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Table 7 Recommendations on medical treatment

From: Multidisciplinary recommendations for diagnosis and treatment of foot problems in people with rheumatoid arthritis

  LoE Ref LoA
Corticosteroid injections can be applied in joints and soft tissue of the foot in the treatment of local arthritis and synovitis.*Corticosteroid injections may also be applied in the treatment of tendinitis and pain.** *2 **4a/b * [52] [53] ** [32, 54, 55] 8.7 (7–10)
A corticosteroid injection conducted by ultrasonography (if available) is preferred, because this may result in a more accurate determination of the location of the injection. 4b n/a 9.4 (7–10)
Early in the treatment process, consultation by an orthopaedic surgeon should be considered. Surgical intervention should be considered when the following foot conditions do not respond to conservative therapy: i) persistent pain and stiffness, ii) > 6 months of synovitis in foot and ankle joints, iii) tenosynovitis or tendon ruptures, iv) malalignment of the foot (e.g., hammer toes) causing mobility limitations and pain or problems finding adequate shoes, v) returning callosity/clavus, vi) wounds/(pre)ulcers, and vii) osteomyelitis/septic arthritis. 4a/b [27, 32, 56] 9.1 (6–10)
Resection arthroplasty of the MTP joints can be applied to improve joint mobility and to reduce pain, forefoot plantar pressure, and problems finding well-fitting shoes.* In severe malalignments of the toes or damage to the MTP joints, resection arthroplasty is preferred. Without severe malalignments/damage, a MTP joint-preserving surgical technique can be considered.** *3 **4a * [57] ** [56] 8.9 (6–10)
An arthrodesis of the MTP1 joint can be performed to reduce pain and improve the weight-bearing capacity of the forefoot. 3 [37] 9.1 (7–10)
When surgical treatment of the hindfoot is necessary, arthrodesis of the subtalar joint is preferred. For flat feet, an additional arthrodesis of the calcaneocuboid joint and talonavicular joint should be considered (triple arthrodesis). 4a [39] 8.9 (6–10)
In the treatment of severe pain and damage of the tibiotalar joint, an arthrodesis of the tibiotalar joint or an ankle prosthesis can be applied.* An arthrodesis is preferred, provided that the Chopart-joint-line is intact and the status of other joints does not form a contraindication. An ankle prosthesis can be considered when preservation of mobility in the tibiotalar joint is important (according to the patient) and the preoperative status of the patient does not form a contra-indication.** *1 **4b * [58] ** n/a 9.0 (7–10)
  1. LoE Level of Evidence for the recommendations: (1) research of level A1 or at least 2 independently conducted studies of level A2, (2) 1 study of level A2 or at least 2 independently conducted studies of level B, (3) 1 study of level B or C, (4a) expert opinion described in the literature, (4b) opinion of the expert group. Ref. references, LoA Level of Agreement for the recommendations: Numeric Rating Scale from 0 (total disagreement) to 10 (total agreement) reported as mean (range). n/a not applicable. * refers to the first part of the recommendation with corresponding level of agreement and references. ** refers to the second part of the recommendation with corresponding level of agreement and references