Over the past two decades, we have seen significant advances in modern medicine and technology. We know that cardiac surgery rates are decreasing with earlier detection of cardiovascular disease and advances in interventional cardiology. Although technology enables improved outcomes for patients, cardiac surgeons are becoming increasingly less busy. Furthermore, the cases that they are seeing are increasingly more complex. With our advances in RA management, is the same thing happening to the relationship between rheumatology and orthopedic surgery?
This morning at EULAR, a group from Norway showed that orthopedic surgery rates for RA-related joint disease has indeed been declining over the past 40 years. They used administrative data to identify rates of surgery in three periods, 1972-1985, 1986-1998 and 1999-2009. The rates of surgery were relatively static from 1972-1999 (periods 1-2). Since the introduction of biologics, however, there has been a significant reduction in the rates of joint surgery, with a relative risk reduction of around 2.4. Risk factors for surgery included female sex and joint damage at diagnosis. Disease activity at baseline did not affect outcome, which is likely a reflection of more aggressive treatment strategies and treating to target.
While RA-associated surgery rates are decreasing, we don't know if complications associated with surgery in RA have increased, particularly with the advent of biologics and advanced therapeutics. A group from Denmark looked at risks associated with RA joint replacements compared to OA. They linked data from DANBIO (a biologics registry), Danish patient register, and Danish TKR and THR registries, and they were able to analyze data on 3913 RA and 120,499 OA patients. They found higher rates of death and prosthetic joint infections in RA patients compared to OA patients, which we already know from previous studies. In RA patients, the use of prednisone was associated with increased risk of death. The important finding of this study is that there was no increased risk of prosthetic joint infection or death with DMARDs or biologics.
Bottom line: Not surprisingly, surgical rates in RA are decreasing with earlier and more aggressive treatment strategies. Despite higher use of immunosuppressants, we are not seeing an increase in surgical-related complications or death. We should stop using chronic steroids. Until we can find better therapies for osteoarthritis, I suspect that we will continue to work with our orthopedic colleagues!
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Dr. Jamal is a Clinical Associate Professor at the University of British Columbia and an active staff physician at Vancouver Coastal Health. Her interests include diagnosis and prognosis of early inflammatory arthritis, and timely assessment and access to care for patients with rheumatoid arthritis.View Full Bio