Leg ulceration in Rheumatoid Arthritis: prevalence, aetiology

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Leg ulceration in Rheumatoid Arthritis
prevalence, aetiology factors affecting tissue
viability
Jill Firth Honorary Rheumatology Nurse
Specialist Smith Nephew Foundation Doctoral
Student
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Quick quiz

• Q. What is the third most common cause of leg
  ulceration?
• A. RA (Ertl, 1991)
• Q. What is a rheumatoid ulcer?
• A. An ulcer that is characteristic of or
  affected by rheumatoid arthritis (Cochrane
  library, 2006)

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Aims of todays talk

• Quick overview of rheumatoid arthritis
• Prevalence aetiology of leg ulceration in
  rheumatoid arthritis
• Factors affecting tissue viability in rheumatoid
  arthritis (RA)
• Implications for practice

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Rheumatoid arthritis

• Most common form of inflammatory arthritis
• Unknown aetiology
• Usually a symmetrical polyarthritis
• Features exacerbation and remission of disease
  flare ups
• Characterised by thickening inflammation of the
  synovial membrane leading to bone erosion
• Systemic autoimmune disease with articular
  extra-articular features

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How is the joint affected?
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Criteria for diagnosis

• Morning stiffness gt 1 hour gt 6 weeks
• Arthritis involving 3 or more joints gt 6 weeks
• Arthritis of the hand or wrist joints gt 6 weeks
• Symmetrical arthritis at least 1 area gt 6 weeks
• Positive serum rheumatoid factor (RF)
• Rheumatoid nodules
• Radiographic changes

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Course of disease
75 continue to have active disease with pain,
synovitis flare ups
5 have severe disease with extensive disability
20 always have very mild disease
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Leg ulceration in RA

• Leg ulceration is often poorly defined in
  research
• Surprisingly little is known about the prevalence
  and aetiology of wounds in this client group
• Investigation often focuses on relatively small
  samples of patients in secondary care

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The prevalence of leg ulceration in RA

• The validated overall prevalence of leg
  ulceration in 324 in-patients was over 8
• (Wilkinson Kirk, 1965)
• A postal survey of 250 RA patients taken from a
  diagnostic register found a validated overall
  prevalence of 9
• (Thurtle Cawley, 1983)

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The prevalence of RA in leg ulcer patients

• RA was the third most common underlying
  pathology, after venous disease and arterial
  insufficiency. This finding came from the
  clinical examination of 600 of 1,477 patients
  with leg ulceration
• (Callam et al, 1985 1987)
• 9-18 of affected patients have a diagnosis of RA
  
• (Callam et al, 1987 OBrien et al, 2000 Baker
  et al, 1991 Johnson, 1995)

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Aetiology of leg ulcers in RA

• Primary rheumatoid diabetic causes have been
  found to be rare
• The aetiology of such wounds appears to be
  multi-factorial venous arterial
  insufficiency, trauma or pressure are factors
  commonly involved
• (McRorie et al, 1998 Pun et al, 1990 Thurtle
  Cawley, 1983)
• There are no analytical grounds for determining
  which abnormality is the dominant influence on
  wound healing

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Myths?

• RA is the third most common cause of leg
  ulceration (Ertl, 1991)
• Aetiology is not the same as underlying
  pathology
• The rheumatoid ulcer exists (Cochrane library,
  2006)
• There is no evidence to date of ulceration that
  is characteristic of RA but we can identify
  factors that affect tissue viability in RA.

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Factors affecting tissue viability in RA

• Reduced mobility and self care capacity
• Poor nutrition
• Joint disease
• Systemic disease anaemia, nodules, vasculitis,
  peripheral neuropathy
• Peripheral vascular disease
• Side effects of medication

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Articular (joint) disease

• Synovitis
• Decreased mobility
• Foot ankle deformity
• increased plantar pressures
• friction from ill-fitting footwear
• loss of movement at the ankle impairs the
  venous muscle pump, increases venous pressure
  may damage the veins

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Figure 2
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Extra-articular (systemic) disease

• Anaemia of chronic disease affects 33-60 of
  patients
• Nodules affect 15-39
• Cutaneous vasculitis affects around 3.6 (No
  reliable data on the prevalence of skin
  ulceration per se 14-62?)
• Neuropathy may be entrapment, distal sensory,
  mononeuritis multiplex (3-58) or sensorimotor

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Peripheral vascular disease

• Link between RA and coronary heart disease
• Higher prevalence of carotid peripheral
  arterial disease than controls Alkaabi et al
  (2003)
• Extent of micro and macrovascular disease in RA
  poorly understood

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Side effects of medication

• NSAIDs inhibit platelet aggregation increase
  risks of bleeding, bruising haematoma formation
• Cytotoxics the inflammatory cells that are
  activated in tissue repair are potential targets
  for these drugs increase risk of infection
• Anti-TNF therapies increase risk of infection
  but little is known about the impact on tissue
  viability
• Steroids interfere with both the inflammatory
  and proliferative stages of tissue repair
  inhibit wound contracture

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The evidence from post-op studies

• Some evidence that NSAIDs can effect the wound
  healing of soft tissues (55)
• Little or no evidence for the effect of MTX on
  post-op complications (56-59) 2 studies of
  inadequate power found a small difference but 2
  larger studies (1 randomized) found no difference
• No evidence TNF inhibition increases infection
  rates healing complications yet (60)

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Implications for practice

• A failure to accurately assess ulcer aetiology
  may adversely influence management outcomes
• An understanding of the nature of RA aids
  accurate assessment highlights possible risk
  factors
• A collaborative approach to wound management in
  rheumatic disease is essential

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Conclusions

• Leg ulceration in RA is a common unusual problem
  in the lower limb
• Its aetiology is still poorly understood
• This is an area that warrants further
  investigation, particularly in terms of
  aetiology, effective management, the
  identification of risk factors and the prevention
  of recurrence

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With thanks to

• Professor Claire Hale
• Dr. Jackie Hill
• Dr. Philip Helliwell
• The FASTER team

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Thanks for listening!