Declining use of orthopedic surgery in patients with rheumatoid arthritis? Results of a long-term, population-based assessment

Authors


Abstract

Objective

To describe the use of orthopedic surgery, including joint replacement surgery, in a well-defined, population-based cohort of patients with rheumatoid arthritis (RA) and to identify characteristics that predict such use.

Methods

A retrospective medical record review was performed of cases of RA incident in Rochester, Minnesota, during the years 1955–1995. All joint surgeries were recorded.

Results

Of the total 609 RA incident cases, 242 patients underwent 1 or more (maximum of 20/patient) surgical procedures involving joints during their followup. Overall, this RA cohort had 7.4 surgeries per 100 person-years of followup; the cumulative incidence for joint surgery for RA-related joint disease at 30 years was 33.7% ± SEM 3.8%. The risk of having a disease-related joint surgery for RA is increased in patients who are women, younger, positive for rheumatoid factor, and have rheumatoid nodules. When adjusted for duration of followup, patients with RA diagnosed after 1985 were significantly less likely to have undergone joint surgery for RA (P < 0.001). Survival of patients who underwent total joint arthroplasty was similar to those who did not.

Conclusion

Reconstructive surgeries are common in RA, although patients diagnosed after 1985 are less likely to require joint surgery. These findings may reflect trends in medical disease management and have importance for health care resource utilization planning.

INTRODUCTION

Rheumatoid arthritis (RA) is a common inflammatory joint disease that affects about 1% of the population and up to 3% of the population over the age of 65 years (1). The disease is an immune-mediated process that affects the synovial and lined appendicular joints as well as the atlantoaxial joint of the cervical spine. It is associated with marked disability and decreased life expectancy (2–4). The need for orthopedic surgery is considered a marker of disease severity (5). Orthopedic procedures, including joint replacement surgeries, have substantially improved the overall function and quality of life of patients with RA (5, 6). At the same time, they are a major factor in the high medical cost for patients with this disease (4). It is unknown how use of orthopedic surgery has changed since the introduction of modern joint replacement surgical techniques and more aggressive management of RA in the past 2 decades. The aim of this study was to describe the use of orthopedic surgery, including joint replacement surgery, in a population-based incidence cohort of patients with RA in Rochester, Minnesota. Knowledge of disease- and patient-associated risk factors for joint surgery provides important insights into the disease course and its impact in affected patients, with potential consequences for health care resource utilization planning.

PATIENTS AND METHODS

Patients.

This study is based on a cohort of 609 patients with RA incident in Rochester between January 1, 1955 and January 1, 1995. The cohort was assembled using the facilities of the Rochester Epidemiology Project. All residents of Rochester, Minnesota aged ≥18 years with a diagnosis of RA based on the 1987 American College of Rheumatology (ACR; formerly American Rheumatism Association) classification criteria for RA were identified by searching the computerized diagnostic index for any diagnosis of arthritis (excluding degenerative arthritis or osteoarthritis) (7–9). The complete (inpatient and outpatient care by any provider) medical record was reviewed by a trained nurse abstractor using a pretested data collection form. All cases were followed longitudinally until December 31, 1998 or until death or migration out of the county.

Description of orthopedic surgeries.

The entire medical record of each patient was reviewed to obtain data on orthopedic procedures. The date of each procedure was registered. Surgeries occurring before the incident date of the diagnosis of RA were excluded. Joint surgery data were collected for the following joints: right and left temporomandibular joints, shoulders, elbows, wrists, thumbs (base, metacarpophalangeal joint [MCP], interphalangeal joint [IP]), other fingers (MCP, proximal interphalangeal joint [PIP], distal interphalangeal joint [DIP]), hips, knees, ankles, first toes (metatarsophalangeal joint [MTP] and IP), MTP 2–5, toes 2–5 (PIP, DIP), and cervical spine.

