Arthritis can make the foot and ankle so stiff and deformed it's impossible to walk. Surgery can fix the problem but for some patients, the procedure has been too risky. That's changed.
Until her surgery, Barb Hartlaub had a very painful foot deformity.
“Right now it’s, it has really become good," she says. "It’s straight. Before, I was walking crooked.”
The problem was a combination of a ruptured tendon and arthritis. Over time, her arch fell. Then her heel turned out and her ankle turned so far in she was literally walking on it and she says, "I just couldn't take it anymore."
Dr. Clifford Jeng says, "Ms. Hartlaub was especially in trouble because she’s a diabetic. And in diabetics we all know that they have problems with skin and wound healing and blisters and ulcers. And so if she were to continue to walk that way, she probably would have walked through, right out of her skin.”
Fortunately, Dr. Jeng had high-risk patients like Barb in mind when he helped modify the surgery typically used to fix the problem.
He says, "The difference that we made here at Mercy Medical Center (Baltimore, MD.) over what everyone else has done in the country is that we tried to figure out how we could do it with a smaller less invasive approach.”
In the standard procedure, doctors make two incisions, one on each side of the foot. The modified version requires one incision.
"By only doing it on the one side, in the side that has a lot less tension on it, we minimized or halved her risk of having a wound healing problem,” Dr. Jeng says.
The surgery is tricky. Doctors realign the heel and foot and lock it into place with screws. Eventually the ankle fuses into a solid chunk of bone. So far, the patients who’ve had the procedure are doing fine.
Dr. Jeng performed the minimally invasive procedure on 17 study patients. The average time it took for their ankles to fuse was 11 weeks.
Supplemental Information
Fast Facts:
About 2.1 million Americans have rheumatoid arthritis.
90 percent of those with rheumatoid arthritis eventually develop symptoms in their feet. Arthritis of the hindfoot can cause severe pain, problems walking and foot deformities.
Triple arthrodesis is a technique to eliminate pain and restore alignment of the foot and ankle.
Surgeons at Mercy Medical Center in Baltimore are now using a single incision technique for triple arthrodesis.
Rheumatoid Arthritis
Rheumatoid arthritis is a type of arthritis in which the lining of a joint (synovium) becomes inflammed, causing warmth, tenderness, swelling and pain. The inflammation eventually damages the cartilage and bone in the joint. The condition is an autoimmune type disease, caused when the body’s immune system inappropriately attacks its own tissue.
According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, rheumatoid arthritis affects about 2.1 million Americans. It can develop at any age, but is most commonly diagnosed in people of middle age and older. Women are affected two to three times more often than men.
Arthritis of the Foot
The foot is made of 28 bones and 30 joints. Ligaments support the joints and muscles, and tendons help it move.
Patients with rheumatoid arthritis of the foot may experience foot pain, swelling and stiffness. Sometimes the foot feels warm. Patients may have a hard time fitting into their shoes or walking. Some people may develop corns, bunions or foot deformities.
About 90 percent of patients with rheumatoid arthritis eventually develop symptoms in their feet. Usually arthritis starts in the joints of the toes and the forefeet. Over time, the symptoms spread to the hindfeet and finally the ankles.
Treating Hindfoot Arthritis
The hindfoot consists of three joints: (1) the talocalcaneal (subtalar) joint, where the bottom of the talus (ankle bone) connects with the calcaneus (heel bone), (2) the talonavicular joint, where the talus meets the inner midfoot bone (the naviculus), and (3) the calcaneocuboid joint, where the heel bone connects to the outer midfoot bone (the cuboid).
Initially, doctors may try to treat the arthritis symptoms with pain medications, braces or canes and physical therapy. When conservative treatments don’t help, or when the patient has severe deformity, surgery may be recommended.
One type of surgery for severe rheumatoid arthritis of the hindfoot is called triple arthrodesis. Arthrodesis is a FUSION surgery, where the bones of the joint are permanently welded together. Ideally, the procedure eliminates pain and provides stability for the affected joints. In triple arthrodesis, the three joints of the hindfoot are fused.
Traditionally, triple arthrodesis is performed through two incisions, one on each side of the foot. Surgeons at Mercy Medical Center are now using a single incision approach to minimize trauma to the foot (there is only one incision to heal). Once the incision is made, the surface of the bones are cleaned and any remaining cartilage is removed. The bones are properly positioned and then held in place with screws. The procedure realigns the heel with the body and improves the patient’s step. Since foot deformity can also cause hip and knee pain, the surgery may also improve those symptoms as well.
The single incision triple arthrodesis is a technically difficult procedure and carries a higher risk of injury to nerves and blood vessels. So patients who are considering the surgery should make sure their physician has training and experience with the technique. Doctors say the procedure is ideal for patients with hindfoot arthritis who need surgery, but have problems with wound healing. For those patients, the single incision enables the body to concentrate its resources on healing just one incision. Besides rheumatoid arthritis, triple arthodesis may also be beneficial for those who have traumatic arthritis in the hindfoot (arthritis that has developed from an old injury).
Web Resources
For general information on arthritis or foot problems:
American Academy of Orthopaedic Surgeons Web site.
Arthritis Foundation Web site.
National Institute of Arthritis and Musculoskeletal and Skin Diseases Web site.
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