FOOT & ANKLE INTERNATIONAL
Copyright  2004 by the American Orthopaedic Foot & Ankle Society, Inc.
A Review of Rheumatoid Arthritis Affecting the Foot and Ankle
ABSTRACT
Rheumatoid arthritis is a systemic disease that often
affects the foot and ankle. Approximately 20% of patients
with rheumatoid arthritis present initially with foot and
ankle symptoms, and most patients will eventually develop
foot and ankle symptoms. Although early intervention
includes conservative measures, operative treatment
often is needed to adequately treat rheumatoid patients.
Treatment of foot and ankle problems in patients with
rheumatoid arthritis is directed to maintaining ambulatory
capacity. This article reviews the clinical presentation,
evaluation, and treatment of rheumatoid arthritis affecting
the foot and ankle.
Key Words: Rheumatoid Arthritis; Forefoot; Midfoot; Hind-
foot; Review.
INTRODUCTION
Rheumatoid arthritis (RA) can be a devastating
systemic disease, which may have widespread muscu-
loskeletal manifestations. Although the cause of the
disease remains unknown, advancements have been
made in understanding the mechanism of the disease.
RA has been strongly associated with the class II
major histocompatibility complex, specificity human
lymphocyte antigen DR4, and it has been hypothe-
sized that a viral infection, either directly or indirectly,
may trigger the inflammatory reaction.42,74 Regardless
of the etiology, the final common pathway of joint
destruction results from T-cells (and B-cells) inciting
up-regulation of endothelial adhesion molecules, and
leukocyte migration into proliferative synovial tissue,
1
The Orthopedic Center, Savannah, GA.
2
Private Practice, Oakland, CA
Corresponding Author:
Juha I. Jaakkola, M.D.
210 East DeRenne Avenue
Savannah, GA 31405
Email: juhajaakkola@yahoo.com
For information on prices and availability of reprints, call 410-494-4994 X226
866
Downloaded from fai.sagepub.com at Bobst Library, New York University on May 15, 2015
Juha I. Jaakkola, M.D.1 ; Roger A. Mann, M.D.2
1 Savannah, GA; 2 Oakland, CA
and stimulating chondrocytes and synovial fibroblasts
to release degradative enzymes (e.g. proteases).42,74
The clinical course of rheumatoid arthritis follows
one of three variants. The most destructive and
least common type is the progressive variant (10%),
which follows a progressive destructive course without
remission.74 Patients with a monocyclic course (20%)
have a single episode of synovitis that lasts several
months but does not cause permanent articular injury.74
Most (70%), however, develop a polycyclic course
with multiple episodes of synovitis with intermit-
tent remissions.
EPIDEMIOLOGY
The prevalence of rheumatoid arthritis has been
estimated to be between 0.5 to 1.0% in North America
and Europe,23 and in 1998 it was estimated that there
were 4 to 6 million cases in the United States.74 The
disease is two to four times more common in women
than in men, and is least common in young men.23,42
The prevalence of RA has been reported to increase
with age, with patients over 65 to 70 years old having
the highest prevalence.23
CLINICAL PRESENTATION
The initial presentation of rheumatoid arthritis often
is pain in the foot and ankle. Vainio86 reported that, of
1000 patients admitted for the treatment of RA, 16%
had symptoms initially in the foot and ankle. In another
report, 19% of 102 patients with RA initially presented
with foot and ankle symptoms.25 In time most patients
with RA will have complaints of symptoms in the foot
and ankle. Vainio86 reported a 91% prevalence of foot
and ankle symptoms in female rheumatoid patients
and 85% in male patients in an inpatient setting, while
another study54 noted a 94% prevalence of foot and
ankle symptoms in an outpatient setting.
Foot & Ankle International/Vol. 25, No. 12/December 2004
Forefoot involvement has been reported to occur
more often in patients with RA for less than 1 year’s
duration, while hindfoot involvement is more prevalent
later in the disease. Fleming et al.25 reported that the
site of onset of RA was the foot in 13% of patients
and the ankle in 6% of patients with RA for less than
a year. Michelson et al.54 reported that 42% of patients
thought their ankle symptoms were worse than their
forefoot symptoms 13.5 years after diagnosis of RA;
and 28% thought their forefoot symptoms were worse.
The prevalence of midfoot and hindfoot symptoms is
about half that of forefoot and ankle symptoms.27,54,88
Although midfoot changes frequently are seen on
radiographs of patients with RA, symptoms are far less
common. Vidigal et al.88 reported radiographic changes
in the tarsometatarsal joints in 62% of 204 feet, only
27% of which were painful. Similarly, the subtalar joint
was clinically involved in only 21% of feet, even though
radiographic changes were present in 32%.
CLINICAL EVALUATION
It is important to begin with a thorough history and
physical examination of the lower extremity including
gait. Although most patients present with a previous
diagnosis of RA, a number of patients present first with
foot and ankle complaints. To ensure that these patients
obtain the appropriate treatment to delay or prevent
severe joint destruction and deformity, an appropriate
diagnosis is essential. Often the appropriate laboratory
tests are essential to confirm the diagnosis of RA such
as rheumatoid factor, ANA, and ESR and CRP.
Radiographic examination routinely includes weight-
bearing anteroposterior, lateral and medial oblique
views of the foot and anteroposterior, lateral, and
anterior mortise views of the ankle.
NON-ARTICULAR MANIFESTATIONS
Soft tissue manifestations include synovitis, bursitis,
tendinitis, fasciitis, neuritis, and vasculitis.63
The incidence of tendinitis in patients with RA is
somewhat controversial. Although any tendon can be
inflamed, involvement of the posterior tibial tendon
(PTT) has received the most attention. Hindfoot valgus
and pes planus are common findings in patients
with RA,31,54,75,88 but controversy exists whether the
deformity is caused by PTT dysfunction or ligamentous
laxity secondary to RA. Michelson et al.54 reported
a 64% occurrence of pes planus and determined
that 11% had PTT dysfunction based on physical
examination. ‘‘Rheumatoid flatfoot’’ caused by PTT
rupture identified by magnetic resonance imaging and
ultrasound was reported in two patients (confirmed
Downloaded from fai.sagepub.com at Bobst Library, New York University on May 15, 2015
A REVIEW OF RHEUMATOID ARTHRITIS 867
operatively in one).20 However, others have stated
that the valgus deformity of the hindfoot is caused
by tarsal joint arthritis or subtalar joint inflammation
that leads to ligamentous laxity and PTT weakness.35,37
Keenan et al.35 noted that the posterior tibial muscle
had an increased intensity and duration of activity
on electromyography in rheumatoid patients with a
planovalgus deformity compared to a matched group
without hindfoot malalignment. They attributed this
finding to an attempt by the PTT to support the
collapsed arch and minimize the valgus deformity.
