SLR - May 2014 - Sonia Mvuemba
Reference: Jebakumar AJ, Udayakumar PD, Crowson CS, Gabriel SE, Matteson EL. Occurrence and Effect of Lower Extremity Ulcer in Rheumatoid Arthritis—A population-based study. The Journal of Rheumatology 2014; 41; 437-443.
Scientific Literature Review
Reviewed By: Sonia Mvuemba, DPM
Residency Program: University Hospital, Newark, New Jersey
Podiatric Relevance: Rheumatoid arthritis (RA) is a common systemic inflammatory disorder mainly affecting the joints. Longstanding RA can lead to multiple complications, with lower extremity (LE) ulceration being one of the known common complications. Unlike diabetic foot ulcers, little is known in regards to the morbidity associated with LE ulcers in RA. Therefore, the authors of this study aimed to assess the occurrence, risk factors, as well as the morbidity and mortality associated with LE ulcers in RA.
Methods: A retrospective review of the Rochester Epidemiology Project (REP) medical linkage system, which includes medical providers in Olmsted County, Minnesota USA was conducted. Cases of RA between January 1, 1980, and December 31, 2007, among residents of the above mentioned county and who met the 1987 American College of Rheumatology criteria for RA were included and followed up to death, migration, or April 2012. Only LE ulcers which developed following the diagnosis of RA were included, while those resulting from surgery, biopsy, burns, animal bites, ingrown toenail, toenail removal, abrasion, cellulitis, foreign body, or herpes zoster were excluded. The Cox proportional hazards models were used to evaluate the relationship between the risks factors and the LE ulcers, while the rate of occurrence was estimated using the person-year methods.
Results: A total of 813 patients were included in the study, with 556 women and 257 men. The average length of follow-up was 12 years, with 9771 total person-years follow-up. Of these patients, 125 developed LE ulcers with a total of 171 episodes, which corresponds to a rate of occurrence of 1.8 episodes per 100 person-years. The cumulative incidence of first LE ulcers was 4.8 percent at five years following the diagnosis of RA and increased to 26.2 percent by 25 years. The median time for a given ulcer to heal was 30 days. The rate of amputation of 6 percent (10 of the 171 episodes), and RA related LE ulcers were associated with increased mortality.
Conclusion: Lower extremity ulcers are not uncommon in patients with RA, and a significant number of patients require some type of amputation. Patients with RA who develop LE ulcers are at a 2-fold risk of premature death. This study provides unique data on the clinical importance of this patient subset.