Lower Limb Joint Replacement in Patients with Rheumatoid Arthritis - Perioperative management considerations for patients with RA who need a total hip, knee, or ankle replacement


  • Nicholas Clement
  • Stephen Breusch
  • Leela Biant




Rheumatoid arthritis (RA) is a chronic systemic connective tissue disease, and it is the third most common indication for lower limb joint replacement in Northern Europe and North America. [1] The etiology of the disease remains unclear, but there are strong associations with human leukocyte antigens (DRB1). [2] The prognosis is poor, with 80% of patients being disabled 20?years from primary diagnosis. [3] The medical treatment of RA has improved during the last 25?years, which is reflected by a 40% decrease in the rate of hip and knee surgery since a peak that was observed in the mid 1990s. [4] Anemia, raised erythrocyte sedimentation rate, and a high disease activity score have all been identified as risk factors for the need for large joint arthroplasty. [5]

Seventeen percent of patients with RA undergo an orthopaedic intervention within 5?years of initial diagnosis. [5] More than one third of patients will need a major joint replacement, of which the majority will receive a total hip or knee replacement (THR, TKR). [4]  This review article summarizes factors involved in the perioperative management of major lower limb arthroplasty surgery for patients with RA.


Sledge CB: Introduction to surgical management of patients with arthritis. In Kelly’s Textbook of rheumatology. Edited by Saunders WB. Philadelphia; 2001. PubMed Abstract

Macgregor AJ, Snieder H, Rigby AS, Koskenvuo M, Kaprio J, Aho K, Silman AJ: Characterizing the quantitative genetic contribution to rheumatoid arthritis using data from twins. Arthritis Rheum 2000, 43:30-37.

Scott DL, Symmons DP, Coulton BL, Popert AJ: Long-term outcome of treating rheumatoid arthritis: results after 20 years. Lancet 1987, 1:1108-1111.

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(5):868-871.

James D, Young A, Kulinskaya E, Knight E, Thompson W, Ollier W, Dixey J: Orthopaedic intervention in early rheumatoid arthritis. Occurrence and predictive factors in an inception cohort of 1064 patients followed for 5 years. Rheumatology (Oxford) 2004, 43:369-376.

http://www.ncbi.nlm.nih.gov/sites/entrez, http://www.ncbi.nlm.nih.gov/sites/entrez

Wilkinson JM, Stanley D, Getty CJM: Surgical management of the rheumatoid patient. Curr Orthop 2004, 18:357-370.

Conlon PW, Isdale IC, Rose BS: Rheumatoid arthritis of the cervical spine. An analysis of 333 cases. Ann Rheum Dis 1966, 25:120-126.

Roche CJ, Eyes BE, Whitehouse GH: The rheumatoid cervical spine: signs of instability on plain cervical radiographs. Clin Radiol 2002, 57:241-249.

Takatori R, Tokunaga D, Hase H, Mikami Y, Ikeda T, Harada T, Imai K, Nishimura T, An HS, Inoue N, Kudo T: Three-dimensional morphology and kinematics of the craniovertebral junction in rheumatoid arthritis. Spine 2010, 35:1278-1284.

Anstead GM: Steroids, retinoids, and wound healing. Adv Wound Care 1998, 11:277-285.

Weinblatt ME, Maier AL, Fraser PA, Coblyn JS: Longterm prospective study of methotrexate in rheumatoid arthritis: conclusion after 132 months of therapy. J Rheumatol 1998, 25:238-242.

Grennan DM, Gray J, Loudon J, Fear S: Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis 2001, 60:214-217.

Chen YF, Jobanputra P, Barton P, Jowett S, Bryan S, Clark W, Fry-Smith A, Burls A: A systematic review of the effectiveness of adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis in adults and an economic evaluation of their cost-effectiveness. Health Technol Assess 2006, 10(iii-xiii):1.

Bibbo C, Goldberg JW: Infectious and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int 2004, 25:331-335.

