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Abstract
BackgroundReconstructive joint surgery is an indicator of poor prognosis in rheumatoid arthritis (RA). Objectives of this study were to describe the incidence rate of orthopedic and hand surgery indication (OHSI) in an ongoing cohort of Hispanic early RA patients treated according to a T2T strategy and to investigate predictors.MethodsThrough February 2018, the cohort comprised 185 patients recruited from 2004 onwards, with variable follow-up, and rheumatic assessments at fixed intervals that included prospective determination of OHSI. Charts were reviewed by a single data abstractor. OHSI incidence rate was calculated. A case-control study nested within a cohort investigated the predictors; cases (OHSI patients) were paired with controls (1:4) according to age, sex and autoantibodies. A logistic regression model included baseline and cumulative (up to OHSI or equivalent) variables related to disease activity, treatment and to persistence with therapy. The IRB approved the study.ResultsPatients from the cohort were predominantly middle-aged (mean ± SD age: 38.5 ± 12.9 years) females (87.6%) with 5.4 ± 2.6 months of disease duration. The cohort contributed to 1538 patient-years of follow-up. Twelve patients received incidental OHSI at a follow-up of 85 ± 44.5 months. The OHSI incident global rate was 8/1000 patient-years. Longer symptom duration at cohort referral (OR: 1.313, 95%CI: 1.02–1.68, p = 0.032) and a higher number of flares/patient (OR: 1.608, 95%CI: 1.05–1.61, p = 0.015) predicted OHSI. OHSI patients had more severe flares than their counterparts, and the opposite figure was true for mild flares.ConclusionEarly referral for appropriate management and flare control may prevent OHSI in Hispanic recent-onset RA patients.
Highlights
Reconstructive joint surgery is an indicator of poor prognosis in rheumatoid arthritis (RA)
We found a low incident global rate of orthopedic and hand surgery indication (OHSI) (8/1000 patient-years) after a mean follow-up of 7 years
Few inception cohorts of early RA had assessed rates of orthopedic and small joint surgery, with conflicting results [9,10,11,12,13,14, 18, 19]; prevalence ranged from 5.3% at a mean follow-up of 4.6 years [13] to 58% after a mean follow-up of 16 years [12]; variations may be explained by a lack of a uniform definition of “early disease” [9,10,11,12,13,14, 19], a wide spectrum of follow-ups that may last up to 25 years [19], Table 3 Comparison of cumulative disease activity, treatment and persistence with therapy between OHSI and paired controls
Summary
Reconstructive joint surgery is an indicator of poor prognosis in rheumatoid arthritis (RA). Treating RA to target (T2T) has become an internationally agreed standard of good practice [4] the implementation of such strategy may be restricted in Despite early and more aggressive treatment guidelines adopted in the last decades, some patients present progressive joint destruction and eventually require a surgical solution. The most important time-varying factors associated with a reduced risk of joint surgery have been early treatment with conventional DMARDS during the first 2 years [10], good response to treatment during the first years of follow-up [10, 13, 14], lower annual radiographic progression rate [10, 12] and lower HAQ score at the beginning of a follow-up window [11] or in the early course of the disease [12]. The intensity of RA-specific treatment during the first year of disease diagnosis has been associated with longer time to joint replacement surgery [13]
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