Inflammatory Arthritis: Collaboration Between Specialties

Adapted from the Spring 2013 issue of Discovery to Recovery

Since HSS established its first arthritis clinic in the 1920s, our rheumatologists and orthopedic surgeons have worked together to care for patients with inflammatory arthritis. Their collaboration extends to research, where clinical experience inspires investigation, and findings are integrated into patient care.

“Within their specialties and across disciplines, our rheumatologists, orthopedic surgeons, and basic scientists are expanding the understanding of inflammatory arthritis and its treatment,” says Mary K. Crow, MD, physician-in chief and chairman, Division of Rheumatology, and the Benjamin M. Rosen Chair in Immunology and Inflammation Research.

Extraordinary Advances

Until recently, most patients with rheumatoid arthritis developed severe joint damage that often required multiple orthopedic surgeries. Treatment for people with inflammatory arthritis has been transformed by disease-modifying drugs that became available in the 1980s, and by medications that target inflammatory proteins, called biologics, that were approved by the FDA in the 1990s. These medications protect joints from debilitating inflammation and often make surgery unnecessary.

Today at HSS, some 70 percent of patients with rheumatoid arthritis (RA) are on medications that modify the body’s immune response, and more than 50 percent are on a biologic. Despite these therapeutic advances, however, orthopedic surgery continues to play a significant role for patients with RA.

Forty years ago, when surgery was still the norm for people with inflammatory arthritis, Charles L. Christian, MD, then chief of the Division of Rheumatology, along with former Division Chief Richard H. Freyberg, MD, and orthopedic surgeon Lee Ramsey Straub, MD, conceived the Comprehensive Arthritis Program (CAP) – an interdisciplinary program unique for its time.

Today, under the direction of rheumatologist Susan M. Goodman, MD, and orthopedic surgeon Mark P. Figgie, MD, the program’s rheumatologists and orthopedic surgeons continue to co-manage one of the largest populations of patients with inflammatory diseases in the world, including people with inflammatory arthritis who need surgery. Building on the success of its cooperative clinical approach, HSS established the Surgical Arthritis Research Group in which rheumatologists, orthopedic surgeons, and basic scientists conduct collaborative research to advance treatments for inflammatory arthritis.

Surgical Success

A new study by Dr. Goodman, Dr. Figgie, rheumatologist Lisa Mandl, MD, MPH, and orthopedic surgeon Michael M. Alexiades, MD, finds that joint replacement in patients with RA can be highly successful. “Patients with inflammatory diseases are frequently at high risk for renal, pulmonary, cardiac, and other complications,” says Dr. Goodman. “The success of their surgery is influenced by many factors associated with their disease.”

While patients with RA historically had higher rates of postoperative complications, it was unclear if this was the case in patients on disease modifying drugs or biologic agents that target inflammatory proteins. Analyzing data from the HSS Total Joint Replacement Registry, the investigators compared contemporary total knee replacement outcomes in patients with osteoarthritis to those with RA under treatment with these medications.

“Prior to surgery, patients with RA had worse pain and function and lower perceived health status compared to patients with osteoarthritis,” says Dr. Figgie. “However, we found that operative time and length of stay in the hospital were the same in both groups. Neither group experienced deep joint infections. Both sets of patients had comparable complication rates.”

“The study shows that infection and wound healing are not increased in patients with RA who undergo knee replacement, at least in a high- volume hospital,” adds Dr. Goodman. “When their disease is controlled with medication, RA patients can expect excellent outcomes.”

Uncovering New Treatment Options

HSS laboratory scientists continue to investigate how inflammatory diseases work, with the goal of developing new therapeutic interventions. For example, Program Director Carl P. Blobel, MD, PhD, and his team in the Arthritis and Tissue Degeneration Program have learned how a family of molecules, called ADAMS, regulates an inflammation-causing protein, called TNF alpha. Most recently, they identified a potential mechanism to inactivate TNF alpha conversion in immune cells without affecting its function in other organs.

“This is an important finding, as it opens the door to the possibility of treatments for inflammatory diseases with small molecules that could be taken as pills, cause fewer side effects, and be less expensive than current therapies,” says Dr. Blobel.

Supporting Future Research: The Allan E. Inglis, MD, Chair

To ensure continued support of clinical research and education in orthopedics, inflammatory and rheumatoid arthritis, the Hospital has initiated the Allan E. Inglis, MD, Chair in Surgical Arthritis, recognizing Dr. Inglis’s years of remarkable service at HSS (1961-1991), in which he cared for patients with inflammatory arthritis and educated future surgeons.

“Allan Inglis was an innovative surgeon and a great educator,” says Dr. Figgie, who is the first holder of the chair. “The Allan Inglis Chair has been established to promote cooperative research for problems facing patients with inflammatory diseases, including rheumatoid arthritis and juvenile idiopathic arthritis.” A fundraising campaign to fully endow the Inglis Chair is currently under way, as the Hospital continues to seek support to advance efforts that will improve clinical care and outcomes for patients living with these conditions.

Read the full Discovery to Recovery Spring 2013 issue.


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