Abstract
ObjectivesTo analyse predictors and outcomes of major orthopaedic surgery in a cohort of RA patients followed for 20 years. MethodsPatients were recruited to the Norfolk Arthritis Register from 1990 to 1994. Demographic and clinical variables (including the HAQ and swollen and tender joint counts) were assessed at baseline; the 2010 ACR/EULAR RA classification criteria were applied. Patients reported incident comorbidities and major orthopaedic joint surgery (replacement, synovectomy, fusion, excision) when reassessed at years 1, 2, 3, 5, 7, 10, 15 and 20. Baseline and time-varying predictors of orthopaedic surgery were assessed using a conditional risk set model, a type of multiple-failure survival analysis. Change in disability after surgery was assessed using weighted mixed-effects linear regression.ResultsOf 589 RA patients [median age 56 years (IQR 45–68); 66.7% women] recruited to the Norfolk Arthritis Register with at least one follow-up, 102 reported a total of 180 major surgeries, with hip replacement being the most common (n = 68/180). Patients reporting major surgery had worse functional disability at all time points, but similar swollen/tender joint counts to those without major surgery. Each unit increase in HAQ score was associated with a doubling of the patient’s risk of having surgery by the next assessment [hazard ratio 2.11 per unit increase in HAQ (95% CI 1.64, 2.71)]. Patients had worse HAQ scores after surgery than patients not undergoing surgery [β = 0.17 (95% CI 0.03, 0.32)].ConclusionHAQ was the strongest predictor of future major surgery. This supports the argument that HAQ should be included in routine clinical assessment.
Highlights
The joint inflammation associated with RA, especially if persistent, may lead to progressive joint damage [1]
Each unit increase in HAQ score was associated with a doubling of the patient’s risk of having surgery by the assessment [hazard ratio 2.11 per unit increase in HAQ]
Patients had worse HAQ scores after surgery than patients not undergoing surgery [b = 0.17]
Summary
The joint inflammation associated with RA, especially if persistent, may lead to progressive joint damage [1]. Kapetanovic et al [10] followed 183 patients with recent-onset RA in Sweden for a mean of 16 years and showed that baseline functional disability (HAQ) [hazard ratio (HR) 1.74/1 unit increase in HAQ (95% CI 1.04, 2.93)], baseline CRP [HR 1.39/10 mg/l increase in CRP (95% CI 1.23, 1.46)] and radiological damage at year 1 [HR 1.47/10 unit increase in Larsen score (95% CI 1.22, 1.77)] were associated with an increased risk of first joint replacement surgery. An analysis of patients recruited from 1986 to 2012 to the Early RA Study/Early RA Network (ERAS/ERAN) found that high 28-joint DAS (DAS28 >5.1) between years 1 and 5 was associated with an increased risk of orthopaedic surgery compared with remission mean DAS28 (42.6) [HR 2.59 (95% CI 1.49, 4.52)] [12]
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