Surgical management of end-stage rheumatoid arthritis

INTRODUCTION — Rheumatoid arthritis (RA) is a chronic, progressive disorder in many patients. Despite therapy with disease-modifying antirheumatic drugs (DMARDS), including biologic agents, joint erosion and destruction can develop over time. (See "General principles and overview of management of rheumatoid arthritis in adults".)

The major symptom of joint destruction is pain. With further progression of the arthritis, there are signs of loss of motion, diminution in motor strength, and ultimately decline in function. (See "Evaluation and medical management of end-stage rheumatoid arthritis".)

This topic will review the surgical indications, procedures, management approach, and complications of total joint replacement in patients with severe RA. Overviews of total hip and knee arthroplasty and their complications, as well as the perioperative management of patients with rheumatic diseases, are presented elsewhere:

●(See "Total hip arthroplasty".)

●(See "Total knee arthroplasty".)

●(See "Complications of total hip arthroplasty".)

●(See "Complications of total knee arthroplasty".)

●(See "Preoperative evaluation and perioperative management of patients with rheumatic diseases".)

DECLINING FREQUENCY OF JOINT REPLACEMENT — With modern therapeutics, the need for total joint replacement among patients with rheumatoid arthritis (RA) has declined substantially [1]. In a nationwide registry of patients in Finland, the annual incidence of joint replacement from 1995 to 2010 had declined by 42 percent (ie, 18.5 versus 11 per 100,000 population) [2]. The decline was greater for upper extremity (ie, shoulder and elbow replacement) joint replacement than for lower extremity (ie, hip and knee) joint replacement.

The declining frequency of joint replacement has been attributed to more aggressive treatment of RA, including the widespread use of biologic agents. Since the introduction of biologic agents for the treatment of RA, the incidence of total arthroplasty of the knee and hip have declined by 12.6 percent and 26.9 percent, respectively [3]. Less than 5 percent of total hip replacement surgeries are performed for inflammatory arthropathies [4].

PREOPERATIVE CONSIDERATIONS

General indications — The main indications for surgery are joint disease leading to intractable pain or unacceptable loss of function despite optimal medical therapy.

The goal of surgery in the management of rheumatoid arthritis (RA) is relief of pain and improvement of joint function. Various surgical procedures, including total joint arthroplasty, may be indicated for the damaged joint.

Contraindications — The major contraindication to joint replacement is active systemic or intraarticular infection.

Comorbid medical conditions, such as hypertension, cardiovascular disease, diabetes, obesity, or bleeding disorders, are not absolute contraindications to surgery since improvements in their perioperative management have markedly reduced the associated risks. (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Management based on risk'.)

Preoperative medical evaluation and management

●Exclude other causes of joint pain – We evaluate the patient to confirm that the joint pain is caused primarily by arthritis and not another etiology. Bursitis, tendonitis and nerve entrapment frequently coexist with arthritis and can also cause intractable pain that may be attributed to joint damage. (See "Overview of soft tissue musculoskeletal disorders".)

●Radiographs of the involved joints and cervical spine – Prior to surgery, we obtain plain radiographs to confirm the end-stage nature of the arthritis.

We also image the cervical spine, since patients with RA may have asymptomatic cervical subluxation. In a patient with undiagnosed cervical subluxation, neck positioning required for intubation could cause paralysis or death. (See "Cervical subluxation in rheumatoid arthritis".)

●Other considerations – Other issues regarding patient management before and after surgery are discussed separately. These include:

•Preoperative and perioperative considerations specific to RA (see "Preoperative evaluation and perioperative management of patients with rheumatic diseases", section on 'Rheumatoid arthritis')

•Management of antirheumatic drug therapy in the perioperative period (see "Preoperative evaluation and perioperative management of patients with rheumatic diseases", section on 'Medication management')

•Post-surgical complications associated with immunosuppression (eg, delayed wound healing, prosthetic joint infection) (see "Risk factors for impaired wound healing and wound complications", section on 'Immunosuppressive therapy' and "Prosthetic joint infection: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations' and "Prosthetic joint infection: Treatment")

SURGICAL PRIORITIES

Timing of surgery — When clinically indicated, surgery should take place in a timely manner because a prolonged delay can lead to fixed deformities, soft tissue contractures, or excessive muscle atrophy, which prevents a good postoperative recovery [5].

