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Inflammatory and Rheumatoid Arthritis

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Rheumatoid, psoriatic and gouty arthritis affecting the hand, wrist and upper limb — what they are, how they are managed, and when surgery helps.

Updated Jul 2026
A hand with swollen knuckle joints.
Inflammatory arthritis attacks the joint lining, causing swelling, stiffness and, untreated, joint damage. Kieran Hirpara 4.0

What you're feeling

You may notice that your joints feel stiff and painful, especially when you first wake up. This morning stiffness often makes simple tasks difficult. You might struggle to reach behind your back to fasten a bra or tuck in a shirt. Reaching for items on high shelves can also become a challenge. These daily movements may cause discomfort that lingers throughout the day.

Your pain might flare up after you have been active. Resting may help ease the ache, but prolonged inactivity can sometimes make the stiffness worse. You might find it hard to sleep on your side if your shoulder or hip is affected. The pain can disrupt your rest, leaving you feeling tired and frustrated. This is a common experience for people with inflammatory arthritis.

It is important to know that your body handles surgery differently than someone with wear-and-tear arthritis. If you undergo joint replacement, such as for your elbow, knee, or shoulder, you face a higher risk of complications. This includes both medical issues and surgical problems. You are also more likely to need revision surgery later on compared to patients without inflammatory conditions.

Despite these risks, many patients still see significant benefits. After total hip replacement, you can expect reduced pain and improved function similar to others. Your surgeon may discuss options like robot-assisted techniques for your knee to help select the best surgical method. For your ankle, you may experience functional improvement from your starting point, even if outcomes are not as strong as for other arthritis types.

If you also have osteoporosis, your bone health is a priority. Your care team may recommend treatments like denosumab to maintain bone strength and prevent further joint damage. Understanding these risks and benefits helps you prepare for the journey ahead. Your surgeon will tailor the plan to your specific needs and health profile.

What's actually happening

Rheumatoid arthritis is an autoimmune condition. Your immune system mistakenly attacks the lining of your joints. This lining is called the synovium. Think of it as the sleeve that cushions and lubricates your joint. When this sleeve becomes inflamed, it swells and thickens. This process damages the smooth coating on your bone ends, known as cartilage. Cartilage acts like a shock absorber. Without it, your bones rub against each other. This causes pain, stiffness, and swelling.

This inflammation does not stay in one place. It often affects multiple joints at once. The constant irritation weakens the structures around the joint. Tendons, which are like strong ropes of fibers, can stretch or tear. Ligaments, which hold bones together, may loosen. This leads to joint instability and deformity over time. Because the disease is systemic, it affects your whole body. This is why you might feel tired or unwell even when your joints are not actively hurting.

The damage caused by this inflammation changes how your joints function. In some cases, like with osteoporosis, the bones themselves become weaker and more fragile. This makes them more susceptible to breaks. When surgery is needed, such as joint replacement, your surgeon must account for this weakened tissue. The inflamed environment can increase the risk of complications after surgery. For example, patients with rheumatoid arthritis may face higher risks of medical issues or infections compared to those with wear-and-tear arthritis.

Despite these challenges, surgery can still be very effective. Many patients experience significant pain relief and improved function. Your surgeon will tailor the procedure to your specific joint damage. They will consider the health of your bones and soft tissues. The goal is to restore movement and reduce pain. While the risks are higher than for simple wear-and-tear, the outcomes can be excellent. You can expect a reduction in pain and better daily function after procedures like hip or knee replacement. The key is managing the underlying inflammation to protect your new joint and your overall health.

What to expect

Your outlook depends heavily on which joint is affected and the type of arthritis you have. Rheumatoid arthritis is a systemic condition that can make recovery more complex than wear-and-tear arthritis. In many cases, joint replacement surgery provides significant relief. You can expect reduced pain and improved function after procedures like hip or knee replacement. These outcomes are often similar to those seen in patients with non-inflammatory arthritis.

