BIRMINGHAM, ENGLAND — Two-thirds of rheumatoid arthritis patients in the United Kingdom do not receive any foot care, despite a high prevalence of foot pathology known to be associated with the disease, according to new study findings.
Conservative foot treatment is often bypassed, with many patients going straight to surgery if foot problem develops, judging from data from the Early Rheumatoid Arthritis Study (ERAS), which has been collecting data since 1987 and now has over 9 years of follow-up data available.
“This is the largest study to date to look at patients with rheumatoid arthritis and conservative foot care and foot surgery on a national level,” said Michael R. Backhouse, a doctoral student in musculoskeletal disease at the University of Leeds (England).
“The striking finding that two-thirds of patients did not receive any foot care is unfortunately consistent with previously described suboptimal service provision across the country,” he reported.
Foot pathology is estimated to occur in up to 90% of RA patients (Foot Ankle Int. 1994;15:608-13; Acta Orthop. 2008;79:257-61), with about 10% developing foot ulcers (Arthritis Rheum. 2008;15;59:200-5) and almost half unable to perform basic foot care themselves (Musculoskeletal Care. 2009;7:57-65). Few data exist on the value of conservative and surgical foot interventions, however, with little randomized, controlled trial evidence.
Using data from the ERAS inception cohort, Mr. Backhouse and associates aimed to describe the use of foot care services and surgery in patients with early RA.
The mean age of the 1,237 patients they studied was 54 years at the onset of disease, with a median disease activity score of 4.09, and with 82% ever identified as being rheumatoid factor positive.
Erosions were identified on x-ray in 79% of patients, with 34% showing evidence of rheumatoid nodules.
Follow-up data were available for all recruited patients at 3 years, for 1,123 patients (91%) at 5 years, and for 680 (55%) at 9 years.
Overall, only 36% (n = 444) of patients received foot care, of which the majority (82%) had consulted a podiatrist. The remainder had seen an orthotist or had surgery.
Within the first 9 years of follow-up, 54 foot operations were performed in 38 patients (3%). The time to surgery ranged from 7 months to 81 months, with a median of 51 months. Over half (n = 22) of the patients who received surgery, however, had never seen a podiatrist.
Over the more than 9 years of follow-up, 101 operations were performed on the feet of 71 patients (6%), with 47 patients having one operation, 19 patients having two procedures, 4 patients undergoing three surgeries, and 1 patient requiring four interventions.
The time to the first operation ranged from 7 months to 221 months, with a median time to surgery of 79 months. The location of surgery was the metatarsophalangeal joint in the majority of patients (67%), with the other locations being the soft tissue (24%), and ankle or hindfoot (9%).
More women than men accessed podiatry and surgical services, and younger patients were more likely than were older patients to undergo surgery instead of conservative therapy, “although there is no real justification for the latter,” Mr. Backhouse observed.
He noted that one limitation of the study was that patient recruitment began before the publication of the U.K. guidelines on RA treatment and before the routine use of biologic therapies. However, the timing also meant that there are now long-term data on the development of foot problems and their management in this RA population.
Disclosures: Arthritis Research UK and the Bupa Foundation funded the ERAS study. Mr. Backhouse had no conflicts of interest to declare.
Foot pathology is estimated to occur in up to 90% of patients with RA, with about 10% developing foot ulcers and close to half unable to care for their own feet.
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