Another common soft-tissue lesion found in patients
with RA is the rheumatoid nodule. These nodules
typically are firm, nontender, and movable masses
measuring up to 5 cm. They often occur on extensor
surfaces and in areas of increased pressure, such as
the medial and lateral malleoli and the medial and lateral
eminences of the forefoot. Histologically, the nodules
are composed of granulation tissue, inflammatory cells
in a palisading pattern and a central area of fibrinoid
necrosis.63 Treatment consists of shoe modifications
and inserts or excision if conservative measures are
unsuccessful. Rheumatologists are now beginning to
report success in nodule shrinkage with injection of
anti-tumor necrosis factors (i.e. Enbrel).
Neurological involvement can be a generalized
neuropathy, but tarsal tunnel syndrome or an interdigital
neuroma may occur. Proposed etiologic factors include
compression from rheumatoid nodules, synovitic tissue,
tenosynovitis, vascular lesions, and valgus de-
formity.28,63,86 Grabois et al.28 found neuropathy in six
(15%) of 39 patients with RA based on nerve conduc-
tion velocities; three patients were symptomatic. The
frequency of tarsal tunnel syndrome based on electro-
diagnostic studies is reported to be between 5% and
25%; however, a clinical correlation was only found
in two of 13 patients with abnormal nerve conduction
velocities.4,28 Treatment of tarsal tunnel syndrome may
include corticosteroid injection or operative release.38
Vainio85 reported 52 patients with rheumatoid arthritis
who had resection of interdigital neuromas. He found
histologic evidence that the neuromas often were adja-
cent to rheumatoid nodules. He also reported that
early synovectomy of the metatarsophalangeal (MTP)
joint decreased the need for resection of interdigital
neuromas by five times.
TREATMENT
Pharmacologic therapy is the cornerstone of treat-
ment for all patients with RA. A variety of anti-
inflammatory and immunosuppressive medications
are available, the most common of which include
nonsteroidal antiinflammatory drugs, glucocorticoids
868 JAAKKOLA AND MANN
(i.e. prednisone), and disease-modifying antirheumatic
drugs (DMARDs). Commonly used DMARDs include
hydroxychloroquine, methotrexate, penicillamine, gold
and sulfasalazine.52 Recently an interleukin-1 receptor
agonist named anakinra (Kineret), a pyrimidine synthesis
inhibitor named leflunomide (Arava), and two tumor
necrosis factor (TNF) antagonists, etanercept (Enbrel)
and infliximab (Remicade), have been approved for the
treatment of RA. All of the new DMARDs have provided
marked improvement in the symptoms of RA; however,
because of the immunosuppressive effects of the TNF-
blocking agents and IL-1 antagonists, infection is a
major concern if surgery is considered.58 The use of
prednisone also has been shown to increase the risk of
infection.13
Several other general considerations should be kept in
mind when foot and ankle surgery is planned in patients
with RA. Patients with recent total joint replacements
should be given antibiotics preoperatively. Patients
on long-term corticosteroid therapy may have adrenal
insufficiency and may require perioperative corticos-
teroids. Although some authors suggest discontinuing
methotrexate in perioperative period,16,38 Sany et al.70
in a prospective study found no adverse affects in
patients who continued its use compared to those who
discontinued methotrexate before surgery.
Nonoperative treatment can include physical therapy,
orthotic appliances, modified shoewear, and pharma-
cologic agents. When nonoperative treatment is deter-
mined to inadequately alleviate symptoms or prevent
the progression of deformity, operative intervention
should be considered.
FOREFOOT
The forefoot is the most common site of involvement
in the lower extremity early in the course of the
RA.86,88 The most common deformity is progressive
dorsal subluxation of the lesser MTP joints with a
hallux valgus deformity. Vidigal et al.88 noted lesser MTP
joint subluxation in 77% of 104 patients, with pressure
lesions due to hammertoes in 30% and hallux valgus
deformities in 70%. However, other causes also should
be considered, such as MTP joint synovitis (without
subluxation), compression neuritis, and synovial cysts.
The progressive forefoot deformity in RA begins
with inflammation and proliferation of the MTP joint
synovium, leading to capsular distention, loss of
integrity of the stabilizing structures (the collateral liga-
ments and plantar plate), and destruction of the articular
cartilage and bone. The loss of stability of the MTP
joints makes them susceptible to deformity imposed
by muscular forces, walking forces, and constrictive
shoewear. The dorsiflexion forces exerted on the MTP
Downloaded from fai.sagepub.com at Bobst Library, New York University on May 15, 2015
Foot & Ankle International/Vol. 25, No. 12/December 2004
joints at toe-off cause a progressive subluxation and
eventual dorsal dislocation at the MTP joints. As the
proximal phalanx dislocates dorsally onto the neck of
the metatarsal, the metatarsal head is forced plantar-
ward and the plantar fat pad is pulled distal to the
metatarsal heads. Hammertoe and clawtoe formation
follow because of an imbalance between the intrinsic
and extrinsic muscles. With time, the prominent and
unprotected metatarsal heads often develop keratotic
lesions that may ulcerate.
The hallux also loses its capsular integrity, and most
often shifts into valgus, but occasionally varus. The
prevalence of valgus deformity in patients with RA
has been reported88 to be up to 70%, whereas varus
deformity is reported to be only 0.2% to 10%.23,86
Progression of the hallux valgus deformity can be
exacerbated by loss of the lateral support from the
dorsally dislocated lesser toes and hindfoot valgus.
A variety of nonoperative modalities exist to alleviate
the pain caused by the RA forefoot deformity. Patients
with hard corns over hammertoes or soft corns between
toes can be treated with toe sleeves and shoes with an
extra depth toe box. Plantar calluses can be treated with
debridement. Commercially available felt pads with an
adhesive backing (Hapad, Inc, Bethel Park, PA) also
can be used to unload areas of pressure or pain. These
pads or other soft orthoses (e.g. Plastizote) are useful
to treat plantar calluses, interdigital neuromas, MTP
joint synovitis, and prominent metatarsal heads with an
atrophic, displaced fat pad.
