Recent trends in orthopedic surgery performed in Japan for rheumatoid arthritis

Preoperative degree of deformity and underlying disease affect the postoperative deformity of joint-preserving hallux valgus surgery

BACKGROUND

The combination of distal osteotomy with lateral dissection in joint-preserving surgery for severe hallux valgus deformity has recently begun to yield encouraging results. We examined the frequency of complications and risk factors of those for joint-preserving surgery in patients with and without rheumatoid arthritis (RA).

METHODS

A retrospective, observational study of 72 feet (27 patients with RA) was performed. The inclusion criteria were patients who underwent joint-preserving surgery for hallux valgus deformity at our hospital between January 2008 and March 2016 who could be followed up with for longer than 12 months.

RESULTS

The mean preoperative and immediate postoperative hallux valgus angles (HVA) were 41.8 and 4.4, respectively. The mean preoperative and immediate postoperative intermetatarsal angles between the first and second metatarsal bones (M1-M2A) were 14.6 and 5.8, respectively. At the final postoperative evaluation, the mean HVA was 8.8 and the mean M1-M2A was 6.4.Data were compared among the patients with complications (recurrent valgus deformity, varus deformity), and those without complications (normal HVA) at the final postoperative evaluation. The rate of RA in the varus deformity group was 71.4%, which tended to be higher than in other groups (p = .058). The mean preoperative HVA were 48.2 and 52.6 in the group of recurrent valgus deformity and varus deformity, which was higher than the normal HVA group (p = .001).

CONCLUSIONS

High preoperative HVA was a risk factor for the recurrence of valgus deformity. Most of the varus deformities were observed in the RA group with high preoperative HVA; therefore, caution should be exercised in operating on patients with severe deformity or those with RA.

LEVEL OF EVIDENCE

III.

Relationship between the physician-based clinical scale for foot and ankle surgery and patient-reported outcomes in patients with long-standing rheumatoid arthritis: Results from a multicenter prospective observational cohort study

OBJECTIVES

To validate and establish targets for the physician-based clinical scale for foot surgery in rheumatoid arthritis (RA) patients based on patient-reported outcomes from a multicenter prospective cohort.

METHODS

We collected data on demographics, values from the RA foot and ankle scale by the Japanese Society for Surgery of the Foot (JSSF-RA), and patient-reported outcomes (PROs) including the Health Assessment Questionnaire Disability Index (HAQ-DI) before (baseline) and 6 and 12 months after joint surgery. Target values for JSSF-RA were determined according to the lower limit of the 95% CI of JSSF-RA in patients with HAQ-DI ≤0.5 after adjusting for age and sex. We used multiple linear regression analysis to examine potential predictors of JSSF-RA target achievement at baseline.

RESULTS

Cross-sectional analysis was conducted on data from 417 cases. The JSSF-RA target for foot and ankle surgery was set at 74 according to the JSSF-RA value corresponding to HAQ-DI ≤0.5 (mean 77.6, 95% CI: 74.3-80.9). Longitudinal analysis of patients who underwent foot surgery (N = 59) determined target cut-off values of 1.188 and 65 for HAQ-DI and JSSF-RA at baseline, respectively, as being predictive for achieving JSSF-RA ≥74 after surgery.

CONCLUSIONS

A JSSF-RA value of 74 represents an important target for patients with RA who have undergone foot surgery. In order to achieve this target, the timing of the surgery should be considered in the treatment of established RA patients.

A modified Terrono classification for Type 1 thumb deformity in rheumatoid arthritis: a cross-sectional analysis

The most common thumb deformity in rheumatoid arthritis is Nalebuff Type 1 deformity (boutonniere deformity). Type 1 deformity severely impairs hand function, and this impairment is evaluated by the Terrono classification. In some cases, the Terrono classification incorrectly categorizes advanced thumb deformity into earlier stages. We modified the Terrono classification by assessing the active range of motion of the interphalangeal joint prior to assessing the passive range of movement of the metacarpophalangeal joint. An active range of movement of the interphalangeal joint was strongly correlated with hand function. In 55 hands that we treated between 2004 and 2015, we compared the modified classification with the original Terrono classification. Our modified classification could detect advanced deformity earlier, and was more strongly correlated with hand function. Additionally, correlation analysis showed that advanced Type 1 deformity should be treated first, even in cases with severe ulnar drift. Our results suggest that the modified classification may benefit the treatment of Type 1 deformity, including joint-preserving surgery. Level of evidence: III.

