Editorial Comment (1998)

This symposium on arthritis of the foot and ankle was generated by the arthritis subcommittee of the The American Orthopaedic Foot and Ankle Society. Approximately 5 years ago, this committee, under the chairmanship of Ronald Smith of Long Beach, CA, was founded. At the annual meeting of the American Academy of Orthopaedic Surgeons in Washington, DC, a group of orthopaedic surgeons with a shared interest in treatment of arthritis of the foot and ankle met to determine an agenda. At that meeting, the future of the committee was discussed and this included a publication devoted to this topic. Since that time, many discussions have been held, and there have been an abundant amount of conference calls. Finally, the symposium is being published. We hope that the many sections of foot and ankle arthritic disease discussed can be incorporated in the practicing orthopaedic surgeon's basic knowledge, so that the importance of arthritic morbidities can be understood in treating the complexities of the foot and ankle. It is difficult to treat arthritis of the foot without understanding the effects of arthritis on the ankle and vice versa. Whether this arthritis is inflammatory or noninflammatory in nature, these joints respond in concert with each other. Treatment of the morbid arthritic lesions can be frustrating and demanding. However, these complexities and frustrations must be dealt with because the pain and disability of the patients with arthritis demands empathy of the treating physician. We hope the insights and highlights printed in this text can alleviate some of this despair and produce improved functional outcomes and happier patients. The treatment of arthritis of the foot and ankle consists of nonoperative and operative measures. The nonoperative measures include rest, avoidance of the offending activities, medications, prosthetics and orthotics, and physical therapy. Surgical options for treatment include soft tissue and/or bony debridement, ligamentous reconstruction, corrective osteotomies, arthrodesis, or arthroplasty. A combination of the above treatments is at times indicated. Understanding the needs and the comorbidities of the patient must be taken into consideration. The arthritides can be part of an inflammatory process of the young and the old, or a process occurring in the middle aged. Knowledge of anatomy, biomechanics, and pharmacology need to be taken into consideration with each patient. Activities of daily living, occupational, and recreational goals must be considered in the treatment protocol. Preoperative planning, including skin incisions and use of implants, whether internal or external, should be given consideration days before surgery so that postoperative problems and complications may be avoided. Before surgical intervention, the medical aspects of the treatment of arthritis must be considered. In her article, Dr. Leslie Kerr, a rheumatologist, stresses the importance of metatarsal phalangeal joint synovitis. She thinks that this may preclude the development of a significant inflammatory disease and, in fact, may be a presenting symptom of various systemic disorders. Although many orthopaedic surgeons will depend on a rheumatologist of Kerr's credentials, it is imperative for orthopaedic surgeons to understand and to make use of the medical options mentioned in this fine paper. The section on seronegative spondyloarthropathies highlights an excellent and informative presentation from an important person on the team of professionals treating arthritis. Arthritis of the hallux metatarsal phalangeal joint may be an initial presentation for different etiologies. The work of Schon and Weinfeld present a 7-year experience of 449 surgical cases of arthritis of the metatarsal phalangeal joint of the hallux. They report on the difficulties that these patients have during their gait cycle and with obtaining proper shoewear. Their discussion includes shoe modifications, the effectiveness of physical therapy, and often the need for surgical treatment. Their indications for surgery, and their indications of the several surgical procedures that they have performed, are indicative of the complexity of treatment. Strauss, Demetriades, and Gallina discuss primary osteoarthritis. Included in their section are the many different forms of treatment and the complications associated with each. This section is meant to give a broad overview and an introduction to the more specific operative treatment of ankle osteoarthritis manifestations. The paper by Katcherian introduces a series of papers on the treatment of ankle arthrosis with an emphasis on surgical treatment. Katcherian concludes that the gold standard is an ankle arthrodesis. However, one also should consider orthotics and prosthetics and be prepared to treat patients' specific needs. The difficulty in obtaining arthrodesis of the tibiotalar joint in the rheumatoid foot led Dereymaeker and her colleagues to stress the importance of fibular strut grafting. Although the Charnley compression clamps have not been used routinely for this procedure in the United States, Dereymaeker and coworkers found the procedure indicated in a selected group of patients. Osteoporotic bone can be the enemy of the orthopaedic surgeon and this is stressed again by the authors. Their feeling is that whether an external fixator or an internal fixator is used, the possibility of adding a fibular strut graft should be considered. Historically, healing is aided by stability and stability leads to healing. Although many orthopaedic surgeons do not use external fixation for arthrodesis, it may be interesting, or tempting to add the fibular strut graft to internal fixation procedures, if additional stability is needed. Felix and Kitaoka discuss the treatment of the painful ankle associated with rheumatoid arthritis. In a series of 21 patients, they report a surgical union rate of 96%. The rate of surgical union and associated complications in their series are comparable with arthrodesis for posttraumatic and degenerative osteoarthritis. Interesting, Felix and Kitaoka's results of techniques of internal fixation and external fixation were comparable. The satisfaction of their patients was high in this most