Frequently, the patient’s symptoms are greatly exac-
erbated by tight or otherwise improper shoes. The shoe
should be evaluated to ensure that it will accommodate
the patient’s deformity. Ideally, the shoe should have
a lace-up style upper, deep wide toe box, a firm heel
counter, and a low, soft heel. Often a walking or jogging
shoe will provide enough room to accommodate a mild
to moderate deformity and an orthotic device if neces-
sary. Patients with more severe deformities may require
an extra-depth shoe for severely dislocated lesser toes
and a soft Plastizote orthosis.
OPERATIVE TREATMENT
Operative management is indicated for patients with
pain or deformity that persists despite nonopera-
tive treatment. The operative procedures described
for the first MTP joint include treatment of hallux
valgus deformity and arthrosis with resection arthro-
plasty,3,9,10,19,32,34,87 silastic arthroplasty,77,79 metal
arthroplasty,81 and arthrodesis.32,51,66 Lesser toe defor-
mities are treated concomitantly with resection arthro-
plasty of the metatarsal head,11,30,50 base of the prox-
imal phalanx,12 or both.11,50,53 Additionally, hammertoe
Foot & Ankle International/Vol. 25, No. 12/December 2004
deformity should be corrected at surgery with either
a proximal phalangeal condylectomy or closed mani-
pulation.15
Early synovectomy as an adjunct to medicinal therapy
may delay progression of joint destruction. Aho2
reported that 20 of 21 feet with MTP joint synovitis
resistant to insoles and medical treatment became
symptom-free for an average of 18 months after MTP
joint synovectomy. Other procedures that can be
considered before a fixed deformity has occurred
include capsular releases and realignment procedures.
OPERATIVE TREATMENT OF THE HALLUX
The earliest reports of treatment of the hallux in
the rheumatoid forefoot described resection of the
MTP joint. In 1912, Hoffman34 described resection
of the metatarsal heads through a plantar approach.
Later, other authors reported removal of the base of
the hallucal proximal phalanx (Keller procedure)26 or
proximal phalanx and metatarsal head.9 Several authors
reported 60% to 90% satisfactory long-term results with
this approach.3,11,87 However, others observed frequent
recurrent hallux valgus, metatarsalgia, and recurrent
plantar callosities.14,50,51,66 Mann and Thompson51
noted that resection of the first MTP joint results
in the fat pad becoming displaced distally as the
hallux and toes are forced into dorsiflexion and lateral
deviation at toe-off. This causes the unstable toes
to assume a dorsiflexed position, with recurrence of
plantar callosities.
The use of metallic81 and silastic im-
11,18,71,77,78,79
plants has been described for the treat-
ment of hallux valgus and the degenerative changes
of the hallux MTP joint associated with RA. Although
some reports of silastic implants showed encouraging
results,57,79 others18,29 noted high rates of osteophyte
formation, osteolysis, and implant failure. The patho-
logic process leading to implant failure in these reports
was inflammatory synovitis caused by silastic wear
particle formation. The use of titanium grommets to
protect the silastic implant from abrasive wear has
improved results, but no large long-term series is
available.18,78
Arthrodesis of the MTP joint is the most popular
method of treatment of the hallux.14,50,51 An arthrodesis
provides stability to help protect the hallux and the
lesser toes from the deforming forces of gait. Gait
analysis of the foot after hallux MTP arthrodesis has
shown that lift-off begins as weightbearing progresses
to the MTP joints, thereby protecting the lesser MTP
joints from dorsiflexion forces.51 These findings have
been supported by clinical reports that have shown
definitive hallux imprints on Harris-mat studies.14,51 The
Downloaded from fai.sagepub.com at Bobst Library, New York University on May 15, 2015
A REVIEW OF RHEUMATOID ARTHRITIS 869
recommended position of arthrodesis of the MTP joint is
neutral rotation, 10 to 15 degrees of valgus, and 20 to 30
degrees of dorsiflexion in relation to the first metatarsal
or 5 to 10 degrees in relation to the floor. Raunio et al.66
reported more frequent patient dissatisfaction when the
arthrodesis was fused in less than 20 degrees or more
than 35 degrees of dorsiflexion. In the largest series with
the longest followup, Coughlin14 reported 96% good to
excellent results and a 100% fusion rate at an average
followup of 6.2 years.
Opponents of hallux MTP joint arthrodesis note that
it requires an exacting technique, causes a limitation
in shoe-wear, and may lead to arthritis of the hallux
interphalangeal (IP) joint.71,80,87 Although 21 of 33 feet
(64%) seen at followup had radiographic evidence of
degenerative arthritis of the IP joint of the hallux in the
combined series of Mann and Thompson and Mann and
Schakel, only three feet (9%) were symptomatic.50,51
In all of the patients with IP joint arthritis, threaded
Steinmann pins crossing the IP joint had been used
for internal fixation, possibly increasing the frequency
of arthritis. Coughlin14 reported a 38% prevalence of
progressive IP joint arthritis and noted that both of the
IP joints (5%) requiring arthrodesis for advanced arthritis
were initially fixed with threaded Steinmann pins; one
other IP joint with intramedullary Steinmann pins did not
require another procedure and was asymptomatic.
OPERATIVE TREATMENT OF THE LESSER TOES
In 1912, Hoffman34 described resection of the lesser
toe metatarsal heads in addition to the metatarsal
head of the hallux. This procedure was later modified
by Fowler26 and Clayton10 to include resection of
the proximal phalanx, with a variable portion of the
metatarsal head. The procedure described by Fowler26
included a partial proximal phalangectomy with beveling
of the metatarsal head; he reported a 65% success
rate in 177 cases. Other authors have reported similar
success rates with partial proximal phalangectomy.11,68
Clayton’s original article9 described a combined partial
proximal phalangectomy and metatarsal head resection
through a dorsal approach with ‘‘very satisfactory’’
results in 35 patients. The cumulative success rate
of the Clayton procedure is approximately 80% good
to excellent results,15 while Hoffman’s procedure34 of
lesser toe metatarsal head resection without proximal
phalanx resection has been reported15 to have a
cumulative success rate of 89% good to excellent
results. Coughlin14 reported 96% good to excellent
results with resection of the lesser toe metatarsal heads
in 58 feet; when resection was done with a arthrodesis
of the first MTP joint, only three feet had recurrent
plantar callosities.