However, your body may react differently than someone with simple osteoarthritis. For example, shoulder surgery in patients with inflammatory arthritis carries a higher risk of both medical and surgical complications. You are also at an increased risk of needing revision surgery compared to those with primary wear-and-tear issues. Similarly, ankle replacement may result in poorer patient-reported scores compared to other arthritis types, though you will still experience functional improvement from your starting point.

If you have osteoporosis alongside rheumatoid arthritis, maintaining bone health is critical. Treatments like denosumab can help prevent further joint damage and support your bones. Without proper management, the risk of complications rises. Inflammatory arthritis presents a distinctly higher risk profile for postoperative medical issues than osteoarthritis does.

It is important to be honest about these risks. While many patients achieve good results, you should anticipate a more cautious recovery path. Your surgeon will tailor your care to address these specific risks. The goal is to manage the disease effectively so you can regain mobility and reduce pain, even if the path is slightly more challenging than for others.

Reviewed by Kieran Hirpara · 13 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

Overview

  • Total elbow arthroplasty in patients with rheumatoid arthritis is associated with increased revision rates compared to non-RA cohorts, despite comparable complication rates [1].
  • Denosumab demonstrates efficacy in maintaining bone health and preventing joint damage in rheumatoid arthritis patients with coexisting osteoporosis [2].
  • Robot-assisted total knee arthroplasty provides evidence for selecting surgical methods in rheumatoid osteoarthritis compared to conventional techniques [3].
  • Rheumatoid arthritis is associated with higher 90-day systemic complications compared to osteoarthritis after total shoulder arthroplasty [4].
  • Patients with rheumatoid arthritis are at higher risk of systemic and joint-related complications following total shoulder arthroplasty compared to patients with primary osteoarthritis [4].
  • Patient-reported outcome measures after direct anterior total hip arthroplasty are comparable between patients with rheumatoid arthritis and osteoarthritis [5].
  • Patients with rheumatoid arthritis can expect reduced pain and improved functional outcomes similar to those with osteoarthritis following primary total hip arthroplasty [5].
  • Patients with rheumatoid arthritis may be at an increased risk of complications and revision surgery following total hip arthroplasty [5].
  • Patients with rheumatoid arthritis reported poorer patient-reported outcome scores compared with osteoarthritis and posttraumatic arthritis groups after total ankle arthroplasty [6].
  • Patients with rheumatoid arthritis experienced functional outcome improvement from the preoperative baseline after total ankle arthroplasty [6].
  • Shoulder arthroplasty for inflammatory arthritis is associated with higher rates of medical and surgical complications compared to osteoarthritis [7].
  • Inflammatory arthritis represents a distinctly morbid risk profile with multiple increased surgical and postoperative medical complications in patients undergoing anatomic and reverse total shoulder arthroplasty [7].
  • Total knee arthroplasty in patients with rheumatoid arthritis yields significant improvement in physician- and patient-reported outcomes [8].
  • Cutaneous psoriasis and psoriatic arthritis are associated with higher rates of infections and all-cause revisions following total hip arthroplasty [13].

