Pamidronate: An Effective Tool in Treating Tarsal Arthropathy

Background:Tarsal arthropathy is an important cause of painful feet. It usually presents as pain with or without swelling of the midfoot, extending from ankle to the metatarsophalangeal joints. It can be seen as an isolated condition or in association with inflammatory or degenerative arthritides . In its acute phase tarsal arthropathy can cause temporary disability and discomfort due to pain. Chronic tarsal arthropathy can lead to structural damage resulting in worsening functional outcome. Most patients are treated with analgesics, anti inflammatories and moulded inserts. A minority of patients are however resistant to these modalities of treatment.
Pamidronate has been used for treatment of Paget’s disease, malignancy related hypercalcaemia, metastatic bone pains and also in prevention and treatment of osteoporosis. It has also been found effective in the management of arthritic pain due to rheumatic conditions like ankylosing spondylitis and juvenile chronic arthritis.
Objective: To assess the effectiveness of pamidronate infusions in relieving the pain associated with tarsal arthropathy.
Methods:We retrospectively identified six cases of tarsal arthropathy who were treated with intravenous pamidronate infusions in the past 3 years. All were females,the mean age was 61 years (range: 53 - 71). All of them presented with long standing pain in the feet (bilateral in two). There was no h/o trauma or any systemic illness. None of them had evidence of arthritis elsewhere and all were negative for rheumatoid factor. Two patients were getting treatment for osteoporosis. X rays of feet were inconclusive. Bone scan revealed increased uptake at the tarsal region in all patients (Figure), bilateral in two. One of the patients had an MRI scan of the foot which showed bone marrow replacement of the proximal third metatarsal with deformity of the proximal 3^rd metatarsal and 3^rd cuneiform bone, presumably owing to traumatic osteolysis. All patients were given a single dose of pamidronate infusion at a dose of 60 mgs.
Results:All patients reported significant improvement of pain within few days. The mean follow up period after pamidronate treatment was 19 months (range: 4 -31). All patients remained pain free at the end of study period except one who had a recurrence of her symptoms at 22 months necessitating a second dose of pamidronate infusion with immediate relief of pain. This patient remained symptom free five months after the second infusion.
Conclusions: Pamidronate is effective in relieving pain associated with tarsal arthropathy. The response is quick and fairly longlasting. Long term placebo controlled trials are needed before it can be routinely recommended in the treatment of tarsal arthropathy.

 S. Kallankara, None; T.J. Gillott, None; T.J. Tait, None.