870 JAAKKOLA AND MANN
Several approaches have been described for the
lesser MTP joints, including a transverse or ellip-
tical plantar incision,19,32,34,80 a transverse dorsal
incision,3,9,10,32,71 plantar and dorsal incisions,25 and
multiple dorsal longitudinal incisions.14,50,51 Proponents
of the plantar incision state that it allows for removal
of plantar calluses, reduces deformity, and offers easy
access to the plantarly displaced metatarsal heads.34,80
Proponents of the dorsal incisions state that there is
no need to risk the complications of the plantar inci-
sion, such as hypertrophic plantar scar formation and
delayed wound healing, since the plantar callosities go
away without the pressure of the metatarsal heads and
the patient can ambulate immediately after surgery.14,50
A high level of satisfaction, lower wound complica-
tions, and an earlier return to weightbearing have
been reported with dorsal incisions than with plantar
incisions.14 Multiple dorsal incisions were reported to
give a 90% success rate and low wound complication
rate (7%) in 46 feet.50,51
MIDFOOT
Although a high rate of midfoot involvement has
been shown radiographically, the prevalence of clinical
symptoms in the midfoot is low. Often symptoms in
the first tarsometatarsal (TMT) joint are not caused by
rheumatoid synovitis, but by hindfoot valgus and hallux
valgus deformities that increase the stress across this
area. Over time, the increased stress can lead to first
TMT dorsiflexion and eventually lesser toe TMT joint
abduction and dorsiflexion.
Nonoperative management of midfoot disease often
is unsuccessful because of the degree of fixed deformity
and the large plantar prominence in some patients.
An ankle foot orthosis (AFO) can be used to help
prevent disease progression and relieve stress across
the TMT joint. The brace should be built up laterally
to prevent progressive abduction deformity. Many
patients, however, poorly tolerate an AFO and often
develop skin irritation medially at a pressure point. Other
options include an accommodative arch support, a soft
orthosis (Hapad), and a UCBL (University of California
Biomechanic Laboratory) insert.
Operative management of midfoot involvement in-
volves arthrodesis of the involved TMT joints. Deter-
mining which joints to fuse can be difficult. A bone scan
or a computed tomography (CT) scan, in addition to
routine radiographs and a thorough examination, can
help determine the extent of TMT involvement. If defor-
mity is present, then realignment of the foot at surgery
is indicated. If only a single joint is involved, with little
deformity, then an in situ arthrodesis is appropriate. In
general, if the fourth and fifth TMT joints are affected,
Downloaded from fai.sagepub.com at Bobst Library, New York University on May 15, 2015
Foot & Ankle International/Vol. 25, No. 12/December 2004
the cuboid should not be fused to the lateral cuneiform;
this helps maintain flexibility. Little information is avail-
able about TMT joint arthrodesis in patients with RA, but
reports regarding treatment of other kinds of TMT joint
arthritis can be applied to RA. Mann et al.48 reported a
6-year followup of 40 patients with TMT arthrodeses,
only one of whom had a preoperative diagnosis of
RA; the other 39 patients had primary or posttraumatic
arthrosis. They reported a 93% patient satisfaction rate
and a 98% successful arthrodesis rate in 179 joints.
HINDFOOT AND ANKLE
Involvement of the hindfoot (subtalar, talonavicular,
and calcaneocuboid) and ankle in patients with RA
increases with a longer duration of disease.16,36,47,72
Spiegel and Spiegel75 noted that only 8% of patients
with RA of less than 5 years’ duration had hindfoot
deformity, but 25% had hindfoot involvement when the
RA duration was longer than 5 years. The reported75,88
prevalence of hindfoot disease in patients with RA is
21% to 29%, with subtalar joint involvement reported72
in 29%, talonavicular joint in 39%, and calcaneocuboid
joint in 25%. Clinically, the most common physical
finding is valgus deformity; varus deformity is rare.
Nonoperative treatment for involvement of the ankle
and hindfoot must consider the underlying pathology.
Patients with flexible valgus deformities caused by
hindfoot involvement may obtain relief with the use
of a semirigid arch support such as a Spenco orthosis
(Spenco, Waco, Texas), a medial heel and sole wedge,
or a UCBL insert. More often an AFO is needed to
improve alignment or to immobilize an inflamed or
arthritic ankle or subtalar joint.
OPERATIVE MANAGEMENT OF THE HINDFOOT
Rheumatoid arthritis afflicting the hindfoot often is
localized to one or two, but usually not all of the joints
of the hindfoot. Opinions differ regarding which joint
or joints should be included in the arthrodesis. Some
authors suggest that in patients without deformity and
only talonavicular joint involvement, an isolated talon-
avicular arthrodesis provides good results.7,36,43 Others
have stated that the addition of the calcaneocuboid joint
to the arthrodesis adds increased stability to the fusion
mass, with a negligible difference in loss of motion,
compared to an isolated talonavicular arthrodesis.44
Both procedures essentially eliminate subtalar motion.
The advantage of an isolated subtalar joint arthrodesis
is that the motion of the transverse tarsal joint is spared
and the frequency of degenerative joint disease of the
ankle joint is less after subtalar arthrodesis than after
triple arthrodesis.45
Foot & Ankle International/Vol. 25, No. 12/December 2004
Triple arthrodesis is indicated when disease involves
all three joints of the hindfoot or a fixed forefoot or
hindfoot deformity is present.24,64 Good results have
been reported after triple arthrodesis. Figgie et al.24
reported a 98% union rate and high satisfaction at
5-year followup of 49 rheumatoid patients who were
treated with triple arthrodesis. Pell et al.64 reported
a high rate of satisfaction and a 98% fusion rate
in 183 feet, 22 of which were in patients with RA.
However, at an average followup of 5.7 years, 60%
showed radiographic evidence of progression of ankle
joint arthritis.
OPERATIVE TREATMENT OF THE ANKLE
Ankle joint involvement can be operatively treated
with arthrodesis or arthroplasty. Arthrodesis of the ankle
joint has provided acceptable results, with high union
rates and high patient satisfaction. Several methods
of ankle arthrodesis have been described, including
external fixation,17,22,73,84 internal fixation,17,22,31,49,55,84
and both external and internal fixation.84 Ankle
arthrodesis using arthroscopic techniques also has
been reported. Turan et al.82 reported a 100% fusion
rate with no complications in 10 patients with RA, eight
of whom had ankle arthrodesis done with arthroscopic
techniques. Rates of union for ankle arthrodesis using
external fixation in patients with RA vary from 79%
to 100%.17,22,84 Felix and Kitaoka reported a 96%
union rate in 24 ankle arthrodeses (20 ankles with
external fixation); at 5-year followup of 19 patients (24
arthrodeses) 96% had mild or no pain and 92% were
satisfied with their results.22 Conversely, Cracchiolo
et al.17 reported a 79% union rate, a 33% infection
rate, and a 17% occurrence of neurapraxia in 18 ankles
with arthrodesis using an external fixator. Frequent pin
track infections and nonunions have led some authors
to recommend internal fixation rather than external fixa-
tion except in patients with deep infections.56 Excellent
results also have been reported using internal fixation
for arthrodesis. Miehlke et al.55 reported a 93% union
rate in 28 arthrodeses of the ankle joint. New implants
such as blade plates8 and new screw designs33 may
further improve results of internal fixation. However,
Uuspää and Raunio84 evaluated 148 ankle arthrodeses
in patients with RA and reported that the lowest union
rate was with internal fixation only (55% union rate)
compared to internal and external fixation (68% to 83%
union rate) and external fixation only (86% union rate).