Procedures were recorded as 1) implant arthroplasty with a total joint arthroplasty (TJA) or hemiarthroplasty with an implant component; 2) nonimplant arthroplasty: resection arthroplasty (such as Keller bunionectomy), fusion, wire arthrodesis, Girdlestone procedure, osteoectomy, or osteotomy; 3) soft tissue procedures (STPs): synovectomies, tendon repairs, tendon transfers, tendon releases, ligament releases (such as carpal tunnel release), cartilage repair, or meniscus repair; 4) fractures with a nonimplant surgical repair (plate and pinning), or amputations at a joint level; 5) fractures repaired with an implant TJA; 6) arthrotomy for a septic native joint; 7) arthrotomy for a septic prosthetic joint; 8) diagnostic arthroscopy or biopsy; 9) revision surgery of an implant prosthesis; 10) revision surgery for the other procedures; and 11) cervical spine atlantoaxial fusion or multiple-level fusions performed for RA-related cervical spine disease.

Data analysis and measurements.

The demographic and disease-specific characteristics of the population were assessed and the orthopedic surgeries each patient underwent were recorded. The cumulative incidence of any orthopedic surgery following the incident diagnosis of RA was estimated using the method of Gooley et al to account for the competing risk of death (10). Similarly, the incidence of surgery of specific sites was estimated for those sites. The Cox proportional hazards model was used to determine the influence of sex, age, rheumatoid factor positivity (titer ≥ 1:40), rheumatoid nodulosis, and decade of diagnosis of RA on the rate of first surgery. To avoid possible bias due to different length of followup and cohort effect, we truncated followup comparably for each decade cohort. Because the 1985–1994 cohort was followed until December 31, 1998, we truncated followup of the other 3 decades (1955–1964, 1965–1974, and 1975–1984) at December 31, 1968, December 31, 1978, and December 31, 1988, respectively. The proportional hazards model was also used to assess the influence of joint surgeries on survival.

RESULTS

Between 1955 and 1995, there were 609 Rochester residents aged ≥18 years who fulfilled the 1987 ACR criteria for RA, forming the incident RA cohort (9). Of these patients, 26.9% (164) were male and 73.1% (445) were female. Rheumatoid factor was positive in 341 (56.0%) of the patients, and 148 (24.3%) patients developed rheumatoid nodules. The average age at diagnosis was 58.0 years. The average age at first surgery for RA-related joint disease was 58.9 years (range 28.9–85.1 years). The mean followup was 13.9 years (range 0.0–40.9 years).

A total of 242 (39.7%) patients underwent 1 or more (maximum of 29) surgical procedures involving joints, of which 174 (28.6%) were directly related to RA (that is, not related to trauma, sepsis, or other causes). The cumulative incidence at 30 years for surgical procedures for RA was 33.3% ± SEM 3.8%. The number and types of surgeries are contained in Table 1. Primary TJA for RA was performed in 85 patients; other joint reconstructive procedures (JRP) were performed in 84 patients, and STPs for RA-related joint disease were done in 108 patients. Only 2 patients underwent cervical spine fusion for RA-related disease. Trauma and other joint surgeries performed in 60 patients (30 year cumulative incidence 12.4% ± SEM 3.4%) included TJA for fractures in 37 patients, arthrotomy for septic arthritis in 10 patients, and revision of a previous TJA in 20 patients (Table 1).

Table 1. Orthopedic surgeries performed in 609 patients with incident rheumatoid arthritis in Rochester, Minnesota
Type of surgeriesPatients having surgery total; male/femaleCumulative incidence at 30 years % ± SEM
TotalMaleFemale
  • *

    Significantly more frequent in women than in men.

RA disease related174; 36/138*33.7 ± 3.825.9 ± 8.836.7 ± 4.0
 Primary total joint arthroplasty85; 17/6817.8 ± 4.013.9 ± 10.319.4 ± 4.1
 Joint reconstructive procedures84; 8/76*17.0 ± 3.06.7 ± 6.220.8 ± 3.3
 Soft tissue procedures108; 21/8719.8 ± 2.914.4 ± 7.010.8 ± 3.0
Trauma and other surgeries60; 6/54*12.4 ± 3.44.8 ± 3.615.2 ± 4.3
 Total joint arthroplasty37; 3/34*7.7 ± 2.92.3 ± 2.49.6 ± 3.6
 Septic joint arthrotomy10; 2/81.7 ± 0.81.6 ± 2.11.8 ± 0.8
 Open fracture reduction64; 17/4712.2 ± 2.510.8 ± 3.212.7 ± 3.1
 Revision of total joint arthroplasty20; 2/184.3 ± 2.31.8 ± 2.75.2 ± 2.9
Total: any surgeries242; 55/18747.0 ± 3.738.3 ± 7.950.4 ± 4.1