Kawakami K, Ikari K, Kawamura K, Tsukahara S, Iwamoto T, Yano K, Sakuma Y, Tokita A, Momohara S: Complications and features after joint surgery in rheumatoid arthritis patients treated with tumour necrosis factor-alpha blockers: perioperative interruption of tumour necrosis factor alpha blockers decreases complications? Rheumatology (Oxford) 2010, 49(2):341-347.

Guidance on the use of metal on metal hip resurfacing arthroplasty. London: National Institute for Clinical Excellence; 2002. http://www.nice.org.uk/nicemedia/pdf/HipResurfacing-FinalGuidance.pdf.

Chmell MJ, Scott RD, Thomas WH, Sledge CB: Total hip arthroplasty with cement for juvenile rheumatoid arthritis. Results at a minimum of ten years in patients less than thirty years old. J Bone Joint Surg Am 1997, 79:44-52.

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, 80:1439-1446.

Eskelinen A, Paavolainen P, Helenius I, Pulkkinen P, Remes V: Total hip arthroplasty for rheumatoid arthritis in younger patients: 2,557 replacements in the Finnish Arthroplasty Register followed for 0–24 years. Acta Orthop 2006, 77:853-865.

Havelin LI, Hallan G, Dybvik E: Cemented verses uncemented femoral stems in rheumatoid arthritis patients in th Norwegian arthroplasty register. European Federation of National Associations Of Orthopaedics and Traumatology (8th Congress) 2007, Vol. Florence(91-B ed):89-90.

Sotelo-Garza A, Charnley J: The results of Charnley arthroplasty of hip performed for protrusio acetabuli. Clin Orthop Relat Res 1978, 12:8.

Hirst P, Esser M, Murphy JC, Hardinge K: Bone grafting for protrusio acetabuli during total hip replacement. A review of the Wrightington method in 61 hips. J Bone Joint Surg Br 1987, 69:229-233.

Laskin RS, O’Flynn HM: The Insall Award. Total knee replacement with posterior cruciate ligament retention in rheumatoid arthritis. Problems and complications. Clin Orthop Relat Res 1997, 24:8.

Goldberg VM, Figgie MP, Figgie HE, Heiple KG, Sobel M: Use of a total condylar knee prosthesis for treatment of osteoarthritis and rheumatoid arthritis. Long-term results. J Bone Joint Surg Am 1988, 70:802-811.

Kristensen O, Nafei A, Kjaersgaard-Andersen P, Hvid I, Jensen J: Long-term results of total condylar knee arthroplasty in rheumatoid arthritis. J Bone Joint Surg Br 1992, 74:803-806.

Gill GS, Joshi AB: Long-term results of retention of the posterior cruciate ligament in total knee replacement in rheumatoid arthritis. J Bone Joint Surg Br 2001, 83:510-512.

Meding JB, Keating EM, Ritter MA, Faris PM, Berend ME: Long-term followup of posterior-cruciate-retaining TKR in patients with rheumatoid arthritis. Clin Orthop Relat Res 2004, 146:52.

Morgan H, Battista V, Leopold SS: Constraint in primary total knee arthroplasty. J Am Acad Orthop Surg 2005, 13:515-524.

Sculco TP: The role of constraint in total knee arthroplasty. J Arthroplasty 2006, 21:54-56.

Rodriguez JA, Saddler S, Edelman S, Ranawat CS: Long-term results of total knee arthroplasty in class 3 and 4 rheumatoid arthritis. J Arthroplasty 1996, 11:141-145.

Shoji H, Yoshino S, Kajino A: Patellar replacement in bilateral total knee arthroplasty. A study of patients who had rheumatoid arthritis and no gross deformity of the patella. J Bone Joint Surg Am 1989, 71:853-856.

Kajino A, Yoshino S, Kameyama S, Kohda M, Nagashima S: Comparison of the results of bilateral total knee arthroplasty with and without patellar replacement for rheumatoid arthritis. A follow-up note. J Bone Joint Surg Am 1997, 79:570-574.

Michael JM, Golshani A, Gargac S, Goswami T: Biomechanics of the ankle joint and clinical outcomes of total ankle replacement. J Mech Behav Biomed Mater 2008, 1:276-294.