Sequence of procedures — When a patient with rheumatoid arthritis (RA) has multiple joints in need of surgical attention, establishing the proper surgical sequence is an important issue. Upper extremity surgery should generally precede lower extremity surgery when possible [6]. This sequence is helpful because lower extremity surgery generally requires prolonged periods of non-weightbearing, which increases use of the upper extremities (eg, to use crutches).

●Upper extremity – Wrist deformities should be corrected before hand surgery in order to maintain distal stability and alignment. Whether elbow or shoulder replacement should precede wrist and hand surgery should be decided on an individual basis [7,8].

●Lower extremity

•Hip and lumbar spine – For patients who require both hip and lumbar spine surgery, the correct sequence of surgeries is less clear. For most patients, total hip replacement is performed before lumbar spine fusion. This is because patients with prior lumbar fusion have an increased risk of prosthetic dislocation following total hip arthroplasty (THA) [9-13]. However, in some cases, stabilization of the pelvis may be important for hip replacement surgery to be successful [9-13].

With either sequence, specific changes to the surgical approach may be required to compensate for lack of flexibility between the spine and pelvis (See 'Hip' below.)

•Hip before knee – THA should be performed before total knee arthroplasty (TKA) for the following reasons:

-THA may alter the hip’s center of rotation, which is used to establish alignment goals for TKA

-Hip rehabilitation generally requires less functional range of motion of the ipsilateral knee than knee rehabilitation requires of the hip

-Knee pain may improve substantially following ipsilateral THA, potentially making TKA unnecessary

However, if there is severe pain, instability, or contracture of the knee joint, arthroplasty of the ipsilateral knee may need to take place first.

•Hip/knee before foot/ankle – THA and TKA are performed before foot and ankle surgery, also to ensure that the foot aligns with the correct mechanical axis.

•Ankle/hindfoot before forefoot – In general, ankle and hindfoot procedures should be performed before forefoot reconstruction to ensure alignment with the correct mechanical axis [7].

SURGICAL OPTIONS

Overview — Surgical options for patients with rheumatoid arthritis (RA) are not limited to total joint replacement and may also include:

●Tenosynovectomy to excise inflamed tendon sheaths or tenosynovectomy and tendon transfer to reconstruct a recent tendon rupture(s) (eg, hand tendons)

●Arthroscopic or open repair of soft tissue rupture (eg, rotator cuff)

●Synovectomy to excise inflamed synovium refractory to immunosuppression

●Joint fusion to stabilize destroyed joints that are not easily replaced (eg, ankle, wrist, thumb, and cervical spine)

●Soft tissue release to correct severe contractures

●Metatarsal head excision arthroplasties to alleviate severe forefoot pain and to improve gait

Upper extremity joints

Shoulder

●Arthroplasty options – Surgical options for severe shoulder joint destruction include:

•Hemiarthroplasty – A hemiarthroplasty may replace either the humeral head (ie, a stemmed hemiarthroplasty) or just the joint surface of the humeral head (ie, a resurfacing hemiarthroplasty).

•Total shoulder arthroplasty – Total shoulder arthroplasty (TSA) involves replacement of both the glenoid and the humeral head (figure 1).

-Standard total shoulder arthroplasty – In a standard TSA, the glenohumeral joint is replaced with a glenoid cup and an artificial humeral head (figure 2).

-Reverse total shoulder arthroplasty – In a reverse total shoulder arthroplasty (RSA), the glenohumeral joint is replaced with a glenosphere and a humeral cup. This reverses the standard mechanics of the joint by allowing the socket to move around a fixed sphere (figure 1).

●Deciding among options – The choice of shoulder arthroplasty type depends on the integrity of the rotator cuff:

•Standard total shoulder arthroplasty for patients with intact rotator cuff – In patients with an intact rotator cuff, we suggest standard TSA over shoulder hemiarthroplasty or RSA.

-Outcomes – In patients with an intact rotator cuff, TSA is associated with better outcomes with respect to pain relief, activity level and function, longevity, and need for revision than other options.

In a 2007 study of 195 TSAs and 95 hemiarthroplasties involving 247 patients with RA who underwent surgery between 1976 and 1991, patients with an intact rotator cuff who received a TSA had more pain relief, greater improvement in range of motion, and a lower risk of undergoing a revision procedure than patients who received a hemiarthroplasty [14].

In a 2014 follow-up of this study, survivorship free of revision at 10 years was higher following TSA versus hemiarthroplasty among patients with an intact rotator cuff (97 versus 76 percent) [15]. None of the variables analyzed, including age or gender, could differentiate the risk of revision surgery in TSA versus hemiarthroplasty patients.

