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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.

27 citationsUpdated Sep 2026

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Overview

The volume of total joint arthroplasty procedures in patients with rheumatoid arthritis has trended markedly upward over the past decade, with a sharp increase after 2015 [1]. While total knee arthroplasty yields significant improvement in physician- and patient-reported outcomes [10], and primary total hip arthroplasty provides reduced pain and improved functional outcomes similar to those seen in osteoarthritis [6], the complication profile differs. Inflammatory arthritis is associated with higher rates of medical and surgical complications compared to osteoarthritis in patients undergoing anatomic or reverse total shoulder arthroplasty [9]. Following total shoulder arthroplasty, patients with rheumatoid arthritis are at higher risk of systemic and joint-related complications compared to patients with primary osteoarthritis [5]. Similarly, patients with rheumatoid arthritis undergoing total hip arthroplasty may be at an increased risk of complications and revision surgery [6].

Despite these risks, arthroplasty remains effective for pain reduction and functional improvement across multiple joints. Shoulder arthroplasty in patients with rheumatoid arthritis reduces pain and improves function [11]. Patient-reported outcome measures after direct anterior total hip arthroplasty are comparable between patients with rheumatoid arthritis and osteoarthritis [6]. In the largest single-institution study to date, patients with rheumatoid arthritis reported poorer patient-reported outcome scores compared with osteoarthritis and posttraumatic arthritis groups after total ankle arthroplasty [8], yet they still experienced functional outcome improvement from the preoperative baseline [8]. For total elbow arthroplasty, patient-reported functional outcomes at 6 months were significantly lower in the fracture group compared to osteoarthritis and rheumatoid arthritis groups [12].

Specific clinical considerations include the need for careful monitoring in total elbow arthroplasty cases with a short duration from disease onset to surgery, preoperative instability, misalignment of the implant, and the use of the all-polyethylene ulnar component [16]. Further investigation into the underlying mechanisms of increased revision rates in rheumatoid arthritis patients undergoing total elbow arthroplasty is warranted [2]. Systemic management also plays a role; denosumab demonstrates promising efficacy in maintaining bone health and preventing joint damage in rheumatoid arthritis patients with coexisting osteoporosis [3]. There is preclinical evidence for an antioxidant, anti-inflammatory, antinociceptive, cartilage- and bone-protective effect of calcitonin in rheumatoid arthritis and osteoarthritis [13]. Discontinuation of antiviral prophylaxis correlates with a high prevalence of hepatitis B virus reactivation in rheumatoid arthritis patients with hepatitis B virus carrier state [14]. Additionally, both cutaneous psoriasis and psoriatic arthritis are associated with higher rates of infections and all-cause revisions following total hip arthroplasty [15].

Background & Causes

Hepatitis B Reactivation: Discontinuation of antiviral prophylaxis correlates with a high prevalence of hepatitis B virus reactivation in rheumatoid arthritis patients with an HBV carrier state [14].

Distal Radius Fracture Complications: Nonsurgical management of distal radius fractures in patients with inflammatory arthropathies carries the risk of attritional dorsal carpal dislocation and multiple flexor tendon ruptures [25].

Radiolunate Arthrodesis Risk Factors: Preoperative severe ulnar translation deformity is a risk factor for postoperative degeneration of the midcarpal joint following radiolunate arthrodesis in the rheumatoid wrist [22]. Additionally, pre-existing degenerative changes at the midcarpal joint may lead to loss of wrist range of motion following radiolunate arthrodesis in the rheumatoid wrist [22].

Symptoms & Presentation

Rheumatoid arthritis patients undergoing shoulder arthroplasty experience reduced pain and improved function [11]. However, negative affect moderates pain following this procedure in this population [11]. In the lower extremity, patients with rheumatoid arthritis report poorer patient-reported outcome scores compared with osteoarthritis and posttraumatic arthritis groups following total ankle arthroplasty [8]. Despite these comparative differences, these patients experience functional outcome improvement from the preoperative baseline following total ankle arthroplasty [8].

Upper extremity outcomes in rheumatoid arthritis demonstrate consistent benefits across various joint replacements. Unlinked total elbow arthroplasty via the lateral para-olecranon approach achieves significant improvements in pain, range of motion, strength, and overall elbow function [24]. Similarly, total wrist arthroplasty using the semiconstrained arthroplasty system achieves favorable clinical outcomes in patients with rheumatoid arthritis [26].

