Recent trends in orthopedic surgery performed in Japan for rheumatoid arthritis

Validity of adopting a Health Assessment Questionnaire Disability Index less than 0.5 as a target in elderly rheumatoid arthritis patients

OBJECTIVES

The effect of age on the Health Assessment Questionnaire Disability Index (HAQ-DI) scores of rheumatoid arthritis (RA) patients and the validity of adopting HAQ-DI < 0.5 as the target for functional remission and comprehensive disease control (CDC) under a treat-to-target (T2T) treatment strategy were investigated.

METHOD

A total of 441 RA patients with > 3-year treatment under T2T were evaluated. The relationships between the HAQ-DI score at follow-up (HAQ) and 28-joint Disease Activity Score with C-reactive protein, Sharp/van der Heijde Score, age at follow-up, and HAQ-DI at baseline were statistically evaluated with best subset regression analysis in groups separated according to age and the EULAR response. CDC status was evaluated with a chi-square test.

RESULTS

The HAQ score significantly correlated with all indices in the group ≥ 65 years old (G-O) and in the group with good or moderate EULAR responses (p < 0.01). No significant correlation was observed in the group < 65 years old (G-Y) or in the group with no EULAR response. The CDC ratio was not significantly different between the age groups, whereas the HAQ failure ratio was significantly greater in G-O than in G-Y (p < 0.01). No significant difference was found between the EULAR response groups.

CONCLUSIONS

The HAQ score is influenced by age in patients > 65 years. T2T is appropriate for attaining good disease activity control but does not always lead to functional remission in these patients. The HAQ score < 0.5 is not an appropriate target for functional remission according to the CDC criteria for elderly patients.Key Points• ADL in elderly RA patient aged ≥ 65 years declines corresponding to his/her aging.• Functional remission for elderly RA patients is not the same as that for young RA patients.• The HAQ score < 0.5 in elderly RA patient is not an appropriate target for CDC.

Have the annual trends of total hip arthroplasty in rheumatoid arthritis patients decreased?

Background

Rheumatoid arthritis (RA) is characterized by chronic systemic and synovial inflammation, resulting in damage to both cartilage and bone. Medical treatment, which has increasingly relied upon disease modifying anti-rheumatic drugs (DMARDs), may fail to slow disease progression and limit joint damage, ultimately warranting surgical intervention. Up to 25% of RA patients will require lower extremity total joint arthroplasty. Though total hip arthroplasty (THA) is known to improve quality of life and functional measures, clarification is still required with respect to the impact of increased DMARD use on annual rates of THA. Thus, the purpose of this study was to evaluate: (I) the annual trends of THAs due to RA in the United States population; (II) the annual trends in the proportion of THAs due to RA in the United States.

Methods

This study utilized the Nationwide Inpatient Sample (NIS) to identify all patients who underwent THA between 2002 and 2013 (n=3,135,904). Then, THA patients who had a diagnosis of RA, which was defined by the International Classification of Disease 9^th revision diagnosis code 714.0, were identified. The incidence of THAs with a diagnosis of RA in the United States was calculated using the United States population as the denominator. Regression models were used to analyze the annual trends of RA in patients who underwent THA.

Results

Review of the database identified 90,487 patients who had a diagnosis of RA and underwent THA from 2002 to 2013. The annual prevalence of RA in those who underwent THA slightly decreased over the specified time period, with 28.7 per 1,000 THAs in 2002 and 28.6 per 1,000 THAs in 2013; however, this change was not statistically significant (R²=0.158, P=0.200).

Conclusions

The annual rates of THA among RA patients did not show any significant change between 2002 and 2013. DMARD use has decreased both disease progression and joint destruction, and DMARDs are now often utilized as primary treatment. The increase in population of the country during the study period may have overestimated THA trends. Moreover, patients may be more likely to opt for surgical management, given the advances in operative techniques as well as peri- and post-operative course.

Early medication use in new-onset rheumatoid arthritis may delay joint replacement: results of a large population-based study

Introduction

Use of disease-modifying anti-rheumatic drugs (DMARDs) in rheumatoid arthritis (RA) may prevent joint damage and potentially reduce joint replacement surgeries. We assessed the association between RA drug use and joint replacement in Quebec, Canada.

Methods

A cohort of new-onset RA patients was identified from Quebec’s physician billing and hospitalization databases from 2002–2011. The outcome was defined using procedure codes submitted by orthopedic surgeons. Medication use was obtained from pharmacy databases. We used alternative Cox regression models with time-dependent variables measuring the cumulative effects of past use during different time windows (one model focussing on the first year after cohort entry) for methotrexate (MTX), and other DMARDs. Models were adjusted for baseline sociodemographics, co-morbidity and prior health service use, time-dependent cumulative use of other drugs (anti-tumor necrosis factor [anti-TNF] agents, other biologics, cyclooxygenase-2 inhibitors [COXIBs], nonselective nonsteroidal antiinflammatory drugs [NSAIDs], and systemic steroids), and markers of disease severity.

