Background With biologic treatment of rheumatoid arthritis (RA), uncontrollable synovitis in the past were well controlled. However, some patients with long-standing established RA were still difficult to reach the treatment target and surgical reconstruction for the damaged joint was needed. Recently, patients desired to achieve functional remission aiming at higher level of quality of life (QOL).
Objectives The objective of this cohort study was to clarify the effect of orthopedic intervention for the disabled patients with RA using the assessment of patient-reported outcome (PRO) and disease activity prospectively.
Methods Surgical treatment was performed on 136 sites in 136 patients (male: 19, female: 117) with RA during the period between October 2012 and October 2013. The average age was 65 (33-89) years old and the average duration of RA was 17 (1-45) years. The site of operation was shoulder in 3 patients, elbow in 16, wrist in 34, hand in 20, hip in 8, knee in 28, ankle in 5, and forefoot in 22. The procedure included alloarthroplasty (shoulder: 3, elbow: 14, hand: 15, hip: 8, knee: 26), arthroplasty without prosthesis (wrist:22, hand:2, forefoot:22), arthrodesis (wrist: 6, hand: 3, ankle: 5), and synovectomy (elbow: 2, wrist: 6, knee: 2). Steinbrocker stage I, II, III, IV was 5, 28, 52, 51 sites, and Steinbrocker class I, II, III, IV was 7, 64, 64, 1 patient(s), respectively. MTX was used in 81 patients (60%) with the average dose of 7.6mg/w, and PSL was used 86 patients (63%) with the average dose of 4.0mg/d. Biologics was used 30 patients (22%) including ETN: 8, TCZ: 8, IFX: 5, GOL: 5, ADA: 4 patients. PRO was assessed by HAQ-DI, DASH, EQ-5D, BDI-II, and Pt-GH. Disease activity was assessed by DAS28-CRP(4) and SDAI. They were measured just before surgery (baseline), at 6 months and 1 year after surgery.
Results On the whole, physical function (HAQ-DI), QOL (HAQ-DI, EQ-5D, Pt-GH), disability in the upper extremity (DASH) and mental/ depression (BDI-II, Pt-GH), disease activity (DAS28-CRP(4), SDAI) significantly improved at 6 months and 1 year after surgery compared to those at baseline (Table1). The rate of clinical remission in DAS-CRP(4) (<2.3) and SDAI (<3.3) at baseline, 6months and 1 year after surgery was 18.3%, 47.1%, 47.8% and 35.3%, 68.4%, 66.9%, respectively. The rate of functional remission in HAQ-DI (<0.5) at baseline, 6 months and 1year after surgery was 17.7%, 26.5% and 26.5%. The rate of no depression in BDI-II (≤13) at baseline, 6months and 1 year after surgery was 48.0%, 58.8% and 63.2%.
Conclusions Favorable effect of orthopedic intervention in the disabled patients with RA was confirmed. To achieve functional and mental remission for the long-standing established RA, surgical treatment for the damaged joint should be considered in combination with tight medical control. It also had an ameliorating effect on disease activity.
Ishikawa H, Murasawa A, Nakazono K, et al. The patient-based outcome of upper-extremity surgeries using the DASH questionnaire and the effect of disease activity of the patients with rheumatoid arthritis. Clin Rheumatol. 2008;27:967-973.
Disclosure of Interest None declared