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

Rheumatoid Arthritis — Knee

Rheumatoid arthritis (RA) is an autoimmune disease in which the immune system attacks the lining of the joints (the synovium), causing chronic inflammation, cartilage destruction, and bone erosion. The knee is among the most commonly affected large joints. Today, rheumatology has transformed RA management: disease-modifying antirheumatic drugs (DMARDs) and biologic therapies have reduced the number of RA patients progressing to end-stage joint destruction. But when the knee is severely damaged and non-operative treatment has been exhausted, total knee arthroplasty (TKA) reliably restores function with excellent outcomes. Maryland Orthopedic Specialists works closely with our patients' rheumatologists to deliver coordinated care.

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What is rheumatoid arthritis — knee?

In RA, the synovial membrane lining the knee joint becomes chronically inflamed (synovitis). Activated synoviocytes and immune cells release proteolytic enzymes (MMPs) and cytokines that degrade cartilage and erode the adjacent subchondral bone. Synovectomy and knee replacement used to be the only good treatments. Most patients are managed medically now.

In RA, the synovial membrane lining the knee joint becomes chronically inflamed (synovitis). Activated synoviocytes and immune cells release proteolytic enzymes (MMPs) and cytokines (TNF-α, IL-1, IL-6) that degrade cartilage and erode the adjacent subchondral bone. Unlike osteoarthritis, which typically affects one or two compartments, RA tends to cause pancompartmental (all three compartments) symmetric joint destruction and may affect both knees simultaneously. Periarticular osteoporosis, soft tissue swelling, and joint deformity develop over years without adequate disease control.

Symptoms — do you recognize these?

  • Bilateral knee swelling, warmth, and pain — often symmetric
  • Morning stiffness lasting more than one hour (a hallmark distinguishing RA from OA)
  • Fatigue and systemic symptoms (weight loss, low-grade fever)
  • Progressive loss of range of motion
  • Deformity: valgus (knock-knee) alignment is more common in RA than varus
  • Soft tissue rheumatoid nodules in some patients

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

How we diagnose it

RA is a clinical and serological diagnosis made with rheumatology. For patients referred to us with RA affecting the knee:

  • Weight-bearing X-rays: Uniform joint-space narrowing across all compartments, periarticular erosions, osteopenia, and loss of normal joint contour.
  • Laboratory workup: Rheumatoid factor (RF), anti-CCP antibodies, ESR, CRP. These provide disease activity context and help tailor peri-operative medication management.
  • MRI: Used selectively to assess cartilage, synovitis, and soft tissue involvement.

Treatment options

All RA patients are managed in partnership with a rheumatologist. Disease-modifying therapy is the foundation, with surgery reserved for end-stage joint destruction that fails medical management.

Non-Surgical (First-Line)

Medical management is the cornerstone of RA treatment. Methotrexate remains the cornerstone DMARD. Biologic agents, including TNF-α inhibitors (etanercept, adalimumab), IL-6 inhibitors (tocilizumab), B-cell depletion (rituximab), and JAK inhibitors, have dramatically changed disease trajectories and reduced the need for surgery over the past two decades. Intra-articular corticosteroid injections provide temporary relief of synovitis and pain flares. Physical therapy maintains range of motion and muscle strength despite inflammation.

Surgical Procedure

Total Knee Replacement

Complete resurfacing of the knee joint (femur, tibia, and patella) with metal and polyethylene implants to eliminate arthritis pain and restore mechanical alignment. Performed in a hospital or surgical facility with full perioperative support.

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Recovery & rehabilitation

Frequently Asked Questions

Do I need to stop my RA medications before surgery?
Yes. Most biologic agents are held for approximately one dosing interval before elective joint replacement to reduce infection risk. Your rheumatologist and orthopedic surgeon coordinate this plan. DMARDs such as methotrexate may be continued or held depending on surgeon preference and patient disease control.
Can both knees be done at the same time?
Simultaneous bilateral TKA carries higher risk in RA patients, who often have cardiac and pulmonary comorbidities. Sequential surgery, typically staged 6–12 weeks apart, is more common.
How is knee replacement for rheumatoid arthritis different from replacement for osteoarthritis?
Knee replacement for RA is technically similar to replacement for osteoarthritis, but several RA-specific factors influence planning and recovery. RA patients tend to be younger and may have more bone loss, deformity, and soft-tissue laxity at the time of surgery. A more constrained implant design may be needed to restore stability in knees with significant ligament involvement. Coordination with your rheumatologist to manage medications and disease activity before and after surgery is an essential part of the process at MOS.
Will my knee replacement relieve all of my RA-related knee symptoms?
Knee replacement very effectively addresses pain and stiffness caused by joint destruction, and most RA patients report dramatic improvement in knee function after surgery. However, it does not treat the systemic inflammatory disease itself. RA affecting other joints, tendons, and soft tissues around the knee will continue to be managed by your rheumatologist. In some cases, soft-tissue inflammation outside the replaced joint can cause residual symptoms that require ongoing medical management.
How long does recovery take after knee replacement for rheumatoid arthritis?
Most patients with RA are walking with assistance on the day of surgery and return home within one to two days. Active physical therapy typically begins immediately and continues for six to twelve weeks. Functional recovery (including walking without a device and returning to daily activities) is usually achieved within six to twelve weeks, though maximum strength and endurance may take up to six months. Patients with significant pre-operative weakness or deformity may take longer, and your MOS care team will set realistic, personalized goals for your recovery.

Meet the specialists

Christopher S. Raffo, MD

Christopher S. Raffo, MD

Orthopedic Surgery · Sports Medicine · Knee & Shoulder Arthroscopy · Joint Replacement

Meet Dr. Raffo →
James S. Gardiner, MD

James S. Gardiner, MD

Orthopedic Surgery · Sports Medicine · Knee & Shoulder Arthroscopy · Knee Replacement

Meet Dr. Gardiner →
Brian McCormick, MD

Brian McCormick, MD

Adult Reconstruction · Hip and Knee Replacement

Meet Dr. McCormick →

Related conditions

Total Knee Replacement
Medically reviewed by Brian McCormick, MD
Last reviewed June 15, 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 the perioperative management of antirheumatic medication in patients with rheumatic diseases. J Arthroplasty. 2022;37(8):1595–1606. https://doi.org/10.1016/j.arth.2022.05.007
  2. Figgie MP, Goldberg VM, Figgie HE, Sobel M. The results of treatment of synovial sarcoma of the extremities. Clin Orthop Relat Res. 1992;(282):217–222. https://doi.org/10.1097/00003086-199209000-00030
  3. Huo MH, Zatorski LE, Keggi KJ. Oblique femoral osteotomy in total hip arthroplasty. J Arthroplasty. 1995;10(3):319–327. https://doi.org/10.1016/S0883-5403(05)80182-X
  4. Sany J, Anaya JM, Canovas F, et al. Influence of methotrexate on the frequency of postoperative infectious complications in patients with rheumatoid arthritis. J Rheumatol. 1993;20(7):1129–1132. PMID: 8371191
  5. American Academy of Orthopaedic Surgeons. Arthritis of the Knee. OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/arthritis-of-the-knee/
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