Whether to remove22,49,84 or retain31,51 the fibula also
remains a matter of controversy.
The ideal position of arthrodesis is neutral dorsi-
flexion, 0 to 5 degrees of valgus, and rotation to
match the contralateral side. High patient satisfaction
Downloaded from fai.sagepub.com at Bobst Library, New York University on May 15, 2015
A REVIEW OF RHEUMATOID ARTHRITIS 871
and union rates are dependent on obtaining correct
alignment of the arthrodesis. Malalignment is the most
common cause of failure after triple arthrodesis60 and
ankle arthrodesis.61 Uuspää and Raunio84 reported that
only 29% of their patients’ ankles were in neutral and
60% of the fused joints looked deformed. They noted
that 49% of their patients had callosites, 40% required
support for ambulation, and 14% had pain on weight-
bearing.
Despite adequate alignment, patients with ankle
arthrodeses may have a limp and difficulty with ambu-
lation and may require shoe modifications or orthoses.
Felix and Kitaoka22 reported that of 19 patients returning
for followup only 10 (53%) were able to walk without
support and eight (42%) thought that they walked with
an obvious limp. Mann and Rongstad49 noted that 12
(16%) of 73 ankle arthrodeses required shoe modifica-
tions and five (7%) used ankle-foot orthoses.
Rheumatoid patients with severe deformity or involve-
ment of both the ankle and hindfoot may require a tibio-
talocalcaneal, tibiocalcaneal, or pantalar arthrodesis.
A pantalar arthrodesis involves fusion of the tibio-
talar, talocalcaneal, calcaneocuboid and talonavicular
joints. Occasionally a pantalar arthrodesis is necessary
to treat ankle arthrosis in a patient with a previous triple
arthrodesis, or tibiotalocalcaneal arthrodesis may be
necessary after subtalar arthritis develops in a patient
with a previous tibiotalar arthrodesis. A tibiocalcaneal
arthrodesis involves resection of a portion or all of
the talus. This may be necessary to correct a severe
valgus deformity in a rheumatoid patient with ankle
or subtalar involvement. Most studies reporting ankle
arthrodesis or hindfoot arthrodesis have included these
more extensive arthrodeses and found that union rates
are similar.19,46,67 The extensive hindfoot arthrodeses
result in a higher rate of complications and a lower level
of function than ankle joint arthrodesis and should be
reserved as a salvage procedure.1,59 Mann and Chou46
reported a 100 % union rate and seven good or excel-
lent results in nine feet with tibiocalcaneal arthrodesis
at a 40-month average followup. They also noted two
infections, two malunions, one wound slough, and
one patient with a prominent fibula, concluding that
tibiocalcaneal arthrodesis is technically difficult with a
significant risk of complications.46
Ankle arthroplasty as a treatment of advanced
ankle arthritis in rheumatoid patients may be a viable
alternative to arthrodesis. Because of the frequency
of concomitant and sequential involvement of the
hindfoot and ankle, and the poor results of pantalar
arthrodesis,1,59 maintaining tibiotalar motion may be
of great benefit to rheumatoid patients. Therefore,
a number of ankle prostheses became available in
the 1970s; the early reports were variable.21,62,69,76
The first prostheses were developed to be implanted
872 JAAKKOLA AND MANN
with cement, and they were designed to be either
constrained or semi-constrained. In the 1980s and
early 1990s, several authors reported high prevalences
of failure and cautioned against the use of total
ankle arthroplasty (TAA).6,39,83,90 At a 5.5-year average
followup of 62 TAA’s (34 for RA), Bolton-Maggs6
reported only 13 satisfactory results (21%). Although
their results were slightly better in patients with RA than
in patients with osteoarthritis (OA), they recommended
arthrodesis as the treatment of choice for all arthritic
ankles rather than TAA. Kitaoka and Patzer39 reported a
39% failure rate at 15-year followup and recommended
that the Mayo implant not be used for RA or OA of
the ankle.
The poor results of constrained prostheses leadled
to changes in implant design and operative technique.
A reduction in the mechanical constraint of the pros-
theses and conversion from cemented to cementless
techniques have resulted in lower rates of implant failure
and higher patient satisfaction. In an early report of a low
contact stress (LCS) cementless TAA, Buechel et al.5
reported that 20 of 23 ankles (87%) had complete
pain relief, with no failures at nearly 3-year followup;
however, only six of the 23 patients had RA. In a more
recent study Wood et al.89 compared a constrained
cemented prosthesis (Thompson Parkridge Richards-
TPR) to an uncemented minimally constrained pros-
thesis (Scandinavian Total Ankle Replacement — STAR)
in patients with RA. Four of six TPR prostheses were
radiographically loose at 7.2-year average followup (two
converted to arthrodesis), compared to no radiographi-
cally or clinically loose prostheses in the STAR group.89
Kofoed and Sørensen41 compared results in 25 patients
with OA and 27 patients with RA using a cemented
minimally constrained prosthesis and found that the
survivorship analysis was 72.7% and 75.5%, respec-
tively, at 14 years. Using the same STAR implants with
cementless technique, Kofoed and Lundberg-Jensen40
reported only 12 failures (revision or arthrodesis) in
100 ankle replacements with longer than 6-year median
followup; 39 patients had RA. The authors correlated
these results with good pain relief and retained ankle
range of motion.40 Using the Agility ankle prosthesis
currently available for use in the United States, Pyevich
et al.65 reported five revisions, one conversion to an
arthrodesis, and a 93% satisfaction rate in 100 TAAs;
26 patients had RA. The only outcome measure compar-
ison reported was a lower pain score for patients with
RA and primary OA than patients with posttraumatic
arthritis.65
CONCLUSION
Foot and ankle problems are common in patients with
RA, and they require timely attention and appropriate
Downloaded from fai.sagepub.com at Bobst Library, New York University on May 15, 2015
Foot & Ankle International/Vol. 25, No. 12/December 2004
treatment. Early treatment focuses on prevention and
palliative care, consisting of pharmacologic treatment,
orthoses, braces, and shoe modifications. Early oper-
ative treatment may include synovectomy of inflamed
joints. Later, surgery is used to maintain a plantigrade
foot with arthrodesis, resection arthroplasty, or replace-
ment arthroplasty of degenerated joints. The goal of all
treatment of foot and ankle problems in patients with
RA is to provide pain relief while maintaining ambula-
tory capacity.
