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The predictors of foot ulceration in patients with rheumatoid arthritis

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Abstract

This study was conducted to determine the predictors of foot ulceration occurring in patients with rheumatoid arthritis (RA) without diabetes. A multi-centre case control study was undertaken; participants were recruited from eight sites (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 / below the midline of the malleoli and requiring > 14 days to heal. Controls met the same criteria but were ulcer naive. Clinical examination included loss of sensation (10g monofilament); ankle-brachial pressure index (ABPI); forefoot deformity (Platto); plantar pressures (PressureStat); RA disease activity (36 swollen/tender joint counts) and the presence of vasculitis. History taking included past ulceration/foot surgery; current medication and smoking status. Participants completed the Health Assessment Questionnaire (HAQ) and Foot Impact Scale. A total of 83 cases with 112 current ulcers and 190 ulcer naïve controls participated. Cases were significantly older (mean age 71 years; 95 % confidence interval [CI], 69–73 vs. 62 years, 60–64) and had longer RA disease duration (mean 22 years; 19–25 vs. 15, 13–17). Univariate analysis showed that risk of ulceration increases with loss of sensation; abnormality of ABPI and foot deformity. Plantar pressures and joint counts were not significant predictors. HAQ score and history of foot surgery were strongly associated with ulceration (odds ratio [OR] = 1.704, 95 % CI 1.274–2.280 and OR = 2.256, 95 % CI 1.294–3.932). Three cases and two controls presented with suspected cutaneous vasculitis. In logistic regression modelling, ABPI (OR = 0.04; 95 % CI, 0.01–0.28) forefoot deformity (OR = 1.14; 95 % CI, 1.08–1.21) and loss of sensation (OR = 1.22; 95 % CI, 1.10–1.36) predicted risk of ulceration. In patients with RA, ABPI, forefoot deformity and loss of sensation predict risk of ulceration but, in contrast with diabetes, raised plantar pressures do not predict risk.

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Authors and Affiliations

  1. Pennine Musculoskeletal Partnership Ltd, Oldham Integrated Care Centre, New Radcliffe Street, Oldham, Lancashire, OL1 1NL, UK

    Jill Firth

  2. Division of Rheumatic and Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK

    Robin Waxman, Philip Helliwell & Heidi Siddle

  3. Division of Biostatistics, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK

    Graham Law

  4. School of Healthcare, University of Leeds, Leeds, UK

    Jill Firth & E. Andrea Nelson

  5. School of Health Professions, University of Brighton, Brighton, UK

    Simon Otter

  6. Greater Glasgow and Clyde NHS Trust, Glasgow, Scotland, UK

    Violet Butters

  7. East Sussex Hospitals NHS Trust, East Sussex, UK

    Lesley Baker

  8. North Lancashire PCT and University Hospitals of Morecambe Bay, Lancashire, UK

    Rosemary Hryniw

  9. Calderdale and Huddersfield NHS Foundation Trust, West Yorkshire, UK

    Sarah Bradley

  10. Leeds Teaching Hospitals NHS Trust, Leeds, UK

    Lorraine Loughrey & Begonya Alcacer-Pitarch

  11. Bradford Teaching Hospitals NHS Foundation Trust, West Yorkshire, UK

    Begonya Alcacer-Pitarch

  12. Pennine Acute Hospitals NHS Trust, Lancashire, UK

    Samantha Davies

  13. School of Community Health Sciences, University of Nottingham, Nottingham, UK

    Jennifer Tranter

Authors
  1. Jill Firth
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  2. Robin Waxman
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  3. Graham Law
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  4. E. Andrea Nelson
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  5. Philip Helliwell
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  6. Heidi Siddle
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  7. Simon Otter
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  8. Violet Butters
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  9. Lesley Baker
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  10. Rosemary Hryniw
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  11. Sarah Bradley
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  12. Lorraine Loughrey
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  13. Begonya Alcacer-Pitarch
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  14. Samantha Davies
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  15. Jennifer Tranter
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Corresponding author

Correspondence to Jill Firth.

Additional information

Significance and Innovations

• ABPI, forefoot deformity and loss of sensation predict risk of foot ulceration in patients with RA

• In contrast with diabetes, raised plantar pressures did not predict risk of ulceration in this study

This work was funded by the award of the Ann Wilks Grant by the Arthritis Research Trust (Yorkshire).

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Firth, J., Waxman, R., Law, G. et al. The predictors of foot ulceration in patients with rheumatoid arthritis. Clin Rheumatol 33, 615–621 (2014). https://doi.org/10.1007/s10067-013-2428-7

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  • DOI: https://doi.org/10.1007/s10067-013-2428-7

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