The median number of RA-related procedures per patient in the 174 patients who had surgery was 2 (minimum of 1/patient and maximum of 20/patient). Many patients underwent multiple types of surgeries, and many patients had multiples of each type of surgery. For example, 85 patients had primary TJA; of these, 39 (45.9%) had only 1 primary TJA, 30 (35.3%) had 2 TJAs, and 6 (7%) had 3 TJAs. The results for primary TJA, JRP, and STP are shown in Table 2. The hip was the most frequently operated joint in this cohort (Table 3). For surgery related to RA itself, the knee joints were the most frequently operated, followed by the joints of the wrist, first toes, and fingers (Table 4).

Table 2. Types and frequencies of orthopedic procedures performed for rheumatoid arthritis-related joint disease*
Type of surgeryTotal number of patientsTotal number of proceduresNumber of surgeries
1 n (%)2 n (%)3 n (%)4 n (%)5 or more n (%)
  • *

    TJA = primary total joint arthroplasty; JRP = non-TJA joint reconstructive procedures; STP = soft tissue procedures.

TJA8516939 (45.9)30 (35.3)6 (7.0)3 (3.5)7 (8.2)
JRP8423929 (34.5)23 (27.4)6 (7.1)9 (10.7)17 (20.2)
STP10821657 (25.0)27 (25.0)7 (6.5)8 (7.4)9 (8.3)
Table 3. Joints involved in orthopedic surgery in 609 patients with rheumatoid arthritis
JointsPatients having surgery, by joint total; male/femaleCumulative incidence at 30 years % ± SEM
TotalMaleFemale
  • *

    Significantly more frequent in women than in men.

  • Number of surgeries. Patients may for example have had from 1 to 5 MCP joints operated on in a single surgery session, but each surgery session is counted only once for the respective joint group. MTP = metatarsophalangeal; IP = interphalangeal; PIP = proximal interphalangeal; DIP = distal interphalangeal; MCP = metacarpophalangeal.

Hips84; 12/72*17.7 ± 3.87.6 ± 2.921.5 ± 4.8
Knees81; 23/5816.0 ± 3.016.4 ± 7.016.0 ± 3.3
Wrists75; 13/6214.2 ± 2.79.4 ± 5.216.1 ± 3.2
First toes (MTP, IP)48; 4/44*10.0 ± 2.63.7 ± 5.712.4 ± 2.9
Other fingers (MCP, PIP, DIP)56; 11/4511.3 ± 3.29.9 ± 9.611.8 ± 2.5
Feet, MTPs 2–544; 5/399.6 ± 3.14.3 ± 5.711.5 ± 3.6
Thumbs (base, MCP, IP)42; 4/38*8.5 ± 3.04.5 ± 9.310.0 ± 2.6
Toes 2–5 (PIP, DIP)27; 2/25*6.1 ± 2.31.2 ± 1.07.9 ± 3.0
Elbows16; 3/132.9 ± 1.21.9 ± 3.03.3 ± 1.4
Ankles9; 1/81.7 ± 1.00.7 ± 0.92.0 ± 1.3
Shoulders12; 4/82.5 ± 1.62.7 ± 1.72.5 ± 2.1
Cervical spine fusion2; 0/20.4 ± 0.40.00.5 ± 0.5
Temporomandibular1; 0/10.2 ± 0.20.00.2 ± 0.3
Table 4. Joints involved in orthopedic surgery for rheumatoid arthritis-related joint disease
JointsPatients having surgery, by joint total; male/femaleCumulative incidence at 30 years % ± SEM
TotalMaleFemale
  • *

    Significantly more frequent in women than in men.

  • See Table 3 footnote.

