SLR - September 2023 - Costales
Title: High Prevalence of Foot Insufficiency Fractures in Patients with Inflammatory Rheumatic Musculoskeletal DiseasesReference: Buehring B, Al-Azem N, Kiltz U, Fruth M, Andreica I, Kiefer D, Tsiami S, Baraliakos X, Braun J. High Prevalence of Foot Insufficiency Fractures in Patients With Inflammatory Rheumatic Musculoskeletal Diseases. J Rheumatol. 2022 Dec 15:jrheum.220758.
Reviewed By: Christian Costales DPM
Residency Program: Boston University Medical Center, Boston, MA
Podiatric Relevance: Low bone mineral density (BMD)/osteoporosis is one of the major risks for insufficiency fractures (IF). Chronic inflammatory rheumatic diseases such as Rheumatoid Arthritis, and Psoriatic arthritis often affect small joints on the foot, which are associated with joint-damage, loss of functions, and premature mortality. Dislocations and subluxations at the joint level doubles risk for fractures due to bone loss as evident at the metatarsophalangeal joints which represents 90% of the cases. This study aimed to assess the prevalence of IF of the feet in patients with rheumatic musculoskeletal disease using plain radiographs and MRI and to determine risk factors.
Methods: This is a retrospective Level 3 study evaluating 1752 MRI scans of patients with complaints of pain in the foot and ankle from June 30, 2016 to July 1, 2018. Patients with insufficiency fractures (IF) were compared with patients with the same demographic but without fractures. The primary endpoint of this study was to determine the number of patients with insufficiency fracture (IF) diagnosed with MRI. The secondary endpoint is to determine the differences between insufficiency fractures diagnosed by MRI versus conventional radiography.
Results: Among 358 patients 129 were found to have IF. A total of 1752 MRI scans were evaluated and 7.5 % (129) had IF. 81.6% of the scans were of the foot and 18.4% were of the ankle. The majority of these MRI scans that had IF with inflammatory rheumatic disease were found to be of the foot. Insufficiency fractures (IF) were only detected in 25% of the cases using conventional radiography. Inflammatory rheumatic muscular diseases were found to have increase incidence for IF versus non inflammatory.
Conclusion: This study confirms that (IF) should be added as a differential diagnosis for patients with RA and foot pain. There was no correlation mentioned between the physical exam and MRI. A recommendation of MRI was given if unclear physical exam was evident given its superiority in sensitivity to IF compared to plain images. The study performed in one center in 2 different periods offers strength to the results due to analogous outcomes.
Due to the retrospective nature of this study, it’s possible that IF’s were missed in patients with other comorbidities such as diabetes mellitus with polyneuropathy that may have IF but no foot pain. Due to limited information obtained from patient records some observed insufficiency fractures (IF) may also be considered as stress fractures primarily associated with altered biomechanics and foot deformities. A specific threshold for low BMD needed further investigation. However, patients with low BMD seen in patients with osteoporosis and methotrexate use were noted to have higher incidence of (IF).