Rheumatoid arthritis is a systemic inflammatory disease characterized by chronic synovitis and progressive structural joint damage. [1,2] Although modern disease-modifying antirheumatic drugs have substantially changed the natural history of the disease, large-joint destruction can still occur in patients with longstanding or inadequately controlled disease. [3,4] The hip is less frequently involved than the small joints of the hands and feet but, when affected, may result in severe pain, functional limitation, reduced mobility, and substantial disability. Arthroplasty therefore remains an important treatment for end-stage rheumatoid hip disease. [5-7]. Total hip arthroplasty has undergone major advances in implant design, surgical technique, perioperative infection prevention, thromboprophylaxis, and postoperative rehabilitation. At the same time, improved control of rheumatoid inflammation has reduced the need for large-joint replacement in many populations. Longitudinal studies have demonstrated a substantial decline in the incidence of hip replacement among patients with rheumatoid arthritis during the era of modern disease-modifying treatment. [2,8] Patients with rheumatoid arthritis undergoing arthroplasty may nevertheless have a different complication profile from patients undergoing arthroplasty for primary osteoarthritis. Chronic inflammation may contribute to impaired bone quality and altered periarticular soft tissues, while immunomodulatory treatment can influence susceptibility to infection. Rheumatoid involvement of the acetabulum may also produce protrusio acetabuli and bone loss, making reconstruction technically challenging. [9] Historically reported complications following THA in RA include aseptic loosening, infection, dislocation, periprosthetic fracture, and revision surgery. A systematic review and meta-analysis by Ravi et al. demonstrated that patients with RA had a higher risk of dislocation following THA than patients with osteoarthritis. [3] Subsequent population-based studies have provided additional evidence that inflammatory arthritis is associated with multiple postoperative complications. [4,5] The complication profile has also changed over time. Taylor-Williams et al. reviewed four decades of evidence and demonstrated a reduction in the overall complication rate and in the incidence of revision and periprosthetic fracture, whereas infection and aseptic loosening remained relatively stable and dislocation showed less consistent improvement. [2] More recent studies have emphasized the importance of preoperative rheumatoid disease activity. Lai et al. demonstrated an association between higher Simplified Disease Activity Index values and postoperative complications following THA. [6] The objective of the present systematic review was to summarize the available evidence regarding complications encountered after total hip arthroplasty in patients with rheumatoid arthritis, with particular emphasis on infection, dislocation, aseptic loosening, periprosthetic fracture, revision, thromboembolic events, mortality, and the influence of disease activity.

This systematic review was structured according to the PRISMA 2020 recommendations. [1] The review focused on postoperative complications following primary total hip arthroplasty in patients with rheumatoid arthritis. Search strategy: The literature was examined for studies addressing complications following total hip arthroplasty in rheumatoid arthritis. A reproducible database search for a final submission may be conducted using combinations of the following terms: ("rheumatoid arthritis" OR "rheumatoid") AND ("total hip arthroplasty" OR "total hip replacement" OR "hip replacement") AND ("complication" OR "infection" OR "dislocation" OR "loosening" OR "revision" OR "periprosthetic fracture" OR "mortality" OR "venous thromboembolism") MEDLINE/PubMed, Embase, Scopus, and Cochrane Library are appropriate databases for the final reproducible search. The previously published systematic review by Taylor-Williams et al. used MEDLINE, EMBASE, Scopus, and Cochrane and searched publications from January 1980 through December 2019. [2] Eligibility criteria: Studies were considered eligible when they: 1. Included adult patients with rheumatoid arthritis. 2. Evaluated patients undergoing primary total hip arthroplasty or total hip replacement. 3. Reported at least one postoperative complication or clinically relevant arthroplasty outcome. 4. Were observational studies, cohort studies, registry studies, comparative studies, or systematic reviews/meta-analyses relevant to the review question. 