Hips26; 4/225.5 ± 2.52.0 ± 1.36.8 ± 3.3
Knees63; 16/4713.1 ± 3.112.0 ± 7.213.5 ± 3.4
Wrists59; 9/50*11.5 ± 2.76.9 ± 5.213.2 ± 3.2
First toes (MTP, IP)44; 3/41*9.1 ± 2.43.1 ± 5.711.3 ± 2.6
Other fingers (MCP, PIP, DIP)40; 7/338.1 ± 2.25.8 ± 5.38.9 ± 2.4
Feet, MTPs 2–535; 4/31*7.7 ± 2.73.7 ± 5.79.2 ± 3.1
Thumbs (base, MCP, IP)42; 4/38*8.5 ± 3.04.5 ± 9.310.0 ± 2.6
Toes 2–5 (PIP, DIP)25; 1/24*5.8 ± 2.30.6 ± 0.77.7 ± 3.0
Elbows14; 1/132.7 ± 1.21.0 ± 2.33.3 ± 1.4
Ankles4; 0/40.9 ± 0.90.01.3 ± 1.2
Shoulders11; 3/82.4 ± 1.62.1 ± 1.62.5 ± 2.1
Cervical spine fusion1; 0/10.2 ± 0.20.00.3 ± 0.3
Temporomandibular1; 0/10.2 ± 0.20.00.3 ± 0.3

In univariate Cox proportional hazards models, the risk of having a disease-related joint surgery for RA was increased in patients who are younger (relative risk [RR] = 0.84, 95% confidence interval [95% CI] 0.76–0.93 per 10 year increase in age at diagnosis of RA, P < 0.001), in those who are positive for rheumatoid factor (RR = 1.73, 95% CI 1.27–2.37, P < 0.001), and in those with subcutaneous nodules (RR = 2.84, 95% CI 2.00–4.03, P < 0.001). Multivariate analyses did not provide different results. There was a borderline increase in the time to first joint surgery in women (RR = 1.47, 95% CI 1.02–2.12, P = 0.04). However, women had significantly more joint surgeries than men, with a rate of 8.6/100 RA-related surgeries per person-year; for men the rate was of 4.0/100 per person-year (P < 0.0001).

When evaluated as a continuous variable, there was no effect of year of diagnosis of RA on the risk for joint surgery (P = 0.19). However, when evaluated by decade of diagnosis of RA, there was a clear reduction in the risk for all types of joint-related surgery (P < 0.0001) and for each subgroup considered separately (TJA, P < 0.001; JRP, P < 0.002; STP, P = 0.01) for the cohort of patients diagnosed 1985–1994. For the decade 1955–1964, there were slightly fewer surgeries (likely reflecting the fact that TJA became more feasible for technical reasons during the mid-1960s); and for the decade 1985–1994, a markedly lower risk was seen for an RA-related joint surgery than for the patients diagnosed with RA during 1965–1974 and 1975–1984 (P < 0.0001; Figure 1).

Figure 1.

Cumulative incidence of surgery (% of patients with surgery) by decade, January 1, 1955–January 1, 1995.

At some point during the followup period, most patients had taken a disease-modifying antirheumatic drug (DMARD). However, we could not with certainty determine whether the use of a DMARD, or any specific DMARD, affected the risk for having orthopedic surgery in this study (data not shown).

There were 333 deaths during the followup period. The survival of patients undergoing RA-related joint surgery was similar to those who did not.

DISCUSSION

Reconstructive surgeries for RA are common, with 28.6% of 609 RA patients having undergone such a procedure. The cumulative incidence at 30 years was 33.7%. Soft tissue and joint reconstructive procedures were most often performed, but primary TJAs were also frequent, performed in 85 of 609 patients with a cumulative incidence at 30 years of 17.8%. Surgery of the knee for RA-related disease was more frequent than any other joint or group of joints (multiple MCP or MTP joints operated on during 1 operative session considered together).

The likelihood of surgery was higher in patients who were younger at disease diagnosis; there was a 16% decrease in risk for every 10 year increase in age at incidence. A woman with RA was 1.5 times as likely to have an orthopedic surgery than was a man, a finding noted by other authors (11). The risk for joint surgery was 70% higher for those with rheumatoid factor positivity and was 2.8 times higher in patients with subcutaneous nodules than those without. If the requirement for joint surgery can be viewed as a marker of severe disease and poor outcome (at least with respect to joint integrity), these findings would seem to confirm other epidemiologic observations of younger age at disease onset, female sex, and rheumatoid factor positivity as markers of disease severity (12).

