“There’s been a perception that surgery has been on the decline, but we haven’t been able to quantify it until now. And it’s not good to make assumptions due to feelings or perceptions,” she says. “But several studies do now suggest that there are fewer surgeries for rheumatoid arthritis patients. The reasons for that are, one, more aggressive treatment of rheumatoid arthritis. If one drug doesn’t work, then we add more drugs. And two, we have a larger arsenal of drugs. We are combining drugs and treating earlier.”

Surgeons also notice the decline in RA patients coming to their offices to seek joint replacements, notes Jeffrey N. Katz, MD, Professor of Medicine and Orthopaedic Surgery at Brigham and Women's Hospital in Boston. “It’s nice to have some scientific data to back it up, but the impressions that you are getting from people in the field is that the biologic drugs are working and reduce the incidence of advanced arthritis, and because of that there is a reduced need for surgery.”  In the past, about 20 percent of the joint replacements performed by his department were related to RA; now they only perform 10 percent of joint replacements on RA patients.

Today, the RA patients needing joint surgery are mostly older patients who developed RA prior to the new crop of drugs coming on the market or people who have not had access to these drugs, including uninsured people and immigrants coming from poor countries where the treatments are not available, says Dr. Katz. He also travels to the Dominican Republic each March to perform joint replacements on many poor RA patients. “We see people with severe, multiple-joint rheumatoid arthritis. It’s a reminder of what this disease can do.”

Orthopaedic surgeons remind us that some RA patients still need joint surgery to correct both soft-tissue damage and either deformed or misaligned joints. “I agree that recent improvements in the medical treatment of rheumatoid arthritis is delaying the need for joint replacement,” says Henry Blum, MD, a surgeon at Houston Orthopedic and Spine Hospital in Houston. “However, if  the knee alignment is too far misaligned (usually too "knock-kneed") from the arthritis, then even if the swelling and discomfort is well controlled with medication, it is better to perform the total knee [replacement] soon.  If the patient waits too long, bone damage can occur, and that would decrease the chance of a successful and long lasting joint replacement.”