Hand and Foot Surgery Rates in Rheumatoid Arthritis Have Declined From 1986 to 2011, but Large-Joint Replacement Rates Remain Unchanged: Results From Two UK Inception Cohorts

Postoperative complications in rheumatic disease patients undergoing arthroscopy on immunosuppression

BACKGROUND

There are currently no guidelines on peri-arthroscopic management of immunosuppressive (IS) treatment in rheumatic disease patients.

PURPOSE

The purpose of this study is to characterize the rheumatic disease patient population undergoing arthroscopy, compare the incidence of postoperative complications among patients who either remained on IS perioperatively, held IS perioperatively or were not on IS at baseline, and compare the incidence of postoperative complications by rheumatic disease type, medication type, and procedure.

METHODS

We conducted a retrospective review of all arthroscopic sports medicine surgeries in patients with a rheumatic disease diagnosis at our institution over an 11-year period. Patients on IS at baseline were grouped into those who remained on IS perioperatively or held all IS before the date of their surgery. These two groups were compared to patients who were not on IS at baseline. Incidence of postoperative complications was calculated for the three cohorts and by medication class, rheumatic disease type, and procedure risk. Analysis of variance (ANOVA), chi-squared, and Fisher's exact tests were used to determine the statistical significance of between-group differences in postoperative complication incidence.

RESULTS

We identified 1,316 rheumatic disease patients undergoing arthroscopy, with 214 of them taking IS medications at baseline. In total, 8.4% (n = 110) remained on IS perioperatively, 7.9% (n = 104) held IS perioperatively, and 83.7% (n = 1102) were not on IS at baseline. In all cohorts, seven patients experienced postoperative complications; six of whom experienced infections. Two (1.82%) occurred in patients remaining on IS perioperatively, zero infections occured in patients who held all IS, and four (0.36%) occured in patients who were not on any IS at baseline. There was no statistically significant difference in postoperative infections or complication rates among the three cohorts or further subgroups.

CONCLUSION

The risk of postoperative complications including infectious, major, and minor complications in patients on IS at the time of arthroscopy is low and acceptable.

Is Total Joint Arthroplasty an Effective and Safe Option for Psoriatic Arthritis Patients? A Scoping Review

Recent advancements in the treatment of psoriatic arthritis (PsA) have improved patient outcomes, but many still experience disease progression, potentially leading to joint replacement surgery. In this scoping review, we examine the relationship between PsA and orthopedic surgery, focusing on the risks and temporal trends of total hip arthroplasty (THA) and total knee arthroplasty (TKA), the prevalence of postoperative complications, and the effectiveness of these procedures in PsA. The included studies suggest that PsA patients have an overall higher risk of undergoing THA and TKA compared to the general population, but with temporal trends showing a decreased risk for patients diagnosed in recent years. Acute complications, such as renal failure, stroke, and postoperative infections, may be more common in PsA patients than in those with osteoarthritis after THA and TKA. No significant differences were found in pain, function, or satisfaction between PsA, skin psoriasis, and osteoarthritis patients after THA. A key conclusion from our review is the need to strengthen the collaboration between rheumatologists and orthopedic surgeons, as interdisciplinary evaluation is crucial for improving the outcomes of PsA patients undergoing orthopedic surgery.

Development of a Machine Learning Model to Predict the Use of Surgery in Patients With Rheumatoid Arthritis

OBJECTIVE

One in five patients with rheumatoid arthritis (RA) rely on surgery to restore joint function. However, variable response to disease-modifying antirheumatic drugs (DMARDs) complicates surgical planning, and it is difficult to predict which patients may ultimately require surgery. We used machine learning to develop predictive models for the likelihood of undergoing an operation related to RA and which type of operation patients who require surgery undergo.

METHODS

We used electronic health record data to train two extreme gradient boosting machine learning models. The first model predicted patients' probabilities of undergoing surgery ≥5 years after their initial clinic visit. The second model predicted whether patients who underwent surgery would undergo a major joint replacement versus a less intensive procedure. Predictors included demographics, comorbidities, and medication data. The primary outcome was model discrimination, measured by area under the receiver operating characteristic curve (AUC).

RESULTS

We identified 5,481 patients, of whom 278 (5.1%) underwent surgery. There was no significant difference in the frequency of DMARD or steroid prescriptions between patients who did and did not have surgery, though nonsteroidal anti-inflammatory drug prescriptions were more common among patients who did have surgery (P = 0.03). The model predicting use of surgery had an AUC of 0.90 ± 0.02. The model predicting type of surgery had an AUC of 0.58 ± 0.10.

CONCLUSIONS

Predictive models using clinical data have the potential to facilitate identification of patients who may undergo rheumatoid-related surgery, but not what type of procedure they will need. Integrating similar models into practice has the potential to improve surgical planning.

Postoperative flares and peri-arthroscopic management of immunosuppressive medications in patients with rheumatic disease

PURPOSE

To determine the rate and characteristics of postoperative flares in rheumatic disease patients undergoing arthroscopic surgery, and the role of perioperative immunosuppression (IS) management in preventing or provoking these exacerbations.

METHODS

We conducted a retrospective review of arthroscopic surgeries in patients with rheumatologic disease over 11 years. Patients taking IS at baseline and those without were matched 1:1 using propensity scores on age, sex, rheumatic disease type, and procedure complexity. Patients taking IS at baseline were sub-divided into those remaining on IS perioperatively versus those who held IS before surgery. Multivariable logistic regression identified risk factors for postoperative flares for the three IS groups, and survival analysis was used to compare the probability of remaining flare-free up to 12 weeks postoperatively.

RESULTS

After matching, 428 patients (214 on various types of baseline IS, 214 not on baseline IS) were included, with 110 on baseline IS remaining on it perioperatively. Rates of postoperative flares were similar for those staying on vs holding their baseline IS (9.1% vs 9.6%) but flares were less frequent in patients not on baseline IS (1.9%). Patients who remained on perioperative IS did not have significantly less flares compared to patients taken off perioperative IS (OR 0.764 [0.267, 2.181]; p = 0.61). Patients not on baseline IS had a significantly higher probability ofremaining flare-free up to 12 weeks (p = 0.004).

CONCLUSION

Rheumatic disease patients who hold IS medication before undergoing arthroscopy, out of concern for potential infection or complications, do not significantly increase their risk of flaring their autoimmune disease whether they had been taking csDMARDs or biologic agents. Those not taking any IS at baseline have a much lower risk of post-arthroscopic flaring, though as a group they likely harbor less of an autoimmune burden.

Advanced surgical tool: Progress in clinical application of intelligent surgical robot

Surgical robot is a revolutionary tool conceived in the progress of clinical medicine, computer science, microelectronics and biomechanics. It provides the surgeon with clearer views and more comfortable surgical postures. With the assistance of computer navigation during delicate operations, it can further shorten the patient recovery time via reducing intraoperative bleeding, the risk of infection and the amount of anesthesia needed. As a comprehensive surgical revolution, surgical robot technique has a wide range of applications in related fields. This paper reviews the development status and operation principles of these surgical robots. At the same time, we also describe their up-to-date applications in different specialties and discusses the prospects and challenges of surgical robots in the medical area.

Global epidemiology of rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic autoimmune disease that predominantly affects the joints. The prevalence of RA varies globally, with generally a higher prevalence in industrialized countries, which may be explained by exposures to environmental risk factors, but also by genetic factors, differing demographics and under-reporting in other parts of the world. Over the past three decades, strong trends of the declining severity of RA probably reflect changes in treatment paradigms and overall better management of the disease. Other trends include increasing RA prevalence. Common risk factors for RA include both modifiable lifestyle-associated variables and non-modifiable features, such as genetics and sex. A better understanding of the natural history of RA, and of the factors that contribute to the development of RA in specific populations, might lead to the introduction of specific prevention strategies for this debilitating disease.

2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

OBJECTIVE

To develop updated American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA).

METHODS

We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process.

RESULTS

This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids.

CONCLUSION

This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.

2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

OBJECTIVE

To develop updated guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA).

METHODS

We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process.

RESULTS

This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids.