5. Provided sufficient information regarding the population and postoperative outcomes. Studies unrelated to rheumatoid arthritis, studies focusing exclusively on total knee arthroplasty, case reports without relevant aggregate evidence, and publications without adequate outcome information were excluded. Outcomes: The principal outcomes were: 1. postoperative infection; 2. hip dislocation; 3. aseptic loosening; 4. periprosthetic fracture; 5. revision arthroplasty; • venous thromboembolism; • postoperative mortality; and • overall or composite complications. Where available, associations with rheumatoid disease activity and comparisons with osteoarthritis were also evaluated. Data synthesis: Because the included literature differed substantially in study design, population, follow-up period, definitions of complications, and statistical methodology, the findings were synthesized narratively. Published pooled estimates from previous systematic reviews and effect estimates from comparative cohort studies were reported without recalculating a new pooled effect estimate from heterogeneous studies

Characteristics of the evidence: The available literature included systematic reviews, population-based cohort studies, national registry studies, retrospective cohort studies, and large administrative database studies. The evidence spans several decades, allowing assessment of temporal changes in both the utilization of THA and postoperative complications. Taylor-Williams et al. conducted a systematic review and meta-analysis covering literature from 1980 through 2019. The search identified 1715 articles, of which 44 studies were included in the quantitative synthesis. [2] The review reported that the incidence of THA in RA declined from approximately 11 per 1000 patient-years in the 2000s to 7 per 1000 patient-years in the 2010s. The overall complication rate also decreased over time. Table 1. Major studies evaluating complications after total hip arthroplasty in rheumatoid arthritis Study Design/population Principal findings Ravi et al. [3] Systematic review/meta-analysis RA associated with increased risk of THA dislocation compared with OA Ravi et al. [5] Population-based cohort Increased postoperative complication risk, particularly dislocation, in RA Taylor-Williams et al. [2] Systematic review/meta-analysis; 1980–2019 Overall complication rate 12.8%; revision and aseptic loosening were major outcomes Taylor-Williams et al. [8] Long-term population-based cohort Declining incidence of hip replacement and postoperative complications over 35 years Zhang et al. [10] Systematic review/meta-analysis; 23 studies Increased risks of revision, dislocation, periprosthetic infection, and wound infection in RA Sakthivelnathan et al. [11] National Inpatient Sample study Increased blood-loss anemia, transfusion, periprosthetic fracture, and length of stay Lai et al. [6] Retrospective cohort; 337 RA patients Higher RA disease activity associated with postoperative complications Mori et al. [12] Japanese nationwide claims database Increased early dislocation and reoperation rates in RA Taylor-Williams et al. [13] Australian national registry Increased long-term revision risk, including infection and dislocation revisions Overall complication rates: The largest synthesized evidence comes from the systematic review by Taylor-Williams et al. [2] The pooled overall complication rate was 12.8% (95% CI 8.4–17.9). Individual complication rates are shown in Table 2. Table 2. Pooled complication rates following total hip arthroplasty in rheumatoid arthritis Complication Pooled rate (%) 95% CI (%) Overall complications 12.8 8.4–17.9 Revision 8.8 6.1–11.9 Aseptic loosening 4.0 2.2–6.4 Infection 2.6 1.4–4.2 Dislocation 0.8 0.2–1.7 Periprosthetic fracture 0.3 0.1–0.6 Venous thromboembolism 0.4 0–1.2 90-day mortality 0.6 0.2–1.1 Data derived from the systematic review and meta-analysis by Taylor-Williams et al. [2]. Infection: Infection is one of the most clinically important complications following arthroplasty in patients with rheumatoid arthritis. Chronic systemic inflammation, immunomodulatory therapy, comorbidities, and impaired tissue response may contribute to susceptibility to infection. The pooled infection rate in the systematic review by Taylor-Williams et al. was 2.6% (95% CI 1.4–4.2). [2] The rate remained relatively stable across the decades examined, despite improvements in arthroplasty and perioperative care. Comparative evidence suggests that the risk may be higher in RA than in osteoarthritis. Zhang et al., in a meta-analysis involving 23 studies and 877,695 patients, reported increased risks of periprosthetic infection and wound infection among patients with RA compared with those with osteoarthritis. [10] Similarly, a large Nordic registry study found an increased risk of revision for infection following THA among patients with RA. [14] More recent evidence suggests that disease activity may influence infection risk. In a retrospective cohort of 337 RA patients undergoing primary THA, Lai et al. found a higher frequency of postoperative infection among patients with higher disease activity. [6] Dislocation: Dislocation is a recognized complication of THA in rheumatoid arthritis. Several factors may contribute, including altered