Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Total joint replacement for severe rheumatoid arthritis

Michael H Weisman, MD
Renee Z Rinaldi, MD
Section Editor
Ravinder N Maini, BA, MB BChir, FRCP, FMedSci, FRS
Deputy Editor
Paul L Romain, MD


Rheumatoid arthritis (RA) is a chronic, progressive disorder in many patients. Despite therapy with disease-modifying antirheumatic drugs (DMARDS), including biologic agents, joint erosion and destruction can develop over time. (See "General principles of management of rheumatoid arthritis in adults".)

The major symptom of joint destruction is pain. With further progression of the arthritis, there are signs of loss of motion, diminution in motor strength, and ultimately decline in function. (See "Evaluation and medical management of end-stage rheumatoid arthritis".)

This topic will review the surgical indications, procedures, management approach, and complications of total joint replacement (TJR) in patients with severe RA. Overviews of total hip and knee arthroplasty and their complications, as well as the perioperative management of patients with rheumatic diseases, are presented elsewhere. (See "Total hip arthroplasty" and "Total knee arthroplasty" and "Complications of total hip arthroplasty" and "Complications of total knee arthroplasty" and "Preoperative evaluation and perioperative management of patients with rheumatic diseases".)


The advent of total joint replacement (TJR) has been considered to be a major breakthrough and an important therapeutic option in the management of rheumatoid arthritis (RA). A 23-year, prospective, longitudinal, observational study (from a single referral center) of TJR and its predictors in 1600 patients with RA followed between 1974 and 1997 from the time of diagnosis revealed the following [1]:

Approximately 25 percent underwent TJR.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 05, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Wolfe F, Zwillich SH. The long-term outcomes of rheumatoid arthritis: a 23-year prospective, longitudinal study of total joint replacement and its predictors in 1,600 patients with rheumatoid arthritis. Arthritis Rheum 1998; 41:1072.
  2. Massardo L, Gabriel SE, Crowson CS, et al. A population based assessment of the use of orthopedic surgery in patients with rheumatoid arthritis. J Rheumatol 2002; 29:52.
  3. Kapetanovic MC, Lindqvist E, Saxne T, Eberhardt K. Orthopaedic surgery in patients with rheumatoid arthritis over 20 years: prevalence and predictive factors of large joint replacement. Ann Rheum Dis 2008; 67:1412.
  4. Louie GH, Ward MM. Changes in the rates of joint surgery among patients with rheumatoid arthritis in California, 1983-2007. Ann Rheum Dis 2010; 69:868.
  5. Ballard WT, Buckwalter WT. Operative treatment of rheumatic disease. Primer on Rheumatic Diseases 1997; 11:443.
  6. Grauer JN, Tingstad EM, Rand N, et al. Predictors of paralysis in the rheumatoid cervical spine in patients undergoing total joint arthroplasty. J Bone Joint Surg Am 2004; 86-A:1420.
  7. Luessenhop CP, Higgins LD, Brause BD, Ranawat CS. Multiple prosthetic infections after total joint arthroplasty. Risk factor analysis. J Arthroplasty 1996; 11:862.
  8. Poss R, Thornhill TS, Ewald FC, et al. Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop Relat Res 1984; :117.
  9. Schrama JC, Espehaug B, Hallan G, et al. Risk of revision for infection in primary total hip and knee arthroplasty in patients with rheumatoid arthritis compared with osteoarthritis: a prospective, population-based study on 108,786 hip and knee joint arthroplasties from the Norwegian Arthroplasty Register. Arthritis Care Res (Hoboken) 2010; 62:473.
  10. Goodman SM, Figgie MP, Mackenzie CR. Perioperative management of patients with connective tissue disease. HSS J 2011; 7:72.
  11. Dunbar RP, Alexiades MM. Decision making in rheumatoid arthritis. Determining surgical priorities. Rheum Dis Clin North Am 1998; 24:35.
  12. Moran SL, Bishop AT. Clinical update: surgical management of rheumatoid hand. Lancet 2007; 370:372.
  13. Charnley J. Arthroplasty of the hip. A new operation. Lancet 1961; 1:1129.
  14. Cornell CN, Ranawat CS. The impact of modern cement techniques on acetabular fixation in cemented total hip replacement. J Arthroplasty 1986; 1:197.
  15. Ranawat CS. Surgical management of the rheumatoid hip. Rheum Dis Clin North Am 1998; 24:129.
  16. Pivec R, Johnson AJ, Mears SC, Mont MA. Hip arthroplasty. Lancet 2012; 380:1768.
  17. Polkowski GG, Callaghan JJ, Mont MA, Clohisy JC. Total hip arthroplasty in the very young patient. J Am Acad Orthop Surg 2012; 20:487.
  18. Creighton MG, Callaghan JJ, Olejniczak JP, Johnston RC. Total hip arthroplasty with cement in patients who have rheumatoid arthritis. A minimum ten-year follow-up study. J Bone Joint Surg Am 1998; 80:1439.
  19. Chmell MJ, Scott RD. Total knee arthroplasty in patients with rheumatoid arthritis. An overview. Clin Orthop Relat Res 1999; :54.
  20. Schai PA, Scott RD, Thornhill TS. Total knee arthroplasty with posterior cruciate retention in patients with rheumatoid arthritis. Clin Orthop Relat Res 1999; :96.
  21. Schai PA, Thornhill TS, Scott RD. Total knee arthroplasty with the PFC system. Results at a minimum of ten years and survivorship analysis. J Bone Joint Surg Br 1998; 80:850.
  22. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results. J Bone Joint Surg Am 1998; 80:464.
  23. Throckmorton TW. Shoulder and elbow arthroplasty. In: Campbell's Operative Orthopaedics, 12th ed, Canale ST, Beaty JH (Eds), Mosby, Philadelphia 2013. p.532.
  24. Sperling JW, Cofield RH, Schleck CD, Harmsen WS. Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases. J Shoulder Elbow Surg 2007; 16:683.
  25. Barlow JD, Yuan BJ, Schleck CD, et al. Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up. J Shoulder Elbow Surg 2014; 23:791.
  26. Holcomb JO, Hebert DJ, Mighell MA, et al. Reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg 2010; 19:1076.
  27. John M, Pap G, Angst F, et al. Short-term results after reversed shoulder arthroplasty (Delta III) in patients with rheumatoid arthritis and irreparable rotator cuff tear. Int Orthop 2010; 34:71.
  28. Schemitsch EH, Ewald FC, Thornhill TS. Results of total elbow arthroplasty after excision of the radial head and synovectomy in patients who had rheumatoid arthritis. J Bone Joint Surg Am 1996; 78:1541.
  29. Hargreaves D, Emery R. Total elbow replacement in the treatment of rheumatoid disease. Clin Orthop Relat Res 1999; :61.
  30. Jensen CH, Jacobsen S, Ratchke M, Sonne-Holm S. The GSB III elbow prosthesis in rheumatoid arthritis: a 2- to 9-year follow-up. Acta Orthop 2006; 77:143.
  31. Canale ST, Beaty JH. Campbell's Operative Orthopaedics, 11th, Mosby, 2007. p.483.
  32. Nestor BJ. Surgical treatment of the rheumatoid elbow. An overview. Rheum Dis Clin North Am 1998; 24:83.