Certainly the decision to undergo joint replacement surgery is complex and not simply a reflection of joint damage and attendant loss of function. Women had more surgeries than men in absolute and relative terms, with increased utilization of small joint (hand and foot) surgery in women accounting for the major part of this difference. We did not examine psychosocial factors including occupational, educational, or marital status, or outcome of previous joint surgery as predictors of the need for joint surgery. Whether this increased use of surgery by women reflects functional, cosmetic, pain perception, greater disease extent, or in the case of previous surgery, greater satisfaction with functional and cosmetic outcomes is uncertain. It is clear that there are significant sex differences in the rates of utilization of joint surgery.

There are no directly comparable studies of joint surgery for patients with RA. In another study of 1,600 patients with RA, 25% underwent TJA within 21.8 years of disease onset, whereas in the present study we found that 122 of 609 had TJA (20.3%; 85 patients with primary TJA and 37 patients with TJA due to trauma) (13). A cross-sectional epidemiologic study of 1,629 patients with RA seen in a private practice in France during a 6-month period in 1996 revealed that 24% of patients had 1 or more surgical procedures for joint disease during their disease course (mean disease course, 8 years; mean number of procedures, 3), a figure somewhat lower than that in our study (14). Referral and temporal trends in disease management may explain these differences.

We attempted to evaluate whether the use of DMARDs or glucocorticoids had an influence on the risk for orthopedic joint surgery. There were important methodologic limitations that complicated this analysis, including the fact that this was a retrospective study not designed to address this question, and that indication and disease severity probably confounded the results regarding use of these drugs. We could not with certainty determine whether glucocorticoid or DMARD use, including individual DMARDs, had any influence on the risk for joint surgery.

There was a clear difference in the utilization of and risk for having joint surgery in patients with RA diagnosed in the decade after 1985. This may well reflect improvements in disease management, and could be an indication that modern therapies for RA are having a positive impact on important measures of outcome. This trend could reflect a change in the nature of the disease, possibly that it has milder expression in more recent years, or could reflect a change in rheumatologic and orthopedic practice patterns. Certainly enthusiasm for hip replacement and knee replacement surgeries increased in the 1970s as surgical techniques and prosthetic materials improved, but the overall trend toward less surgery in more recent years is noteworthy. We did not specifically evaluate the presence of risk factors for osteoporotic and other fractures necessitating joint surgery in these patients with RA; this has been the subject of other reports (15–17).

Our results suggest that survivorship among RA patients undergoing surgery was similar to the RA population at large. There are no comparable studies, although in a case series of nonambulatory Japanese patients with RA undergoing total knee arthroplasty or total hip arthroplasty, only 8 were alive after 10 years of followup (18).

From this and other studies it is evident that patients with RA have high rates of utilization of orthopedic services. That these rates are higher than expected from the general population is reflected in a study of total hip arthroplasties done in Rochester, Minnesota between 1969 and 1990: 63.2% of these procedures were for degenerative joint disease, 19.8% for fractures, and 19.8% for RA (19). Our longitudinal, population-based assessment data support and extend these findings.

Because of the demographic make up of the community (more than 90% white), estimates of the need for joint surgery in nonwhites would be unstable; however, the majority of RA cases nationally are among whites. We cannot demonstrate that the medical and surgical practice in Rochester is optimal, but most (98%) surgeries were performed at Mayo Clinic. Although the generalizability of our findings is limited, utilization rates from the above mentioned study of total hip arthroplasty in Rochester were consistent with European data and slightly higher than in other studies from the US (19).

Although it is uncertain how the need for joint surgeries in patients with RA will be affected by changes in disease therapies, it is clear that the need for such services will remain high in the foreseeable future, with important impacts on patient quality of life and health care resource utilization planning. Patients recently diagnosed with RA who are treated according to modern therapeutic concepts may require less disease-related joint surgery than their predecessors.

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