REFERENCES
1. Acosta, R; Ushiba, J; Cracchiolo, A: The results of a primary
and stage pantalar arthrodesis and tibiotalocalcaneal arthrodesis
in adult patients. Foot Ankle. 21:182 – 194, 2000.
2. Aho, H; Halonen, P: Synovectomy of the MTP joints in rheumatoid
arthritis. Acta. Orthop. Scand. Suppl. 243:1, 1991.
3. Amuso, SJ; Wissinger, HA; Margolis, HM; Eisenbeis, CH;
Stolzer, BL: Metatarsal head resection in the treatment of
rheumatoid arthritis. Clin. Orthop. 74:94 – 100, 1971.
4. Baylan, SP; Paik, SW; Barnert, AL; Ko, KH; Yu, J; Persellin, RH:
Prevalence of the tarsal tunnel syndrome in rheumatoid arthritis.
Rheumatol Rehabil. 20:148 – 150, 1981.
5. Buechel, FF; Pappas, MJ; Iorio, LJ: New Jersey low contact
stress total ankle replacement: Biomechanical rationale and
review of 23 cementless cases. Foot Ankle. 8:279 – 290, 1988.
6. Bolton-Maggs, BG; Sudlow, RA; Freeman, MA: Total ankle
arthroplasty. A long-term review of the London Hospital
experience. J Bone Joint Surg. 67-B:785 – 790, 1985.
7. Chiodo, CP; Martin, T; Wilson, MG: A technique for isolated
arthrodesis for inflammatory arthritis of the talonavicular joint.
Foot Ankle. 21:307 – 310, 2000.
8. Chin, KR; Nagarkatti, DG; Miranda, MA; Santoro, VM;
Baumgaertner, MR; Jupiter, JB: Salvage of distal tibia
metaphyseal nonunions with the 90 degrees cannulated blade
plate. Clin. Orthop. 409:241 – 249, 2003.
9. Clayton, ML: Surgery of the forefoot in rheumatoid arthritis. Clin.
Orthop. 16:136 – 140, 1960.
10. Clayton, ML: Surgery of the lower extremity in rheumatoid
arthritis. J Bone Joint Surg. 45-A:1517 – 1536, 1963.
11. Clayton, ML; Leidholt, JD; William, C: Arthroplasty of
rheumatoid metatarsophalangeal joints:an outcome study. Clin.
Orthop. 340:48 – 57, 1997.
12. Conklin, MJ; Smith, RW: Treatment of the atypical lesser
toe deformity with basal hemiphalangectomy. Foot Ankle.
15:585 – 594, 1994.
13. Conn, DL; Lim, SS; new role for an old friend: prednisome is a
disease-modifying agent in early rheumatoid arthritis. Curr Opin
Rheumatol. 15:193 – 196, 2003.
14. Coughlin, M: Rheumatoid forefoot reconstruction: a long-term
follow-up study. J Bone Joint Surg. 82-A:322 – 341, 2000.
15. Coughlin, M: Arthritides. In Surgery of the foot and ankle, edited
by MJ Coughlin and RA Mann Ed. 7, pp. 560 – 593. St. Louis,
Mosby-Yearbook, 1999.
16. Cracchiolo, A: Rheumatoid Arthritis. Hindfoot disease. Clin.
Orthop. 340:56 – 68, 1997.
17. Cracchiolo, A; Cimino, WR; Lian, G: Arthrodesis of the ankle
in patients who have rheumatoid arthritis. J Bone Joint Surg.
74-A:903 – 909, 1992.
18. Cracchiolo, A; Weltmer, JB; Dalseth, T; Dorey, F: Arthroplasty
of the first metatarsophalangeal joint with a double-stem silicone
Foot & Ankle International/Vol. 25, No. 12/December 2004
implant. Results in patients who have degenerative joint disease,
failure of operations, or rheumatoid arthritis. J Bone Joint Surg.
74-A:552 – 5633, 1992.
19. Craxford, AD; Stevens, J; Park, C: Management of the deformed
rheumatoid forefoot. A comparison of conservative and surgical
methods. Clin. Orthop. 166:121 – 126, 1982.
20. Downey, DJ; Simkin, PA; Mack, LA; Richardson, ML; Kilcoyne,
RF; Hansen, ST: Tibialis posterior tendon rupture: A cause of
rheumatoid flat foot. Arthritis Rheum. 31:441 – 446, 1988.
21. Evanski, PM; Waugh, TR: Management of arthritis of the ankle:
An alternative to arthrodesis. Clin. Orthop. 122:110 – 115, 1977.
22. Felix, NA; Kitaoka, HB: Ankle arthrodesis in patients with
rheumatoid arthritis. Clin. Orthop. 349:58 – 64, 1998.
23. Felson, DT: Epidemiology of the rheumatic diseases. In
Koopman, WJ (ed.): Arthritis and allied conditions: a textbook of
rheumatology, Ed. 13, p. 6. Baltimore, Williams & Wilkins, 1997.
24. Figgie, MP; O’Malley, MJ; Ranawat, C; Inglis, AE; Sculco,
TP: Triple arthrodesis in rheumatoid arthritis. Clin. Orthop.
292:250 – 254, 1993.
25. Fleming, A; Crown, JM; Corbett, M: Early rheumatoid disease.
I. Onset. Ann Rheum. Dis. 35:357 – 360, 1976.
26. Fowler, AW: A method of forefoot reconstruction. J. Bone Joint
Surg. 41-B:507 – 513, 1959.
27. Fuchs, HA; Brooks, RH; Callahan, LF; Pincus, T: A simplified
twenty-eight-joint quantitative articular index in rheumatoid
arthritis. Arthritis and Rheumatism. 32:531 – 537, 1989.