CONCLUSION

This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.

2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

OBJECTIVE

To develop updated guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA).

METHODS

We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process.

RESULTS

This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids.

CONCLUSION

This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.

Surgical Intervention for Patients With Rheumatoid Arthritis is Declining Except for Foot and Ankle Surgery: A Single-Center, 20-Year Observational Cohort Study

OBJECTIVE

A global downward trend in the number of rheumatoid arthritis (RA)-related surgeries has been reported. The purpose of our study was to investigate the latest trends in RA-related surgeries in a single-center Japanese RA cohort.

METHODS

This study was a retrospective analysis of RA-related surgeries between 2001 and 2020 in the Institute of Rheumatology Rheumatoid Arthritis cohort. An average of 4,944 patients per semiannual survey was included in the study. The primary goal was to analyze the half-year period prevalence proportion (HPP) of RA-related surgeries in a 20-year period, and the secondary goal was to analyze the HPP of surgeries by site or by categories of disease activity.

RESULTS

There has been a downward trend in the HPP of RA-related surgeries in the 20-year study period. The total HPP of RA-related surgeries decreased by 50.3% during the 20-year study period. There was a significant decrease in knee, hip, shoulder/elbow, and hand procedures. Only foot/ankle joint surgeries significantly increased in volume during this period (p=0.001). The HPP of RA-related surgeries remained unchanged in patients with remission or low disease activity.

CONCLUSION

The number of RA-related surgeries decreased over a 20-year period, but foot/ankle joint surgeries increased in the site-specific evaluation.

Perioperative Management of Rheumatic Disease and Therapies

Patients with rheumatic disease, including those with systemic lupus erythematous, rheumatoid arthritis, and spondyloarthritis, use total hip and knee arthroplasties at high rates. They represent a particularly vulnerable population in the perioperative setting because of their diseases and the immunosuppressant therapies used to treat them. Careful planning among internists, medical specialists, and the surgical team must therefore occur preoperatively to minimize risks in the postoperative period, particularly infection. Management of immunosuppressant medications, such as conventional synthetic disease-modifying antirheumatic drugs and targeted therapies including biologics, is one avenue by which this infectious risk can be mitigated.

OUP accepted manuscript

OBJECTIVES

Control of disease activity in RA is a crucial part of its management to prevent long-term joint damage and disability. This study aimed to identify early predictors of poor disease activity at 5 and 10 years, focusing on comorbidities and clinical/sociodemographic factors at first presentation.

METHODS

Patients from two UK-based RA cohorts were classified into two groups; low (<3.2) and moderate/high (≥3.2) DAS using 28 joint counts (DAS28) at 5/10 years. Clinical variables (e.g. rheumatoid nodules, erosions), sociodemographic factors (e.g. ethnicity, deprivation) and comorbidities were recorded at baseline and yearly thereafter. The Rheumatic Diseases Comorbidity Index quantified patient comorbidity burden. Binary logistic regression models (outcome low vs moderate/high DAS28) were fitted using multiple imputation.

RESULTS

A total of 2701 patients living with RA were recruited (mean age 56.1 years, 66.9% female); 5-year data were available for 1718 (63.4%) patients and 10-year data for 820 (30.4%). Baseline Rheumatic Diseases Comorbidity Index was not associated with DAS28 at 5 [odds ratio (OR) 1.05, 95% CI 0.91, 1.22] or 10 years (OR 0.99, 95% CI 0.75, 1.31) in multivariable analyses. Sociodemographic factors (female gender, worse deprivation) and poorer baseline HAQ-Disability Index were associated with DAS28 ≥3.2 at both timepoints. Being seropositive was associated with 5-year DAS28 ≥3.2.

CONCLUSION

This study demonstrates an association between sociodemographic and clinical factors and long-term RA disease activity, in models adjusting for comorbidity burden. The findings call for more holistic and targeted patient management in patients with RA and provide insights for more individualized management plans even on first presentation to rheumatology.

Perioperative Management of Immunosuppressive Medications in Rheumatic Disease Patients Undergoing Arthroscopy

PURPOSE OF REVIEW

This manuscript reviews relevant prior literature regarding management of immunosuppressants in patients with rheumatic diseases around the time of orthopedic surgery, highlighting important considerations specifically regarding arthroscopy.

RECENT FINDINGS

Utilization rates of arthroscopic surgery in patients with rheumatic diseases are on the rise, as immunosuppressive treatment options enable them to lead more active lives and hence experience more injuries. Physicians regularly manage patients' glucocorticoids and conventional synthetic and biologic disease modifying antirheumatic drugs around the time of orthopedic surgery, aiming to minimize infection risk while optimizing disease control. However, there is a paucity of randomized controlled trial data for orthopedic surgery-and specifically nothing in the literature pertaining to arthroscopic surgery. Recent guidelines for rheumatic disease patients undergoing elective total hip and knee arthroplasty recommend that most immunosuppressive medications should be held perioperatively, citing the high-risk profile of arthroplasty cases and arthroplasty patients. While 2017 societal guidelines for perioperative immunosuppression during arthroplasty currently serve as a guide for physicians, they may not be applicable to arthroscopy. The less aggressive arthroscopic surgeries span a broader range of patient ages and risk profiles, indications for surgery, and procedural complexity and associated risks. Given these considerations, the majority of routine arthroscopic patients may not require holding of their immunosuppressive medications in the perioperative period.

Effects of biologics on reducing the risks of total knee replacement and total hip replacement in rheumatoid arthritis

OBJECTIVES

RA damages the joints and increases the risks of total knee replacement (TKR) and total hip replacement (THR). However, the benefits of biologics in preventing TKR or THR remain unclear.

METHODS

This retrospective nationwide study used the 2000-2013 claims-based National Health Insurance dataset. Biologics are reimbursed for refractory cases. The risks of TKR and THR in the biologic cohort were compared with those of age- and sex-matched csDMARD cohort. A multivariate Cox regression model was used to investigate the benefits of bDMARDs for TKR and THR.

RESULTS

TKR was performed in 5979 biologic cases and 11,958 matched controls, of which 249(4.16%) and 871(7.28%) cases received TKR, respectively. THR was performed in 6245 biologic cases and 12,490 matched controls, of which 159(2.55%) and 516(4.13%) cases had THR, respectively. The biologic cohort had significantly lower incidence rates of TKR (11.73 vs. 16.33/1000 person-years, P < 0.001) and THR (7.09 vs. 9.16/1000 person-years, P < 0.001). After adjustment for confounding factors, the regular bDMARD subgroup (average dose >0.95 defined daily dose/day) had significantly lower risks of TKR (aHR: 0.55, 95% CI: 0.38-0.81) and THR (aHR: 0.63, 95% CI: 0.40-0.98). Those without methotrexate use, with steroid use, with biologic switch, and overlapping antiphospholipid syndrome had significantly higher risks of TKR and THR.

CONCLUSIONS

Compared with the csDMARD cohort, the risks of TKR and THR in the bDMARD cohort were the same as those in the low to moderate dose subgroups and significantly lower in those with regular bDMARD use.

Large joints are progressively involved in rheumatoid arthritis irrespective of rheumatoid factor status-results from the early rheumatoid arthritis study

This study aimed to examine the progression of large joint involvement from early to established RA in terms of range of movement (ROM) and time to joint surgery, according to the presence of rheumatoid factor (RF). We used a historical longitudinal cohort of early RA patients. Patients were deemed RF negative if all repeated assessments were negative. The rate of progression from normal to any loss of range of movement (ROM) from years 3 to 14 were modelled using generalized estimating equations, for elbows, wrists, hips, knees and ankle, adjusting for confounders. Time to joint surgery was analysed using multivariable Cox models. A total of 1458 patients were included (66% female, mean age 55 years) and 74% were RF-positive. The prevalence of any loss of ROM, from year 3 through to 14 was highest in the wrist followed by ankle, knee, elbow and hip. Odds of loss of ROM increased over time in all joint regions assessed, at around 7–13% per year from year 3 to 14. Time to surgery was similar according to RF-status for the wrist and ankle, but RF-positive cases had a lower hazard of surgery at the elbow (HR 0.37, 0.15–0.90), hip (HR 0.69, 0.48–0.99) and after 10 years at the knee (HR 0.41, 0.25–0.68). Large joints become progressively involved in RA, most frequently affecting the wrist followed by ankle, which is overlooked in composite disease activity indices. RF-negative and positive cases progressed similarly. Treat-to-target approaches should be followed irrespective of RF status.