Management

Non-Operative

Rheumatoid arthritis is a chronic, systemic inflammatory disease affecting 1% to 2% of the world population, with a female-to-male ratio of 2.5:1 [27]. It most often involves the small joints of the hands and feet, though any synovial joint can be affected [27]. Adult rheumatoid arthritis is usually polyarticular, while systemic involvement in visceral organs or eyes is rare [27]. The clinical picture is characterized by synovitis and joint destruction, with synovitis tending to wax and wane [27]. Joint destruction begins within the first or second year of the disease and continues to progress [27]. Radiographic destruction manifests as joint space narrowing, periarticular erosions, and subchondral osteopenia [27]. Structural damage presents clinically as pain with activity and deformity [27].

Diagnosis relies on specific criteria and serology. A patient is considered to have rheumatoid arthritis if at least four of the seven American Rheumatism Association criteria have been present for at least 6 weeks [27]. The test for rheumatoid factor in adults is positive in 70% to 80% of patients diagnosed with the condition [27]. Treatment of the early stages is primarily medical, although physical and occupational therapy often can be helpful [27]. Pharmacologic agents include nonsteroidal antiinflammatory drugs, corticosteroids, methotrexate, and biologic agents [27]. Biologic agents are recombinant proteins that generally target an inflammatory cytokine, such as tumor necrosis factor [27]. These agents have shown excellent results in treatment but inhibit the immune system, causing an increased risk of infection in patients taking them [27].

Novel therapeutic agents and monitoring tools are emerging. Denosumab reduced joint mTSS, JSN, and BES, alleviated joint space narrowing, and inhibited bone erosion [23]. Tectochrysin may be a novel therapeutic agent, likely acting via macrophage JAK/STAT pathway inhibition, with promising clinical potential [20]. HandScan is able to reliably identify ultrasound-defined remission at the joint level, with good sensitivity and high positive predictive value [18]. At the patient level, DAS-OST can determine ultrasound remission but with lower performance than HandScan [18]. Supervised high-intensity interval training and strength exercise appear to be feasible and well tolerated by patients with well-controlled rheumatoid arthritis and could be recommended to improve cardiovascular and physical health [19].

Preoperative medical management requires specific precautions. Patients on corticosteroids generally require preoperative “stress” dosages of hydrocortisone [27]. Agents that inhibit the immune system should be withheld at least 1 week before and 1 week after a surgical procedure [27]. Discontinuation of antiviral prophylaxis correlates with a high prevalence of hepatitis B virus reactivation in rheumatoid arthritis patients with HBV carrier state [14]. Improved medical management has significantly impacted surgical volume; Jämsen et al. found a 48% decrease in the number of primary arthroplasties performed for rheumatoid arthritis from 1995 to 2010 [27].

Operative

The volume of total joint arthroplasty procedures in patients with rheumatoid arthritis has trended markedly upward over the past decade, with a sharp increase after 2015 [1]. Inflammatory arthritis represents a distinctly morbid risk profile compared to osteoarthritis patients, with multiple increased surgical and postoperative medical complications in patients undergoing anatomic or reverse total shoulder arthroplasty [9]. Following total shoulder arthroplasty, patients with rheumatoid arthritis should be considered at higher risk of systemic and joint-related complications compared to patients with primary osteoarthritis [5].

Outcomes vary by joint. Although patients with rheumatoid arthritis may be at an increased risk of complications and revision surgery, they can expect reduced pain and improved functional outcomes similar to those with osteoarthritis following primary total hip arthroplasty [6]. Patients with rheumatoid arthritis reported poorer patient-reported outcome scores compared with osteoarthritis and posttraumatic arthritis groups after total ankle arthroplasty but experienced functional outcome improvement from the preoperative baseline [8]. 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]. Despite comparable complication rates between rheumatoid arthritis and non-RA cohorts, further investigation into the underlying mechanisms of increased revision rates in rheumatoid arthritis patients undergoing total elbow arthroplasty is warranted [2].

