Stress Fractures in the Forefoot After Arthrodesis of the Hindfoot in a Patient with Rheumatoid Arthritis: A Case Report.

Rheumatoid arthritis (RA) is an autoimmune disease that attacks multiple joints throughout the body. Ankle arthrodesis (AA) has been the gold standard surgery for end-stage ankle arthritis in patients with RA. Here, we report the case of a 67-year-old woman with RA who had displacement and loosening of total ankle arthroplasty (TAA). The ankle was converted to AA using a metal spacer and an intramedullary nail. The patient had no complications in perioperative terms of arthrodesis. However, multiple fractures were found in the metatarsal bones at the routine 3-year follow-up. Although the patient did not remember any symptoms, the clinical outcome deteriorated compared to that a year before. The hindfoot in this case report was fixed completely by an intramedullary nail, while the midfoot had already involved ankylosis because of severe joint destruction present before the surgery. As a result, the range of motion in the joints of the midfoot and hindfoot was lost, and it is probable that an excessive load was applied to the forefoot during push-off by the toes, resulting in a stress fracture. Patients with RA remain at risk of future progressive joint destruction in every joint of their body. Therefore, surgeons should choose a surgery that preserves ankle motion to decrease the rate of adjacent joint degeneration for severe ankle arthropathy in patients with RA.