Has the incidence of total joint arthroplasty in rheumatoid arthritis decreased in the era of biologics use? A population-based cohort study

OBJECTIVES

To determine whether the introduction of biological disease-modifying anti-rheumatic drugs (bDMARDs) was associated with reduced incidences of total hip and knee arthroplasty (THA/TKA) among patients with rheumatoid arthritis (RA) compared with osteoarthritis (OA).

METHODS

Using a population-based cohort in British Columbia, Canada, RA and OA patients diagnosed between 1995-2007 were divided into semi-annual cohorts according to diagnosis date. For each cohort, we calculated 8-year incidence rates of THA and TKA. We compared levels and trends of THA/TKA incidence in RA/OA patients diagnosed during pre-bDMARDs (1995-2001) and post-bDMARDs (2003-2007) periods using interrupted time-series analysis, adjusting for baseline characteristics. Adjusted 8-year TJA incidence estimated for RA/OA cohorts diagnosed five years after bDMARDs introduction were compared with expected rates assuming no bDMARDs introduction, based on extrapolation of pre-bDMARDs trends.

RESULTS

We identified 60,227 RA and 288,260 OA incident cases. For cohorts diagnosed pre-bDMARDs, 8-year THA/TKA incidence rates increased over time in both RA and OA. For cohorts diagnosed post-bDMARDs, these rates decreased over time in RA but continued to increase for OA. For RA, differences between the post- and pre-bDMARDs secular trends in incidence rates were -0.49 (p = 0.002) for THA and -0.36 (p = 0.003) for TKA, compared to + 0.40 (p = 0.006) and +0.54 (p < 0.001), respectively, for OA. For RA cohorts diagnosed five years after bDMARDs introduction, 8-year incidence were 26.9% and 12.6% lower for THA and TKA, respectively, than expected rates. In contrast, corresponding rates in OA were higher by 11.7% and 16.6%, respectively.

CONCLUSION

Arthritis onset after bDMARDs introduction is associated with a significant reduction in THA/TKA incidence in RA, but not in OA. The reduction reflects a significant improvement in RA treatment during the biological era.

Predictors of poor function in RA based on two prospective UK inception cohorts. Do comorbidities matter?

Objectives

Evidence suggests that factors beyond disease activity associate with functional disability in RA. The primary study objective was to explore associations between comorbidities, sociodemographic factors and functional outcomes at five and 10 years.

Methods

RA patients from two UK prospective cohorts were grouped into low (<1.5) and high (≥1.5) five- and 10-year health assessment questionnaire (HAQ) score. Clinical variables (e.g. disease activity, rheumatoid nodules, erosions) and sociodemographic factors (e.g. ethnicity, deprivation) were recorded at baseline and yearly thereafter. Comorbidity was measured using the Rheumatic Diseases Comorbidity Index (RDCI). Binary logistic regression models were fitted using multiple imputation.

Results

In total, 2701 RA patients were recruited (mean age 56.1 years, 66.9% female). A total of 1718 (63.4%) had five-year and 820 (30.4%) 10-year follow-up data. In multivariable analysis, no association was found between RDCI and HAQ ≥ 1.5 at five or 10 years. Sociodemographic factors (increased age at disease onset, female gender, minority ethnicity) were associated with higher odds of HAQ ≥ 1.5 at five and 10 years, with worse deprivation additionally associated with HAQ ≥ 1.5 at 10 years (OR 0.79, 95% CI: 0.69, 0.90).

Conclusion

Comorbidities at baseline have not been found to be associated with worse RA functional outcome in the long-term. On the other hand, sociodemographic factors, independently of disease measures, are associated with worse functional outcome in RA at five and 10 years, in models adjusting for comorbidity burden. Tailoring management interventions according to not only clinical disease parameters but also patient sociodemographic factors may improve long-term outcomes including functional disability.

Perioperative Continuation of Biologic Medications Increases Odds of Periprosthetic Joint Infection in Patients With Inflammatory Arthropathy

BACKGROUND

Rates of prosthetic joint infection (PJI) are elevated among patients with inflammatory arthropathy (IA). The effect of continuing biologic drugs perioperatively with regard to PJI is unknown. The purpose of this study is to compare rates of perioperative biologic continuation in IA patients who did and did not develop PJI after primary total joint arthroplasty (TJA).

METHODS

All cases of PJI within 1 year of primary TJA in IA patients on biologic medications were retrospectively reviewed from 2005 to 2018 in the US Veterans Affairs Corporate Data Warehouse. Matched controls who did not develop PJI after TJA were populated from the same database. Biologic suspension, defined as medication interruption prior to TJA with surgery occurring after the end of the dosing cycle and resumption after wound healing, was compared among cases and controls.

RESULTS

Biologic medications were continued through surgery in 35% (9/26) of patients who developed PJI compared to 14% (8/58) of controls (P = .031; adjusted odds ratio of 3.46 [1.11-10.78]). No significant difference existed among cases (n = 26) and controls (n = 58) for age, gender, procedure, body mass index, rates of diabetes or chronic kidney disease, smoking status, or preoperative opioid use (all P > .05).

CONCLUSION

With the limited sample sizes available in this study, we found an association with perioperative continuation of biologic medications and PJI. This data may provide support for current guidelines from the American Association of Hip and Knee Surgeons to withhold biologics before TJA with surgery scheduled at the end of the dosing cycle and medication resumption only after wound healing.

Epidemiology of Scleritis in the United Kingdom From 1997 to 2018: Population-Based Analysis of 11 Million Patients and Association Between Scleritis and Infectious and Immune-Mediated Inflammatory Disease

OBJECTIVE

To estimate 22-year trends in the prevalence and incidence of scleritis, and the associations of scleritis with infectious and immune-mediated inflammatory diseases (I-IMIDs) in the UK.

METHODS

The retrospective cross-sectional and population cohort study (1997-2018) included 10,939,823 patients (2,946 incident scleritis cases) in The Health Improvement Network, a nationally representative primary care records database. The case-control and matched cohort study (1995-2019) included 3,005 incident scleritis cases and 12,020 control patients matched by age, sex, region, and Townsend deprivation index. Data were analyzed using multivariable Poisson regression, multivariable logistic regression, and Cox proportional hazards multivariable models adjusted for age, sex, Townsend deprivation index, race/ethnicity, smoking status, nation within the UK, and body mass index. Incidence rate ratios (IRRs) and 95% confidence intervals (95% CIs) were calculated.

RESULTS

Scleritis incidence rates per 100,000 person-years declined from 4.23 (95% CI 2.16-6.31) to 2.79 (95% CI 2.19-3.39) between 1997 and 2018. The prevalence of scleritis per 100,000 person-years was 93.62 (95% CI 90.17-97.07) in 2018 (61,650 UK patients). Among 2,946 patients with incident scleritis, 1,831 (62.2%) were female, the mean ± SD age was 44.9 ± 17.6 years (range 1-93), and 1,257 (88.8%) were White. Higher risk of incident scleritis was associated with female sex (adjusted IRR 1.53 [95% CI 1.43-1.66], P < 0.001), Black race/ethnicity (adjusted IRR 1.52 [95% CI 1.14-2.01], P = 0.004 compared to White race/ethnicity), or South Asian race/ethnicity (adjusted IRR 1.50 [95% CI 1.19-1.90], P < 0.001 compared to White race/ethnicity), and older age (peak adjusted IRR 4.95 [95% CI 3.99-6.14], P < 0.001 for patients ages 51-60 years versus those ages ≤10 years). Compared to controls, scleritis patients had a 2-fold increased risk of a prior I-IMID diagnosis (17 I-IMIDs, P < 0.001) and significantly increased risk of subsequent diagnosis (13 I-IMIDs). The I-IMIDs most strongly associated with scleritis included granulomatosis with polyangiitis, Behçet's disease, and Sjögren's syndrome.