Specific surgical considerations and techniques apply to certain joints. Careful monitoring should be conducted for total elbow arthroplasty in rheumatoid arthritis, particularly in cases with a short duration from disease onset to surgery, preoperative instability, misalignment of the implant, and the use of the all-polyethylene ulnar component [16]. Unlinked total elbow arthroplasty performed via the lateral para-olecranon approach provides favorable midterm outcomes in patients with rheumatoid arthritis and Larsen grade III–IV disease, preserving triceps function while achieving significant improvements in pain, range of motion, strength, and overall elbow function [24]. Among patients with rheumatoid arthritis undergoing elective hand surgery, perioperative biologic disease-modifying antirheumatic drug continuation was not associated with significant increases in risks of wound healing failures or surgical site infections [17]. Both cutaneous psoriasis and psoriatic arthritis were associated with higher rates of infections and all-cause revisions following total hip arthroplasty [15].

Key Considerations

Perioperative Risk and Complications

Continuing biologic disease-modifying antirheumatic drugs during the perioperative period for elective hand surgery does not significantly increase the risk of wound healing failures or surgical site infections in patients with rheumatoid arthritis [17].

Joint-Specific Outcomes

Total Hip Arthroplasty: Patients with rheumatoid arthritis undergoing primary total hip arthroplasty achieve reduced pain and improved functional outcomes comparable to those with osteoarthritis, although they face an increased risk of complications and revision surgery [6].

Total Ankle Arthroplasty: In the largest single-institution study to date, patients with rheumatoid arthritis report poorer patient-reported outcome scores compared with osteoarthritis and posttraumatic arthritis groups after total ankle arthroplasty, yet they still experience functional improvement from their preoperative baseline [8].

Total Wrist Arthroplasty: The semiconstrained arthroplasty system for total wrist arthroplasty yields favorable clinical outcomes in patients with rheumatoid arthritis, with no serious complications requiring revision within 10 years post-surgery [26].

Shoulder Arthroplasty: Anatomic shoulder replacement provides superior functional outcomes compared with reverse shoulder replacement in patients with inflammatory arthritis, with no significant difference in revision-free survival rates between the two procedures [28].

Revision and Survivorship

Despite comparable complication rates between rheumatoid arthritis and non-rheumatoid arthritis cohorts undergoing total elbow arthroplasty, further investigation into the underlying mechanisms of increased revision rates in rheumatoid arthritis patients is warranted [2].

Non-Operative and Adjunctive Considerations

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].

Patient Counseling: Physicians should include information regarding online treatment inquiries in counseling and education materials provided to patients with rheumatoid arthritis [7].

Surgical Technique and Deformity Correction

Ulnar Drift: Dynamic tenodesis for rheumatoid arthritis-related ulnar drift requires further comparative and biomechanical validation to define its long-term role in rheumatoid hand surgery [21].

Wrist Arthrodesis: Pre-existing degenerative changes at the midcarpal joint might lead to loss of wrist range of motion following radiolunate arthrodesis in the rheumatoid wrist [22].