Jensen NC, Linde F: Long-term follow-up on 33 TPR ankle joint replacements in 26 patients with rheumatoid arthritis. Foot Ankle Surg 2009, 15:123-126.

Hobson SA, Karantana A, Dhar S: Total ankle replacement in patients with significant pre-operative deformity of the hindfoot. J Bone Joint Surg Br 2009, 91:481-486.

Wood PL, Crawford LA, Suneja R, Kenyon A: Total ankle replacement for rheumatoid ankle arthritis. Foot Ankle Clin 2007, 12:497-508.

Raut VV, Siney PD, Wroblewski BM: Cemented revision Charnley low-friction arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Br 1994, 76:909-911.

Mont MA, Domb B, Rajadhyaksha AD, Padden DA, Jones LC, Hungerford DS: The fate of revised uncemented acetabular components in patients with rheumatoid arthritis. Clin Orthop Relat Res 2002, 140:8.

Schreurs BW, Thien TM, de Waal Malefijt MC, Buma P, Veth RP, Slooff TJ: Acetabular revision with impacted morselized cancellous bone graft and a cemented cup in patients with rheumatoid arthritis: three to fourteen-year follow-up. J Bone Joint Surg Am 2003, 85-A:647-652.

Garcia RM, Hardy BT, Kraay MJ, Goldberg VM: Revision total knee arthroplasty for aseptic and septic causes in patients with rheumatoid arthritis. Clin Orthop Relat Res 2010, 468:82-89.

Nguyen-Oghalai TU, Ottenbacher KJ, Caban M, Granger CV, Grecula M, Goodwin JS: The impact of rheumatoid arthritis on rehabilitation outcomes after lower extremity arthroplasty. J Clin Rheumatol 2007, 13:247-250.

Stanley D, Stockley I, Getty CJ: Simultaneous or staged bilateral total knee replacements in rheumatoid arthritis. A prospective study. J Bone Joint Surg Br 1990, 72:772-774.

Lindahl H, Malchau H, Oden A, Garellick G: Risk factors for failure after treatment of a periprosthetic fracture of the femur. J Bone Joint Surg Br 2006, 88:26-30.

Sarvilinna R, Huhtala HS, Puolakka TJ, Nevalainen JK, Pajamaki KJ: Periprosthetic fractures in total hip arthroplasty: an epidemiologic study. Int Orthop 2003, 27:359-361.

Bongartz T, Halligan CS, Osmon DR, Reinalda MS, Bamlet WR, Crowson CS, Hanssen AD, Matteson EL: Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 2008, 59:1713-1720.

Chotanaphuti T, Ongnamthip P, Songpatanasil T, Veerapan P, Deeprecha K: Risk factors of deep vein thrombosis (DVT) after total knee arthroplasty (TKA) at Phramongkutklao Hospital. J Med Assoc Thai 2007, 90:485-491.

Guan ZP, Lu HS, Chen YZ, Song YN, Qin XL, Jiang J: Clinical risk factors for deep vein thrombosis after total hip and knee arthroplasty. Zhonghua Wai Ke Za Zhi 2005, 43:1317-1320.

Matta F, Singala R, Yaekoub AY, Najjar R, Stein PD: Risk of venous thromboembolism with rheumatoid arthritis. Thromb Haemost 2009, 101:134-138.

Benjamin A, Helal B: Surgical repair and reconstruction in rheumatoid disease. London: The Macmillan Press; 1980.

Ethgen O, Kahler KH, Kong SX, Reginster JY, Wolfe F: The effect of health related quality of life on reported use of health care resources in patients with osteoarthritis and rheumatoid arthritis: a longitudinal analysis. J Rheumatol 2002, 29:1147-1155.




How to Cite

Clement, N., Breusch, S., & Biant, L. (2013). Lower Limb Joint Replacement in Patients with Rheumatoid Arthritis - Perioperative management considerations for patients with RA who need a total hip, knee, or ankle replacement. Reconstructive Review, 3(2). https://doi.org/10.15438/rr.v3i2.34



Original Article