Background/Purpose: Orthopaedic surgery is considered an important, although uncommonly reported, outcome measure in rheumatoid arthritis (RA) and a surrogate marker for joint destruction. The expectation is that orthopaedic surgical rates will decline over time with greater and earlier use of more intensive treatments for RA.

Methods: The Early RA Study (ERAS) recruited from 1986-1999 (n=1465), the Early RA Network (ERAN) from 2002-2011 (n=1236). Standardised clinical, laboratory and X-ray measures were performed at baseline prior to initiation of DMARD therapy and then yearly in both cohorts. Treatment of patients included disease modifying, steroid and biologic therapies according to standard UK practices for management of hospital based RA patients, based on sequential published guidelines over 1986-2011. Source data of all orthopaedic interventions included clinical datasets (patient reports and medical records from 1986), and national data from Hospital Episode Statistics and the National Joint Registry. Length of follow up was based on the National Death Registry. For the analysis, recruitment years were grouped into 6 periods and interventions categorized into major (large joint replacements), intermediate (mainly synovectomies and arthroplasties of wrist/hand, hind/forefoot), and minor (soft tissue/tendon surgery).

Results: A total of 1602 procedures were performed in 770 patients (29%) over maximum 25 year follow up. The 25 year cumulative incidence rate of major interventions was 21.7% (19.4–24.0%), and 21.5% (17.8–25.5%) for intermediate. Secular changes in orthopaedic surgical rates per year from 1987-2011 will be displayed graphically, showing a small, non-significant decline in major interventions (0.02%; p>0.05), but the regression model fitted for intermediate interventions indicated a significant decline (0.03%, p <0.05), and a small but non-significant increase for minor interventions (0.02%; p>0.05). There were only minor differences in demographic and baseline features over the recruitment periods examined, but definite treatment trends showed a gradual change from sequential monotherapy to  combination therapies and biologics, and greater and earlier use of methotrexate and  steroids in later recruitment periods. Methotrexate and combination therapies as first DMARD were used in 1% and less than 1% respectively in recruitment period 1986-1989, and in 70% and 13% in 2006-2011. Anti-TNF agents were used in the first 3 years of disease only the latter two recruitment periods: 2002-2005, 7.8% and 2006-2011, 19.4%.

Conclusion: Orthopaedic surgery is an important and common outcome in RA by 10years. Only hand/foot surgery rates showed a consistent decline from 1986-2011. Possible explanations include differences in pathophysiological processes affecting joints; variations in responses to therapy between large and small joint destructive processes; changes in service provision and thresholds for different types of orthopaedic surgery over time.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/rates-of-orthopaedic-interventions-for-rheumatoid-arthritis-have-changed-over-the-last-25-years-a-report-from-two-uk-inception-cohorts-reflecting-treatment-changes-from-sequential-dmard-monotherapy-t/