-Complications – Among the patients who underwent hemiarthroplasty in the 2014 study, eight had revision to TSA for symptomatic wear of the glenoid, with 11 revisions overall [14]. Among the TSA patients, there was a low rate of revision for glenoid loosening.

•Reverse shoulder arthroplasty for patients without intact rotator cuff – In patients without an intact rotator cuff, we suggest RSA when local expertise is available. When such expertise is not available, we suggest shoulder hemiarthroplasty over standard TSA [16].

-Rationale – The rotator cuff stabilizes the shoulder joint by compressing the humeral head against the glenoid. In the absence of a rotator cuff, the standard TSA’s prosthetic glenoid cup is subject to higher rates of loosening.

Neither the RSA or hemiarthroplasty uses a prosthetic glenoid cup, which makes these options more appropriate for most patients without an intact rotator cuff.

Following a TSA or hemiarthroplasty, the patient requires an intact rotator cuff for arm abduction. The RSA moves the center of rotation inferiorly, which allows the deltoid to compensate for the missing rotator cuff. Therefore, the RSA is preferred for most patients without an intact rotator cuff.

-Outcomes – A systematic review of 121 shoulders from seven studies of RA patients indicated that 95 percent of patients who underwent RSA for RA reported excellent to satisfactory outcomes with good restoration of function (ie, minimum mean forward elevation of 115 degrees) [17].

-Complications – Early studies indicated that RSA in RA patients was associated with a high rate of complications. However, more recent studies indicate that RSA is a safe and effective option for patients with RA.

A systematic review of 121 shoulders from seven studies of RA patients demonstrated a low rate of complications from RSA. These complications included symptomatic glenoid loosening (1.7 percent), joint infection (3.3 percent), and need for revision surgery (5 percent) [17].

In another study of 59 patients with RA who underwent RSA, 96 percent of patients did not need surgical revision after two years of follow-up [18].

Elbow

●Total elbow arthroplasty for most patients – We suggest total elbow arthroplasty (TEA) for most patients with pain and severe elbow joint destruction due to RA. TEA replaces the arthritic distal humerus and proximal ulna. There is a stemmed metal distal humerus component and a similar component for the proximal ulna. The artificial joint is made up of a metal and plastic hinge that connects the two stemmed components. Prostheses with a linked design provide a more stable elbow which has been associated with better clinical performance in patients with RA. TEA was initially developed to address severe elbow joint destruction in patients with RA.

•Outcomes – Improvements in pain and function following total elbow replacement are excellent in most patients with RA [19]. Since 1975, more than 20 elbow protheses have been developed, but comparison of results is difficult because of the small numbers of patients reported and because of the lack of standardized assessment.

Overall, pain relief is successful in more than 90 percent of patients, and long-term complication rates range from 20 to 40 percent [20].

•Complications – Although infection has historically been the main complication in elbow replacements, further development in surgical techniques has reduced the incidence of infection to less than 3 percent [21,22]. However, loosening of the implant remains a concern [23].

Patients who have had previous elbow infections or a history of heterotopic ossification should be advised to avoid TEA, if possible [24].

●Other surgical options – Hemiarthroplasty and lateral resurfacing elbow (LRE) arthroplasty may be considered primarily when joint destruction is isolated to a single compartment of the elbow joint. However, we prefer TEA because it reliably leads to excellent improvements in both pain and function. Moreover, subsequent conversion of these procedures to a standard TEA may be more difficult.

•Hemiarthroplasty – Hemiarthroplasty involves excision of the radial head (or distal humerus) and synovectomy. Distal humerus hemiarthroplasty is primarily used to address humeral fractures, although there are reports of this procedure having been used successfully for patients with RA affecting the elbow [25].

-Outcomes – Hemiarthroplasty may be an effective treatment for refractory elbow pain, although potentially not as effective as TEA.

In a study of 46 patients who underwent either TEA or hemiarthroplasty with synovectomy, patients were followed for at least two years and then evaluated using a 100-point rating system, which assessed pain, function, and joint alignment [26]. Patients who underwent TEA had a higher postoperative score than patients who underwent hemiarthroplasty (94 versus 87 points).

-Complications – Up to 23 percent of radial head hemiarthroplasties may be associated with complications, including symptomatic loosening of the prosthetic joint, progressive joint destruction, and pain [27,28].

