Predictors of foot ulceration in patients with rheumatoid arthritis

NewsBot · Jun 11, 2008

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The predictors of foot ulceration in patients with rheumatoid arthritis: a preliminary investigation.
Firth J, Helliwell P, Hale C, Hill J, Nelson EA.
Clin Rheumatol. 2008 Jun 10. [Epub ahead of print]

We explored the predictors of foot ulceration in patients with rheumatoid arthritis (RA). The cases were 15 patients with RA reporting foot ulceration in response to a postal survey of patients sampled from a diagnostic register in secondary care (n = 1,130). The controls were 66 patients with RA randomly sampled from the survey respondents (n = 883) after matching for age, sex and disease duration. Patients with co-existent diabetes were excluded. Clinical examination included the assessment of known risk factors for foot ulceration in diabetes including: neuropathy (insensitivity to 10 g monofilament), peripheral vascular disease (ankle brachial pressure index [ABPI]), foot deformity (Platto indices) and raised plantar pressure (PressureStattrade mark readings). A 44 swollen-joint count, the presence of pre-ulcerative lesions and current steroid therapy were identified through univariate analysis as additional potential predictors in patients with RA. Forward step-wise logistic regression analysis showed that the following variables were significant predictors of ulceration: steroid therapy (OR = 9.70, 95%CI = 2.09-45.11, p = 0.004), abnormal ABPI (OR = 13.45, 95%CI = 1.19-151.43, p = 0.035), the presence of pre-ulcerative lesions (OR = 7.40, 95%CI = 1.51-36.30, p = 0.014) and swollen-joint count (OR = 1.25, 95%CI = 1.02-1.53, p = 0.034). Abnormal sensation, foot deformity and raised plantar pressures were not significant predictors of ulceration. The wide confidence intervals for ABPI were due to sparse data with very few abnormal values, and the results of exact logistic regression (more accurate where data is sparse and case matching employed) found that ABPI was no longer a significant predictor (p = 0.054). The significance of the other predictors did not differ substantially. In this preliminary study, abnormal sensation, foot deformity and raised plantar pressures were not significantly associated with foot ulceration but active disease and current steroid therapy were. The contribution of peripheral vascular disease to risk is unclear and further investigation is needed in a larger cohort.
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NewsBot · Jun 25, 2011

A qualitative study to explore the impact of foot ulceration on health-related quality of life in patients with rheumatoid arthritis.
Firth J, Nelson EA, Briggs M, Gorecki C.
Int J Nurs Stud. 2011 Jun 20. [Epub ahead of print]

BACKGROUND:
The overall prevalence of foot ulceration occurring in patients with rheumatoid arthritis is estimated at 10-13% in the UK, with a high rate of recurrence. In contrast with diabetes, there has been a lack of research in this area and the impact of the problem from a patient perspective is poorly understood.

OBJECTIVE:
To explore the added impact of foot ulceration on health-related quality of life in non-diabetic patients with rheumatoid arthritis.

DESIGN:
Qualitative research design to elicit patient experiences.

SETTINGS:
Participants were recruited from hospital and community podiatry clinics in West Yorkshire (UK) between May 2008 and June 2009.

PARTICIPANTS:
A purposive sample of 23 adults with RA and open foot ulceration; patients with diabetes were excluded.

METHODS:
In-depth interviews were conducted with 23 participants using a topic guide. Framework analysis was employed to facilitate a case and theme based approach to identifying descriptive and explanatory accounts of the impact of foot ulceration on health-related quality of life.

RESULTS:
Participants indicated that foot ulceration impacted on their health-related quality of life across physical, social and psychological domains. Pain attributed to the ulcer was linked to new walking disability, affecting participants' lives in every domain. Pain and walking disability added to existing limitations in undertaking household tasks and personal care independently. Keeping the ulcer dry was a major problem for many in relation to personal hygiene. Participants described new restrictions in leisure activities which reduced social participation. Increased footwear/clothing restrictions affected self esteem and altered body image. An economic cost was attached to wound care and footwear alterations. Low mood, anxiety, frustration were attributed to the added impact of foot ulceration on their lives. Perceptions of impact fluctuated over time in relation to physical symptoms experienced by participants and the additional social limitations posed by the ulcer.

CONCLUSION:
Foot ulceration has an additional impact on health-related quality of life over and above the impact of rheumatoid arthritis in every domain. Whilst prevention is the ultimate goal, high rates of recurrence mean that clinicians need to consider ways to improve quality of life for affected patients throughout the patient journey.
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NewsBot · Nov 7, 2011

A case series to describe the clinical characteristics of foot ulceration in patients with rheumatoid arthritis.
Siddle HJ, Firth J, Waxman R, Nelson EA, Helliwell PS.
Clin Rheumatol. 2011 Nov 4.