28. Grabois, M; Puentes, J; Lidsky, M: Tarsal tunnel syndrome in
rheumatoid arthritis. Arch Phys Med Rehabil. 62:401 – 403, 1981.
29. Granberry, WM; Noble, PC; Bishop, JO; Tullos, HS: Use of
a hinged silicone prosthesis for replacement arthroplasty of the
first metatarsophalangeal joint. J Bone Joint Surg. 73A:453 – 459,
1991.
30. Gould, N: Surgery of the forepart of the foot in rheumatoid
arthritis. Foot Ankle. 3:173 – 180, 1982.
31. Gschwend, N; Steiger, U: Stable fixation in hindfoot arthrodesis,
a valuable procedure in the complex RA foot. In Schatten-
Kirchner, M (ed.) Rheumatology, Vol. 11, Basel, Karger, 114 – 126,
1987.
32. Hamalainen, M; Raunio P: Long term follow-up of rheumatoid
forefoot surgery. Clin Orthop. 340:34 – 38, 1997.
33. Hintermann, B; Valderrabano, V; Nigg, B: Influence of screw
type on obtained contact area and contact force in a cadaveric
subtalar arthrodesis model. Foot Ankle. 23:986 – 991, 2002.
34. Hoffman, P: An operation for severe grades of contracted or
clawed toes. Am. J. Orthop. Surg. 9:441 – 449, 1912.
35. Keenan, MA; Peabody, TD; Groley, JK; and Perry, J:
Valgus deformities of the feet and characteristics of gait in
patients who have rheumatoid arthritis. J. Bone Joint Surg. 73-
A:237 – 247, 1991.
36. Kindsfater, K; Wilson, MG; Thomas, WH: Management of
the rheumatoid hindfoot with special reference to talonavicular
arthrodesis. Clin Orthop. 340:69 – 74, 1997.
37. Kirkham, BW; Gibson, T: Comment on the article by Downey
et al. [Letter]. Arthritis Rheum. 32(3):359, 1989.
38. Kitaoka, HB: Rheumatoid hindfoot. Orthop. Clin. North America
20:593 – 604, 1989.
39. Kitaoka, HB; Patzer, GL: Clinical results of the Mayo total ankle
arthroplasty. J Bone Joint Surg. 78A:1658 – 1664, 1996.
40. Kofoed, H; Lundberg-Jensen, A: Ankle arthroplasty in patients
younger and older than 50 years:a prospective series with long-
term follow-up. Foot Ankle. 20:501 – 506, 1999.
41. Kofoed, H; Sørensen, TS: Ankle arthroplasty for rheumatoid
arthritis and osteoarthritis: prospective long-term study
of cemented replacements. J Bone Joint Surg. 80-
B:328 – 332, 1998.
Downloaded from fai.sagepub.com at Bobst Library, New York University on May 15, 2015
A REVIEW OF RHEUMATOID ARTHRITIS 873
42. Koopman, WJ: Prospects for Autoimmune Disease: Research
advances in rheumatoid arthritis. JAMA. 285:648 – 650, 2001.
43. Ljung, P; Kaij, J; Knutson, K; Pettersson, H; Rydholm, U:
Talonavicular arthrodesis in the rheumatoid foot. Foot Ankle.
13:313 – 316, 1992.
44. Mann, RA; Beaman, DN: Double arthrodesis in the adult. Clin.
Orthop. 365:74 – 80, 1999.
45. Mann, RA; Beaman, DN; Horton, GA: Isolated subtalar
arthrodesis. Foot Ankle 19:511 – 519, 1998.
46. Mann, RA; Chou, LB: Tibiocalcaneal arthrodesis. Foot Ankle.
16:401 – 405, 1995.
47. Mann, RA; Horton, GA: Management of the foot and
ankle in rheumatoid arthritis. Rheum Dis Clin North Am.
22:457 – 476, 1996.
48. Mann, RA; Prieskorn, D; Sobel, M: Mid-tarsal and
tarsometatarsal arthrodesis for primary degenerative osteo-
arthrosis or osteoarthrosis after trauma. J. Bone Joint Surg.
78-A:1376 – 1385, 1996.
49. Mann, RA; Rongstad, KM: Arthrodesis of the ankle: a critical
analysis. Foot Ankle. 19:3 – 9, 1998.
50. Mann, RA; Schakel, ME: Surgical correction of rheumatoid
forefoot deformities. Foot Ankle. 16:1 – 6, 1995.
51. Mann, RA; Thompson, FM: Arthrodesis of the first
metatarsophalangeal joint for hallux valgus in rheumatoid arthritis.
J. Bone Joint Surg. 66-A:687 – 692, 1984.
52. Matteson, EL: Current Treatment Strategies for Rheumatoid
Arthritis. Mayo Clin Proc. 75:69 – 74, 2000.
53. McGarvey, SR; Johnson, KA: Keller arthroplasty in combination
with resection arthroplasty for the less metatarsophalangeal joints
in rheumatoid arthritis. Foot Ankle. 9:75 – 80, 1988.
54. Michelson, J; Easley, M; Wigley, FM; Hellmann, D: Foot
and ankle problems in rheumatoid arthritis. Foot Ankle.
15:608 – 613, 1994.
55. Miehlke, W; Gschwend, N; Rippstein, P; Simmen, BR:
Compression arthrodesis of the rheumatoid ankle and hindfoot.
Clin. Orthop. 340:75 – 86, 1997.
56. Moeckel, BH; Patterson, BM; Inglis, AE; Sculco, TP: Ankle
Arthrodesis: A comparison of internal and external fixation. Clin.
Orthop. 268:78 – 83, 1991.
57. Moeckel, BH; Sculco, TP; Alexiades, MM; Dossick, PH; Inglis,
AE; Ranawat, CS: The double-stemmed silicone-rubber implant
for rheumatoid arthritis of the first metatarsophalangeal joint.
Long-term results. J Bone Joint Surg. 74-A:564 – 570, 1992.
58. Mohan, AK; Cote, TR; Siegel, JN; Braun, MM: Infectious
complications of biologic treatment of rheumatoid arthritis. Curr
Opin Rheumatol. 15:179 – 184, 2003.
59. Myerson, MS; Alvarez, RG; Lam, PWC: Tibiocalcaneal
arthrodesis for he management of severe ankle and hindfoot
deformities. Foot Ankle. 21:643 – 650, 2000.
60. Mäenpää, H; Lehtö, MUK; Belt, EA: What went wrong in triple
arthrodesis? An analysis of failures in 21 patients. Clin. Orthop.
