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Can Rheumatologists Predict Eventual Need for Orthopaedic Intervention in Patients with Rheumatoid Arthritis? Results of a Systematic Review and Analysis of Two UK Inception Cohorts

  • Surgery and Perioperative Care (S Goodman, Section Editor)
  • Published:
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Abstract

Purpose of Review

The structural damage caused by rheumatoid arthritis (RA) can often be mitigated by orthopaedic surgery in late disease. This study evaluates the value of predictive factors for orthopaedic intervention.

Methods

A systematic review of literature was undertaken to identify papers describing predictive factors for orthopaedic surgery in RA. Manuscripts were selected if they met inclusion criteria of cohort study design, diagnosis of RA, follow-up duration/disease duration ≥3 years, any orthopaedic surgical interventions recorded, and then summarised for predictive factors. A separate predictive analysis was performed on two consecutive UK Early RA cohorts, linked to national datasets.

Recent Findings

The literature search identified 15 reports examining predictive factors for orthopaedic intervention, 4 inception, 5 prospective and 6 retrospective. Despite considerable variation, acute phase, x-ray scores, women and genotyping were the most commonly reported prognostic markers. The current predictive analysis included 1602 procedures performed in 711 patients (25-year cumulative incidence 26%). Earlier recruitment year, erosions and lower haemoglobin predicted both intermediate and major surgery (P<0.05).

Summary

Studies report variations in type of and predictive power of clinical and laboratory parameters for different surgical interventions suggesting specific contributions from different pathological and/or patient-level factors. Our current analysis suggests that attention to non-inflammatory factors in addition to suppression of inflammation is needed to minimise the burden of orthopaedic surgery.

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Abbreviations

anti-TNFa:

Anti-tumour necrosis factor alpha

BMI:

Body Mass Index

CI:

Confidence interval

CRP:

C-reactive protein

DAS:

Disease activity score

DAS-P:

Disease activity score (patient-reported components)

DMARD:

Disease-modifying anti-rheumatic drug

ERAN:

Early Rheumatoid Arthritis Network

ERAS:

Early Rheumatoid Arthritis study

ESR:

Erythrocyte sedimentation rate

EULAR:

European League Against Rheumatism

Fe:

Iron

HAQ:

Health Assessment Questionnaire

HES:

Hospital Episode Statistics

HR:

Hazard Ratio

IRR:

Incidence Rate Ratio

NHS:

National Health Service

MRIS:

Medical Research Information Service

NICE:

National Institute for Health and Care Excellence

NJR:

National Joint Registry

NSAID:

Non-steroidal anti-inflammatory drug

RA:

Rheumatoid arthritis

SHR:

Sub-hazard ratios

SCQM:

Swiss Clinical Quality Management

THR:

Total hip replacements

TJR:

Total joint replacements

TKR:

Total knee replacement

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

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Acknowledgements

We are indebted to all the patients who consented to participate. ERAS received ethical approval from the West Hertfordshire Local Research Ethics Committee and subsequently the Caldicott Guardian. ERAN received ethical approval from the Trent Research Ethics Committee. We are also indebted to the nurses and rheumatologists from both cohorts for their participation and contribution and especially our study coordinator Marie Hunt.

ERAS

Dr Paul Davies and Lynn Hill (Chelmsford), Dr Andrew Gough, Dr Joe Devlin, Prof. Paul Emery and Lynn Waterhouse (Birmingham), Dr David James and Helen Tait (Grimsby), Dr Peter Prouse and Cathy Boys (Basingstoke), Dora White (Medway), Helen Dart (Oswestry), Dr Nigel Cox and Sue Stafford (Winchester), Dr John Winfield (Sheffield) and Annie Seymour (St Albans).