difficult and demanding group of patients. Felix and Kitaoka allude to the good short term results for total ankle arthrosplasty in patients with rheumatoid arthritis. However, their 5-year followup points to a high failure rate. They report that their failure rates were similar for rheumatoid arthritis and osteoarthritis with a 10-year survival rate of 60% with one type of prosthesis and a 12-year survival of 70% with another design. Thus, their conclusion was that arthrodesis provides a more reliable result and remains their standard of treatment. The role of arthroscopy in ankle and subtalar degenerative joint disease continues to expand and, in fact, to become an important part of diagnostic and operative therapy. The paper by Cheng and Ferkel is well balanced and gives a favorable representation of the issues of arthroscopy, including reports of favorable and unfavorable results. As stated by the authors, subtalar arthroscopy is still in its infancy. It is being used more and more for patients with chronic pain and for patients with obvious disease. An important message is that arthroscopic debridement of the subtalar joint continues to evolve and the authors consider it experimental at this time. Arthritic involvement of the hindfoot can lead to progressive deformity, usually valgus, of the calcaneus, which can lead secondarily to loss of the longitudinal arch. Rupture of the posterior tibial tendon, more common in inflammatory arthritis, also can lead to the above mentioned problems. Thus, subtalar arthrodesis as described by Sammarco and Tablante and by Donatto is an important section for hindfoot treatment. Sammarco and Tablante discuss in detail isolated subtalar arthrodesis. However, highlights of their paper include the value of posterior tibial tendon reconstruction and isolated talonavicular capsulotomy. The positive results that the authors report are encouraging, but the surgeon who occasionally performs this procedure should understand the potential pitfalls. The eloquent section of hindfoot treatment offered by Donatto gives an excellent biomechanical review of the complexities of hindfoot surgery. As stated by Donatto, triple arthrodesis has long been considered a standard operation for arthritis of the hindfoot, a review of the literature and personal opinion suggests that triple arthrodesis should be reserved as a salvage procedure. It is thought that it only should be used in cases of multiple joint involvement or complex deformity. Donatto thinks that a limited arthrodesis leads to a more supple foot and may in fact better preserve the ankle joint. This should be given significant consideration in planning hindfoot surgery. In most office practices the management of heel pain can be discouraging. Various forms of treatment, including medication, orthotics, physical therapy, night splinting, and other modalities can yield less than perfect results. The work of Geppert and Mizel strengthens the need to understand the systemic conditions associated with heel pain. The importance of knowing noninflammatory and inflammatory arthritides should not be underestimated. This section is of significance to the practicing orthopaedist and the foot and ankle specialist. It makes one think about how heel manifestations need to be worked up and then treated systemically. The importance of taking a good history and understanding the pathophysiology of seronegative spondyloarthropathies and remembering that heel pain is considered a hallmark presentation is stressed. Many orthopaedists should review the section more than once to have an appreciation of this special group of patients. The paper on the use of prescription footwear is extremely important because of the lack of time that is given to this particular area in most clinical settings, including residency programs. Many orthopaedic surgeons count on the pedorthist to be able to solve many of the problems that are presented by the patient. However, understanding proper prescriptions and the reason for these prescriptions can be obtained from the paper by Janisse. He stresses the importance of conservative treatment and the fact that the pedorthist can solve many intricate problems in the patient with arthritis. The review of hemochromatosis of the foot and ankle by Bailey and Gardner reminds us of the arthropathies associated with systemic disease. Consultations are requested from medical colleagues for joint manifestations. The importance of underlying pathophysiology and systemic manifestations can alert the orthopaedist to be more astute with joint arthrosis presentations. In these cases, the problem becomes easy once the diagnosis is made. The last section on Charcot neuroarthropathy reminds us of the challenge of treating patients with neuroarthropathy and that the treatment is not agreed on. Complications with and without operative intervention are discussed. The large numbers of patients investigated by Schon and his associates perhaps indicates the need to centralize these patients to orthopaedists with a long track record of dealing with this complex group. The complications of treatment of this group is even more demanding and can lead to patient and physician dissatisfaction. Newer methods, invasive and noninvasive, are being investigated and used in this group. Strauss and Gonya reveal early results with low intensity ultrasound as an adjunct in this difficult disease. Perhaps the future will be more satisfying than the past. Inflammatory and noninflammatory arthritis is a significant aspect for the daily practice of the foot and ankle surgeon. The lower extremity is the foundation of the musculoskeletal system. Thus, any disability, no matter how slight, will cause symptomatology affecting ambulation. Many forms of inflammatory arthritis can be debilitating and can be painful even in a nonweightbearing position. We hope that this symposium does justice to this very demanding and intense area of specialization. Many thanks to the contributing authors for their expertise and their willingness to share their vast knowledge and experience. Elton Strauss, MD Department of Orthopaedic Trauma and Reconstructive Surgery; Mount Sinai School of Medicine; New York, NY John Missirian, MD San Francisco, CA