CONCLUSION

From 1997 through 2018, the UK incidence of scleritis declined from 4.23 to 2.79/100,000 person-years. Incident scleritis was associated with 19 I-IMIDs, providing data for rational investigation and cross-specialty engagement.

'Should we stop or continue conventional synthetic (including glucocorticoids) and targeted DMARDs before surgery in patients with inflammatory rheumatic diseases?'

Total hip and total knee arthroplasty) remain important interventions to treat symptomatic knee and hip damage in patients with rheumatoid arthritis, with little change in utilisation rates despite the increasingly widespread use of potent conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and targeted DMARDs including Janus kinase inhibitors and biologics. The majority of patients are receiving these immunosuppressing medications and glucocorticoids at the time they present for arthroplasty. There is minimal randomised controlled trial data addressing the use of DMARDs in the perioperative period, yet patients and their physicians face these decisions daily. This paper reviews what is known regarding perioperative management of targeted and csDMARDs and glucocorticoids.

Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery: A Critical Analysis Review

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Recent literature has shown that continued use rather than discontinuation of various antirheumatic agents throughout the perioperative period may present an opportunity to mitigate the risks of elective surgery.

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For patients with rheumatoid arthritis and systemic lupus erythematosus, perioperative management of medication weighs the risk of infection against the risk of disease flare when immunosuppressive medications are withheld.

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Broadly speaking, current evidence, although limited in quality, supports perioperative continuation of disease-modifying antirheumatic drugs, whereas biologic drugs should be withheld perioperatively, based on the dosing interval of the specific drug.

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For any withheld biologic drug, it is generally safe to restart these medications approximately 2 weeks after surgery, once the wound shows evidence of healing, all sutures and staples have been removed, and there is no clinical evidence of infection. The focus of this recommendation applies to the optimization of wound-healing, not bone-healing.

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In most cases, the usual daily dose of glucocorticoids is administered in the perioperative period rather than administering "stress-dose steroids" on the day of surgery.

Perioperative Management of Rheumatic Disease and Therapies

Patients with rheumatic disease, including those with systemic lupus erythematous, rheumatoid arthritis, and spondyloarthritis, use total hip and knee arthroplasties at high rates. They represent a particularly vulnerable population in the perioperative setting because of their diseases and the immunosuppressant therapies used to treat them. Careful planning among internists, medical specialists, and the surgical team must therefore occur preoperatively to minimize risks in the postoperative period, particularly infection. Management of immunosuppressant medications, such as conventional synthetic disease-modifying antirheumatic drugs and targeted therapies including biologics, is one avenue by which this infectious risk can be mitigated.

Epidemiology of orthopaedic fractures due to firearms

The majority of firearm injuries involve the extremities and have concomitant orthopaedic injuries. National data on the epidemiology of wounds caused by firearms may better inform physicians and identify areas of public health intervention. We conducted an analysis of a national database to describe the epidemiology of orthopaedic firearm injuries in the United States. The Nationwide Inpatient Sample 2001-2013 database was queried for adult patients with fractures excluding those of the skull using injury billing codes. Characterization of injury was determined using External Cause of Injury billing codes. Sociodemographic and geographic variables were reported. Chi square and multinomial logistic regression analyses were performed to identify predictors of type of firearm implicated in injury. 334,212 firearm injuries were reported in the database and about half had concomitant orthopaedic fractures. Most patients were between the ages 19 and 29, were African American, and were male. The most frequent circumstance of injury was assault/homicide, the most common firearm used was a handgun, and the most common fracture site was the femur. Patients without insurance and patients of lower income were most commonly afflicted. Knowing this distribution of the burden of this class of injury provides the opportunity to identify and intervene on behalf of at-risk populations, potentially reducing injuries by promoting firearm safety to these groups and advocating sensible practices to reduce inequitable outcomes caused by these injuries.

Effects of malalignment and disease activity on osteophyte formation in knees of rheumatoid arthritis patients

PURPOSE

Rheumatoid arthritis (RA) patients with secondary osteoarthritis (OA) in a knee joint following a total knee arthroplasty (TKA) procedure have been increasing. Here, we investigated osteophyte formation in knee joints of RA patients and associated factors.

METHODS

We retrospectively examined findings of 35 knees in 30 RA patients (26 females, 4 males; mean age: 63.0 years; median disease duration: 15 years) who underwent TKA, including preoperative anteroposterior view radiographs of the knee joint. Using the ImageJ software package, osteophyte size in the medial femur (MF), medial tibia (MT), lateral femur (LF), and lateral tibia (LT) regions was also determined.

RESULTS

The mean femorotibial angle was 179°, while Larsen grade was 2 in 1, 3 in 12, 4 in 18, and 5 in 2 patients. Osteophyte sizes in the MF, MT, LF, and LT regions were 37.2, 17.0, 27.2, and 4.57 mm², respectively, and significantly greater in the medial compartment (MC; MF+MT) than the lateral compartment (LC; LF+LT) (p < 0.001). In varus cases, osteophyte size in the MC was significantly larger than normal and valgus cases (p = 0.0016). Furthermore, osteophyte size in the MC was negatively correlated with the inflammatory markers C-reactive protein (r = -0.492, p = 0.0027) and erythrocyte sedimentation rate (r = -0.529, p = 0.0016), whereas that in the LC was negatively correlated with disease activity (r = -0.589, p = 0.0023).

CONCLUSION

Our results suggest that alignment and disease activity influence osteophyte formation in RA patients, with secondary OA a more prominent symptom in RA patients with controlled inflammation.

Beyond the joints, the extra-articular manifestations in rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory disease typically affecting the joints, but the systemic inflammatory process may involve other tissues and organs. Many extra-articular manifestations are recognized, which are related to worse long outcomes. Rheumatoid nodules are the most common extra-articular feature, found in about 30% of patients. Secondary Sjögren's syndrome and pulmonary manifestations are observed in almost 10% of patients, also in the early disease. Active RA with high disease activity has been associated with an increased risk of such features. Male gender, smoking habit, severe joint disease, worse function, high pro-inflammatory markers levels, high titer of rheumatoid factor, and HLA-related shared epitope have been reported as clinical predictors of occurrence of these rheumatoid complications. In addition, there is a little evidence deriving from randomized controlled trials in this field, thus the therapeutic strategy is mainly empiric and based on small case series and retrospective studies. However, considering that these extra-articular manifestations are usually related to the more active and severe RA, an aggressive therapeutic strategy is usually employed in view of the poor outcomes of these patients. The extra-articular features of RA remain, despite the improvement of joint damage, a major diagnostic and therapeutic challenge, since these are associated with a poor prognosis and need to be early recognized and promptly managed.

Incidence and Complication Rates for Total Hip Arthroplasty in Rheumatoid Arthritis: A Systematic Review and Meta-Analysis Across Four Decades

INTRODUCTION

Over the past several decades, management of rheumatoid arthritis (RA) has evolved significantly, but few studies have examined the real-world impact of these changes on orthopaedic surgery in patients with RA. This systematic review assessed total hip arthroplasty (THA) incidence and postoperative complication rates across the past four decades.

METHODS

This is a systematic literature review sourcing data on THA in patients with RA from the electronic databases MEDLINE, EMBASE, Scopus, and Cochrane between January 1, 1980 and December 31, 2019.

RESULTS

The search retrieved 1715 articles of which 44 were included for quantitative synthesis. The rate for THA decreased by almost 40% from 11/1000 patient years (PY) in the 2000s to 7/1000 PY in the 2010s, while the overall complication rate decreased from 9.9% in the 1990s to 5.3% in the 2010s. Throughout the duration of the study, THA incidence and overall complication rate decreased. However, not all individual complication rates decreased. For example, revision and periprosthetic fracture decreased, infection and aseptic loosening remained constant, and dislocation increased.

CONCLUSION

Medical management of patients with RA has reduced the need for THA, while postoperative medical and surgical management has improved some postoperative outcomes. Nevertheless, there remains room for further improvement to postoperative outcomes through RA-specific management.