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.

A New Approach for the Correction of Type I Thumb Deformity Owing to Rheumatoid Arthritis

A major transition in the surgical treatment of rheumatoid arthritis has been facilitated by a recent paradigm shift in its diagnosis and treatment. Improved outcomes in the treatment of the rheumatoid thumb are desirable; however, the results of conventional surgery are less than ideal. Even if the rheumatoid arthritis is well-controlled, the progression of thumb deformity may persist owing to an ineffective deformity correction and an insufficient understanding of the mechanism by which the deformity occurs. The mechanism of rheumatoid thumb deformity should be considered, using it to base the appropriate correction. We applied a new deformity correction procedure that accounts for the mechanism of type I rheumatoid thumb deformity and obtained positive results without recurrence. Although the primary cause of type I thumb deformity is believed to be an extensor mechanism failure resulting from synovitis of the metacarpophalangeal (MCP) joint, surgical outcomes are negatively affected as a result of flexion contracture caused by the adductor pollicis (ADP). Because the ADP attaches to the ulnar sesamoid on the palmar side of MCP joint, we release the ADP tendon to improve flexion contracture of the MCP joint. We consider release of ADP to be effective in preventing the recurrence of flexion contracture of the MCP joint and re-tensioning of the extensor pollicis brevis. Rheumatoid thumb deformity can be restored by applying this procedure, improving a patient’s outcome.

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.

Emerging anti-osteoclast therapy for rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune inflammatory disorder characterized by progressive destruction of affected synovial joints. Recently, it was demonstrated that osteoclasts play critical roles in bone destruction in RA. Receptor activator of NF-κB ligand (RANKL), which belongs to the tumor necrosis factor superfamily, is indispensable for osteoclast differentiation and bone destruction in RA. Denosumab, a monoclonal antibody against human RANKL, not only increased bone mineral density, but also efficiently suppressed the progression of bone erosion in RA patients in a randomized controlled study. However, denosumab did not reduce the cartilage destruction or disease activity in RA, and further investigation is required to establish the appropriate positioning of denosumab in the treatment strategy of RA.

Trends in Treatment, Outcomes, and Incidence of Orthopedic Surgery in Patients with Rheumatoid Arthritis: An Observational Cohort Study Using the Japanese National Database of Rheumatic Diseases

OBJECTIVE

In this study, we investigated the changes in clinical outcome, treatment, and incidence of orthopedic surgery in patients with rheumatoid arthritis (RA) from 2004 to 2014.

METHODS

Data were studied from the Japanese nationwide cohort database, NinJa (National Database of Rheumatic Diseases by iR-net in Japan), from 2004 to 2014. The time trends in the incidence of orthopedic procedures were analyzed using linear regression analysis. The cross-sectional annual data were compared between 2004 and 2014 to analyze the changes in clinical outcome and treatment.

RESULTS

The incidence of orthopedic surgeries in patients with RA consistently decreased from 72.2 procedures per 1000 patients in 2004 to 51.5 procedures per 1000 patients in 2014 (regression coefficient = -0.0028, 95% CI -0.0038 to -0.0019, p < 0.001). The greatest reduction was found in total knee arthroplasty and total hip arthroplasty. Disease activity and functional disability improved significantly over this decade. The proportions of patients receiving methotrexate and biologic disease-modifying antirheumatic drugs significantly increased from 39.6% and 1.7% in 2004 to 63.8% and 27.4% in 2014, respectively.

