen. Two independent readers, experienced in scoring by the van der Heijde-modified Sharp method who were not on the expert panel, then scored the complete films that included the joint-of-interest. The panel agreed very well on which of two joints was better, and, even though they did not know the true sequence, the panel accurately assigned a sequence slightly better than chance alone (58%) but worse than their agreement on which image was 'better or worse' (78%). The readers therefore indirectly assigned repair by choosing the second film as the best. Putative repair features were seen in cases of both repair and progression, and were not discriminatory. Similar results were obtained when the experts were presented with the entire hand or foot containing the joint-of-interest. In the third repair exercise, two independent readers who scored whole hands and feet using a standard method found a mean negative score in 22/60 joints-of-interest. All 22 joints were also scored as repair by the panel. Repair was detected reliably by a majority of the panel on viewing paired images based on a better/worse decision and assigning sequence in a set of images that were blinded for sequence by an independent project manager. In this test set of images, repair was manifested by a reduction in the size of erosion in many cases. Size was one feature that aided the experts to detect repair but cannot be the only one; the experts had to find other features to determine whether a smaller erosion was the first in a sequence of radiographs in a patient with progressive damage or was the second film in a patient exhibiting repair. The change in size of erosion was also picked up by independent readers applying the van der Heijde-modified Sharp scoring method and was reflected in their scores.

Ultrasonography (US) is a useful tool for imaging, which can be used for the assessment of joints and periarticular structures in all rheumatological disorders. In patients with pain and/or swelling of the ankle and foot, US provides information about the presence of joint effusion, synovitis, tenosynovitis, tendinosis, and tendons tears, helping in the differential diagnosis between joint or tendon/enthesis involvement. Moreover, US allows clinicians to monitor and guide needle positioning to inject pharmaceutical substances more safely and effectively even in hard-to-reach sites. US represents an accurate, safe and low-cost technique that can be used for the examination of the ankle and foot in rheumatic disorders.

Between 1999 and 2005, 23 failed total ankle replacements were converted to arthrodeses. Three surgical techniques were used: tibiotalar arthrodesis with screw fixation, tibiotalocalcaneal arthrodesis with screw fixation, and tibiotalocalcaneal arthrodesis with an intramedullary nail. As experience was gained, the benefits and problems became apparent. Successful bony union was seen in 17 of the 23 ankles. The complication rate was higher in ankles where the loosening had caused extensive destruction of the body of the talus, usually in rheumatoid arthritis. In this situation we recommend tibiotalocalcaneal arthrodesis with an intramedullary nail. This technique can also be used when there is severe arthritic change in the subtalar joint. Arthrodesis of the tibiotalar joint alone using compression screws was generally possible in osteoarthritis because the destruction of the body of the talus was less extensive. Tibiotalocalcaneal arthrodesis fusion with compression screws has not been successful in our experience.

Assessing structural damage to joints over time is essential for evaluating the effectiveness of therapeutic interventions for patients with inflammatory arthritis. Although radiography is able to quantify joint damage, the changes found with conventional radiography early in the disease course are nonspecific, and late radiographic changes are often irreversible. Although many clinical trials on drug development for children still use radiographic scales as endpoints for the study, more specific therapies have been developed for juvenile idiopathic arthritis (JIA) that would enable imaging to "fine-tune" patients to placement into specific treatment algorithms. As a result, new imaging scales to identify early abnormalities are clearly needed. Many pediatric rheumatology centers around the world persistently apply adult-designed radiographic scoring systems to evaluate the progression of JIA. Few pediatric-targeted radiographic scales are available for assessment of progression of JIA in growing joints, and the clinimetric and psychometric properties of such scales have been poorly investigated. We present a critique to the evaluative, discriminative, and predictive roles of the van der Heijde modification of Sharp's radiographic method, a scale originally designed to assess damage to joints of adults with rheumatoid arthritis, when it is applied to a pediatric population. We discuss the advantages and drawbacks of this radiographic scoring system for assessing growing joints and the ability of MRI to overcome inadequacies of conventional radiography.

