Knee Surgery for Rheumatoid Arthritis

Medically Reviewed by Sabrina Felson, MD on March 29, 2022
5 min read

If you have rheumatoid arthritis, you are no stranger to joint pain. While RA can affect any joint in your body, about 30% of the time, it targets your knees. This can make it hard to do daily activities, like walking or climbing stairs. Eventually you may struggle to go to work and go about your usual life.

When rheumatoid arthritis destroys the knee joint and continues to cause pain or disability even though you take medication, knee surgery may be an option.

RA is an autoimmune disease. That means your immune system accidentally attacks its own tissues. In the case of RA, the body attacks multiple joints such as the hands, wrists, and knees. These attacks usually hit the same joint on both sides. The disease causes inflammation and damage to the lining of the joints.

The lining of the knee joint, commonly called the synovium, is full of inflammation in RA. That’s what causes the pain and stiffness you may know all too well. Over time, cartilage and ligaments in the knee get damaged, and the knee bone softens.

When you have RA, the synovium usually becomes inflamed and swollen. One of its jobs is to produce fluid that lubricates the joint. But in RA, it produces inflammatory fluid filled with immune cells and pain messengers. This destroys the cartilage and causes pain and swelling.

When you get an RA diagnosis, your doctor puts you on several medications to reduce pain and swelling and try to stop the disease from getting worse. Sometimes, though, that’s not enough. If you’re still in the early stages of disease, before there is actual destruction of your knee joint, and you’ve been on medications for at least 6 months, your doctor may recommend a synovectomy.

During a synovectomy, your orthopedic surgeon removes most of the synovium. They can do this in one of two ways: open synovectomy or arthroscopic synovectomy.

Open synovectomy. In this procedure, the surgeon makes a cut over the knee to get to the synovium. The surgeon then cuts out the lining. This can relieve symptoms, sometimes dramatically. One study found that surgery resulted in significant pain relief in about two-thirds of all RA patients. Just keep in mind that it won’t stop the disease from getting worse. Over time, tissue grows back, and your symptoms may return. About half of all RA patients who have this type of surgery need another knee surgery within 5 years.

Arthroscopic synovectomy. During an arthroscopy, your surgeon makes a few very small cuts over your knee, then uses a thin rod containing a video camera and a light source and tiny instruments to do the procedure. Some advantages of arthroscopy over open synovectomy include:

  • Lower infection rate
  • Less chance of loss of motion in the knee
  • Can be done outpatient
  • Faster healing and recovery

Arthroscopic synovectomy is thought to work as well as open synovectomy. Some research even suggests that if you have the surgery done arthroscopically, you’re less likely to need a knee replacement later on. But those studies were done before newer drugs for RA, like biologics, were approved, so it’s hard to know for sure.

After surgery, you’ll still need to take your RA medications to help prevent a recurrence. But you may be able to take a lower dose.

A couple of experimental forms of synovectomy are being studied at a few research centers across the country. In chemical synovectomy, doctors inject osmic acid into the knee to destroy the synovium. In radiosynovectomy, doctors use radiation to do the job.

If you have severe knee pain and continued destruction of the knee that isn’t getting better with RA medications, and you already have damage to your knee joint, your doctor may recommend a total knee replacement. This surgery is very successful for severe RA. More than 80% of patients are happy with the surgery and resume most normal activities for up to 15 years.

Though knee replacement works for many people, rates of knee replacements among RA patients have declined over the years. This is probably because new and better treatments, like biologics, for RA help people avoid surgery.

During a knee replacement, your doctor removes the damaged cartilage and bone and replaces it with a plastic or metal joint. The surgery itself takes a couple of hours and usually requires general anesthesia. You’ll stay in the hospital for 1-3 days.

About one in 25 people with RA develop an infection after a total knee replacement. This is a slightly higher infection rate than for people who get a knee replacement for another reason, like osteoarthritis. A few reasons why this may be include:

  • A weaker immune system
  • Frailer skin
  • Poor wound healing
  • More muscle weakness

You may have to stop some of your RA medications right before surgery, since they make it harder for your body to fight a post-surgery infection. But stopping your medication carries its own risks, including a flare-up of arthritis during your recovery. If this happens, you may not be able to do the physical therapy you’ll need to get better from surgery. Also, if you stop taking medication, even for a short period of time, it may not work as well when you start it back up.

Sometimes, people with RA need several surgeries, since the disease affects multiple joints. You might need hip, wrist, or elbow surgery. In these cases, your surgeon may operate on the most painful area first. Or, they might choose the joint that affects your daily life the most. Usually, that means the ankle and foot first, then the hip, then the knee.

People with RA are more likely than others to have complications from surgery. This can be because arthritis medications weaken your immune system. Or it could be because you have poorer bone and joint quality that can affect your ability to function and rehab after surgery. Your medical team will watch you closely for the first few weeks or months after surgery.

Since people with RA often have more complex medical conditions than others, it’s very important to make sure all your doctors are involved in your care. This includes not just your orthopedic surgeon, but your rheumatologist, your physical therapist, and even your psychologist or psychiatrist. Let them all know that you are considering knee surgery for your rheumatoid arthritis.