Clavicle fractures: Associated trauma and morbidity

BACKGROUND

Clavicle fractures are frequently associated with trauma to regions beyond the immediate zone of injury. In order to provide surgeons with information on injury prevalence to prevent delays in diagnosis and management, we describe the epidemiology of concomitant injuries in patients with clavicle fractures and identify differences between those with open and closed fractures. Methods:The Nationwide Inpatient Sample (NIS) 2001-2013 database was queried for adult patients discharged with a diagnosis of a clavicle fracture using ICD-9 codes. A "common" injury was defined as prevalence ≥4.0% in our study population. We analyzed data for injury locations associated with open vs. closed clavicle fractures with chi square and independent samples t-tests.

RESULTS

A total of 41,1612 patients were included in our study population. The majority of patients had closed clavicle fractures (98.2%). The most common concomitant fracture was that of the rib, followed by the spine. The most common non-vascular, non-nervous injury was a hemo/pneumothorax followed by a lung, bronchus, or diaphragm injury. Fractures of the humerus, rib, scapula, pelvis, tibia or fibula, and facial bones as well as concussion, pneumo/hemothorax, other pulmonary, and splenic injuries were more common in patients with open clavicle fractures. Patients with open clavicle fractures were, on average, 11.8 years younger than those with closed fractures.

CONCLUSION

There is a significant association between clavicle fractures and concussion, splenic, and thoracic injuries, as well as increased rate of complications with open fractures. Clinicians may use this information to perform risk assessments prevent delays in diagnosis.

Remission vs low disease activity: function, quality of life and structural outcomes in the Early Rheumatoid Arthritis Study and Network

Objectives

To examine associations between function, quality of life and structural outcomes in patients achieving remission vs low disease activity in early RA.

Methods

Demographic, clinical and radiographic variables were collected at baseline and then annually from the Early Rheumatoid Arthritis Study (ERAS) and Early Rheumatoid Arthritis Network (ERAN) inception cohorts in routine care from 1986 to 2012. Disease activity was categorized: mean DAS28 score between years 1 and 5: remission [mean remission DAS (mRDAS) <2.6] or low [mean low DAS (mLDAS) 2.6–3.2]; sustained low/remission DAS28 (sLDAS/sRDAS) at years 1 and 2; and sustained Boolean remission (sBR) at years 1 and 2. Changes in HAQ and Short Form 36 Health Survey Questionnaire [SF-36; physical (PCS) and mental (MCS) component score]) and total Sharp van der Heijde (SvdH) scores for each disease activity category were modelled using multi-level models. Covariates included year of onset, age, gender and DMARD use at first visit.

Results

Of 2701 patients, 562 (21%) were categorized mRDAS, 330 (12%) mLDAS, 279 (10%) sRDAS, 203 (7.5%) sLDAS and 93 (3%) sBR. Patients categorized as mRDAS had increasingly divergent improved HAQ, SF-36 PCS, MCS and total SvdH scores compared with mLDAS (P-values 0.001 to <0.0001, all time points). Patients categorized as sRDAS had better HAQ, SF-36 PCS and MCS scores (P-values 0.05 to <0.0001, all time points) and SvdH scores (P = 0.05, years 3–5) over sLDAS. sBR was associated with better HAQ, and SF-36 PCS and MCS scores over sLDAS (P-values 0.002 to <0.0001, all time points).

Conclusion

These findings from routine care support ACR/EULAR guidelines that remission is a preferable goal over low disease activity in early RA.

Major differences in medical and surgical treatment of psoriatic arthritis and rheumatoid arthritis: a comparison of two historic cohorts

OBJECTIVES

Substantial changes in the handling of patients with inflammatory arthritis have occurred during the past half century. Polyarticular psoriatic arthritis (PsA) has been treated with the same synthetic disease-modifying anti-rheumatic drugs (DMARDs) as rheumatoid arthritis (RA), but for PsA there is less documentation regarding their effect. For biologic DMARDs, evidence of effect is more convincing. We have previously investigated the risk of orthopaedic surgery in patients with RA and PsA to see whether the change in treatment over time has improved the long-term outcome of inflammatory arthritis. For RA, patients diagnosed from 1999 onwards had a lower risk of surgery than patients diagnosed in earlier years. For PsA, the risk of surgery did not change similarly. We wished to compare RA patients to PsA patients with regard to medical and surgical treatment.

METHOD

We compared a historic cohort of 1010 RA patients diagnosed in 1972-2009 to a historic cohort of 590 PsA patients diagnosed in 1954-2011.

RESULTS

PsA patients received significantly less medical treatment both in the first year of disease and during the disease course. Risk of surgery during the disease course was lower for PsA than for RA (20% vs 31%). The risk of surgery in RA patients diagnosed from 1999 onwards was similar to that of PsA patients.

CONCLUSIONS

PsA patients received less intensive treatment than RA patients. Their prognosis, regarding orthopaedic surgery, was also less severe. Contrary to RA, the change in treatment did not have beneficial effects regarding the risk of orthopaedic surgery.

Lifetime risk of knee and hip replacement following a diagnosis of RA: findings from a cohort of 13 961 patients from England

Objective

To estimate the lifetime risk of knee and hip replacement following a diagnosis of RA.

Methods

The analysis was undertaken using routinely collected data from the English NHS. Diagnosis of RA was identified using primary care records, with knee and hip replacement observed in linked hospital records. Parametric survival models were fitted for up to 15 years of follow-up, with age, sex, Charlson comorbidity score, socioeconomic status, BMI and smoking status included as explanatory variables. A decision model was used to combine and extrapolate survival models to estimate lifetime risk.

Results

The number of individuals with a diagnosis of RA and included in the study was 13 961. Lifetime risk of knee replacement and hip replacement was estimated to be 22% (95% CI: 16, 29%) and 17% (95% CI: 11, 26%) following a diagnosis of RA for the average patient profile (non-smoking women aged 64 with no other comorbidities, BMI of 27 and in the top socioeconomic quintile). Risks were higher for younger patients.

Conclusion

The lifetime risk of knee and hip replacement for individuals with a diagnosis of RA is approximately double that of the general population. These findings allow for a better understanding of long-term prognosis and healthcare resource use, and highlight the importance of timely diagnosis and effective treatment.

Reduction in Upper Limb Joint Surgery Among Rheumatoid Arthritis Patients: An Interrupted Time-Series Analysis Using Danish Health Care Registers

OBJECTIVE

Joint replacement surgery is a proxy of severe joint damage in rheumatoid arthritis (RA). The aim of this study was to assess the impact of the introduction of biologic disease-modifying antirheumatic drugs (bDMARDs) on the incidence rate (IR) of upper limb joint replacements among newly diagnosed RA patients.

METHODS

Using the Danish National Patient Register, patients with incident RA from 1996-2012 were identified. Each patient was matched on age, sex, and municipality, with up to 10 general population controls. The age- and sex-standardized 5-year IR per 1,000 person-years of a composite outcome of any first joint replacement of the finger, wrist, elbow, or shoulder was calculated, and an interrupted time-series analysis was undertaken to investigate trends and changes of the IR in the pre-bDMARD (1996-2001) and the bDMARD eras (2003-2012), with a 1-year lag period in 2002.

RESULTS

In total, 18,654 incident patients with RA were identified (mean age 57.6 years, 70.5% women). The IR of joint replacements among patients with RA was stable at 2.46 per 1,000 person-years (95% confidence interval [95% CI] 1.96, 2.96) from 1996 to 2001 but started to decrease from 2003 onwards (-0.08 per 1,000 person-years annually [95% CI -0.20, 0.02]). Compared with patients with RA, the IR among controls in 1996 was 1/17 and increased continuously throughout the study period.

CONCLUSION

The IR of upper limb joint replacements started to decrease among patients with RA from 2002 onwards, whereas it increased among controls. Our results suggest an association between the introduction of bDMARDs and a lower need of joint replacements among patients with RA.