Background & Causes

  • Rheumatoid arthritis is associated with higher 90-day systemic complications compared to osteoarthritis after total shoulder arthroplasty [4].
  • Inflammatory arthritis represents a distinctly morbid risk profile compared to osteoarthritis patients with multiple increased surgical and postoperative medical complications in patients undergoing aTSA and rTSA [7].
  • Patients with rheumatoid arthritis may be at an increased risk of complications and revision surgery following primary total hip arthroplasty [5].
  • Rates of long-term risk of revision in total elbow arthroplasty are increased in patients with rheumatoid arthritis compared to non-RA cohorts [1].
  • Denosumab demonstrates efficacy in maintaining bone health and preventing joint damage in rheumatoid arthritis patients with coexisting osteoporosis [2].
  • Denosumab reduced joint mTSS, JSN, and BES, alleviated joint space narrowing, and inhibited bone erosion in rheumatoid arthritis patients [21].
  • Perioperative bDMARD continuation was not associated with significant increases in risks of wound healing failures or SSIs among patients with RA undergoing elective hand surgery [10].
  • Shoulder arthroplasty in patients with rheumatoid arthritis reduces pain and improves function [11].
  • Patients with RA reported poorer PRO scores compared with OA and posttraumatic arthritis groups after total ankle arthroplasty but experienced functional outcome improvement from the preoperative baseline [6].
  • The Kudo type-5 prosthesis demonstrated satisfactory results in patients with RA but failures occurred to some extent over a long-term follow-up period [14].
  • Tectochrysin may be a novel RA therapeutic agent, likely acting via macrophage JAK/STAT pathway inhibition, with promising clinical potential [15].
  • There is preclinical evidence for an antioxidant, anti-inflammatory, antinociceptive, cartilage- and bone-protective effect of calcitonin in RA [16].

Symptoms & Presentation

  • Internet search analysis reveals specific questions and reading behaviors regarding the treatment of rheumatoid arthritis among patients [9].
  • HandScan optical imaging can reliably identify ultrasound-defined remission in rheumatoid arthritis at the joint level with good sensitivity and high positive predictive value [18].
  • DAS-OST can determine ultrasound-defined remission at the patient level in rheumatoid arthritis, but with lower performance compared to joint-level identification [18].
  • Chronic non-specific tenosynovitis with effusion localized at the ankle may present with intermittent symptoms that remain unrecognized for months or even years [17].

Management

  • Total elbow arthroplasty in patients with rheumatoid arthritis is associated with higher long-term revision rates compared to non-RA cohorts, despite comparable complication rates [1].
  • Denosumab demonstrates efficacy in maintaining bone health and preventing joint damage in rheumatoid arthritis patients with coexisting osteoporosis [2].
  • Robot-assisted total knee arthroplasty provides evidence for surgical method selection in rheumatoid osteoarthritis [3].
  • Rheumatoid arthritis is associated with higher 90-day systemic complications compared to osteoarthritis after total shoulder arthroplasty [4].
  • Patients with rheumatoid arthritis undergoing total shoulder arthroplasty are at higher risk of systemic and joint-related complications compared to patients with primary osteoarthritis [4].
  • Patient-reported outcome measures after direct anterior total hip arthroplasty are comparable between patients with rheumatoid arthritis and osteoarthritis [5].
  • Patients with rheumatoid arthritis can expect reduced pain and improved functional outcomes similar to those with osteoarthritis following primary total hip arthroplasty [5].
  • Patients with rheumatoid arthritis undergoing total ankle arthroplasty reported poorer patient-reported outcome scores compared with osteoarthritis and posttraumatic arthritis groups [6].
  • Patients with rheumatoid arthritis undergoing total ankle arthroplasty experienced functional outcome improvement from the preoperative baseline [6].
  • Shoulder arthroplasty for inflammatory arthritis is associated with higher rates of medical and surgical complications compared to osteoarthritis [7].
  • Inflammatory arthritis represents a distinctly morbid risk profile with multiple increased surgical and postoperative medical complications in patients undergoing anatomic and reverse total shoulder arthroplasty [7].
  • Total knee arthroplasty in patients with rheumatoid arthritis yields significant improvement in physician-reported outcomes [8].
  • Total knee arthroplasty in patients with rheumatoid arthritis yields significant improvement in patient-reported outcomes [8].
  • Physicians should provide internet search-derived information on rheumatoid arthritis treatment to patients in counseling and education materials [9].
  • Perioperative biologic disease-modifying antirheumatic drug continuation in patients with rheumatoid arthritis undergoing elective hand surgery was not associated with significant increases in risks of wound healing failures or surgical site infections [10].
  • Shoulder arthroplasty in patients with rheumatoid arthritis reduces pain and improves function [11].
  • Negative affect moderates pain in patients with rheumatoid arthritis who have undergone shoulder arthroplasty [11].
  • Patient-reported functional outcomes at 6 months after total elbow arthroplasty were significantly lower in the fracture group compared to osteoarthritis and rheumatoid arthritis groups [12].
  • Targeting macrophage JAK3/STAT3 signaling with tectochrysin ameliorates bone erosion and synovitis in rheumatoid arthritis [15].
  • Tectochrysin acts via macrophage JAK/STAT pathway inhibition and has promising clinical potential as a novel rheumatoid arthritis therapeutic agent [15].
  • Preclinical evidence supports an antioxidant, anti-inflammatory, antinociceptive, cartilage-protective, and bone-protective effect of calcitonin in rheumatoid arthritis [16].