Objective: Infliximab is effective in improving signs and symptoms of joint/skin involvement, functional status, and quality of life in patients with psoriatic arthritis (PsA). Using IMPACT trial data, we assessed the effect of infliximab (IFX) on structural damage in PsA., Methods: Patients with active PsA were randomly assigned to receive placebo (PBO/IFX) or infliximab 5 mg/kg (IFX/IFX) at weeks 0, 2, 6, and 14, with the primary endpoint at week 16. The PBO group received infliximab loading doses at weeks 16, 18, and 22. Thereafter, all patients received infliximab 5 mg/kg every 8 weeks through week 50. Hand/feet radiographs were obtained at weeks 0 and 50. Total radiographic scores were determined using the PsA modified van der Heijde-Sharp (vdH-S) score. Projected annual rate of progression was calculated by dividing x ray score by disease duration (years)., Results: As reported previously, 65% of infliximab treated patients versus 10% of PBO treated patients achieved an ACR20 response at week 16 (p<0.001). At week 50, 69% of patients achieved an ACR20 response. Radiographs (baseline and week 50) were available for 72/104 patients. At baseline, estimated mean annual rate of progression was 5.8 modified vdH-S points/year. Mean (median) changes from baseline to week 50 in the total modified vdH-S score were -1.95 (-0.50) for PBO/IFX and -1.52 (-0.50) for IFX/IFX patients (p = NS). At week 50, 85% and 84% of patients in the PBO/IFX and IFX/IFX groups had no worsening in the total modified vdH-S score., Conclusion: Infliximab inhibits radiographic progression in patients with PsA through week 50.

This retrospective radiographic study sought to evaluate how primary fracture line location relates to the pattern and severity of intraarticular calcaneal fractures. Preoperative lateral radiographs and semicoronal computed tomography scans of 100 displaced intraarticular calcaneal fractures (89 patients) were evaluated for Bohler's angle, Sanders classification, and calcaneocuboid, anterior, or middle subtalar articular involvement. Primary fracture line location was measured on semicoronal computed tomography views as a ratio of the width of the posterior facet. There were 60 Sanders type II (29 IIA, 29 IIB, 2 IIC), 35 type III (10 IIIAB, 9 IIIAC, 16 IIIBC) and 5 type IV fractures. The mean Bohler's angle was 10.1+/-15.6 degrees. The mean primary fracture line location was calculated to be found at 45.7+/-18.2% of the width of the posterior facet, as measured from lateral to medial. Statistical analysis found a significant association between primary fracture line location and Sanders class (r=.636; P<.001) and Bohler's angle (r=-.287; P=.005); as the fracture line moved medially, comminution increased and Bohler's angle decreased. Forty-eight percent of the fractures involved the calcaneocuboid joint; 39% involved the anterior (n=28) or middle (n=11) subtalar facets, or both. A medial primary fracture line correlated to greater involvement of the calcaneocuboid joint (r=.247; P=.015) and the anterior (r=.241; P<.001) and middle (r=.344; P=.003) facets. These results suggest that intraarticular calcaneal fractures exhibiting a medial primary fracture line are associated with a more severe fracture pattern and an increased incidence of anterior articular extension.

Objective: To study the associations between disability and health-related quality of life (HRQoL), respectively, and radiographic joint damage, disease activity, pain, and depressive symptoms among patients with rheumatoid arthritis (RA)., Methods: Data were collected through questionnaires and clinical examinations at baseline (1997) and at 2 years' follow-up among patients with RA (n = 307). Disability was measured with a validated Dutch questionnaire, derived from the Health Assessment Questionnaire (HAQ), and HRQoL with a validated Dutch version of the RAND-36, using physical (PCS) and mental (MCS) component summary scales. Multivariate linear regression analyses were performed to assess the relationship between disability or HRQoL and radiographic damage, disease activity, pain, and depressive symptoms., Results: Pain, with respect to disability and PCS, and depressive symptoms, with respect to MCS, were more important predictors than radiographic damage and disease activity., Conclusions: Daily RA practice needs to be broadened by regular assessment of disease burden from the patients' perspectives. Patient-reported measures, such as disability or HRQoL, should be incorporated for monitoring health outcomes of individual patients and for initiating and evaluating therapy.

Behçet's disease (BD) is a multisystem disease with typically nondeforming articular manifestations. Erosive arthropathy is an uncommon condition in patients with BD. We report herein an unusual case of long-standing BD with extensive erosive arthropathy radiologically mimicking psoriatic arthritis.

Among the elderly, osteoarthritis often causes chronic pain and disability. Although research has addressed the association between exercise and osteoarthritis, few studies have examined the effect of exercise on the radiographic progression of osteoarthritis. We investigated the relationship between ongoing exercise and radiographic progression of foot osteoarthritis. The first metatarsophalangeal and medial cuneiform-first tarsometatarsal joints were assessed. Joint-specific osteoarthritis radiographic progression scores were determined using four assessments: joint space narrowing, osteophytes, sclerosis, and a composite score. This cohort study included a subset of 221 men and women aged 40 to 91 years participating in a community-based osteoarthritis study. Adjusted risk estimates (95% confidence intervals) summarizing the relationship between ongoing exercise and radiographic progression in the first metatarsophalangeal joint ranged from 0.34 (0.11-0.99) for osteophytes to 0.66 (0.23-1.92) for sclerosis; because only eight individuals experienced medial cuneiform-first tarsometatarsal joint progression, these estimates were less stable, ranging from 2.41 (0.49-11.83) for composite to 4.29 (0.11-166.52) for osteophytes. Overall, our findings do not suggest that regular exercise is a risk factor for foot osteoarthritis progression. Future replication studies are warranted to confirm these findings.