Joint Surgery in Tunisian Rheumatoid Arthritis Patients: Prevalence and Risk Factors

Objectives

This study aims to assess the prevalence of joint surgery in Tunisian patients with rheumatoid arthritis (RA) and to determine the risk factors of surgical treatment.

Patients and methods

This retrospective cross-sectional study was performed over a period of 15 years between January 2000 and December 2014 and included 500 Tunisian patients with RA (78 males, 422 females; mean age 53.4 years; range, 21 to 83 years). The prevalence of joint surgery indication was evaluated. Clinical, paraclinical and therapeutic characteristics of RA were compared according to the need of surgery.

Results

Female to male ratio was 5. The indication of joint surgery was noted in 59 patients (12%). Knee joint surgery was the most performed surgical procedure (56% of surgical treatment). A decrease in surgery prevalence from 30% in 2004 to 4% in 2013 was noted. Statistical study showed that factors associated with joint surgery were: delayed diagnosis (p=0.037), long RA duration (p=0.017), young onset of RA (p<0.001), presence of joint deformities (p=0.034), presence of osteoporosis (p=0.029), presence of antinuclear antibodies (p<0.001), combination therapy of methotrexate with other conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) (p=0.001), short period of first medical treatment (p=0.012) and high erythrocyte sedimentation rate (ESR) (p=0.027). In multivariate analysis, three factors were independently related to the use of joint surgery: age at disease onset [odds ratio (OR): 2.799 95% confidence interval (CI): 1.49-5.22; p=0.01], high ESR level (OR: 2.807 95% CI: 1.5-5.24; p=0.01) and association of methotrexate with other csDMARDs (OR: 3.500 95% CI: 1.61-7.56; p=0.01).

Conclusion

Twelve percent of RA patients needed joint surgical treatment. Predictive factors of surgery were age at disease onset, high ESR level and association of methotrexate with other csDMARDs.

Descriptive epidemiology of hip and knee replacement in rheumatoid arthritis: An analysis of UK electronic medical records

OBJECTIVE

To provide descriptive data on rates of total hip replacement (THR) and total knee replacement (TKR) within a large RA cohort and describe variation in risk.

METHODS

Incident RA patients (1995 to 2014) were identified from the Clinical Practice Research Datalink (CPRD). First subsequent occurrence of THR and TKR were identified (analysed separately) and incidence rates calculated, stratified by sex, age, BMI, geographic region, and quintiles of the index of multiple deprivation (IMD) score.

RESULTS

There were 27,607 RA patients included, with a total of 1,028 THRs (mean age at surgery: 68.4 years) and 1,366 TKRs (mean age at surgery: 67.6 years), at an overall incidence rate per 1,000 person-years (PYs) [95% CI] of 6.38 [6.00-6.78] and 8.57 [8.12-9.04], respectively. TKR incidence was similar by gender but THR rates were higher in females than males. Rates of TKR but not THR rose according to BMI. An increasing trend was observed in rates of both outcomes according to age (although not ≥75) but of decreasing rates according to socio-economic deprivation. There was some evidence for regional variation in TKR. The 10-year cumulative incidence was 5.2% [4.9, 5.6] and 7.0% [6.6, 7.4] for THR and TKR, respectively.

CONCLUSION

We provide generalizable estimates of THR and TKR incidence in the UK RA patient population and note variation across several key variables. Increased BMI was associated with a large increase in TKR but not THR incidence. Increased deprivation was associated with a downward trend in rates of THR and TKR.

Types of pain and their psychosocial impact in women with rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disease predominantly affecting middle-aged women. Very commonly, pain is a manifestation of active disease and because untreated RA can result in joint deformities, the current evaluation of pain has largely focused on inflammation. In addition, treatment has centered on the premise of reducing disease activity with the hopes of halting worsening damage, preventing future deformities, and ultimately providing pain relief for the patient. Yet research shows that all patients with RA, but women in particular, often suffer from increased mechanical pain and fibromyalgia, as well as anxiety, depression, sleep disturbances, sexual dysfunction, and disability, which add to the burden of the illness. Determining and addressing alternative pain triggers as well as understanding the psychosocial burden of RA is key in treating patients, especially in those who may not improve with traditional pharmacotherapy.

Impact of TNF inhibitor therapy on joint replacement rates in rheumatoid arthritis: a matched cohort analysis of BSRBR-RA UK registry data

OBJECTIVES

Previous ecological data suggest a decline in the need for joint replacements in RA patients following the introduction of TNF inhibitor (TNFi) therapy, although patient-level data are lacking. Our primary aim was to estimate the association between TNFi use and subsequent incidence of total hip replacement (THR) and total knee replacement.

METHODS

A propensity score matched cohort was analysed using the British Society for Rheumatology Biologics Registry (2001-2016) for RA data. Propensity score estimates were used to match TNFi users to similar conventional synthetic DMARD users (with replacement) using a 1:1 ratio. Weighted multivariable Cox regression was used to estimate the impact of TNFi on study outcomes. Effect modification by baseline age and disease severity were investigated. Joint replacement at other sites was also analysed. An instrumental variable sensitivity analysis was also performed.

RESULTS

The matched analysis contained a total of 19 116 patient records. Overall, there was no significant association between TNFi use vs conventional synthetic DMARD on rates of THR (hazard ratios = 0.86 [95% CI: 0.60, 1.22]) although there was significant effect modification by age (P < 0.001). TNFi was associated with a reduction in THR among those >60 years old (hazard ratio = 0.60 [CI: 0.41, 0.87]) but not in younger patients. No significant associations were found for total knee replacement or other joint replacement.

CONCLUSION

Overall, no association was found between the use of TNFi and subsequent incidence of joint replacement. However, TNFi was associated with a 40% relative reduction in THR rates among older patients.

Orthopedic Surgery in Rheumatoid Arthritis: Results from the Spanish National Registry of Hospitalized Patients over 17 Years

OBJECTIVE

To analyze the trend of orthopedic surgery (OS) rates on patients with rheumatoid arthritis (RA).

METHODS

Retrospective observational study based on information provided by the Spanish National System of Hospital Data Surveillance. All hospitalizations of patients with RA for orthopedic surgery [total hip arthroplasty (THA), total knee arthroplasty (TKA), arthrodesis, and upper limb arthroplasty (ULA)] during 1999-2015 were analyzed. The age-adjusted rate was calculated. Generalized linear models were used for trend analysis.

RESULTS

There were 21,088 OS in patients over 20 years of age (77.9% women). OS rate adjusted by age was 754.63/100,000 RA patients/year (women 707.4, men 861.1). Neither an increasing nor a decreasing trend was noted for the total OS. However, trend and age interacted, so in the age ranges 20-40 years and 40-60 years, an annual reduction of 2.69% and 2.97%, respectively, was noted. In the age ranges over 80 years and 60-80 years, we noted an annual increase of 5.40% and 1.09%, respectively. The average age at time of OS increased 5.5 years during the period analyzed. For specific surgeries, a global annual reduction was noted in rates for arthrodesis. In THA, there was an annual reduction in patients under 80 years. In TKA and ULA, there was an annual reduction in patients under 60 years.

CONCLUSION

Although the overall OS rate has not changed, there is a decrease in the rate of arthrodesis at all ages, THA in patients under 80 years of age, as well as TKA and ULA in patients under 60 years of age.

Does Abatacept Increase Postoperative Adverse Events in Rheumatoid Arthritis Compared with Conventional Synthetic Disease-modifying Drugs?

Objective.

To investigate whether abatacept (ABA) causes more adverse events (AE) than conventional synthetic disease-modifying antirheumatic drugs (csDMARD) after orthopedic surgery in patients with rheumatoid arthritis (RA).

Methods.

A retrospective multicenter nested case–control study was performed in 18 institutions. Patients receiving ABA (ABA group) were matched individually with patients receiving csDMARD and/or steroids (control group). Postoperative AE included surgical site infection, delayed wound healing, deep vein thrombosis or pulmonary embolism, flare, and death. The incidence rates of the AE in both groups were compared with the Mantel-Haenszel test. Risk factors for AE were analyzed by logistic regression model.

Results.

