Reduced Need for Joint Surgery in Patients with Rheumatoid Arthritis Over Time

Newswise — SAN DIEGO —Treating rheumatoid arthritis patients with intensive pharmacological agents, such as biologic drugs, may reduce the need for orthopedic joint surgery, according to research presented this week at the American College of Rheumatology Annual Meeting in San Diego.

Rheumatoid arthritis is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well. An estimated 1.3 million Americans have RA, and the disease typically affects women twice as often as men.

Researchers based in Malmö, Sweden, looked at the incidence of any type of orthopedic joint surgery performed in Sweden on a total of 2,342 people with RA who fulfilled the 1987 ACR criteria for the disease. Of these, 68.7 percent were female. Patients drawn from RA patient registries from the years 1997, 2002, 2005 and 2009, were sent questionnaires to assess their general health and pain levels. Between 62 and 74 percent of RA patients contacted responded to the survey. Patient questionnaire responses were linked to the Swedish national health registry records to correlate the data with records of inpatient and outpatient surgeries, as well as use of biologic drugs. The incidence rate of orthopedic joint surgeries in this population from 1998 to 2001 was compared to the rates in the 2002 to 2006 and 2007 to 2011 time periods.

The researchers conducted the study to determine “whether the incidence of orthopaedic surgery is declining over time in patients with RA, and whether patient-reported outcomes predict the need for such procedures in future,” according to Korosh Hekmat, MD; specialist in internal medicine rheumatology and PhD fellow; Malmö University; and the lead author on the study.

Incidence of all orthopedic surgeries for RA patients from 1998 to 2011 was 82.3 out of 1,000 people, but the researchers noticed significant declines over the time periods studied. In the 1998 to 2001 time period, there was a 94.6 incidence rate, while in the 2007 to 2011 time period, there was a 71.8 incidence rate. Decreases were noted in both large joint (hips) and small joint (hands, wrists, feet and ankles) surgeries. Knee surgeries did not show a decline. Factors that increased the incidence of joint surgery were female gender and a higher rate of disability according to standard Health Assessment Questionnaire scores.

The time period studied coincided with increased use of early pharmacologic intervention in RA cases, especially with biologic drugs, although the researchers did not confirm the patients were using these drugs. Using these drugs early in the RA disease process may help halt inflammation and the joint erosion it can cause, thus preventing the need for orthopedic surgery the study’s authors concluded.

“Our study suggests that the rate of orthopedic surgery was reduced by early intensive treatment in patients with severe RA,” says Dr. Hekmat.Patients should talk to their rheumatologists to determine their best course of treatment.

The American College of Rheumatology is an international professional medical society that represents more than 9,000 rheumatologists and rheumatology health professionals around the world. Its mission is to advance rheumatology. The ACR/ARHP Annual Meeting is the premier meeting in rheumatology. For more information about the meeting, visit http://www.acrannualmeeting.org/ or join the conversation on Twitter by using the official hashtag: #ACR13

Editor’s Notes: Dr. Hekmat will present this research during the ACR Annual Meeting at the San Diego Convention Center at 3 PM on Tuesday, October 29 in Room 33 A. Dr. Hekmat will be available for media questions and briefing at 8:30 AM on Monday, October 28 in the on-site press conference room, 27 AB.

Funding sources for this study included the Swedish Research Council, Lund University and The Swedish Rheumatism association.

Abstract Number: 2682

Incidence Trends and Predictors Of Orthopedic Surgery In Patients With Rheumatoid Arthritis – Results From a Well Defined Population

Korosh Hekmat1, Lennart Jacobsson1, Jan-Åke Nilsson1, Minna Willim1, Martin Englund2, Ingemar F. Petersson3 and Carl Turesson1, 1Lund University, Malmö, Sweden, 2Lund University, Lund, Sweden, 3Musculoskeletal Scienes, Department of Orthopedics, Clinical Sciences, Lund, Sweden

Background/Purpose: Orthopedic surgery is used effectively in many patients with severe rheumatoid arthritis (RA). The aim of modern pharmacologic treatment is to prevent joint destruction and reduce the need for orthopedic surgery. Our purpose was to investigate trends in the incidence as well as predictors for such procedures in a population-based sample of patients with RA.

Methods: The study was based on a dynamic cohort of all known patients from a defined geographical area with a clinical diagnosis of RA who fulfilled the 1987 American College of Rheumatology criteria for RA. A total of 2342 patients (68.7% women) were included. Questionnaires were sent to the RA patients in the register in 1997, 2002, 2005 and 2009(response rates 62-74 %) including visual analogue scales (VAS) for general health and pain and the health assessment questionnaire (HAQ). This register was linked to a regional health care register, which contains information on all inpatient and outpatient procedures in the area, to the national population register to add information on vitality and residential address, and to a regional register of patients with arthritis treated with biologics, which covers >90% of such patients in the region. The total follow-up was calculated for each calendar year from 1998 through 2011, and the annual incidence rate of orthopedic surgery procedures was estimated. The incidence rate for 1998-2001 was compared to those of 2002-2006 and 2007-2011. The impact of demographics and patient reported outcomes on the risk of future orthopedic surgery was analyzed using Cox proportional hazard models.

Results: The incidence of all orthopedic surgery procedures during the whole study period was 82,3/1000 person-years (95 % confidence interval (CI) 78,7-86,0). The incidence of all procedures declined significantly over time, with a decrease also for large joint surgery and small joint surgery (hand, wrist, foot and ankle surgery), when studied separately (Table). There was a decline in hip surgery, but not in knee surgery (Table). The incidence of large joint surgery was reduced already in 2002-2006 compared to 1998-2001, whereas a decline in small joint surgery was apparent only in the final period (2007-2011).Female sex was a predictor of orthopedic surgery [age adjusted hazard ratio (HR) 1.50; 95 % CI 1.23-1.83). Greater disability, measured by HAQ, was associated with a higher rate of orthopedic surgery (HR per standard deviation 1.37; 95 % CI 1.25-1.50 adjusted for age, sex and duration of RA), and similar, although weaker, associations were observed for VAS pain and VAS global.

Conclusion: The overall incidence of orthopedic surgery declined over time which coincides with increasing use of more intensive pharmacological treatment including the use of biologics. The decrease in large joint surgery predated that of small joint surgery. Improved management may reduce the need for orthopedic interventions in patients with RA.