CONCLUSION

The overall incidence of orthopedic surgeries in patients with RA significantly decreased, accompanied by improved clinical outcomes because of the expanded use of effective drugs; however, the declining trend differed between procedures or locations. The results from the present study suggest that there might be a change in supply and demand for orthopedic surgeries.

Effect of total knee arthroplasty on other joints in patients with rheumatoid arthritis evaluated by 18-FDG-PET

AIM

The objective of this study was to assess arthritis of the whole body before and after total knee arthroplasty (TKA) in patients with rheumatoid arthritis (RA) using positron emission tomography (PET).

METHOD

Seventeen knees of 17 RA patients (median age 68 years) who underwent TKA were included in this study. Clinical assessments of disease activity, knee function and activities of daily living (ADL) were performed before and after TKA. ¹⁸ Fluorodeoxyglucose (FDG)-PET was performed preoperatively and 12 weeks postoperatively when RA disease activity was assessed. The maximal standardized uptake value (SUV) in the region of interest was used to assess FDG uptake.

RESULTS

Disease activity and knee function improved in all patients after TKA. There was a significant decrease in the number of patients with swollen or tender joints involving the right wrist, right knee and left knee. The SUV of bilateral wrist joints decreased significantly 12 weeks after TKA, whereas the SUVs of other large joints were unchanged.

CONCLUSION

TKA can improve not only ADL and knee function, but also the disease activity index in RA patients. However, TKA has limited effectiveness against synovitis of the joints not undergoing surgery.

Rheumatoid Arthritis: Trends in Antirheumatic Drug Use, C-reactive Protein Levels, and Surgical Burden

Objective.

Over the past decade, the therapeutic approach used to treat patients with rheumatoid arthritis (RA) has considerably changed. It remains unclear whether these changes have been accompanied by decreased disease severity and surgical treatment burden at the population level. Therefore, we investigated time trends in antirheumatic drug consumption, C-reactive protein (CRP) levels, and use of orthopedic surgery among Danish patients with RA.

Methods.

Using medical databases, we identified all patients with RA living in Northern Denmark during 1996–2012. For each calendar year, we computed the annual rate of antirheumatic drug use (1996–2010), the median CRP value in mg/l (1996–2011), and the proportions of patients who underwent hip replacement and other orthopedic procedures (1996–2012).

Results.

Antirheumatic drug consumption per patient increased 5-fold, from 145.0 defined daily doses (DDD) in 1996 to 695.4 DDD in 2010. Median CRP declined from 20.5 mg/l [interquartile range (IQR), 10.0 to 43.5 mg/l] in 1996 to 10.0 mg/l (IQR, 4.2–17.8 mg/l) in 2011. From 1996 to 2012, declining proportions of patients with RA underwent hip replacement (14.9% to 10.1%) and other joint operations (29.1% to 23.4%), while the annual proportion of patients who underwent soft tissue procedures increased from 20.7% to 23.4%.

Conclusion.

Antirheumatic drug consumption has substantially increased among patients with RA since 1996, in association with reduced disease activity (i.e., lower CRP levels), fewer joint procedures (including hip replacements), and more soft tissue procedures.

Perioperative Treatment of Patients with Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease mediated by a widespread chronic systematic inflammatory process that causes joint deterioration, which leads to pain, disability, and poor quality of life. The increased use of disease-modifying antirheumatic drugs has been shown to markedly slow disease progression, which has translated into a decrease in the need for orthopaedic intervention in this population. However, a substantial percentage of patients with the disease fail optimal pharmacologic treatment and still require surgical intervention. A thorough understanding of medical considerations in these patients and improved knowledge of the medical complications caused by the disease process and the pharmacologic therapy used to treat it may lead to improved preoperative planning and medical clearance, which may ultimately improve the overall postoperative outcome.

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.