ERAN

Annie Seymour (City Hospital, St Albans); Dr Richard Williams, Karina Blunn and Jackie McDowell (Hereford County Hospital); Dr Peter Prouse and Sheryl Andrews (North Hampshire Hospital); Deborah Wilson (King’s Mill Hospital); Dr Malgorzata Magliano and Ursula Perks (Stoke Mandeville Hospital); Dr Amanda Coulson (Withybush General Hospital); Dr Andrew Hassle, Elizabeth Barcroft and Janet Turner (Haywood Hospital); Francesca Leone (St George’s Hospital); Dr Ciaran Dunne and Lindsey Hawley (Christchurch Hospital); Dr Paul Creamer, Julie Taylor and Wendy Wilmott (Southmead Hospital); Dr Sally Knights and Rebecca Rowland-Axe (Yeovil District Hospital); Dr Sandra Green and Dawn Simmons (Weston-Super-Mare General Hospital), Dr Joel David and Maureen Cox (Nuffield Orthopaedic Centre); Dr Marwan Bukhari and Bronwen Evans (Lancaster Royal Infirmary); Dr Michael Batley and Catherine Oram (Maidstone Hospital) and Dr Tanya Potter (Coventry University Hospital).

The authors acknowledge Hospital Episode Statistics (HES) and the National Joint Registry (NJR) for providing the valuable data on orthopaedic episodes and the Medical Research Information Service for death notifications.

Authors’ Contributions

EN and AY developed the research questions, recruited and performed follow-up assessments in patients for ERAS and ERAN in one rheumatology unit. JD, DW, PK and PW recruited and performed follow-up assessments for patients in the study at separate rheumatology units. EN collected, interrogated and cross-validated the data from the clinical cohorts with the national datasets, coded the procedures, analysed the results and performed statistical tests with supervision from AY. SM and AM contributed to the data analysis and statistical tests. LC and SN contributed to the statistical analysis of the results. EN, LC, SN, JD, DW, PW, PK and AY contributed to the drafting of the manuscript. All authors read and approved the final manuscript.

ERAS received grants from the Arthritis Research Campaign (ARC), the British United Providence Association (BUPA) Foundation and is supported by the NIHR Essex and Hertfordshire CLRN.

ERAN received a grant from the Healthcare Commission.

Elena Nikiphorou received a grant from the Essex and Hertfordshire CLRN.

Author information

Authors and Affiliations

  1. ERAS, Department of Rheumatology, St Albans City Hospital, St Albans, UK

    Elena Nikiphorou & Adam Young

  2. Academic Rheumatology Department, King’s College London, London, UK

    Elena Nikiphorou & Stephen Morris

  3. Whittington Hospital NHS Trust, London, UK

    Elena Nikiphorou, Lewis Carpenter & Adam Young

  4. Health Psychology Section, Institute of Psychiatry, King’s College London, London, UK

    Sam Norton

  5. Institute of Musculoskeletal Science, University College London, London, UK

    Alex MacGregor

  6. Department of Rheumatology, New Cross Hospital, Wolverhampton, UK

    Josh Dixey

  7. Department of Rheumatology, Medway Maritime Hospital, Gillingham, UK

    Peter Williams

  8. Department of Rheumatology, St Georges Healthcare Trust, London, UK

    Patrick Kiely

  9. Arthritis UK Pain Centre, University of Nottingham, Nottingham, UK

    David Andrew Walsh

Authors
  1. Elena Nikiphorou
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  2. Lewis Carpenter
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  3. Sam Norton
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  4. Stephen Morris
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  5. Alex MacGregor
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  6. Josh Dixey
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  7. Peter Williams
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  8. Patrick Kiely
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  9. David Andrew Walsh
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  10. Adam Young
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Corresponding author

Correspondence to Adam Young.

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Nikiphorou, E., Carpenter, L., Norton, S. et al. Can Rheumatologists Predict Eventual Need for Orthopaedic Intervention in Patients with Rheumatoid Arthritis? Results of a Systematic Review and Analysis of Two UK Inception Cohorts. Curr Rheumatol Rep 19, 12 (2017). https://doi.org/10.1007/s11926-017-0636-x

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