A total of 3358 cases were collected. After inclusion and exclusion, 2651 patients were selected for matching, and 194 patients in 97 pairs were chosen for subsequent comparative analyses between the ABA and control groups. No between-group differences were detected in the incidence rates of each AE or in the incidence rates of total AE (control vs ABA: 15.5% vs 20.7% in total, 5.2% vs 3.1% in death).

Conclusion.

Compared with csDMARD and/or steroids without ABA, adding ABA to the treatment does not appear to increase the incidence rates of postoperative AE in patients with RA undergoing orthopedic surgery. Large cohort studies should be performed to add evidence for the perioperative safety profile of ABA.

Is incident rheumatoid arthritis interstitial lung disease associated with methotrexate treatment? Results from a multivariate analysis in the ERAS and ERAN inception cohorts

OBJECTIVES

To assess predictive factors for rheumatoid arthritis interstitial lung disease (RA-ILD) in two early rheumatoid arthritis (RA) inception cohorts with a focus on methotrexate (MTX) exposure.

DESIGN

Multicentre prospective early RA inception cohort studies; the early RA study (ERAS) and the early RA network (ERAN).

SETTING

Secondary care, ERAS nine centres, ERAN 23 centres in England, Wales and Ireland.

PARTICIPANTS

Patients with new diagnosis of RA, n=2701. Standardised data including demographics, drug therapies and clinical outcomes including the presence of RA-ILD were collected at baseline, within 3-6 months, at 12 months and annually thereafter.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was the association of MTX exposure on RA-ILD diagnosis. Secondary outcomes were the association of demographic, comorbid and RA-specific factors on RA-ILD diagnosis and the association of MTX exposure on time to RA-ILD diagnosis.

RESULTS

Of 92 eligible ILD cases, 39 occurred in 1578 (2.5%) MTX exposed and 53 in 1114 (4.8%) non-MTX exposed cases. The primary analysis of RA-ILD cases only developing after any conventional synthetic disease-modifying antirheumatic drug treatment (n=67) showed MTX exposure not to be associated with incident RA-ILD (OR 0.85, 95% CI 0.49 to 1.49, p=0.578) and a non-significant trend for delayed ILD diagnosis (OR 0.54, 95% CI 0.28 to 1.06, p=0.072). In an extended analysis including RA-ILD cases present at RA diagnosis (n=92), MTX exposure was associated with a significantly reduced risk of incident RA-ILD (OR 0.48, 95% CI 0.3 to 0.79, p=0.004) and longer time to ILD diagnosis (OR 0.41, 95% CI 0.23 to 0.75, p=0.004). Other independent baseline associations with incident RA-ILD were higher age of RA onset, ever smoking, male gender, rheumatoid nodules and longer time from first RA symptom to first outpatient visit.

CONCLUSIONS

MTX treatment was not associated with an increased risk of RA-ILD diagnosis. On the contrary, evidence suggested that MTX may delay the onset of ILD.

Real world long-term impact of intensive treatment on disease activity, disability and health-related quality of life in rheumatoid arthritis

Background

The emphasis on treating rheumatoid arthritis (RA) intensively reduces disease activity but its impact in routine care is uncertain. We evaluated temporal changes in disease activities and outcomes in a 10-year prospective observational cohort study of patients in routine care at one unit.

Methods

The Guy’s and St Thomas’ RA cohort was established in 2005. It involved most RA patients managed in this hospital. Clinical diagnoses of RA were made by rheumatologists. Patients were seen regularly in routine care. Each visit included measurement of disease activity scores for 28 joints (DAS28), health assessment questionnaire scores (HAQ) and EuroQol scores. Patients received intensive treatments targeting DAS28 remission.

Results

In 1693 RA patients mean DAS28 scores fell from 2005 to 15 by 11% from 4.08 (95% CI: 3.91, 4.25) in 2005 to 3.64 (3.34, 3.78); these falls were highly significant (p < 0.001). DAS28 components: swollen joint counts fell by 32% and ESR by 24%; in contrast tender joint counts and patient global assessments showed minimal or no reductions. The reduction in DAS28 scores was predominantly between 2005 and 2010, with no falls from 2011 onwards. Associated with falls in mean DAS28s, patients achieving remission increased (18% in 2005; 27% in 2015) and the number with active disease (DAS28 > 5.1) decreased (25% in 2005; 16% in 2015). In 752 patients seen at least annually for 3 years, persisting remission (68 patients) and intermittent remission (376 patients) were associated with less disability and better health related quality of life. Over time biologic use increased, but they were used infrequently in patients in persistent remission.

Conclusions

Over 10 years an intensive management strategy in a routine practice setting increased combination DMARD and biologic use: disease activity levels declined; this association is in keeping with a causal relationship. Patients who achieved remission, even transiently, had better functional outcomes than patients never achieving remission.

Electronic supplementary material

The online version of this article (10.1186/s41927-019-0054-y) contains supplementary material, which is available to authorized users.

Resection or preservation of the metatarsal heads in rheumatoid forefoot surgery? A randomised clinical trial

BACKGROUND

Despite impressive results of the pharmacological management of rheumatoid arthritis, still certain patients suffer from rheumatoid forefoot problems. Surgical treatment of these forefoot deformities can be an option. In literature no high-quality studies on this topic can be found. The goal of present study is to compare the results of a metatarsal head (MTH) resecting technique with a MTH preserving technique in the operative treatment of severe rheumatoid forefoot deformity.

METHODS

Patients suffering from well-defined rheumatoid forefoot deformity were prospectively enrolled in three institutions. This non-blinded study had a randomised clinical design and eligible patients were randomly assigned to undergo either resection of preservation of the MTH. The primary outcome measure consisted of the AOFAS score. Secondary outcome measures were: the FFI, the VAS for pain and the SF-36.

RESULTS

Twenty-three patients (10 in MTH preservation group) were included and analysed. After one year follow-up no significant differences in AOFAS score and additional outcome factors were found. A total of 10 complications in 23 patients were reported.

CONCLUSIONS

This randomised clinical study did not show significant clinical difference between a MTH resecting and a preserving procedure in patients suffering from rheumatoid forefoot deformity. Both procedures resulted in considerable improvement of pain and activity scores.

Early referral and control of disease's flares prevent Orthopedic and Hand Surgery Indication (OHSI) in a dynamic cohort of Hispanic early rheumatoid arthritis patients

Background

Reconstructive joint surgery is an indicator of poor prognosis in rheumatoid arthritis (RA). Objectives of this study were to describe the incidence rate of orthopedic and hand surgery indication (OHSI) in an ongoing cohort of Hispanic early RA patients treated according to a T2T strategy and to investigate predictors.

Methods

Through February 2018, the cohort comprised 185 patients recruited from 2004 onwards, with variable follow-up, and rheumatic assessments at fixed intervals that included prospective determination of OHSI. Charts were reviewed by a single data abstractor. OHSI incidence rate was calculated. A case-control study nested within a cohort investigated the predictors; cases (OHSI patients) were paired with controls (1:4) according to age, sex and autoantibodies. A logistic regression model included baseline and cumulative (up to OHSI or equivalent) variables related to disease activity, treatment and to persistence with therapy. The IRB approved the study.

Results

Patients from the cohort were predominantly middle-aged (mean ± SD age: 38.5 ± 12.9 years) females (87.6%) with 5.4 ± 2.6 months of disease duration. The cohort contributed to 1538 patient-years of follow-up. Twelve patients received incidental OHSI at a follow-up of 85 ± 44.5 months. The OHSI incident global rate was 8/1000 patient-years. Longer symptom duration at cohort referral (OR: 1.313, 95%CI: 1.02–1.68, p = 0.032) and a higher number of flares/patient (OR: 1.608, 95%CI: 1.05–1.61, p = 0.015) predicted OHSI. OHSI patients had more severe flares than their counterparts, and the opposite figure was true for mild flares.

Conclusion

Early referral for appropriate management and flare control may prevent OHSI in Hispanic recent-onset RA patients.