391:218 – 223, 2001.
61. Mäenpää, H; Lehtö, MUK; Belt, EA: Why do ankle
arthrodeses fail in patients with rheumatic disease? Foot Ankle.
22:403 – 408, 2001.
62. Newton, SE: Total ankle arthroplasty. Clinical study of fifty cases.
J Bone Joint Surg. 64-A:104 – 111, 1982.
63. O’Brien, TS; Hart, TS; Gould, JS: Extraosseous manifestations
of rheumatoid arthritis in the foot and ankle. Clin. Orthop.
340:26 – 33, 1997.
64. Pell, RF; Myerson, MS; Schon, LC: Clinical outcome after
primary triple arthrodesis. J Bone Joint Surg. 82-A:47 – 57, 2000.
65. Pyevich, MT; Saltzman, CL; Callaghan, JJ; Alvine, FG: Total
ankle arthroplasty:a unique design: two to twelve year follow-up.
J Bone Joint Surg. 80-A:1410 – 1420, 1998.
874 JAAKKOLA AND MANN
66. Raunio, P; Lehtimäki, M; Eerola, M; Hämäläinen, M; Pulkki,
T: Resection arthroplasty versus arthrodesis of the first
metatarsophalageal joint for hallux valgus in rheumatoid arthritis.
In Schatten-Kirchner, M. (ed.), Rheumatology, Vol. 11, Basel,
Karger, pp. 114 – 125, 1987.
67. Russotti, GM; Cass, JR; Johnson, KA: Isolated talocalcaneal
arthrodesis. A technique using moldable bone graft. J Bone Joint
Surg. 70-A:1472 – 1478, 1988.
68. Saltzman, CL; Johnson, KA; Donnelly, RE: Surgical
treatment for mild deformities of the rheumatoid forefoot
by partial phalangectomy and syndactylization. Foot Ankle.
14:325 – 329, 1993.
69. Samuelson, KM; Freeman, MAR; Tuke, MA: Development
and evolution of the ICLH ankle replacement. Foot Ankle.
3:32 – 36, 1982.
70. Sany, J; Anaya, JM; Canovas, F; et al: Influence of
methotrexate on the frequency of postoperative infections
complications in patients with rheumatoid arthritis. J Rheumatol.
20:1129 – 1132, 1993.
71. Sebold, EJ; Cracchiolo, A: Use of titanium grommets in silicone
implant arthroplasty of the hallux metatarsophalangeal joint. Foot
Ankle. 17:145 – 151, 1996.
72. Seltzer, SE; Weissman, BN; Braunstein, EM; Adams, DF;
Thomas, WH: Computed tomography of the hindfoot with
rheumatoid arthritis. Arthritis Rheum 28:1234 – 1242, 1985.
73. Smith, EJ; Wood, PLR: Ankle arthrodesis in the rheumatoid
patient. Foot Ankle. 10:252 – 256, 1990.
74. Smyth, CJ; Janson, RW: Rheumatologic view of the rheumatoid
foot. Clin. Orthop. 340:7 – 17, 1997.
75. Spiegel, TM; Spiegel, JS: Rheumatoid arthritis in the foot
and ankle- diagnosis, pathology and treatment. Foot Ankle.
2:318 – 324, 1982.
76. Stauffer, RN; Segal, NM: Total ankle arthroplasty. Four years
experience. Clin. Orthop. 160:217 – 221, 1981.
77. Swanson, AB; de Groot Swanson, G: Use of grommets for
flexible hinge implant arthroplasty of the great toe. Clin. Orthop.
340:87 – 94, 1997.
78. Swanson, AB; de Groot Swanson, G; Maupin, BK; Shi, SM;
Peters, JG; Alander, DH; Cestari, VA: The use of a grommet
Downloaded from fai.sagepub.com at Bobst Library, New York University on May 15, 2015
Foot & Ankle International/Vol. 25, No. 12/December 2004
bone liner for flexible hinge implant arthroplasty of the great toe.
Foot Ankle. 12:149 – 155, 1991.
79. Swanson, AB; de Groot Swanson, G; Mayhew, DE; Khan, AN:
Flexible hinge results in implant arthroplasty of the great toe.
In Schatten-Kirchner, M. (ed.), Rheumatology, Vol. 11, Basel,
Karger, pp. 136 – 152, 1987.
80. Tillman, K: Surgery of the rheumatoid forefoot with special
reference to the plantar approach. Clin. Orthop. 340:39 – 47, 1997.
81. Townley, CO; Taranow, WS: A metallic hemiarthroplasty
resurfacing prosthesis for the hallux metatarsophalangeal joint.
Foot Ankle. 15:575 – 580, 1994.
82. Turan, I; Wredmark, T; Felländer-Tsai, L: Arthroscopic
ankle arthrodesis in rheumatoid arthritis. Clin. Orthop.
320:110 – 114, 1995.
83. Unger, AS; Inglis, AE; Mow, CS; Figgie, HE: Total ankle
arthroplasty in rheumatoid arthritis: A long-term follow-up study.
Foot Ankle. 8:173 – 179, 1988.
84. Uuspää, V; Raunio, P: Ankle arthrodesis: a material of 148 ankle
fusions on 130 ankle joint of 118 patients. In Schatten-Kirchner,
M. (ed.), Rheumatology, Vol. 11, Basel, Karger, pp. 104 – 113,
1987.
85. Vainio, K: Morton’s metatarsalgia in rheumatoid arthritis. Clin.
Orthop. 142:85 – 89, 1979.
86. Vainio, K: Rheumatoid foot. Clinical study with pathological
and roentgenological comments. Ann. Chir. Gynaecol. Fenniae.
45(Supplement):1 – 107, 1956.
87. Vallier, GT; Petersen, SA; LaGrone, MO: The Keller
resection arthroplasty: a 13-year experience. Foot Ankle.
11:187 – 194, 1991.
88. Vidigal, E; Jacoby, RK; Dixon AS, Ratliff, AH; Kirkup, J: The foot
in chronic rheumatoid arthritis. Ann. Rheum. Dis. 34:292 – 297,
1975.
89. Wood, PLR; Clough, TM; Jari, S: Clinical comparison of two
total ankle replacements. Foot Ankle. 21:546 – 550, 2000.
90. Wynn, AH; Wilde, AH: Long-term follow-up of the conaxial (Beck-
Steffee) total ankle arthroplasty. Foot Ankle. 13:303 – 306, 1992.