Key Evidence

  • [L4] The volume of total joint arthroplasty (TJA) procedures conducted in patients with rheumatoid arthritis has trended markedly upward over the past decade, with a sharp increase after 2015. [1] (10.5435/jaaosglobal-d-22-00209)
  • [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. [2] (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. [3] (10.1186/s12891-025-08688-8)
  • [L3] Following TSA, RA patients should be considered at higher risk of systemic and joint-related complications compared to patients with primary OA. [5] (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. [6] (10.5435/jaaos-d-24-00656)
  • [L4] Physicians should provide such information to patients with RA in the counseling and education materials. [7] (10.1371/journal.pone.0285869)
  • [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. [8] (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. [9] (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] (10.1016/j.arth.2026.03.021)
  • [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)
  • [L1] There is preclinical evidence for an antioxidant, anti-inflammatory, antinociceptive, cartilage- and bone-protective effect of CT in RA and OA. [13] (10.1530/eor-23-0133)
  • [L4] Discontinuation of antiviral prophylaxis correlates with high prevalence of hepatitis B virus (HBV) reactivation in rheumatoid arthritis patients with HBV carrier state. [14] (10.1186/1471-2474-15-449)
  • [L3] In particular, both PsC and PsA were associated with higher rates of infections and all-cause revisions. [15] (10.1016/j.arth.2026.03.054)
  • [L4] Careful monitoring should be conducted, particularly in cases with a short duration from RA onset to surgery, preoperative instability, misalignment of the implant, and the use of the all-polyethylene ulnar component. [16] (10.1016/j.jse.2024.10.025)
  • [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. [17] (10.1016/j.jhsa.2026.03.003)
  • [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)
  • [L1] Supervised HIIT and strength exercise appear to be feasible and well tolerated by patients and could be recommended to improve cardiovascular and physical health in patients with well-controlled RA. [19] (10.1136/bjsports-2024-108369)
  • [L5] Tectochrysin may be a novel RA therapeutic agent, likely acting via macrophage JAK/STAT pathway inhibition, with promising clinical potential. [20] (10.1186/s13018-025-06481-w)
  • [Letter] The described dynamic tenodesis is an elegant solution to rheumatoid arthritis-related ulnar drift, but further comparative and biomechanical validation is needed to define its long-term role in rheumatoid hand surgery. [21] (10.1016/j.jhsg.2025.100883)
  • [L4] Preoperative severe ulnar translation deformity was a risk factor for postoperative degeneration of the midcarpal joint, and pre-existing degenerative changes at the midcarpal joint might lead to loss of wrist range of motion. [22] (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. [23] (10.1186/s12891-025-09206-6)
  • [L4] Unlinked TEA performed via the lateral para-olecranon approach provides favorable midterm outcomes in patients with RA and Larsen grade III–IV disease, preserving triceps function while achieving significant improvements in pain, ROM, strength, and overall elbow function. [24] (10.1016/j.jse.2026.02.023)
  • [L4] This case highlights the risks associated with nonsurgical management of distal radius fractures in patients with inflammatory arthropathies, specifically the potential for attritional dorsal carpal dislocation and multiple flexor tendon ruptures. [25] (10.1016/j.jhsg.2025.100933)
  • [L4] Total wrist arthroplasty using the semiconstrained arthroplasty system achieves favorable clinical outcomes with no serious complications requiring revision for 10 years after surgery. [26] (10.1016/j.jhsa.2024.03.002)
  • [L3] There was no significant difference in revision-free survival rates between the two procedures. [28] (10.1016/j.jse.2026.02.009)

See Also

References

[1] Trends in Total Joint Arthroplasty Among Patients With Rheumatoid Arthritis: The Effect of Recent Disease Modifying Antirheumatic Drug Utilization Guidelines. JAAOS: Global Research and Reviews. 2022. DOI: 10.5435/jaaosglobal-d-22-00209

[2] 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

[3] 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

[5] 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

[6] 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

[7] 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

[8] 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

[9] 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

[10] 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

[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] 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

[14] Discontinuation of antiviral prophylaxis correlates with high prevalence of hepatitis B virus (HBV) reactivation in rheumatoid arthritis patients with HBV carrier state: a real-world clinical practice. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-449

[15] 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

[16] 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

[17] 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

[18] Optical imaging (HandScan) can identify ultrasound remission in rheumatoid arthritis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07472-4

[19] High-intensity interval training improves cardiovascular and physical health in patients with rheumatoid arthritis: a multicentre randomised controlled trial. British Journal of Sports Medicine. 2024. DOI: 10.1136/bjsports-2024-108369

[20] 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

[21] Regarding “Dynamic Tenodesis Technique for Ulnar Drift With Extensor Tendon Subluxation due to Rheumatoid Arthritis” by Oda et al. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100883

[22] 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

[23] 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

[24] The Lateral Para-olecranon Approach for Unlinked Total Elbow Arthroplasty with the Kudo Prosthesis in Patients with Rheumatoid Arthritis: Midterm Outcomes. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.02.023

[25] Attritional Carpal Dislocation and Flexor Tendon Rupture as a Rare Complication of Conservatively Managed Distal Radius Fracture in a Rheumatoid Patient. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100933

[26] 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

[27] Campbell S Operative Orthopaedics 4 Volume Set. SOFT-TISSUE PROCEDURES AND OSTEOTOMIES ABOUT THE KNEE > RHEUMATOID ARTHRITIS OF THE KNEE > ADULT-ONSET RHEUMATOID ARTHRITIS.

[28] Anatomic shoulder replacement has superior functional outcomes with equivalent survivorship compared with reverse shoulder replacement in patients with inflammatory arthritis—New Zealand registry results. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.02.009

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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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