Orthopedic Surgery Among Patients With Rheumatoid Arthritis: A Population-Based Study to Identify Risk Factors, Sex Differences, and Time Trends

OBJECTIVE

To identify risk factors for large-joint surgery (LJS) versus small-joint surgery (SJS) in rheumatoid arthritis (RA) and evaluate trends in surgery rates over time.

METHODS

A retrospective medical record review of all orthopedic surgeries following first fulfillment of the 1987 American College of Rheumatology criteria for adult-onset RA among residents of Olmsted County, Minnesota between 1980 and 2013 was performed. Risk factors were examined using Cox models adjusted for age, sex, and calendar year of RA incidence. Trends in incidence of joint surgeries were examined using Poisson regression models.

RESULTS

A total of 1,077 patients with RA (mean age 56 years, 69% female, 66% seropositive for rheumatoid factor [RF] and anti-cyclic citrullinated peptide [anti-CCP] antibodies) were followed for a median of 10.7 years, during which 112 patients (90 women) underwent at least 1 SJS and 204 (141 women) underwent at least 1 LJS. Risk factors included advanced age, and RF and anti-CCP antibody positivity for both SJS and LJS, and body mass index ≥30 kg/m² for LJS. Risk factors for SJS and LJS at any time during followup included the presence of radiographic erosions, large-joint swelling, and methotrexate use. SJS rates decreased by calendar year of incidence (hazard ratio 0.53, P = 0.001), with significant decline in the rates of SJS after 1995. The cumulative incidence of SJS was higher in women than men (P = 0.008).

CONCLUSION

In recent years, there has been a significant decline in the rates of SJS but not LJS in patients with RA. The incidence of SJS is higher among women. Traditional RA risk factors are strong predictors for SJS and LJS. Increasing age and obesity are predictive of LJS.

Incidence and Predictive Factors for Orthopedic Surgery in Patients with Psoriatic Arthritis

Objective.

To investigate the incidence of orthopedic procedures in patients with psoriatic arthritis (PsA), and how patient characteristics, time of diagnosis, and treatment affect the need for surgery.

Methods.

We reviewed the medical history of 1432 patients with possible PsA at Haukeland University Hospital in Bergen, Norway. There were 590 patients (mean age 49 yrs, 52% women) who had sufficient journal information and a confirmed diagnosis of PsA, and who were included in the present study. Relevant orthopedic procedures were obtained from the hospital’s administrative patient records. Survival analyses were completed to evaluate the effect of different factors such as year of diagnosis, age, sex, radiographic changes, disease activity, and treatment, on the risk of surgery.

Results.

There were 171 procedures (25% synovectomies, 15% arthrodesis, and 53% prostheses) performed on 117 patients. These factors all increased the risk of surgery: female sex [relative risk (RR) 1.9, p = 0.001], age ≥ 70 years at diagnosis (RR 2.4, p = 0.001), arthritis in initial radiographs (RR 2.2, p = 0.006), and maximum erythrocyte sedimentation rate 30–59 mm/h (RR 1.6, p = 0.026). Time period of diagnosis had no effect on the outcome. In a subanalysis of surgery exclusive of hip and knee arthroplasty, diagnosis in earlier years (1954–1985 vs 1999–2011) was a risk factor (RR 2.1, p = 0.042). Antirheumatic treatment changed significantly over time.

Conclusion.

There were 20% of patients with PsA who needed surgery. We found that the prognosis of patients with PsA did not change regarding the risk of orthopedic surgery, despite the change in treatment. A possible explanation is the increase in large joint replacements in the general population.

Total Joint Arthroplasty in Patients with Inflammatory Rheumatic Diseases

Since its introduction, total joint arthroplasty (TJA) has improved the quality of life of patients with degenerative joint disorders. In the last decades, a number of conventional and biological disease-modifying antirheumatic drugs have become available for the treatment of patients with inflammatory rheumatic diseases (IRD), leading to a reduction in the need to undergo TJA. However, TJA is still frequently performed in IRD patients. Both rheumatologists and orthopedics should be aware that patients with IRD have a peculiar perioperative risk profile due to disease-related, patient-related, and surgery-related risk factors. On the basis of current evidence, TJA is a safe procedure for IRD patients as long as an accurate risk stratification and a multidisciplinary approach are applied. We here describe the current strategies for an appropriate surgical management of osteoarthritis in IRD patients and the fascinating opening perspectives that surgeons and clinicians may expect in the future.

Optimizing Rheumatoid Arthritis Patients for Surgery

PURPOSE OF REVIEW

The purpose of this review is to guide providers on how best to optimize the health of patients with rheumatoid arthritis (RA) planning surgery, to reduce risk and complications and achieve the best outcomes.

RECENT FINDINGS

The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) have issued a recent guideline on perioperative management of antirheumatic medications in patients with RA. Patients with RA will continue to need surgery. Newer literature is helping to plan the perioperative period to help reduce complications and improve outcomes.

The association of obesity with disease activity, functional ability and quality of life in early rheumatoid arthritis: data from the Early Rheumatoid Arthritis Study/Early Rheumatoid Arthritis Network UK prospective cohorts

OBJECTIVES

To examine associations between BMI and disease activity, functional ability and quality of life in RA.

METHODS

Data from two consecutive, similarly designed UK multicentre RA inception cohorts were used: the Early RA Study (ERAS) and the Early RA Network (ERAN). Recruitment figures/median follow-up for the ERAS and ERAN were 1465/10 years (maximum 25 years), and 1236/6 years (maximum 10 years), respectively. Standard demographic and clinical variables were recorded at baseline and annually. Multilevel piecewise longitudinal models with a change point at 2 years were used with the 28-joint DAS (DAS28), ESR, HAQ and 36-item Short Form Health Survey (SF-36) physical (PCS) and mental (MCS) components as dependent variables. BMI was examined in separate models as both continuous and categorical variables (based on World Health Organization definitions) and up to 5 years from disease onset.

RESULTS

BMI data from 2386 newly diagnosed RA patients (11 348 measures) showed an increase in BMI of 0.27 U annually (95% CI 0.21, 0.33). Baseline obesity was associated with a significant reduction in the odds of achieving a low year 2 DAS28 [OR 0.52 (95% CI 0.41, 0.650)]. At year 2, HAQ and SF-36 PCS scores were significantly worse but not at year 5 in patients obese at baseline. Obesity at year 2 was associated with higher DAS28 scores at year 2, but not at year 5, and also associated with significantly higher HAQ and SF-36 PCS scores at years 2 and 5.

CONCLUSION

Obesity prevalence is rising in early RA and associates with worse disease activity, function and health-related quality of life, with a significant negative impact on achieving a low DAS28. The data argue strongly for obesity management to become central to treatment strategies in RA.

Predictors for orthopaedic surgery in patients with rheumatoid arthritis: results from a retrospective cohort study of 1010 patients diagnosed from 1972 to 2009 and followed up until 2015

OBJECTIVES

To investigate how patient characteristics, time of diagnosis, and treatment affect the need for orthopaedic surgery in patients with rheumatoid arthritis (RA).

METHOD

We reviewed the medical history of 1544 patients diagnosed with RA at Haukeland University Hospital in Bergen, Norway, from 1972 to 2009, of whom 1010 (mean age 57 years, 69% women) were included in the present study. Relevant orthopaedic procedures were obtained from the Norwegian Arthoplasty Register and the hospital's administrative patient records. In total, 693 procedures (joint synovectomies 22%, arthrodeses 21%, prostheses 41%, and forefoot procedures 12%) were performed in 315 patients. Survival analyses were completed to evaluate the impact of different factors such as age, gender, radiographic changes, and year of diagnosis, on the risk of undergoing surgery.

RESULTS

Patients diagnosed in 1972-1985 and 1986-1998 had a relative risk of undergoing surgery of 2.4 and 2.2 (p < 0.001), respectively, compared to patients diagnosed in 1999-2009. Radiographic changes at diagnosis and female gender were also significant risk factors. Anti-rheumatic medication was significantly different in the three time periods.

CONCLUSION

Patients with a diagnosis in the early years had a greatly increased risk of having orthopaedic surgery performed. This is probably due to the year of diagnosis being a proxy for the type and intensity of medical treatment.