Prominent midfoot involvement in children with enthesitis-related arthritis category of juvenile idiopathic arthritis

Abstract

Foot involvement is common in juvenile idiopathic arthritis (JIA) but is often unrecognized and difficult to treat. This study was done to assess clinical and radiological involvement of the feet and its impact on function in Indian children with enthesitis-related arthritis (ERA). We enrolled consecutive children with ERA with disease duration of less than 5 years. All patients underwent clinical examination of the feet and filled the juvenile arthritis foot index (JAFI) questionnaire. Ultrasound (US) of foot joints and entheses and extremity magnetic resonance imaging (MRI) scan of one foot were done. Fifty-five patients (53 boys), with median 14 years and disease duration 1.9 years, were included. Thirty-seven of 46 were HLA-B27-positive. Mean juvenile spondyloarthritis disease activity (JSpADA) index and juvenile idiopathic arthritis disease activity scrore-10 (JADAS10) scores were 4 and 14.25. Forty-six had history of foot pain, 36 had foot involvement on examination (15 ankle, 8 subtalar, 24 midfoot, 10 forefoot, and 21 tendoachilles), and 7 had plantar fascia involvement. On US (N = 55), 16 had ankle involvement and 8 had subtalar involvement, and 19 patients had midfoot arthritis, 24 had tendoachilles enthesitis, and 11 had plantar fasciitis. On MRI (N = 50), 27 had midfoot involvement. Thirty-three had bone edema. Fourteen had midfoot enthesitis and 17 had tenosynovitis. Clinical and US had 82% concordance at the midfoot and 90% at the ankle. MRI had 74% concordance with examination and 72% with US at the midfoot. The median JAFI scores were as follows: total JAFI = 4 (0-11), impairment = 1, activity limitation = 2, and participation restriction = 1. JAFI total and individual domains correlated with JADAS10, JSpADAS, and childhood health assessment questionnaire (CHAQ) but not duration of foot disease. JAFI was higher in children with midfoot arthritis on US. Foot joints and entheses are involved in a substantial proportion of patients with ERA patients and the midfoot is commonly involved. Foot disease produces significant functional limitation.

The Development of Extra-Articular Manifestations in Children With Enthesitis-Related Arthritis: Natural Course or Different Disease Entity?

“…However, in accordance with recent literature, the midfoot involvement seems to be one of the key characteristics of ERA-JIA and may significantly affect the ERA prognosis. Phatak et al (39), in an elegant prospective study, reported that the midfoot disease produced important functional limitation. During the course of the last years, numerous studies addressed the midfoot involvement as characteristic feature of ERA-JIA (40)(41)(42).…”

Midfoot Arthritis in Children: Is There Any Relation With Malignancy?

“…Midfoot arthritis is a challenging problem that causes chronic pain and affects daily activity. In the Phatak et al 14 study, 55 children with ERA were studied, with a prevalence of Midfoot involvement in 24 patients (43.6%); only 2 case studies were found in the literature review. In a study by Dewar et al, a 5-year-old boy was described who had suffered left ankle injury 2 weeks before admission.…”

Outcomes in Juvenile-Onset Spondyloarthritis

“…Indeed, in one study comparing JoAS and other Juvenile Rheumatoid Arthritis (JRA), 85.7% of children with JoAS experienced tarsitis, vs. 10.7% in JRA within 1 year of presentation (39). Anatomic involvement of the feet was particularly well described in a study from India (40). Phatak et al described a case series of 55 children diagnosed with ERA for <60 months.…”

“…A significant portion of children with JoSpA/ERA have axial involvement at presentation or develop axial disease within the first 5 years, with some variability by study. For example, in the predominantly male and HLA-B27+ ERA case series from India, 55% had inflammatory back pain (IBP) and 38% clinical sacroiliitis during the first 5 years of disease (mean duration of disease 1.9 years) (40). Of these, 33% had radiographic sacroiliitis.…”