Joint replacement surgery continues to become less common in patients with rheumatoid arthritis, probably reflecting the widespread adoption of disease modifying antirheumatic drugs, judging from findings of a population-based study published in this month’s Journal of Rheumatology.
Previous studies have found a trend for declining rates of joint surgery in patients with RA since 1985. In this study, "we examined whether the prior sex differences and use trends in reduced surgical intervention for RA persist in patients diagnosed after 1995, and evaluated the effect of RA surgery on survival in these patients," wrote Dr. Courtney A. Shourt and her associates from the Mayo Clinic in Rochester, Minn. (J. Rheumatol. 2012 Jan. 15 [doi:10.3899/jrheum.111056]).
"The possible contribution of RA-related joint surgery to excess mortality in patients with RA is largely unexplored," they pointed out.
A retrospective medical record review was performed using data from the Rochester Epidemiology Project (www.rochesterproject.org). The researchers reviewed records from a population-based cohort of 813 adult residents of Olmsted County, Minn., who had incident RA between Jan. 1, 1980, and Dec. 31, 2007. All cases were followed longitudinally until Dec. 31, 2008; death; or migration out of the county.
Dr. Eric L. Matteson
All joint surgeries were marginally associated with mortality (hazard ratio, 1.3; 95% confidence interval, 0.96-1.8; P = .09), but joint reconstructive procedures (JRPs) showed a significant association with mortality, adjusted for known RA mortality risk factors, compared with findings in patients not requiring JRP (HR, 2.8; 95% CI, 1.9-4.1; P less than .001). "The need for joint replacement surgery is still a marker of bad disease," commented Dr. Eric L. Matteson, professor of medicine and chair of rheumatology at the Mayo Clinic, in an interview.
The proportion of patients undergoing RA-related surgeries dropped between the two time periods of 1980-94 and 1995-2007. Of the 813 Olmsted County residents in the analysis, 189 underwent at least one surgical procedure involving joints, during a mean follow up of 9.6 years. The cumulative incidence of any joint surgery at 10 years after RA incidence for the 1980-94 cohort was 27.3%, compared with 19.5% for the 1995-2007 cohort (P = 0.08), which was not statistically significant.
More aggressive use of effective DMARDs with a reduction in the progression of radiographic joint damage was suggested as a possible reason for the decline in surgical procedures. "These findings reveal that modern medical management strategy has had markedly beneficial effects on the disease course," with less damage to the target small- and medium-size joints such as the hands, wrists, and feet than in past decades, noted Dr. Matteson, one of the report’s authors.
The greatest reduction in surgeries was seen in soft tissue procedures (synovectomy, tendon repair, tendon transfer, meniscus repair, ligament release, and/or cartilage repair). These decreased from 12% in 1980-94 to 6% in 1995-2007 at 10 years after RA incidence (P = .012).
No differences were found in the cumulative incidence of total hip arthroplasty (P = .77) or total knee arthroplasty (P = .18) between the time periods, reported the authors. Addressing the continued need for surgery on weight-bearing joints, particularly total knee and total hip arthroplasties, Dr. Matteson added, "in this respect patients are beginning to be more like people from the general population who have hip and knee replacements for osteoarthritis."
Study coinvestigator Cynthia Crowson of the Mayo Clinic’s biostatistics division noted in an interview that "persons with RA are requiring fewer surgeries, which may indicate [that] current management strategies are leading to less disability among patients who have developed RA since 1995" compared with previous times.
The study was supported by a grant from the National Institutes of Health, and was made possible by the Rochester Epidemiology Project. The authors reported having no financial disclosures.