Rheumatology (Oxford). 2004;43( 3):369-76.
OBJECTIVES: To assess the occurrence of and predictive factors for orthopaedic surgery
in an inception cohort of rheumatoid arthritis (RA) patients recruited and followed
prospectively for 5 yr in nine regions in England. METHODS: Standard clinical, laboratory
and radiological assessments and all interventions were recorded at baseline and yearly
in RA patients (less than 2 yrs symptoms) prior to the use of disease-modifying drugs.
RESULTS: One thousand and sixty-four patients completed 5 yr of follow-up. Two hundred
and sixty-four orthopaedic procedures for RA were performed in 181 (17%) patients
at a median of 36.5 months from baseline. Seventy-five (7%) had replacements of major
joints. Risk factors at baseline for large joint replacement surgery were a low haemoglobin
concentration [odds ratio scores (OR) 3.4, 95% confidence interval (CI) 2.1-5.8] and
high scores for erythrocyte sedimentation rate (ESR) (OR 3.2, CI 1.8-5.3), disease
activity (DAS) (OR 2.1, CI 1.2-3.5) and Larsen X-rays (OR 2.6, CI 1.4-4.8). For hand
or foot joint surgery (4%), risk factors included female gender (OR 3.2, CI 1.3-7.6),
joint score (OR 2.3, CI 1.2-4.3), erosions (OR 2.3, CI 1.1-4.8), DAS (OR 2.4, 1.3-4.5)
and Health Assessment Questionnaire score (OR 1.9, CI 1.0-3.6). No significant associations
were seen for tendon, soft tissue or other minor procedures (6%). The HLA-DRB1 RA
shared epitope was associated with any type of orthopaedic surgery (OR 1.7, CI 1.1-2.7).
CONCLUSIONS: Eleven per cent of RA patients treated with conventional drug therapy
for 5 yr underwent large- or small-joint surgery, an outcome which could be compared
against that for new disease-modifying drugs. Risk factors varied according to type
of surgery, but included standard clinical and laboratory measures. In order to reduce
the eventual need for surgery, a therapeutic target in the first year of RA is the
suppression of disease activity, as measured by haemoglobin and ESR. These are useful
details for clinicians, health professionals and patients.