Background/Purpose: Lower extremity (LE) ulcer is a known complication of rheumatoid arthritis (RA). However, little is known regarding the magnitude and morbidity associated with this complication. We aimed to assess the occurrence, risk factors, morbidity and mortality associated with LE ulcers in RA.

Methods: We retrospectively reviewed a population-based incidence cohort of patients who fulfilled 1987 ACR criteria for RA in 1980-2007. All subjects were longitudinally followed through their complete community medical records until death, migration or April 2012. Ulcers in the lower extremities that developed after the diagnosis of RA were included. Foot ulcers due to surgery, biopsy, burns, animal bites, ingrowing toe nail, toe nail removal, abrasion, cellulitis, foreign body or herpes zoster were excluded. Cumulative incidence of lower extremity ulcers adjusted for the competing risk of death was estimated. Cox models were used to assess risk factors for LE ulcers and their impact on mortality.

Results: The study population included 813 patients, 537 (66%) were rheumatoid factor positive; during follow-up, 33% had rheumatoid nodules and 53% had erosive joint disease. During 9771 total person-years of follow-up (mean 12.0 years per patient), 125 patients developed LE ulcers with total occurrence of 171 episodes. The cumulative incidence of LE ulcers in RA patients was 4.8 % (± 0.8%) at 5 years after diagnosis of RA and increased to 26.2% (± 2.5%) by 25 years. Mean age of RA patients with at first LE ulcer occurrence was 73.5 years (74% female). The most common ulcer locations were between ankle and knee (58 ulcers, 34%) and in the tips of toes (46 ulcers, 27%). Majority were pressure (62 ulcers, 36%) or traumatic (49 ulcers, 29%) in etiology; 22 (13%) were ischemic ulcers and only 2 (1%) were vasculitic ulcers. The incidence of LE ulcers was higher among patients diagnosed with RA in 1995-2007 compared to those diagnosed in 1980-1994 (hazard ratio [HR] 2.03; p=0.001). Median time for the LE ulcer to heal was 30 days. 10 (6%) of 171 episodes lead to amputation. LE ulcers in RA were associated with increased mortality (HR 2.42; p < 0.001) adjusted for age, sex and calendar year.

Risk factors for LE ulcers in RA were: age (HR 1.90 per 10 year increase; p<0.001); current smoking (HR 1.51; p = 0.048); diabetes mellitus (HR 1.65; p = 0.015); coronary heart disease or heart failure (HR1.56; p = 0.035); presence of rheumatoid nodules (HR 1.64; p = 0.010); ESR ≥ 60 mm/hour on three occasions (HR 1.78; p = 0.022); venous thromboembolism (HR 2.08; p = 0.014); severe extra-articular manifestations (HR 1.67; p = 0.048). 79 (46%) of 171 ulcer episodes occurred in patents on corticosteroid therapy.

Conclusion: LE ulcers are common among patients with RA.  The cumulative incidence increased by 1% per year, and the incidence of LE ulcers in RA has doubled in the recent years. A significant number require amputation.  LE ulcers are associated with double the mortality rate in RA patients. Clinicians should be aware of the significance of LE ulcers in RA for better management of these patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/occurrence-and-morbidity-of-lower-extremity-ulcer-in-rheumatoid-arthritis-a-population-based-study/