SLR- February 2014- Hani Badahdah
Reference: The Predictors of Foot Ulceration in Patients with Rheumatoid Arthritis. Firth, J. Waxman; R. Law, G. Nelson; EA. Helliwell; P. Siddle; H. Otter; S. Butters; V. Baker; L. Hryniw; R. Bradley; S. Loughrey;, L. Alcacer-Pitarch; B. Davies; S. Tranter; J. Clinical Rheumatology. 2013 Dec 6.
Scientific Literature Review
Reviewed By: Hani Badahdah, DPM, MD
Residency Program: Mercy Hospital, Miami, FL
Podiatric Relevance: Ten to thirteen percent of the patients with rheumatoid arthritis (RA) present with foot ulceration during the course of their disease. Additionally, RA is one of the systemic diseases that present with lower extremity pathologies. As a podiatric physician, we have to be aware of the systemic diseases that manifest in the lower extremity which help us to reach the correct diagnosis and treat the patients adequately. This study was conducted to determine the predictors of foot ulceration occurring in the patient with RA without diabetes.
Methods: A multi-center case control study was undertaken; participants were recruited from eight centers in the UK. Cases were adults diagnosed with RA (without diabetes) and the presence of a validated foot ulcer, defined as a full thickness skin defect occurring in isolation on or below the midline of the malleoli and requiring more than 14 days to heal. Controls met the same criteria but reported no history of ulceration. Clinical examination included loss of sensation (10g monofilament); ankle-brachial pressure index (ABPI); forefoot deformity (Platto); plantar pressure (Pressure Stat); RA disease activity (36 swollen/tender joint counts), and the presence of vasculitis. History taking included a record of any previous foot ulceration or surgery; duration of current ulceration; current medication and smoking status. Participants completed the Health Assessment Questionnaire (HAQ) and Foot Impact Scale.
Results: A total of 83 cases with 112 current ulcers and 190 controls without history of ulceration participated. Ulceration patients were significantly older (mean age 71; 95 percent confidence interval [CI], 69-73 vs.62 years, 60-64) and had longer RA disease duration (mean 22 years; 19-25 vs.15 years, 13-17). Univariate analysis showed that risk of ulceration increases with loss of sensation, abnormal ABPI and foot deformity. Plantar pressure, swollen and tender joint counts were not significant predictors of ulceration. HAQ and history of foot surgery were strongly associated with ulceration. Three ulceration cases and two controls presented with suspected cutaneous vasculitis. In logistic regression modeling, ABPI, forefoot deformity and loss of sensation predicted risk of ulceration but in contrast with diabetes, raised plantar pressure did not predict risk.
Conclusion: This is the first study to identify predictors of foot ulceration in patients with RA without diabetes. Loss of sensation, foot deformity and decreased ABPI values are the predictors that increase risk of ulceration. The findings of this study indicate a need to screen patients with RA for peripheral neuropathy and peripheral vascular disease, implement care to accommodate or surgically correct foot deformity and educate patients regarding foot health to address risk factors and prevent ulceration. Future work needs to be undertaken to develop practical criteria for the prospective screening of patients and identification and management of those at risk.