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Inflammatory and Rheumatoid Arthritis

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

Overview

Inflammatory arthritis, including rheumatoid and psoriatic forms, presents a distinctly morbid risk profile with multiple increased surgical and postoperative medical complications compared to osteoarthritis [7]. Total shoulder arthroplasty in this population is associated with higher rates of medical and surgical complications than in osteoarthritis patients undergoing anatomic or reverse procedures [7]. Similarly, rheumatoid arthritis is associated with higher 90-day systemic complications after total shoulder arthroplasty, and these patients face an increased risk of complications and revision surgery compared to those with primary osteoarthritis [4].

Despite these elevated risks, total knee arthroplasty in patients with rheumatoid arthritis yields significant improvement in physician- and patient-reported outcomes [8]. Robot-assisted total knee arthroplasty provides evidence for selecting surgical methods in rheumatoid osteoarthritis compared to conventional techniques [3]. For total hip arthroplasty, patients with rheumatoid arthritis can expect reduced pain and improved functional outcomes similar to those with osteoarthritis following primary procedures [5]. Patient-reported outcome measures after direct anterior total hip arthroplasty are also comparable between rheumatoid arthritis and osteoarthritis cohorts [5].

Conversely, total ankle arthroplasty outcomes differ; patients with rheumatoid arthritis reported poorer patient-reported outcome scores compared with osteoarthritis and posttraumatic arthritis groups [6]. However, these patients still experienced functional outcome improvement from the preoperative baseline following the procedure [6]. Total elbow arthroplasty in rheumatoid arthritis patients is associated with increased revision rates compared to non-RA cohorts, despite comparable complication rates [1]. Cutaneous psoriasis and psoriatic arthritis are associated with higher rates of infections and all-cause revisions following total hip arthroplasty [13]. Additionally, denosumab demonstrates efficacy in maintaining bone health and preventing joint damage in rheumatoid arthritis patients with coexisting osteoporosis [2].

Background & Causes

Rheumatoid arthritis and inflammatory arthritis present a distinctly morbid risk profile compared to osteoarthritis, characterized by multiple increased surgical and postoperative medical complications. Following total shoulder arthroplasty, patients with rheumatoid arthritis face higher rates of systemic and joint-related complications, including a higher 90-day systemic complication rate [4]. Shoulder arthroplasty for inflammatory arthritis is associated with higher rates of medical and surgical complications compared to osteoarthritis patients [7]. This morbid risk profile extends to anatomic and reverse total shoulder arthroplasty [7].

The elevated risk of adverse outcomes is not limited to the shoulder. Patients with rheumatoid arthritis may be at an increased risk of complications and revision surgery following primary total hip arthroplasty [5]. Similarly, rates of long-term risk of revision in total elbow arthroplasty are increased in patients with rheumatoid arthritis compared to non-rheumatoid arthritis cohorts [1]. The underlying mechanisms of these increased revision rates warrant further investigation [1].

Perioperative management of pharmacotherapy influences surgical outcomes. Perioperative continuation of biologic disease-modifying antirheumatic drugs (bDMARDs) 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].

Pharmacologic and Prosthetic Considerations: * Denosumab: Demonstrates efficacy in maintaining bone health and preventing joint damage in rheumatoid arthritis patients with coexisting osteoporosis [2]. It reduces joint mTSS, JSN, and BES, alleviates joint space narrowing, and inhibits bone erosion in rheumatoid arthritis patients [21]. * Calcitonin: Preclinical evidence supports an antioxidant, anti-inflammatory, antinociceptive, cartilage- and bone-protective effect of calcitonin in rheumatoid arthritis [16]. * Tectochrysin: May be a novel therapeutic agent for rheumatoid arthritis, likely acting via macrophage JAK/STAT pathway inhibition to ameliorate bone erosion and synovitis [15]. * Kudo type-5 prosthesis: Demonstrated satisfactory results in patients with rheumatoid arthritis but experienced failures over a minimum 10-year follow-up period [14].

Symptoms & Presentation

Internet search analysis reveals specific questions and reading patterns regarding the treatment of rheumatoid arthritis [9].

Diagnostic Imaging: HandScan optical imaging reliably identifies ultrasound-defined remission in rheumatoid arthritis at the joint level, demonstrating good sensitivity and high positive predictive value [18]. In contrast, DAS-OST determines ultrasound-defined remission at the patient level but exhibits lower performance than HandScan [18].

Clinical Presentation: Chronic non-specific tenosynovitis with effusion localized at the ankle may present with intermittent symptoms that remain unrecognized for months or years [17].