A 68-year-old man presented with progressive forefoot swelling which coincided with the onset of type 2 diabetes mellitus. Imaging revealed a cystic inter-metatarsal mass containing two foreign bodies, which had been present for many years. Following aspiration of the mass, cholesterol crystals were observed on polarised microscopy. It is postulated that the development of diabetes triggered the shedding of cholesterol crystals around a long-standing quiescent foreign body granuloma.

Ankle and tibiotalocalcaneal arthrodeses are performed for the treatment of painful, arthritic, unstable, and deformed rearfoot and ankle joints. Surgical complications are not uncommon (approximately 30%); some can be attributed to poor preoperative planning and inadequate intraoperative position. Several authors have attempted to define the optimal position for ankle arthrodesis without objective multiplanar radiographic analysis and consistent reference points. This investigation explored the effects of ankle and tibiotalocalcaneal realignment arthrodeses on static lower-extremity position in 20 patients. The most common preoperative diagnosis was severe degenerative joint disease following ankle fractures and ankle instability. Seven tibiotalocalcaneal arthrodeses and 13 isolated ankle arthrodeses were performed (mean follow-up, 22 months). Average time to radiographic osseous union of the isolated ankle and tibiotalocalcaneal arthrodeses was 11 and 7 weeks, respectively. Medical complications occurred in 2 patients (10%). There were no statistically significant differences between preoperative and postoperative angular relationships. This study objectively quantifies multiplanar foot-to-leg realignment and defines the optimal clinical and radiographic positions for ankle and tibiotalocalcaneal realignment arthrodeses.

Background: Arthrodesis is the most common surgical treatment for foot and ankle arthritis. In adults, these procedures are associated with a 5% to 10% rate of nonunion. Pulsed electromagnetic field (PEMF) stimulation was approved by the Federal Drug Administration (FDA) for treatment of delayed unions after long-bone fractures and joint arthrodesis. The purpose of this study was to examine the results of PEMF treatment for delayed healing after foot and ankle arthrodesis., Methods: Three hundred and thirty-four foot and ankle arthrodeses were done. Nineteen resulted in delayed unions that were treated with a protocol of immobilization, limited weightbearing, and PEMF stimulation for a median of 7 (range 5 to 27) months. All patients were followed clinically and radiographically., Results: The use of PEMF, immobilization, and limited weightbearing to treat delayed union after foot and ankle arthrodesis was successful in 5 of 19 (26%) patients. Of the other 14 patients with nonunions, nine had revision surgery with autogenous grafting, continued immobilization, and PEMF stimulation. Seven of these eventually healed at a median of 5.5 (range 2 to 26) months and two did not heal. One patient had a below-knee amputation, and four refused further treatment., Conclusions: The protocol of PEMF, immobilization, and limited weightbearing had a relatively low success rate in this group of patients. We no longer use this protocol alone to treat delayed union after foot and ankle arthrodesis.

Objective: To investigate the effect of long term high intensity weightbearing exercises on radiological damage of the joints of the hands and feet in patients with rheumatoid arthritis (RA)., Methods: Data of the 281 completers of a 2 year randomised controlled trial comparing the effects of usual care physical therapy (UC) with high intensity weightbearing exercises were analysed for the rate of radiological joint damage (Larsen score) of the hands and feet. Potential determinants of outcome were defined: disease activity, use of drugs, change in physical capacity and in bone mineral density, and attendance rate at exercise sessions., Results: After 2 years, the 136 participants in high intensity weightbearing exercises developed significantly less radiological damage than the 145 participants in UC. The mean (SD) increase in damage was 3.5 (7.9) in the exercise group and 5.7 (10.2) in the UC group, p = 0.045. Separate analysis of the damage to the hands and feet suggests that this difference in rate of increase of damage is more pronounced in the joints of the feet than in the hands. The rate of damage was independently associated with less disease activity, less frequent use of glucocorticoids, and with an improvement in aerobic fitness., Conclusion: The progression of radiological joint damage of the hands and feet in patients with RA is not increased by long term high intensity weightbearing exercises. These exercises may have a protective effect on the joints of the feet.