Rheumatoid arthritis of the hand: a five-year longitudinal analysis of clinical and radiographic findings

OBJECTIVES

Treatments for rheumatoid arthritis (RA) have improved since methotrexate and biological agents were approved; however, few longitudinal analyses have tracked joint destruction, deformity progression, or functional impairments that directly affect the activities of daily living. Due to the consequences of functional impairments, we conducted this study to glean more information regarding deformity progression over time.

METHODS

This study enrolled 134 hands in 67 RA patients with hand deformities in 2004. After 5 years, 100 hands in 52 patients were eligible for the final assessment. Analyses consisted of morphological and radiographical evaluations of deformities, functional evaluations by questionnaires and the modified Kapandji index, and activity evaluations.

RESULTS

In this period, the type I deformity (Nalebuff and Millender, Orthop Clin North Am 6(3):753-63, 1975) was the most common thumb deformity. Swan-neck and boutonnière finger deformities also progressed. At the 5-year follow-up, questionnaire score worsened, when disease activity was high.

CONCLUSIONS

Our study showed that there was a marked progression in hand deformities in RA patients over a 5-year period. In order to assist RA patients in performing the activities of daily living, medical and rehabilitative interventions should target the restoration of functional loss through joint destruction as well as the prevention of disease progression.

Radiologic patterning of joint damage to the foot in rheumatoid arthritis

OBJECTIVE

Foot and ankle deformities greatly affect the quality of life of rheumatoid arthritis (RA) patients. The aim of this study was to elucidate the pattern of destruction of the RA foot and its impact on patients.

METHODS

We cross-sectionally investigated RA patients (274 patients and 542 feet) using radiographs. The grade of joint destruction was assigned using Larsen's grading system for 12 joints in the foot and ankle. Cluster analysis was performed using the K-means method to classify the pattern of joint destruction. Of the 274 patients evaluated radiographically, 212 were assessed for functional disability using questionnaires.

RESULTS

Cluster analysis revealed that 542 feet were divided into 5 clusters, named according to the characteristic distribution of joint destruction: cluster I (normal type), cluster II (forefoot type), cluster III (midfoot type), cluster IV (mid-hindfoot type), and cluster V (combined type). Radiographic measurements revealed the characteristic deformities of each cluster: splay foot for cluster II, flat foot for cluster III, hindfoot malalignment for cluster IV, and mixtures of these characteristics for cluster V. A distribution map of each cluster based on disease duration revealed that cluster III peaked in cases of 5-10-year disease duration and subsequently decreased, followed by a gradual increase of cluster IV and cluster V. Cluster IV and cluster V showed significant changes in functional disability compared to cluster III.

CONCLUSION

This report is the first to reveal the pattern of RA foot deformities and their impact on patients using statistical measures in a large series.

Effects of surgical intervention on disease activity of rheumatoid arthritis: cases of surgery for rheumatoid arthritis of the lower limbs treated with biologics

OBJECTIVES

In order to verify combination therapy with drugs and surgery for rheumatoid arthritis (RA), we evaluated changes in clinical outcome affected by surgical intervention in the patient treated with biologics and investigated the effects of surgery on disease activity.

METHODS

Fifty-five lower limb joint surgeries were performed in 48 patients under biological therapy. DAS28-ESR, modified Health Assessment Questionnaire (mHAQ) score, PtGA and serum CRP were examined just before surgery, at 6 months and at 12 months after surgery. A kind of suitable medication and its dose were investigated.

RESULTS

Preoperative DAS28-ESR significantly decreased from 3.71 ± 1.19 (mean ± SD) to 3.37 ± 1.22 at 6 months and to 3.24 ± 1.05 at 12 months postoperatively. mHAQ score did not change, but, PtGA and serum CRP improved. In 43 (78.2%) patients in whom no change or decrease in medication during the follow-up period, excluding the effect of drugs, DAS28-ESR also decreased significantly from 3.53 ± 1.17 to 3.16 ± 1.16 at 6 months, and to 3.16 ± 0.98 at 12 months.

CONCLUSIONS

Lower limb surgery performed under biological therapy enhances the effects of not only improving joint function but also of ameliorating systemic disease activity.