•Lateral resurfacing elbow arthroplasty – LRE arthroplasty replaces the radiocapitellar joint with a prosthesis, leaving the native medial joint compartment intact. LRE arthroplasty was initially developed to treat younger patients with hypotrophic osteoarthritis (OA) of the elbow.

LRE arthroplasty requires fewer activity restrictions than TEA, which may be an important consideration for active patients [29]. However, this technique has not been well studied among patients with RA.

Wrist

●Surgical options – Surgical options for severe wrist joint destruction include total wrist arthroplasty (TWA) and total wrist arthrodesis.

•Total wrist arthrodesis – Total wrist arthrodesis improves joint stability and pain, at the loss of range of motion.

•Total wrist arthroplasty – TWA preserves some range of motion, with improvements in pain and function comparable to arthrodesis.

●Deciding between options – For patients with RA, either procedure may be appropriate, and the decision to proceed with either arthroplasty or arthrodesis must be made on an individual basis.

TWA had previously been associated with a high incidence of complications, including loosening, infection, collapse of the bone adjacent to the prosthetic (ie, subsidence), and dislocations [30].

However, TWA outcomes for patients with RA have continued to improve. A systematic review of 343 cases of wrist arthrodesis and 618 cases of TWA among patients with RA indicate that both procedures are associated with improvements in pain and grip strength and have a comparable complication rate (17 versus 19 percent) [31]. As expected, arthrodesis was associated with a loss in range of motion, while TWA led to improvements in pronation, supination, radial deviation, and ulnar deviation.

Hand — Surgical options for severe destruction of the hand joints depends on the joints involved. For metacarpophalangeal (MCP) joint damage, we prefer arthroplasty over arthrodesis. For thumb interphalangeal (IP) joint damage, we prefer arthrodesis over arthroplasty.

●Metacarpophalangeal joint arthroplasty for most patients – For the MCP joints, we suggest arthroplasty over arthrodesis.

•Outcomes – MCP arthroplasty is associated with pain relief, an arc of motion in the 40 to 50 degree range, improvement of joint extension, and correction of ulnar deviation by up to 20 degrees [32,33]. The final outcome with implant arthroplasty is never a normal functioning articulation; rather, the goal is a painless joint with a useful arc of motion [34].

A prospective, multicenter, cohort study of 46 RA patients followed two years after silicone MCP arthroplasty found objective improvement in MCP arc of motion, ulnar drift, and joint extension that correlated well with patient satisfaction scores as measured by the Michigan Hand Questionnaire (MHQ) [35]. However, there were minimal improvements in grip and pinch strength.

A 2000 systematic review also concluded that silicone implant arthroplasty improved hand function, pain, activities of daily living, and patient satisfaction [36].

•Complications – Possible complications with implant arthroplasty include recurrence of ulnar deviation, loss of the MCP’s arc of flexion, infection, and implant breakage or dislocation [37]. However, a broken prosthesis does not necessarily require surgical replacement [38].

●Thumb interphalangeal joint arthrodesis for most patients – For severe destruction of the thumb IP joint, we suggest arthrodesis over arthroplasty, since joint fusion does not generally lead to loss of function.

Lower extremity arthroplasty

Hip — We suggest total hip arthroplasty (THA) for most patients with RA.

The indications, preoperative evaluation, selection of components and of fixation technique, perioperative management, and outcomes of THA in general are presented separately. (See "Total hip arthroplasty".)

Hip destruction often coexists with lumbar spinal disease and deformity. This altered spinal-pelvic relationship may explain the increased risk of dislocation in this population. This increased risk may be mitigated with larger head articulations (including dual-mobility options, which use a liner that can move between the prosthetic hip socket and femoral head) and by adjusting the prosthetic cup position [39].

●Outcomes – Patients with RA report improvement in joint function and quality of life following THA. In a study of 98 patients with RA and 2030 patients with OA who underwent THA, patients with RA reported comparable improvements in hip pain and function, as measured by the Oxford Hip Score, compared with patients with OA (42 versus 39 on a 48 point scale) [40]. Patients with RA also reported comparable improvements in quality of life, as measured by the EuroQol 5-dimension 3-level, compared with patients with OA (0.69 versus 0.85, on a weighted scale that ranges from -0.59 to 1).

●Complications – Patients with RA may have a higher risk of complications with THA than patients with hip OA undergoing the same procedure.

