Total Knee Arthroplasty (TKA) in Rheumatoid Arthritis


Rheumatoid arthritis (RA) is a progressive auto-immune disorder damaging articular cartilage and bone, resulting in joint destruction. The knee joint is involved in 90% of the patients with RA. Total Knee Arthroplasty (TKA) has been described as an effective treatment for the alleviation of pain and restoration of
function in patients with rheumatoid arthritis.

Clinical Features

If a person has RA in their knees, they may have symptoms such as stiff, swollen joints that are difficult to bend and straighten, pain, and swelling, which may be worse after periods of rest, and pain that increases with vigorous physical activity, sudden sticking or locking of joints during movement and deformity, particularly valgus.


Doctors use a combination of medical history, physical examination, and laboratory tests to diagnose RA in the knees:

Medical History

A doctor will ask questions about joint symptoms, including when they began, how severe they are, what improves or
worsens them, and whether any relatives have RA or other autoimmune conditions.

Physical Examination

A doctor will look for signs of tenderness, swelling, heat, or limited movements in the knees and joints. They will also check for a
low-grade fever and bumps under the skin.

Blood Tests

These tests can identify inflammatory markers, such as erythrocyte sedimentation rate and C-reactive protein. Tests also look for rheumatoid factor (RF),
an antibody present in 80% of individuals with RA, or cyclic citrullinated peptide (CCP), which is present in 60–70% of people with this condition.

Imaging Tests

Because RA can damage the joints, doctors can use X-rays, ultrasound scans, or MRI scans to identify bone and joint erosion. However, images may not help doctors diagnose RA in the early stages when there is minimal bone damage.


The knee is affected up to 90% of the cases and 70% of them are bilateral. Nowadays some disease-modifying antirheumatic drugs (DMARDs) including
inhibitors of tumor necrosis factor (TNF) and some biological immunomodulating agents have been studied for reducing inflammation and disease progression and
found to be very effective in a considerable number of patients and provided reduced incidence of primary arthroplasty. In spite of newer or traditional disease-modifying treatment methods, the disease continues to progress in some of the patients and eventually leads to the need for joint arthroplasty.

Total knee arthroplasty (TKA) is known to be the most successful procedure for advanced knee rheumatoid arthritis. If it is performed at the correct time, with appropriate indications and techniques, it has the potential to improve quality of life measures. Because of the complexity of the disease, TKA procedures are difficult and have much more complications than other diseases, thus special consideration should be given in this group population.

Rheumatoid arthritis patients pose a challenge to surgeons due to osteopenia and synovitis in the surrounding tissue leading to disuse atrophy. The variety of bony, soft tissue deformities and joint laxity can hinder the initial success and long-term results of
TKA in these patients. There is always a debate regarding implant selection in these patients.

In order to wheelchair dependence and lower movement capability, flexion contractures and fixed flexion deformities may usually occur in the patients that are candidates for TKA. Some authors recommend intensive physiotherapy or serial casting before the surgery. Soft tissue release may be adequate in the majority of patients.


Because of the pre-operative decreased ambulation and advantage deformity of the patients, post-op physical rehabilitation is crucial for success.
Effective rehabilitation is aimed to improve ambulation, range of motion, and muscular strength. Recent studies have suggested that postoperative rehabilitation influences short and long-term functional outcomes. Due to poor bone quality, a higher rate of infection, poor healing of soft tissue, preoperative joint deformity, and involvement of multiple joints, the risk of complications increased and all of them make adequate rehabilitation difficult to perform.


RA is a multisystem disorder therefore multi-disciplinary management is crucial for functional outcomes. Despite all unfavorable characteristic
features of RA, TKA is the most effective and successful method in patients with advanced knee rheumatoid arthritis. Meticulous pre-operative assessment and
preparation, appropriate surgical technique and efficient post-operative rehabilitation improve the functional outcomes.


Dr. Avinash Pal (MS ORTHOPAEDICS) is one of the top orthopedic and hip and knee replacement surgeons in North India. He has trained at Apollo
Indraprastha and Safdarjung Hospital, Delhi. He has expertise in knee, hip, elbow, and shoulder replacement surgeries, including primary and revision
surgeries. He has done over 1000 joint replacements with a success rate of 97 percent.