The Chopart articular space was described by François Chopart (1743-1795) as a practical space for amputations in cases of distal foot necrosis. It corresponds to the limit between the anatomical hind-foot and the mid-foot. The bones involved are the talus and the calcaneus proximally, and the navicular and the cuboid distally. This space thus holds two functionally distinct entities, the anterior part of the coxa pedis (an essential functional joint) and the calcaneo-cuboidal joint,which can be considered to be an "adaptive joint" within a normal foot. Trauma to this region may cause fractures and/or dislocations and, in high energy trauma,compartment syndromes. Principles of treatment are immediate reduction of dislocations and realignment of the medial and lateral column of the foot in length and orientation. Open reduction and internal fixation of talus and navicular fractures are often indicated to restore the "coxa pedis". Open reconstruction or fusion in correct length of the calcaneo-cuboidal joint is occasionally indicated. Salvage procedures in malunions include navicular osteotomies and calcaneo-cuboidal bone block fusions. Treatment of joint destructions, especially involving the talo-navicular joint, include triple arthrodesis.

Despite appropriate acute treatment, many foot and ankle injuries result in posttraumatic arthritis. Arthrodesis remains the mainstay of treatment of end-stage arthritis of the foot and ankle. An understanding of the biomechanics of the foot and ankle, particularly which joints are most responsible for optimal function of the foot, can help guide reconstructive efforts. A careful history and physical examination, appropriate radiographs, and, when necessary, differential selective anesthetic blocks help limit fusion to only those joints that are causing pain. Compression fixation, when possible, remains the treatment of choice. When bone defects are present, however, neutralization fixation may be necessary to prevent a secondary deformity that could result from impaction into a bone defect.

To quantitatively evaluate the shape of the transverse arch in the forefoot with hallux valgus, a method for axial imaging and analysis of the forefoot has been developed. A foot was imaged at 30 degrees of flexion. A two-dimensional coordinate system was established by drawing a vertical line on the X-ray image through the lowest point of the head of the second metatarsal. The origin was set at the intersection between the plane of the base of the foot and this vertical line. A control group of 51 feet from 29 normal subjects and a test group of 59 feet from 34 subjects with hallux valgus were examined. Compared with the normal group, the heads of the first, second, and third metatarsal bones were lower in the hallux valgus group, and their sesamoids were shifted outward with a rotational deviation. There was a statistical correlation between the degree of outward dislocation of the fibular sesamoid bone and the hallux valgus angle. The position of the fibular sesamoid bone become higher than the head of the first metatarsal when the angle of the hallux valgus exceeded 25 degrees.

Unlabelled: 99mTc-Sulesomab, the Fab fragment of anti-NCA-90, is used as an in vivo granulocyte labeling agent for imaging inflammation. It is not clear to what extent it targets cells that have already migrated into the interstitial space of an inflammatory lesion as opposed to circulating cells. The contribution to signal of radioprotein diffusion in the setting of increased vascular permeability is also poorly documented., Methods: We compared the local kinetics of (99m)Tc-sulesomab and (99m)Tc-labeled human serum albumin (HSA), which have similar molecular sizes, in 7 patients with orthopedic infection proven by clearly positive (111)In-leukocyte scintigraphy. (99m)Tc-Sulesomab and (99m)Tc-HSA were administered in sequence separated by an interval of 2-6 d. Images were obtained 1, 3, 4, and 6 h after injection, and multiple venous blood samples were obtained for blood clearance measurement. Patlak-Rutland (P-R) analysis was performed to measure lesion and control tissue protein clearance. Target-to-background tissue (T/Bkg) ratios were calculated for each radioprotein and compared with the T/Bkg ratio for (111)In-leukocytes. (99m)Tc-Sulesomab binding to granulocytes was measured in vitro and ex vivo and to primed and activated granulocytes in vitro., Results: After intravenous injection, <5% of the circulating radioactivity was cell bound with both radioproteins so that the P-R curves could therefore be assumed to represent extravascular uptake of free protein. The blood clearance (mean +/- SD) of sulesomab was 23.4 +/- 11.7 mL/min, approximately 5 times greater than that of HSA, for which it was 4.8 +/- 3.1 mL/min. Likewise, clearance into the lesion of sulesomab was consistently higher than that of HSA, on average about 3 times as high. Nevertheless, the T/Bkg ratios for sulesomab and HSA were similar, except at 6 h when that of HSA (2.14 +/- 0.6) was higher than that of sulesomab (1.93 +/- 0.5; P approximately 0.01). Both values were considerably less than the T/Bkg ratio on the (111)In-leukocyte images, which, at 22 h, was 12.3 +/- 5.3. Moderate clearance of sulesomab, but not HSA, was seen in the control tissue. Granulocytes bound significantly more (99m)Tc-sulesomab in vitro when primed or activated., Conclusion: (a) Sulesomab does not localize in inflammation as a result of binding to circulating granulocytes; (b) sulesomab is cleared into inflammation nonspecifically via increased vascular permeability; nevertheless, it may be cleared after local binding to primed granulocytes or bind to activated, migrated extravascular granulocytes; and (c) HSA produces a similar or higher T/Bkg ratio than sulesomab because sulesomab is cleared into normal tissues and because image positivity in inflammation is significantly dependent on local blood-pool expansion.