Results

During follow-up, 608 joint replacements occurred among 11,333 patients (median follow-up: 4.6 years). The best-fitting model relied on the cumulative early use (within the first year after cohort entry) of MTX and of other DMARDs, with an interaction between MTX and other DMARDs. In this model, greater exposure within the first year, to either MTX (adjusted hazard ratio, HR = 0.95 per 1 month, 95 % confidence interval, 95 % CI 0.93-0.97) or other DMARDs (HR = 0.97, 95 % CI 0.95-0.99) was associated with longer time to joint replacement.

Conclusions

Our results suggest that longer exposure to either methotrexate (MTX) or other DMARDs within the first year after RA diagnosis is associated with longer time to joint replacement surgery.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0713-3) contains supplementary material, which is available to authorized users.

[Physical therapy as part of a complex orthopedic rheumatology approach. Physiotherapy, cryotherapy, extracorporeal shockwave lithotripsy, local intra-articular joint injections]

In this review only some of the physical therapeutic options for treating chronic inflammatory diseases are discussed. These include a wide variety of procedures and should not exclusively be assessed using the criteria of evidence-based medicine because in most studies there was no blinding or for ethical reasons no placebo group was included. Nevertheless, these treatment options are quite essential as part of a multimodal treatment concept for patients with inflammatory joint diseases. The increasing interest in adjuvant therapeutic options emphasizes the need for further well designed studies concerning the effectiveness of physical therapy. Dynamic exercise is closely integrated into the treatment strategy for rheumatoid arthritis. In addition to a conditioning stimulus to joints and cartilage it is known that physical therapy is useful in preventing mechanisms of disease chronification. Locally applied and whole body cryotherapy leads to muscular relaxation resulting in a more effective treatment intensity of subsequent exercise. With extracorporeal shockwave therapy (ESWT) a new promising therapeutic approach is available. However, the evidence level is still weak when used for patients with rheumatoid arthritis. Locally applied steroid injections still have a significant value when treating inflammatory synovial conditions.

Cost-effectiveness of biologic treatment for rheumatoid arthritis in clinical practice: an achievable target?

The burden of illness of rheumatoid arthritis (RA) falls on patients, families and society through the direct costs, indirect costs, and intangible costs. A large number of RA cost-of-illness studies have been performed in recent decades with discrepant results due to patient heterogeneity, and different health-care organization, employment rate or social support, job opportunities, and methodologies used to calculate the costs. The greatest burden of RA is the indirect and the intangible costs, but how to estimate them remains controversial. The systematic use of traditional disease modifying anti rheumatic drugs has changed the evolution of the disease. However, a considerable improvement in the management of RA has been obtained since the advent of biologic response modifiers. The use of these drugs, which have demonstrated greater efficacy than conventional therapies, have tripled the direct costs of RA, which rose from about € 4000 to roughly € 12,000, in a period of five years, from 2000 to 2005. The present paper is aimed to examine the effects of this change in therapeutic strategy.

Analysis of perioperative clinical features and complications after orthopaedic surgery in rheumatoid arthritis patients treated with tocilizumab in a real-world setting: results from the multicentre TOcilizumab in Perioperative Period (TOPP) study

OBJECTIVE

To evaluate perioperative changes in rheumatoid arthritis (RA) patients treated with tocilizumab.

METHODS

We collected RA cases with tocilizumab and orthopaedic surgery from 1999 to 2010. Incidences of postoperative infections, delayed wound healing, and RA symptom flare-ups were extracted from the data for comparison with patients without these postoperative events. We also evaluated the changes in C-reactive protein (CRP) and body temperature in patients without postoperative complications with normal CRP before surgery, i.e., patients without postoperative events in whom the tocilizumab level was maintained, for each duration to discontinuation before surgery.

RESULTS

A total of 161 cases (n = 122) were collected. The patients had mean age of 56.9 years, and mean disease duration of 12.8 years at operation. Joint replacement surgery was performed in 89 cases. Three patients had postoperative infections (two superficial and one organ/space surgical-site infection), 20 had delayed wound healing, and 36 had RA symptom flare-ups. Delayed wound healing occurred most commonly in patients who underwent spinal surgery (P = 0.0061, versus patients without delayed wound healing). CRP levels were high when tocilizumab was restarted in patients with RA symptom flare-ups (P = 0.0010, versus patients without RA symptom flare-ups). Increased postoperative CRP was observed in patients without postoperative events when the duration from final tocilizumab infusion to surgery was long. The changes in body temperature showed a similar trend to CRP.

CONCLUSIONS

Although it has been demonstrated that infection rates in patients treated with tocilizumab are by no means high, incidence of delayed wound healing was significantly higher in cases with surgical interventions such as foot and spinal surgeries. Many patients treated with tocilizumab remained in a normal range of CRP even during the perioperative period. For prevention of perioperative complications, observation of postoperative conditions and surgical wounds, and subjective symptoms of patients are considered important.