anatomy, soft-tissue compromise, muscle weakness, previous surgery, and inflammatory destruction of the hip. Ravi et al. performed a systematic review and meta-analysis comparing arthroplasty outcomes in RA and OA and reported a significantly increased risk of THA dislocation in RA, with an adjusted odds ratio of 2.16 (95% CI 1.52–3.07). [3] A population-based cohort study by Ravi et al. subsequently reported age- and sex-standardized dislocation rates of 2.45% in RA compared with 1.21% in OA, with an adjusted hazard ratio of 1.91 for dislocation within two years following arthroplasty. [5] The temporal pattern is somewhat variable. Taylor-Williams et al. reported pooled dislocation rates of 1.1% in studies from the 1990s, 0.4% during the 2000s, and 1.5% during the 2010s. [2] More recent studies continue to identify dislocation as an important complication. Mori et al. reported an increased risk of early postoperative dislocation among RA patients in a Japanese nationwide database study. [12] Aseptic loosening: Aseptic loosening has historically been a major concern following THA in RA. Chronic inflammatory activity, reduced bone quality, osteopenia, and older implant designs have all been considered potential contributors. The pooled rate of aseptic loosening in the Taylor-Williams review was 4.0% (95% CI 2.2–6.4). [2] Unlike revision and periprosthetic fracture, aseptic loosening did not show a substantial reduction over the four decades evaluated. Earlier systematic reviews of cemented and cementless THA have demonstrated heterogeneous results. Cemented arthroplasty literature suggested greater loosening in some older series, particularly with implants used before the widespread adoption of modern designs. [15] The literature concerning cementless implants has also reported concerns regarding acetabular migration and fracture in selected series. [16] The relationship between rheumatoid disease activity and aseptic loosening remains less consistent. In the recent cohort by Lai et al., the frequency of aseptic loosening did not differ significantly across disease-activity groups. [6] Periprosthetic fracture: Periprosthetic fracture is an important complication because rheumatoid arthritis may be associated with reduced bone mineral density and structural bone abnormalities. The pooled periprosthetic fracture rate in the Taylor-Williams review was 0.3% (95% CI 0.1–0.6). [2] Rates were higher in earlier decades and subsequently declined. In contrast, administrative database studies continue to identify periprosthetic fracture as a clinically relevant postoperative complication. Sakthivelnathan et al., using the National Inpatient Sample, reported increased rates of periprosthetic fracture among patients with RA undergoing primary hip arthroplasty. [11] Revision surgery: Revision is a clinically important composite outcome because it may result from infection, dislocation, aseptic loosening, fracture, implant failure, or other causes. Taylor-Williams et al. reported a pooled revision rate of 8.8% (95% CI 6.1–11.9). [2] Revision rates decreased from 8.1% in studies from the 1990s to 6.2% in studies from the 2010s. More recent registry evidence suggests that RA remains associated with increased long-term revision risk. In an Australian Orthopaedic Association National Joint Replacement Registry cohort, RA was associated with an increased hazard of all-cause revision, revision for infection, revision for dislocation, and early aseptic loosening compared with OA. [13] These findings suggest that improvements in short-term outcomes have not eliminated the increased long-term revision burden associated with RA. Venous thromboembolism and mortality: The pooled rate of venous thromboembolism in the Taylor-Williams review was 0.4% (95% CI 0–1.2%). Ninety-day mortality was 0.6% (95% CI 0.2–1.1%). [2] Comparative meta-analysis has not consistently demonstrated a significant difference in thromboembolic or mortality outcomes between RA and OA following THA. [3,10] The available evidence therefore suggests that infection, dislocation, loosening, fracture, and revision are more consistently demonstrated areas of excess risk than mortality or venous thromboembolism. Influence of rheumatoid disease activity: Disease activity appears to be an important potentially modifiable factor. Lai et al. evaluated 337 RA patients undergoing primary THA and found postoperative complications in 38 patients (11.3%). The complication rate increased with increasing disease activity, from 0% among patients in remission to 17.5% among those with high disease activity. The mean Simplified Disease Activity Index was independently associated with postoperative complications (OR 1.015, 95% CI 1.001–1.029; p=0.035). [6] Higher disease activity was particularly associated with dislocation and infection. These findings support the concept that control of systemic inflammation may be relevant to perioperative risk reduction.