•Postoperative complications – In a meta-analysis of 23 studies including 877,695 patients undergoing hip replacement for RA or OA, patients with RA were more likely to need revision (odds ratio [OR] 1.15); develop hip dislocation (OR 2.31), periprosthetic infection (OR 1.44), or wound infection (OR 2.15); or require revision for late infection [41]. In a study of 418 THA due to inflammatory arthritis, the 10-year risk of revision was highest among patients with psoriatic arthritis (16 percent) [42].

•Rehospitalization – A study of elective hospitalizations for total hip replacement identified using the Nationwide Readmissions Database demonstrated that patients with RA had a higher adjusted risk of rehospitalization after THA than patients with OA (OR 1.39) [43]. Nearly half of the rehospitalizations were due to infection, postoperative wound complications, cardiac events, or venous thrombotic embolism.

●Other surgical options – We do not use other surgical options for severe destruction of the hip joint, such as hemiarthroplasty, hip resurfacing, or hip osteotomy, which are less effective for patients with joint damage from RA. These other approaches are discussed elsewhere. (See "Overview of surgical therapy of knee and hip osteoarthritis", section on 'Alternatives to total hip arthroplasty'.)

Knee — We suggest total knee arthroplasty (TKA) for most patients with RA.

The indications, preoperative evaluation, selection of components and of fixation technique, perioperative management, and outcomes of TKA in general are presented separately. (See "Total knee arthroplasty".)

●Outcomes – The reported success rate for TKA in patients with RA is in excess of 85 percent at 10 years [44-46].

Patients with RA report improvement in joint function and quality of life following TKA. In a study of 142 patients with RA and 2070 patients with OA who underwent TKA, patients with RA reported comparable improvements in knee pain and function, as measured by the Oxford Knee Score, compared with patients with OA (36 versus 37 on a 48 point scale) [40]. Patients with RA also reported comparable improvements in quality of life, as measured by the EuroQol 5-dimension 3-level, compared with patients with OA (0.69 versus 0.76, on a weighted scale that ranges from -0.59 to 1).

A second study, which included 315 patients with OA and 834 patients with RA, also concluded that patients with RA experienced improvements in pain, function, and health-related quality of life following TKA [47]. However, the magnitude of improvement was greater among patients with OA.

●Complications – Patients with RA have a higher risk of prosthetic infection and need for rehospitalization following TKA than patients with OA.

•Infection – In a prospective study of all TKAs from the Norwegian arthroplasty registry, a 1.6-fold higher risk of TKA revision surgery due to infection was found in RA patients compared with OA patients [48]. (See "Complications of total knee arthroplasty", section on 'Surgical site infection'.)

•Rehospitalization – A study of elective hospitalizations for total hip replacement identified using the Nationwide Readmissions Database indicated that patients with RA had a higher adjusted risk of rehospitalization after TKA than patients with OA (OR 1.11) [43]. Nearly half of the rehospitalizations were due to infection, postoperative wound complications, cardiac events, or venous thrombotic embolism.

●Other surgical options – We do not use other surgical options, such as unicompartmental arthroplasty or osteotomy, which are more appropriate for diseases that impact a single compartment of the knee joint. (See "Overview of surgical therapy of knee and hip osteoarthritis", section on 'Alternatives to total knee arthroplasty'.)

Ankle

●Total ankle arthroplasty for most patients – For most patients with RA, we prefer total ankle arthroplasty (TAA) over arthrodesis. TAA has the potential to preserve range of motion, restore close to normal gait, and protect adjacent joints.

Patients with RA who undergo TAA have similar levels of improvement in pain and function compared with patients who undergo TAA for other indications (eg, primary OA, trauma). In a meta-analysis of 5508 patients who underwent TAA for either inflammatory or noninflammatory arthritis, the rates of complications (eg, poor wound healing, infection, prosthetic loosening) and revisions were similar in both groups [49].

●Limited role for total ankle arthrodesis – We offer arthrodesis over TAA for patients with extensive joint damage or poor bone quality on imaging studies.

Total ankle arthrodesis can result in a stable, pain-free ankle and improve quality of life [50]. However, total ankle arthrodesis is associated with higher rates of arthrosis in the adjacent joints than TAA, particularly of the hindfoot. One study followed 23 patients who had an isolated ankle arthrodesis for posttraumatic arthritis for a mean of 22 years [51]. In this study, 91 percent of patients developed moderate or severe OA of the subtalar joint ipsilateral (but not contralateral) to the surgery. Other joints in the ipsilateral foot also demonstrated accelerated OA on radiographs.