The aim of this study was to describe the clinical characteristics of foot ulceration in patients with rheumatoid arthritis (RA). Adults with RA and current foot ulceration but without diabetes were recruited. Clinical examination included assessment of RA disease activity, foot deformity, peripheral vascular disease, neuropathy and plantar pressures. Location, wound characteristics and time to healing were recorded for each ulcer. Participants completed the Health Assessment Questionnaire and Leeds Foot Impact Scale. Thirty-two cases with 52 current ulcers were recruited. Thirteen patients (41%) experienced more than one current ulcer: 5 (16%) had bilateral ulceration, 15 (47%) had previous ulceration at a current ulcer site. The majority (n = 33) of open ulcers were located over the dorsal aspect of the interphalangeal joints (n = 12), plantar aspect of the metatarsophalangeal joints (MTPJs) (n = 12) and medial aspect of first MTPJs (n = 9). In ulcerated limbs (n = 37), ankle brachial pressure index (ABPI) was <0.8 in 2 (5%); protective sensation was reduced in 25 (68%) and peak plantar pressures were >6 kg/cm(2) in 6 (16%). Mean ulcer size was 4.84 by 3.29 mm. Most ulcers (n = 42, 81%) were superficial; five (9.6%) were infected. Time to healing was available for 41 ulcers: mean duration was 28 weeks. Three ulcers remained open. In conclusion, foot ulceration in RA is recurrent and multiple ulcers are common. Whilst ulcers are small and shallow, time to achieve healing is slow, posing infection risk. Reduced protective sensation is common in affected patients. The prevalence of arterial disease is low but may be under estimated due to high intolerance of ABPI.
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NewsBot · Jul 29, 2014

From LER:
Foot ulceration in patients with rheumatoid arthritis

NewsBot · Aug 16, 2015

Prevalence and microbiological characteristics of clinically infected foot-ulcers in patients with rheumatoid arthritis: a retrospective exploratory study
Pauline Fitzgerald, Heidi J. Siddle, Michael R. Backhouse and E. Andrea Nelson
Journal of Foot and Ankle Research 2015, 8:38 doi:10.1186/s13047-015-0099-0

Background
The prevalence of foot ulcers in patients with rheumatoid arthritis (RA) has been reported at almost 10 %. These foot ulcers often occur at multiple sites and are reoccurring, with the potential risk of infection increased due to RA diagnosis and disease modifying medications. The objective of this study was to estimate the prevalence of clinical infection in foot-ulcers of patients with RA; describe the microbiological characteristics and investigate risk factors.

Methods
Retrospective clinical data was collected for all patients attending a rheumatology foot ulcer clinic between 1st May 2012 and 1st May 2013: wound swab data was collected from those with clinical infection.

Results
Twenty-eight patients with RA and foot-ulcers were identified; eight of these patients had clinical infection and wound swabs taken (29 %).

Of these eight patients there were equal men and women, with median age 74 years, and average disease duration 22 years.

Cardiovascular disease/peripheral-vascular disease (CVD/PVD) were reported in six patients, diabetes in two patients.

Six patients were treated with disease-modifying anti-rheumatic drugs (DMARDs); three were on biologic medications and two on steroids.

Five wound swabs cultured skin flora, one staphylococcus aureus, one had no growth after culture; and one was rejected due to labelling error.

Conclusion
Almost a third of people with RA and foot ulcers attending clinic over one year had clinical infection, however microbiological analysis failed to isolate pathogens in six of seven wound swabs. This may be due to inaccurate diagnosis of ulcer infection or to issues with sampling, collection, transport, analysis or reporting. There was insufficient data to relate risk of clinical infection with risk factors.

Further research is required to identify the most appropriate techniques for infection diagnosis, wound sampling and processing.
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NewsBot · Nov 16, 2023

Acupuncture for rheumatoid vasculitis complicated by refractory foot ulcer: A case report
Yaqing Cheng et al
Medicine (Baltimore). 2023 Nov 10;102(45)

Introduction: Rheumatoid vasculitis (RV) is a frequently encountered complication of rheumatoid arthritis (RA), wherein skin vasculitis lesions are observed as a common clinical manifestation, encompassing skin purpura, erythema, vascular occlusion, ulcers, and gangrene. As a matter of fact, it marks the most severe extra-articular manifestation of RA. And the resultant ulcers tend to pose a greater challenge with regard to therapeutic interventions. We report a case of RV complicated by refractory foot ulcer that was successfully treated with puncture.

Case presentation: A 62-year-old man with RV caused by RA developed refractory foot ulcers. Despite the application of topical antibiotics, the wound gradually expanded and remained unhealed for 7 months. Consequently, the patient sought an integrated therapeutic approach involving Traditional Chinese Medicine and was subsequently treated with acupuncture. After 12 weeks of acupuncture, the foot ulcers healed completely.

Conclusion: Acupuncture has the potential to facilitate wound healing and may serve as a viable alternative treatment modality for wounds unresponsive to traditional therapeutic interventions
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