Rheumatoid arthritis (RA) is a systemic disease that attacks multiple joints throughout the body. About 90% of the people with rheumatoid arthritis eventually develop symptoms related to the foot or ankle. Usually, symptoms appear in the toes and forefeet first, then in the hindfeet or the back of the feet, and finally in the ankles.

Other inflammatory types of arthritis that affect the foot and ankle include gout, ankylosing spondylitis, psoriatic arthritis, and Reiter’s syndrome.

The exact cause of RA is unknown, but there are several theories. Some people may be more likely to develop RA because of their genes. However, it usually takes a chemical or environmental “trigger” to activate the disease. In RA, the body’s immune system turns against itself. Instead of protecting the joints, the body produces substances that attack and inflame the joints.

If nonoperative treatments fail, surgery may be recommended. Surgery can correct several of the conditions, such as bunions and hammer toes, associated with RA of the foot and ankle. In many cases, however, the most successful surgical option is fusion (arthrodesis). Fusion is often performed on the great toe, in the midfoot, in the heel, and in the ankle. In this procedure, the joint cartilage is removed; in some cases, some of the adjacent bone is also removed. The bones are held in place with screws, plates and screws or a rod through the bone. The surgeon may then implant a bone graft from the hip or leg. Eventually, the bones unite, creating one solid bone.

There is loss of motion, but the foot and ankle remain functional and generally pain-free. Replacing the ankle joint with an artificial joint (arthroplasty) may be possible. However, this is a relatively new surgical technique. Whether it will be as successful in the long term as hip or knee replacement surgery is not yet known.

As in all surgeries, there is some risk. Infections, failure to heal, and loosening of the devices are the most common problems. Intravenous antibiotics and/or repeat surgery may be needed.

General Factors of Recovery

• You are able to walk on the heel of the foot the day after surgery
• You must wear your surgical shoe at all times until the joint is fused
• You may not walk on the bare foot at all even in the house without this shoe
• You may drive as soon as comfortable, usually at 4 days if the left foot and 7 days if the right foot
• The surgical shoe is worn for 6 to 8 weeks
• Limited exercise that does not involve any bending of the big toe joint is allowed at about four weeks after surgery

Specific Post Operative Course

Day 1

• Foot wrapped in bulky bandage and surgical shoe
• Ice, elevate, take pain medication
• Expect numbness in foot for 12 to 24 hours
• Blood drainage through bandage is expected
• Do not change bandage for two to three days
• Do not remove surgical shoe, even at night

Day 3

• Start walking on the heel in surgical shoe only
• Do not remove surgical shoe, even at night
• Ice, elevate as much as possible
• Remove dressings, can clean wound with antibiotic ointment as instructed.

Day 7

• Continue walking in surgical shoe
• There are two types of surgical shoes you will be given, one with a built in heel which you will use for all walking, and the other is a hard shoe for use when you are driving only
• May drive with caution in surgical shoe (if left foot, may be able to drive sooner) * Do not change dressing unless instructed

2 weeks

• Shower when incision dry

6 weeks

• Remove surgical shoe
• Do not roll off on the big toe for one more month
• A stiff soled shoe is important for one to two months
• A regular shoe may then be worn as comfortable
• No high heel is worn for two more months
• A computer gait analysis of the foot will be done
• You will be fitted for orthotic arch supports