Key Considerations

  • Total elbow arthroplasty in patients with rheumatoid arthritis has comparable complication rates to non-RA cohorts [1].
  • Total elbow arthroplasty in patients with rheumatoid arthritis is associated with increased revision rates compared to non-RA cohorts [1].
  • Denosumab demonstrates efficacy in maintaining bone health and preventing joint damage in rheumatoid arthritis patients with coexisting osteoporosis [2].
  • Robot-assisted total knee arthroplasty provides evidence for selecting surgical methods in rheumatoid osteoarthritis [3].
  • Rheumatoid arthritis is associated with higher 90-day systemic complications compared to osteoarthritis after total shoulder arthroplasty [4].
  • Patients with rheumatoid arthritis are at higher risk of systemic and joint-related complications following total shoulder arthroplasty compared to patients with primary osteoarthritis [4].
  • Patient-reported outcome measures after direct anterior total hip arthroplasty are comparable between patients with rheumatoid arthritis and osteoarthritis [5].
  • Patients with rheumatoid arthritis may be at increased risk of complications and revision surgery following total hip arthroplasty [5].
  • Patients with rheumatoid arthritis can expect reduced pain and improved functional outcomes similar to those with osteoarthritis following primary total hip arthroplasty [5].
  • Patients with rheumatoid arthritis reported poorer patient-reported outcome scores compared with osteoarthritis and posttraumatic arthritis groups after total ankle arthroplasty [6].
  • Patients with rheumatoid arthritis experienced functional outcome improvement from the preoperative baseline after total ankle arthroplasty [6].
  • Total knee arthroplasty in patients with rheumatoid arthritis yields significant improvement in physician-reported outcomes [8].
  • Total knee arthroplasty in patients with rheumatoid arthritis yields significant improvement in patient-reported outcomes [8].
  • Physicians should provide information on internet search trends regarding rheumatoid arthritis treatment to patients in counseling and education materials [9].
  • Perioperative biologic disease-modifying antirheumatic drug continuation was not associated with significant increases in risks of wound healing failures or surgical site infections among patients with rheumatoid arthritis undergoing elective hand surgery [10].
  • Patient-reported functional outcomes at 6 months after total elbow arthroplasty were significantly lower in the fracture group compared to osteoarthritis and rheumatoid arthritis groups [12].
  • The Kudo type-5 prosthesis demonstrated satisfactory results in patients with rheumatoid arthritis over a minimum 10-year follow-up period [14].
  • Failures of the Kudo type-5 prosthesis occurred to some extent over a long-term follow-up period in patients with rheumatoid arthritis [14].
  • Radiolunate arthrodesis in patients with rheumatoid arthritis maintained good clinical results and corrected alignment during long-term follow-up [19].
  • Total wrist arthroplasty using the semiconstrained arthroplasty system achieves favorable clinical outcomes with no serious complications requiring revision for 10 years after surgery in patients with rheumatoid arthritis [22].