●Outcomes with ankle procedures – Most studies indicate that the two procedures are associated with similar improvements in function. However, direct comparison is fraught, due to methodological problems in these studies and differences in the specific complications associated with each intervention. For example:

•A 2014 systematic review of data comparing TAA versus arthrodesis found three retrospective studies and only one prospective study, which was nonrandomized [52]. There were multiple other methodological problems noted with the studies. Two of the studies showed statistically significant improvements in function in the TAA group when compared with arthrodesis, but the other two studies showed no differences between the two procedures.

•A 2022 trial randomized 303 patients with end-stage ankle OA to receive either TAA or ankle arthrodesis [53]. After 52 weeks, both procedures were associated with functional improvement. TAA was associated with a higher risk of wound healing complications and nerve injuries, while ankle arthrodesis was associated with a higher risk of thromboembolism. Additionally, ankle arthrodesis in this study had a symptomatic nonunion rate of 7 percent.

GENERAL SURGICAL COMPLICATIONS — The safety and reliability of total joint arthroplasty have improved markedly since the initial use of these procedures. However, there are a number of potential complications, the most important of which are infection, thromboembolic disease, dislocation, and implant loosening. These are discussed elsewhere. (See "Complications of total hip arthroplasty" and "Complications of total knee arthroplasty".)

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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Deciding to have a knee replacement (The Basics)" and "Patient education: Deciding to have a hip replacement (The Basics)")

●Beyond the Basics topics (see "Patient education: Total knee replacement (Beyond the Basics)" and "Patient education: Total hip replacement (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Perioperative management – Prior to surgery, the clinician should confirm that end-stage arthritis is the cause of the patient’s symptoms. Radiographs of the involved joints and the cervical spine should be obtained to confirm the presence of end-stage arthritis and to exclude cervical subluxation, which may complicate intubation for general anesthesia. Other issues regarding the perioperative management of patients with rheumatoid arthritis (RA) is discussed elsewhere. (See "Preoperative evaluation and perioperative management of patients with rheumatic diseases".)

●Contraindications to surgery – Active infection is the primary absolute contraindication to surgery. Other risks can generally be mitigated with preoperative management. Delayed surgery may lead to worse outcomes due to progressive joint destruction and periarticular muscle atrophy. (See 'Contraindications' above and 'Timing of surgery' above.)

●Sequence of procedures – When multiple surgeries are indicated, upper extremity surgery should generally occur prior to lower extremity surgery. When multiple joints in the same extremity requires surgical intervention, the surgeon will generally address proximal joint disease prior to distal joint disease. (See 'Sequence of procedures' above.)

•In the upper extremity, wrist surgery should occur before hand surgery.

•In the lower extremity, hip surgery should occur before knee surgery, hip and knee surgery should occur prior to foot and ankle surgery, and ankle and hindfoot surgery should occur before forefoot surgery.

●Shoulder surgical options – For patients with an intact rotator cuff, we suggest a standard total shoulder arthroplasty (TSA) (Grade 2C). For patients without an intact rotator cuff, we suggest reverse total shoulder arthroplasty (RSA) (Grade 2C). (See 'Shoulder' above.)

●Elbow surgical options – For most patients with severe elbow joint destruction, we suggest total elbow arthroplasty (TEA) over hemiarthroplasty or lateral resurfacing elbow (LRE) arthroplasty (Grade 2C). (See 'Elbow' above.)

●Wrist surgical options – For patients with severe wrist destruction, either arthroplasty or arthrodesis may be appropriate. (See 'Wrist' above and 'Ankle' above.)

●Hand joint surgical options – For patients with severe thumb interphalangeal (IP) joint destruction, we suggest arthrodesis (Grade 2C). For patients with severe metacarpophalangeal (MCP) joint destruction, we suggest arthroplasty (Grade 2C). (See 'Hand' above.)

●Hip surgical options – For most patients with severe hip joint destruction, we suggest total hip arthroplasty (THA) over hemiarthroplasty, hip resurfacing, or hip osteotomy (Grade 2C). (See 'Hip' above.)

●Knee surgical options – For most patients with severe knee joint destruction, we suggest total knee arthroplasty (TKA) over unicompartmental knee arthroplasty or knee osteotomy (Grade 2C). (See 'Knee' above.)

●Ankle surgical options – For most patients with severe ankle joint destruction, we suggest total ankle arthroplasty (TAA) over arthrodesis (Grade 2C). (See 'Wrist' above and 'Ankle' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Michael H Weisman, MD, who contributed to an earlier version of this topic review.