Management

Arthroplasty Outcomes and Complications: Total elbow arthroplasty in rheumatoid arthritis (RA) patients is associated with higher long-term revision rates compared to non-RA cohorts, despite comparable complication rates [1]. Patient-reported functional outcomes at 6 months are significantly lower in the fracture group compared to osteoarthritis and RA groups after this procedure [12]. Total knee arthroplasty yields significant improvement in both physician-reported [8] and patient-reported outcomes [8] in RA patients. Robot-assisted total knee arthroplasty provides evidence for surgical method selection in rheumatoid osteoarthritis [3].

Shoulder Arthroplasty Risk Profile: RA is associated with higher 90-day systemic complications compared to osteoarthritis after total shoulder arthroplasty [4]. Patients with RA are at higher risk of systemic and joint-related complications compared to patients with primary osteoarthritis [4]. 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]. Despite these risks, shoulder arthroplasty in RA patients reduces pain and improves function [11].

Hip and Ankle Arthroplasty: Patients with RA can expect reduced pain and improved functional outcomes similar to those with osteoarthritis following primary total hip arthroplasty [5]. Patient-reported outcome measures after direct anterior total hip arthroplasty are comparable between patients with RA and osteoarthritis [5]. Conversely, patients with RA report poorer patient-reported outcome scores compared with osteoarthritis and posttraumatic arthritis groups after total ankle arthroplasty [6]. However, patients with RA do experience functional outcome improvement from the preoperative baseline after total ankle arthroplasty [6].

Medical Management and Perioperative Care: Denosumab demonstrates efficacy in maintaining bone health and preventing joint damage in RA patients with coexisting osteoporosis [2]. Perioperative biologic disease-modifying antirheumatic drug continuation is not associated with significant increases in risks of wound healing failures or surgical site infections in RA patients undergoing elective hand surgery [10]. Physicians should provide internet search-derived information on RA treatment to patients in counseling and education materials [9].

Novel Therapeutic Agents: Tectochrysin may be a novel therapeutic agent for RA, likely acting via macrophage JAK/STAT pathway inhibition to ameliorate bone erosion and synovitis [15]. Preclinical evidence supports an antioxidant, anti-inflammatory, antinociceptive, cartilage- and bone-protective effect of calcitonin in RA [16].

Key Considerations

Complication Profiles by Joint: Rheumatoid arthritis (RA) alters perioperative risk and outcomes across major joint arthroplasties. Total elbow arthroplasty (TEA) in RA patients demonstrates comparable complication rates to non-RA cohorts but is associated with increased revision rates [1]. Following total shoulder arthroplasty, RA patients face higher risks of both systemic and joint-related complications, specifically including elevated 90-day systemic complications compared to osteoarthritis (OA) [4]. In total hip arthroplasty, while patient-reported outcomes and functional improvements are comparable to OA patients, RA may confer an increased risk of complications and revision surgery [5]. Total ankle arthroplasty yields functional improvement from baseline, yet RA patients report poorer patient-reported outcome scores compared with OA and posttraumatic arthritis groups [6].

Prosthetic and Surgical Outcomes: Total knee arthroplasty in RA yields significant improvements in both physician-reported and patient-reported outcomes [8]. For the wrist, radiolunate arthrodesis maintains good clinical results and corrects alignment during long-term follow-up [19]. Total wrist arthroplasty using a semiconstrained system achieves favorable clinical outcomes with no serious complications requiring revision for 10 years [22]. Regarding elbow prostheses, the Kudo type-5 prosthesis demonstrates satisfactory results over a minimum 10-year follow-up, though failures occur to some extent in the long term [14]. Patient-reported functional outcomes after TEA are significantly lower in fracture groups compared to OA and RA groups [12]. Robot-assisted total knee arthroplasty provides important evidence for selecting surgical methods in rheumatoid osteoarthritis [3].

Medical Management and Counseling: Perioperative continuation of biologic disease-modifying antirheumatic drugs is not associated with significant increases in wound healing failures or surgical site infections among RA patients undergoing elective hand surgery [10]. Denosumab demonstrates efficacy in maintaining bone health and preventing joint damage in RA patients with coexisting osteoporosis [2]. Physicians should provide information on internet search trends regarding RA treatment to patients in counseling and education materials [9].

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. (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. (10.1186/s12891-025-08688-8)
  • [L3] This provides important evidence for selecting surgical methods in rheumatoid osteoarthritis. (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. (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. (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. (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. (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. (10.1016/j.arth.2026.03.021)
  • [L4] Physicians should provide such information to patients with RA in the counseling and education materials. (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. (10.1016/j.jhsa.2026.03.003)
  • [L3] Shoulder arthroplasty in patients with rheumatoid arthritis reduces pain and improves function. (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. (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. (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. (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. (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. (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. (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. (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. (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. (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. (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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