Key Evidence

  • [L3] Despite comparable complication rates between RA and non-RA cohorts, further investigation into the underlying mechanisms of increased revision rates in RA patients is warranted. [1] (10.1016/j.jse.2024.12.032)
  • [L1] Denosumab demonstrates promising efficacy in maintaining bone health and preventing joint damage in rheumatoid arthritis patients with coexisting osteoporosis. [2] (10.1186/s12891-025-08688-8)
  • [L3] This provides important evidence for selecting surgical methods in rheumatoid osteoarthritis. [3] (10.1186/s13018-026-06703-9)
  • [L3] Following TSA, RA patients should be considered at higher risk of systemic and joint-related complications compared to patients with primary OA. [4] (10.5397/cise.2024.00374)
  • [L3] Although patients with rheumatoid arthritis may be at an increased risk of complications and revision surgery, patients can expect reduced pain and improved functional outcomes similar to those with osteoarthritis following primary THA. [5] (10.5435/jaaos-d-24-00656)
  • [L3] In the largest single-institution study to date, patients with RA reported poorer PRO scores compared with the OA and posttraumatic arthritis groups but experienced functional outcome improvement from the preoperative baseline. [6] (10.2106/jbjs.24.00048)
  • [L3] Inflammatory arthritis represents a distinctly morbid risk profile compared to osteoarthritis patients with multiple increased surgical and postoperative medical complications in patients undergoing aTSA and rTSA. [7] (10.1016/j.jse.2023.09.014)
  • [L3] Total knee arthroplasty in patients who have RA yields significant improvement in physician- and patient-reported outcomes. [8] (10.1016/j.arth.2026.03.021)
  • [L4] Physicians should provide such information to patients with RA in the counseling and education materials. [9] (10.1371/journal.pone.0285869)
  • [L2] Among patients with RA undergoing elective hand surgery, perioperative bDMARD continuation was not associated with significant increases in risks of wound healing failures or SSIs. [10] (10.1016/j.jhsa.2026.03.003)
  • [L3] Shoulder arthroplasty in patients with rheumatoid arthritis reduces pain and improves function. [11] (10.1186/s13018-025-06109-z)
  • [L3] Patient-reported functional outcomes at 6 months were significantly lower in the fracture group compared to osteoarthritis and rheumatoid arthritis groups. [12] (10.1016/j.jse.2026.01.019)
  • [L3] In particular, both PsC and PsA were associated with higher rates of infections and all-cause revisions. [13] (10.1016/j.arth.2026.03.054)
  • [L4] Although the Kudo type-5 prosthesis demonstrated satisfactory results in patients with RA, failures occurred to some extent over a long-term follow-up period. [14] (10.1016/j.jse.2024.10.025)
  • [L5] Tectochrysin may be a novel RA therapeutic agent, likely acting via macrophage JAK/STAT pathway inhibition, with promising clinical potential. [15] (10.1186/s13018-025-06481-w)
  • [L1] There is preclinical evidence for an antioxidant, anti-inflammatory, antinociceptive, cartilage- and bone-protective effect of CT in RA and OA. [16] (10.1530/eor-23-0133)
  • [L4] In chronic non-specific tenosynovitis with effusion localized at the ankle, symptoms may be intermittent and the true nature of the condition may remain unrecognized for months or even years. [17] (10.2106/jbjs.25.00400)
  • [L3] HandScan is able to reliably identify US-defined remission in RA at the joint level, with a good sensitivity and high PPV, while at the patient level, DAS-OST can also determine US remission but with lower performance. [18] (10.1186/s12891-024-07472-4)
  • [L4] Radiolunate arthrodesis in patients with RA maintained good clinical results and corrected alignment, even during long-term follow-up. [19] (10.1016/j.jhsa.2022.11.014)
  • [L1] Additionally, it reduced joint mTSS, JSN, and BES, alleviated joint space narrowing, and inhibited bone erosion, providing maximal joint protection and maintaining joint function. [21] (10.1186/s12891-025-09206-6)
  • [L4] Total wrist arthroplasty using the semiconstrained arthroplasty system achieves favorable clinical outcomes with no serious complications requiring revision for 10 years after surgery. [22] (10.1016/j.jhsa.2024.03.002)

