Background The treatment aim of rheumatoid arthritis (RA) is achieving and maintaining remission (REM) or low disease activity (LDA) via tight medical control. However, despite remarkable advances in medication, progressive deterioration and/or deformity of the joint sometimes occurs, if adequate medication is not administered in the early stage. Surgical reconstruction is still required in the joints with functional loss caused by structural damage. Recently, patients have expressed a desire to achieve functional REM with a higher quality of life (QOL) and improved mental wellness.
Objectives The objective of this study was to clarify the effectiveness of intensive combination therapy with medication and orthopedic surgical intervention in patients who have already achieved REM or LDA.
Methods A prospective cohort study was performed on 294 sites in 276 patients with functional loss due to RA scheduled to undergo primary elective surgery between October 2012 and September 2014. There were 99 sites in 96 patients (males: 10, females: 86) whose disease activity was REM or LDA just before surgery. In the REM/LDA group, the average age was 63 (29–82) years, and the average disease duration was 17 (2–60) years. The surgical site was the shoulder in 1 patient, elbow in 7, wrist in 21, hand in 24, hip in 5, knee in 10, ankle in 4, and forefoot in 27. The procedures performed included 38 alloarthroplasties, 41 arthroplasties without prosthesis, 19 arthrodesis, and 9 synovectomies. The patient-reported outcome (PRO) was assessed using the Health Assessment Questionnaire-Disability Index (HAQ-DI), EuroQol-5 Dimensions (EQ-5D), Beck Depression Inventory-II (BDI-II), Patient's General Health using visual analogue scale of 100 mm (Pt-GH), and the Disabilities of the Arm, Shoulder and Hand (DASH) for the upper extremity surgery. The Time Up &Go test (TUG) was administered for patients receiving lower extremity surgery. The disease activity was assessed based on the 28-joint Disease Activity Score using C reactive protein (DAS28-CRP). All of these items were investigated just before surgery (baseline) and again at 6 and 12 months after surgery.
Results On the whole, the physical function (HAQ-DI, DASH, TUG), QOL (HAQ-DI, EQ-5D, Pt-GH), mental wellness (BDI-II, Pt-GH), and disease activity (DAS28-CRP)1) were significantly improved at 6 and 12 months after surgery compared to baseline (p<0.01). In the REM/LDA group, a significant improvement was noted in the physical function (DASH, TUG) and QOL (EQ-5D) at 6 and 12 months after surgery; however, we did not observe any significant changes in any other items (Table 1).
Conclusions Achieving REM or LDA is not the ultimate goal of treatment for patients with functional loss caused by structural damage. Further “wellness” can be achieved by surgical intervention. Intensive combination therapy with medication and orthopedic surgical intervention is effective in improving the QOL and mental health as well as the physical function. Such intervention can also ameliorate the disease activity.
Oh K, Ishikawa H, Abe A, et al. Effects of surgical intervention on disease activity of rheumatoid arthritis: cases of surgery for rheumatoid arthritis of the lower limbs treated with biologics. Mod Rheumatol. 2014;24(4):606–11.
Disclosure of Interest None declared