The Centers for Advanced Orthopaedics
Maryland Orthopedic Specialists
A Division of The Centers for Advanced Orthopaedics
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Hip

Rheumatoid Arthritis — Hip

Rheumatoid arthritis (RA) affects the hip in approximately 40–50% of patients with established disease. The autoimmune-driven synovitis that characterizes RA erodes cartilage, weakens subchondral bone, and can produce a distinctive (and challenging) deformity called protrusio acetabuli, in which the femoral head migrates medially through a weakened acetabular floor. As disease-modifying therapy has improved, fewer RA patients progress to end-stage hip destruction. When they do, total hip arthroplasty (THA) offers reliable, lasting pain relief. Maryland Orthopedic Specialists provides coordinated hip replacement care in close partnership with your rheumatologist.

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What is rheumatoid arthritis — hip?

In RA, the hip synovium is attacked by immune-mediated inflammation, releasing enzymes that destroy cartilage uniformly across the joint (axial joint-space narrowing is characteristic, in contrast to the superior narrowing of primary OA). The subchondral bone becomes osteoporotic and softens.

In RA, the hip synovium is attacked by immune-mediated inflammation, releasing enzymes that destroy cartilage uniformly across the joint (axial joint-space narrowing is characteristic, in contrast to the superior narrowing of primary OA). The subchondral bone becomes osteoporotic and softens. In severe, longstanding RA (particularly prior to the biologic era), the femoral head can erode medially through the acetabular floor, producing protrusio acetabuli: the femoral head sits inside rather than on top of the acetabulum. This changes the hip's center of rotation and creates significant reconstructive challenges at the time of THA.

Symptoms — do you recognize these?

  • Groin pain with weight-bearing and at rest
  • Stiffness that is often bilateral and accompanied by systemic RA symptoms (fatigue, morning stiffness in multiple joints)
  • Progressive limitation of hip range of motion — particularly abduction and internal rotation
  • Antalgic gait
  • In protrusio, the hip may feel "tight" and profoundly restricted even early in the disease course

Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations.

How we diagnose it

  • AP pelvis radiograph: Shows axial (medial) joint-space narrowing characteristic of inflammatory arthritis; identifies protrusio (femoral head medial to the ilioischial line, or Köhler's line); assesses acetabular bone stock.
  • Lateral hip X-ray: Evaluates femoral head sphericity and femoral neck anatomy.
  • CT scan: Defines the degree of protrusio, acetabular floor thickness, and bone stock in three dimensions. This is essential for reconstructive planning.
  • Serology: RF, anti-CCP, ESR, CRP for disease activity context and pre-operative risk stratification.

Treatment options

Non-Surgical

RA management is led by rheumatology. DMARDs (methotrexate) and biologic agents (TNF inhibitors, IL-6 inhibitors, JAK inhibitors) are the cornerstone of preventing hip disease progression. Analgesics, low-impact exercise, and activity modification address symptoms in moderate disease. Corticosteroid injections may provide temporary relief.

Surgical Procedure

Total Hip Arthroplasty (Hip Replacement)

Complete hip joint replacement removing the arthritic femoral head and acetabulum and replacing them with metal, ceramic, and polyethylene components. Anterior approach technique is available for eligible patients, preserving more muscle tissue.

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Recovery & rehabilitation

Frequently Asked Questions

Is RA hip disease different from RA knee disease?
Yes. The hip's ball-and-socket architecture means RA produces uniform axial narrowing and is more prone to protrusio deformity, whereas RA knees develop pancompartmental arthritis with valgus deformity. Both require careful pre-surgical planning.
Will my RA medications cause wound problems after surgery?
Biologic agents are held pre-operatively to minimize infection risk. Conventional DMARDs like methotrexate are generally continued. Your care team will provide specific medication instructions.
When should I consider hip replacement for rheumatoid arthritis?
Hip replacement for rheumatoid arthritis is considered when persistent hip pain and functional limitations significantly affect your quality of life despite optimized medical management of your RA. Because RA patients are often younger and more systemically ill than typical osteoarthritis patients, the decision involves close collaboration between your MOS surgeon and your rheumatologist. Hip replacement in RA reliably reduces pain and restores mobility, and outcomes are generally excellent when disease activity is well controlled at the time of surgery.
Does rheumatoid arthritis affect how a hip replacement is performed?
Yes. RA can cause generalized bone loss (osteoporosis), soft-tissue fragility, and joint deformity that makes surgery more technically demanding. The femoral bone may be weakened, requiring careful implant sizing and sometimes bone grafting. Cervical spine involvement in RA can also affect anesthesia (specifically positioning during surgery), so your anesthesia team will review cervical spine X-rays before the procedure. Your MOS surgeon coordinates with your full medical team to ensure every aspect of the procedure is safely tailored to your RA.
What is the long-term outlook after hip replacement for rheumatoid arthritis?
Hip replacement for RA provides excellent long-term pain relief and functional improvement for the vast majority of patients. Modern implant survival rates at 15 to 20 years are comparable to those for osteoarthritis when RA is well controlled. Continued management of your RA with your rheumatologist after surgery remains important, as active systemic disease can increase the risk of infection and affect bone quality over time. At MOS we coordinate long-term follow-up to protect both your implant and your overall joint health.

Meet the specialists

Brian McCormick, MD

Brian McCormick, MD

Adult Reconstruction · Hip and Knee Replacement

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Medically reviewed by Brian McCormick, MD
Last reviewed May 1, 2026

References

  1. Goodman SM, Springer BD, Chen AF, et al. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for perioperative management of antirheumatic medication. J Arthroplasty. 2022;37(8):1595–1606. https://doi.org/10.1016/j.arth.2022.05.007
  2. Papagelopoulos PJ, Trousdale RT, Lewallen DG. Total hip arthroplasty with femoral osteotomy for proximal femoral deformity. Clin Orthop Relat Res. 1996;332:151–162. https://doi.org/10.1097/00003086-199611000-00020
  3. Huo MH, Salvati EA, Lieberman JR, Burstein AH, Wilson PD. Custom-designed femoral prostheses in total hip arthroplasty done with cement for severe dysplasia of the hip. J Bone Joint Surg Am. 1993;75(10):1497–1504. https://doi.org/10.2106/00004623-199310000-00010
  4. Cameron HU, Botsford DJ, Park YS. Influence of the Crowe rating on the outcome of total hip arthroplasty in congenital hip dysplasia. J Arthroplasty. 1996;11(5):582–587. https://doi.org/10.1016/S0883-5403(96)80112-3
  5. American Academy of Orthopaedic Surgeons. Rheumatoid Arthritis of the Hip. OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/rheumatoid-arthritis-of-the-hip/
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