References

[1] Rates of long-term risk of revision and complications in total elbow arthroplasty in patients with rheumatoid arthritis: a propensity score-matched analysis. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.032 [2] Efficacy of denosumab in treatment of osteoporosis in patients with rheumatoid arthritis: a meta-analysis of randomized controlled trial. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08688-8 [3] Comparative outcomes of robot-assisted versus conventional TKA in rheumatoid arthritis patients. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06703-9 [4] Rheumatoid arthritis is associated with higher 90-day systemic complications compared to osteoarthritis after total shoulder arthroplasty: a cohort study. Clinics in Shoulder and Elbow. 2024. DOI: 10.5397/cise.2024.00374 [5] Patient-Reported Outcome Measures After Direct Anterior Total Hip Arthroplasty Are Comparable Between Patients With Rheumatoid Arthritis and Osteoarthritis: A Propensity-Matched Analysis. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00656 [6] Complication Rates and Functional Outcomes After Total Ankle Arthroplasty in Patients with Rheumatoid Arthritis. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.00048 [7] Shoulder arthroplasty for inflammatory arthritis is associated with higher rates of medical and surgical complications: a nationwide matched cohort analysis from 2016-2020. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.09.014 [8] Patient-Reported Outcomes and Satisfaction Following Total Knee Arthroplasty in Rheumatoid Arthritis: An Observational Cohort Study. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.021 [9] Internet search analysis on the treatment of rheumatoid arthritis: What do people ask and read online?. PLOS ONE. 2023. DOI: 10.1371/journal.pone.0285869 [10] Perioperative Biologic Disease-Modifying Antirheumatic Drugs, Risks of Infections, and Wound Complications in Patients With Rheumatoid Arthritis Undergoing Elective Hand Surgery. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2026.03.003 [11] The moderating role of negative affect on pain in patients with rheumatoid arthritis who have undergone shoulder arthroplasty. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06109-z [12] A comparison of survivorship and functional outcomes for total elbow arthroplasty performed for distal humerus fracture, rheumatoid arthritis, and osteoarthritis, a New Zealand Joint Registry study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.01.019 [13] Outcomes Following Total Hip Arthroplasty in Patients with Cutaneous Psoriasis and Psoriatic Arthritis. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.054 [14] Long-term follow-up study of Kudo type-5 elbow prosthesis in patients with rheumatoid arthritis: minimum 10-year clinical outcomes. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.10.025 [15] Targeting macrophage JAK3/STAT3 signaling with tectochrysin: a novel therapeutic strategy to ameliorate bone erosion and synovitis in rheumatoid arthritis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06481-w [16] Calcitonin treatment for osteoarthritis and rheumatoid arthritis – a systematic review and meta-analysis of preclinical data. EFORT Open Reviews. 2024. DOI: 10.1530/eor-23-0133 [17] Complication Rates and Functional Outcomes After TAA in Patients with Rheumatoid Arthritis Are Less Defined Than for Patients with Osteoarthritis. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.25.00400 [18] Optical imaging (HandScan) can identify ultrasound remission in rheumatoid arthritis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07472-4 [19] Radiolunate Arthrodesis in the Rheumatoid Wrist: A Retrospective Clinical and Radiologic Long-Term Follow-Up. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2022.11.014 [21] Efficacy and safety of denosumab in treatment of osteoporosis in patients with rheumatoid arthritis: a meta-analysis and systematic review. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09206-6 [22] Clinical Outcomes of Total Wrist Arthroplasty in Patients With Rheumatoid Arthritis: Minimum 10-Year Follow-Up Study. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.03.002

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4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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