The present review demonstrates that total hip arthroplasty remains an important intervention for patients with advanced rheumatoid hip disease, while the complication profile has evolved considerably over time. The evidence indicates that the requirement for hip arthroplasty has declined substantially with improvements in rheumatoid disease management. However, patients who undergo THA continue to experience clinically important complications, particularly revision, aseptic loosening, infection, and dislocation. The decline in THA utilization is consistent with the broader change in the management of rheumatoid arthritis. Taylor-Williams et al. reported a reduction in THA incidence from approximately 11 per 1000 patient-years during the 2000s to 7 per 1000 patient-years during the 2010s. [2] A separate longitudinal analysis over 35 years also demonstrated a marked reduction in the incidence of hip replacement. [8] These trends parallel the introduction and increasing use of effective disease-modifying therapies and tighter disease control. Dislocation represents one of the most consistently demonstrated complications in comparative studies. Ravi et al. reported an adjusted odds ratio of 2.16 for dislocation following THA in RA compared with OA. [3] The subsequent population-based study by Ravi et al. similarly demonstrated increased dislocation risk in RA. [5] Potential explanations include muscle weakness, inflammatory destruction, soft-tissue abnormalities, altered hip anatomy, and previous surgical procedures. Infection is another important concern. The pooled infection rate of 2.6% reported by Taylor-Williams et al. [2] is clinically relevant, particularly because infection may require prolonged antibiotic treatment, surgical debridement, component removal, or revision arthroplasty. The Nordic registry study demonstrated increased risk of revision for infection among RA patients, while the 2022 meta-analysis by Zhang et al. also demonstrated increased periprosthetic and wound infection risk. [10,14] These findings support careful perioperative assessment of immunosuppressive treatment and infection risk. Perioperative antirheumatic medication management is therefore an important component of care. Current American College of Rheumatology/American Association of Hip and Knee Surgeons recommendations support continuation of several conventional synthetic disease-modifying antirheumatic drugs through surgery while recommending withholding biologic agents for an appropriate interval before surgery. [17] These recommendations aim to balance the risks of postoperative infection and disease flare and should be integrated with individualized rheumatological and orthopedic management. Aseptic loosening has historically been another major concern. The pooled rate of 4.0% in the four-decade systematic review indicates that loosening remains clinically important. [2] Earlier implant designs and cemented components were associated with higher rates of failure in some older studies, whereas modern implants have improved long-term survivorship. Nevertheless, rheumatoid-associated bone loss and inflammatory activity may continue to affect implant fixation. The contemporary literature also emphasizes the role of disease activity. Lai et al. demonstrated a significant relationship between disease activity and postoperative complications. [6] Patients with high disease activity had a substantially greater complication frequency than those in remission. Although these findings originate from a retrospective cohort and cannot establish causality, they support preoperative optimization of disease control where clinically feasible. The evidence regarding mortality and thromboembolism is less consistent. The pooled 90-day mortality rate was 0.6%, while venous thromboembolism occurred in approximately 0.4% of patients in the Taylor-Williams review. [2] Comparative meta-analyses have not demonstrated a consistent statistically significant excess risk for these outcomes in RA following THA. [3,10] An important finding across the literature is the improvement in overall outcomes over time. The overall complication rate reported by Taylor-Williams et al. declined from 9.9% in the 1990s to 5.3% in the 2010s. [2] Revision and periprosthetic fracture showed reductions, while infection and aseptic loosening remained comparatively stable. The persistence of infection and loosening despite improvements in other outcomes suggests that these complications may be influenced by disease-specific factors that are not completely addressed by advances in surgical technique. The most recent registry evidence indicates that the residual risk is not limited to early postoperative complications. Taylor-Williams et al. reported increased all-cause revision risk in RA, as well as increased revision risks specifically related to infection and dislocation. [13] This emphasizes the importance of long-term surveillance following arthroplasty in rheumatoid patients. Limitations: This review has several limitations. First, the available studies were heterogeneous with respect to study design, patient selection, implant type, surgical approach, follow-up duration, definitions of complications, and calendar period. Second, much of the evidence is observational and therefore susceptible to residual confounding. Third, many studies combine different inflammatory arthritides or include heterogeneous arthroplasty populations. Fourth, treatment of rheumatoid arthritis has changed substantially over the decades, making direct comparison between older and contemporary cohorts difficult.

Total hip arthroplasty remains an important treatment for advanced hip involvement in rheumatoid arthritis. Although the requirement for arthroplasty and the overall complication burden have decreased over time, infection, dislocation, aseptic loosening, periprosthetic fracture, and revision remain important postoperative concerns. Contemporary evidence also indicates that higher rheumatoid disease activity is associated with increased postoperative complications. Careful disease control, individualized perioperative medication management, meticulous surgical technique, and appropriate long-term surveillance remain important components of care.

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