  33. van der Lugt JC, Geskus RB, Rozing PM. Primary Souter-Strathclyde total elbow prosthesis in rheumatoid arthritis. Surgical technique. J Bone Joint Surg Am 2005; 87 Suppl 1:67.
  34. Beckenbaugh RD, Linscheid RL. Arthroplasty in the hand and wrist. In: Operative Hand Surgery, 3rd, Green DP (Ed), Churchill Livingstone, New York 1993. p.143.
  35. Bosco JA 3rd, Bynum DK, Bowers WH. Long-term outcome of Volz total wrist arthroplasties. J Arthroplasty 1994; 9:25.
  36. Dennis DA, Ferlic DC, Clayton ML. Volz total wrist arthroplasty in rheumatoid arthritis: a long-term review. J Hand Surg Am 1986; 11:483.
  37. Gellman H, Hontas R, Brumfield RH Jr, et al. Total wrist arthroplasty in rheumatoid arthritis. A long-term clinical review. Clin Orthop Relat Res 1997; :71.
  38. Cavaliere CM, Chung KC. A systematic review of total wrist arthroplasty compared with total wrist arthrodesis for rheumatoid arthritis. Plast Reconstr Surg 2008; 122:813.
  39. Murphy GA. Total ankle arthroplasty. In: Campbell's Operative Orthopaedics, 12th, Canale ST, Beaty JH (Eds), Mosby, Philadelphia 2013. p.486.
  40. Jordan RW, Chahal GS, Chapman A. Is end-stage ankle arthrosis best managed with total ankle replacement or arthrodesis? A systematic review. Adv Orthop 2014; 2014:986285.
  41. Ghattas L, Mascella F, Pomponio G. Hand surgery in rheumatoid arthritis: state of the art and suggestions for research. Rheumatology (Oxford) 2005; 44:834.
  42. Alderman AK, Chung KC, Demonner S, et al. The rheumatoid hand: a predictable disease with unpredictable surgical practice patterns. Arthritis Rheum 2002; 47:537.
  43. Alderman AK, Ubel PA, Kim HM, et al. Surgical management of the rheumatoid hand: consensus and controversy among rheumatologists and hand surgeons. J Rheumatol 2003; 30:1464.
  44. Beckenbaugh RD. Implant arthroplasty in the rheumatoid hand and wrist: current state of the art in the United States. J Hand Surg Am 1983; 8:675.
  45. Gellman H, Stetson W, Brumfield RH Jr, et al. Silastic metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis. Clin Orthop Relat Res 1997; :16.
  46. Stirrat CR. Metacarpophalangeal joints in rheumatoid arthritis of the hand. Hand Clin 1996; 12:515.
  47. Waljee JF, Chung KC. Objective functional outcomes and patient satisfaction after silicone metacarpophalangeal arthroplasty for rheumatoid arthritis. J Hand Surg Am 2012; 37:47.
  48. Chung KC, Kowalski CP, Myra Kim H, Kazmers IS. Patient outcomes following Swanson silastic metacarpophalangeal joint arthroplasty in the rheumatoid hand: a systematic overview. J Rheumatol 2000; 27:1395.
  49. Blair WF, Shurr DG, Buckwalter JA. Metacarpophalangeal joint implant arthroplasty with a Silastic spacer. J Bone Joint Surg Am 1984; 66:365.
  50. Nalebuff EA. The rheumatoid hand. Reflections on metacarpophalangeal arthroplasty. Clin Orthop Relat Res 1984; :150.
  51. Signorello LB, Ye W, Fryzek JP, et al. Nationwide study of cancer risk among hip replacement patients in Sweden. J Natl Cancer Inst 2001; 93:1405.
  52. Parvizi J, Adeli B, Zmistowski B, et al. Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection. J Bone Joint Surg Am 2012; 94:e104.
  53. Vessely MB, Whaley AL, Harmsen WS, et al. The Chitranjan Ranawat Award: Long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties. Clin Orthop Relat Res 2006; 452:28.
  54. Fehring TK, Odum S, Griffin WL, et al. Early failures in total knee arthroplasty. Clin Orthop Relat Res 2001; :315.
  55. Clohisy JC, Calvert G, Tull F, et al. Reasons for revision hip surgery: a retrospective review. Clin Orthop Relat Res 2004; :188.
  56. Ravi B, Escott B, Shah PS, et al. A systematic review and meta-analysis comparing complications following total joint arthroplasty for rheumatoid arthritis versus for osteoarthritis. Arthritis Rheum 2012; 64:3839.
  57. Ravi B, Croxford R, Hollands S, et al. Increased risk of complications following total joint arthroplasty in patients with rheumatoid arthritis. Arthritis Rheumatol 2014; 66:254.
  58. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e278S.
  59. Canale ST, Beaty JH. Campbell's Operative Orthopaedics, 11th, Mosby, 2007. p.420.
  60. Toumbis CA, Kronick JL, Wooley PH, Nasser S. Total joint arthroplasty and the immune response. Semin Arthritis Rheum 1997; 27:44.
  61. Canale ST, Beaty JH. Campbell's Operative Orthopaedics, 11th, Mosby, 2007. p.428.
  62. Wooley PH, Petersen S, Song Z, Nasser S. Cellular immune responses to orthopaedic implant materials following cemented total joint replacement. J Orthop Res 1997; 15:874.
  63. Allen LA, Ambardekar AV, Devaraj KM, et al. Clinical problem-solving. Missing elements of the history. N Engl J Med 2014; 370:559.
  64. Dahms K, Sharkova Y, Heitland P, et al. Cobalt intoxication diagnosed with the help of Dr House. Lancet 2014; 383:574.
  65. Allen AM, Ward WG, Haygood TM. Imaging of the total hip arthroplasty. J South Orthop Assoc 1995; 4:96.
  66. Walker CW, FitzRandolph RL, Collins DN, Dalrymple GV. Arthrography of painful hips following arthroplasty: digital versus plain film subtraction. Skeletal Radiol 1991; 20:403.