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Most RA patients required orthopedic surgery during pre-biologics era

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – More than half of a cohort of over 180 patients with rheumatoid arthritis (RA) required orthopedic surgery, and one quarter underwent at least one large joint replacement, during a 2-decade study that took place before anti-TNF agents and other biologic therapies were widely available, Swedish investigators report.

“This study could serve as a reference for comparison with cohorts of patients with RA recruited today, in which new, more efficacious treatments are used,” Dr. M. C. Kapetanovic and colleagues write in the October issue Annals of the Rheumatic Diseases.

Dr. Kapetanovic’s group at Lund University initiated their study in 1985, recruiting 183 patients with recent-onset RA (mean age 51 years and mean symptom duration 12 months).

“The approach to pharmacological treatment was conservative compared with current treatment strategies in early RA,” they note. None of the patients had received disease modifying antirheumatic drugs (DMARDs) prior to the study, and “D-penicillamine and antimalarial drugs were most commonly used in the early years and subsequently methotrexate became the most commonly used DMARD.”

By the end of 2005 (mean follow-up 16 years), 106 patients (58%) underwent at least one surgery. In total, 386 orthopedic interventions were performed, primarily synovectomies of shoulder, elbow, wrist and finger joints, followed by tendon transfer surgery and surgery of the forefoot.

Forty-four patients (24%) underwent arthroplasty involving the hip, knee, shoulder, elbow, or wrist. Eleven patients underwent 3 or more large joint replacements.

Cox regression analysis showed that Health Assessment Questionnaire scores, C-reactive protein, and erythrocyte sedimentation rate at enrollment, and radiographic changes in small joints after 1 year, were predictors of large joint surgery.

However, age, gender, symptom duration, the presence of rheumatoid factors and anti-CCP antibodies at inclusion were not associated with surgical interventions.

Dr. Kapetanovic and associates conclude: “The identification of factors associated with large joint arthroplasty can lead to better tailored pharmacological treatment to maintain function and prevent the disability of individual patients.”

Ann Rheum Dis 2008;67:1412-1416.