People diagnosed with rheumatoid arthritis, or RA, in the past 15 years or so are less likely to need joint surgery than are patients diagnosed previously, according to a new study published online in The Journal of Rheumatology. Researchers suggest this is due to more aggressive treatment with traditional disease-modifying antirheumatic drugs, such as methotrexate, and the introduction of biologic agents.

Intrigued by earlier research that showed a decline in RA-related surgeries, Eric Matteson, MD, chair of rheumatology at Mayo Clinic in Rochester, Minn., and his colleagues reviewed the medical records of 813 patients with RA who had orthopeadic surgery between 1980 and 2007. Procedures included total hip or knee replacement, joint reconstruction, soft tissue procedures and joint replacement revisions.

They found an overall reduction in joint surgeries. After adjusting for various factors, about 27 percent of patients diagnosed with RA between 1980 and 1994 needed at least one orthopeadic surgery in the 10 years following diagnosis, whereas only 19.5 percent of those diagnosed between 1995 and 2007 did.

For example, 6 percent of patients diagnosed with RA between 1995 and 2007 required knee surgery within the first 10 years, compared with 11 percent of those diagnosed between between 1980 and 1994.

And there was a significant decline in small-joint surgeries – those involving the ankles, feet or hands. For example, hand surgeries dropped from 6.3 percent in the 1980 to 1994 group to 2.5 percent in the 1995 to 2007 cohort.

"We found that people with rheumatoid arthritis are now having surgery on their hips and knees at rates very similar to people with osteoarthritis (OA) and having less small-joint surgery than in the past," Dr. Matteson says. "We believe that this is because of improved treatment in recent decades – a finding that highlights the importance of active disease management."

In the past, people with RA had surgery more often than people with OA due to more severe joint damage at a younger age.
 

Aggressive treatment spares joints

Patients diagnosed between 1980 and 1994 received traditional disease-modifying antirheumatic drugs, or DMARDs, such as methotrexate. Although methotrexate is still a mainstay treatment, it is now started much earlier in the course of the disease. In addition, about 20 percent of newly diagnosed RA patients receive the more-powerful biologic drugs, such as etanercept, or Enbrel, and infliximab, or Remicade – the first two introduced in the late 1990s.

Dr. Matteson says that at one time, concerns about medication side effects and an incomplete understanding of how well RA drugs worked led to a conservative approach to treatment.   

"But our thinking changed in the late 1980s, based on information collected from hundreds of clinical studies and trials," he says. "Until then, we didn't appreciate that treating RA aggressively would make such a huge difference. Now, we're no longer content to say that a patient is 'some better.' The therapeutic goal is remission or minimal disease activity – no swelling, with minimized pain and optimized function."

The result is improved quality of life with less joint damage and fewer surgical procedures, he says.

That doesn't mean that surgery is no longer necessary. Dr. Matteson says that obesity, more common now than a few decades ago, puts additional stress on hip and knee joints.

"Much as in the general arthritis population, overweight people with RA are more likely to need hip and knee surgery than RA patients of normal weight are," he explains. "And the surgery is more often on the knees, similar to people with other types of arthritis."

The patients in the Mayo Clinic study were from a single county in Minnesota, but studies of other populations, in the United States and internationally, demonstrate similar findings.

“Based on what we’ve seen, I would predict that the need for orthopeadic surgery in people with RA will continue to decline because of the reduction in joint damage. This is a time of increasing optimism for people with this disease."

John FitzGerald, MD, a practicing rheumatologist and assistant clinical professor in the division of rheumatology at UCLA Medical Center, who was not involved in the study, says the findings are indeed encouraging and attributes the decline in RA-related orthopaedic surgeries to improved therapies.

Still, he says, "the data are not overwhelming. They had a population cohort they could follow so there is a real-world example of what RA patients are undergoing. But the challenge is to have more patients. Even with more than 800 patients, the number of people with a 10-year follow-up is relatively small."

Dr. FitzGerald adds that according to the study, the biggest decline was in soft tissue procedures such as tendon or cartilage repair. "It would have been nice to see a greater reduction in big-ticket surgeries like total joint replacement," he says.