What is Rheumatoid Arthritis?
Rheumatoid Arthritis is a disease that affects many tissues in the body. It affects bones, joints, ligaments, tendons and blood vessels. In joints, a component of the joint lining is attacked by the body’s own immune system, as it mistakenly thinks that there is an infection. The immune system causes the release of chemicals to attack the infection and this leads to damage within the joint.
Rheumatoid arthritis causes deformities in feet. The joints can become painful and swollen. The ligaments can become damaged and stretch. The joint lining can stretch and allow abnormal joint positions. Tendons can stretch or snap. This leads to multiple deformities. The arch of the foot can collapse. Bunions can develop. Hammering and clawing of the toes can occur. The toes can dislocate. Often the patient describes a feeling of walking on marbles, and there are bony prominences on the sole of the foot.
Rheumatoid arthritics often have multiple problems in other areas too. The heart and blood vessels may be affected, and the neck may be arthritic.
If you have feet affected by rheumatoid arthritis, it is best to see an orthopaedic surgeon who specialises in foot and ankle surgery. You should have x-rays taken in a standing position – this is when deformities are worst.
How is the Surgery Performed?
How much surgery your foot requires depends on the deformities present and the symptoms. Some rheumatoid patients have dislocated toes and a severe bunion. They cannot put weight on their big toes and they feel like they are walking on marbles. They require a fusion of the great toe joint to give them a solid base, and removal of the prominence of the bones in the sole of the foot that causes a lot of pain. Wires are inserted into the toes to hold the foot in a reasonable position while the tissues heal. These remain in place for six weeks.
Some rheumatoid patients do not have such aggressive disease. They can be treated as any other patient with a bunion.
The risks of surgery are greater in rheumatoid patients compared to others because of increased wound breakdown and infection. There is also a greater risk of fusion operations failing. Anti-TNF drugs should be stopped at least 2 weeks prior to surgery and not recommenced until 4 weeks after surgery to decrease the risk of wounds not healing. Methotrexate can be continued.
The toes can end up flail and sitting off the ground as they have been shortened and there is no bony continuity in the lesser rays. This is cosmetic, but should still allow painfree walking.
Surgery is carried out under general anaesthetic, but can be carried out with local anaesthetic injections behind the knee or around the ankle. The injections are normally given while you are asleep for your comfort. They can give good pain relief for the first day after the operation. You can go home the same day in the evening.
Risks of Surgery
Bleeding, infection, poor bone healing, poor skin healing, injury to tendons, injury to nerves, recurrence, and a need for further surgery.
There is a small risk of blood clots in the legs or lungs (DVT and PE), and there are also risks from anaesthesia – the process of being put to sleep for your operation.
Risks of Anaesthesia
The injection behind your knee is given using an ultrasound machine to guide the needle. There is a less than 1% chance of injury to the nerve. General anaesthetic also carries risks. These risks are proportional to your general health. You will need to be assessed for your fitness for surgery and an Anaesthetist will be able to advise you on your individual risk.
What Happens After Surgery?
You will have had injections to numb your foot so that you are not in pain after the operation. This injection will wear off after 18-24 hours, so you must take regular painkillers so that you are not in severe pain when the injection wears off. Ibuprofen and Diclofenac should not be used for more than a few days after the operation as they can interfere with bone healing.
The pain will settle over a few weeks. You may see blood stains on the dressings. This is normal and not a cause for alarm. If blood is dripping from the dressings however, return to hospital.
The foot will be swollen as well as sore. You should keep the foot elevated as much as possible for the first two weeks. Keep walking down to a minimum – going to the toilet or for meals. Letting the leg hang down will cause the foot to become more swollen. Most of the swelling will settle within the first few months, but swelling can continue for up to one year.
If you are resting on your sofa, keep your foot elevated on the back rest or arm rest. If you are resting in bed, then place a few pillows under the foot to keep it elevated.
You have been given a special shoe that does not allow you to put weight on the front of the foot. This is because the re-set bone is held together by two screws, and putting weight on it can dislodge the screws holding the bone. You should wear this continuously for the first two weeks, including in bed. After that, you should wear it whenever you are walking, even at home. Crutches are for balance only.
After two weeks, you will be seen in the clinic and the stitches will be removed. You should perform exercises to keep the ankle mobile, but no foot exercises are required.
RETURNING TO WORK
You will be wearing the special shoe for six weeks, and we will then take an xray. I advise that you do not return to work before this, especially if you are on your feet all day at work. Most people can drive after 8 weeks. Remember that not everyone is the same, and some people take a longer time to recover from their surgery. This is especially the case for patients with rheumatoid arthritis. Please request a sick note before you leave hospital, if you need one.