Rheumatoid Arthritis of the Hip
Rheumatoid arthritis is an autoimmune disease in which the immune system attacks the synovial lining of the joints. Hip involvement occurs in 15 to 28 per cent of rheumatoid arthritis patients and can progress to severe cartilage and bone destruction. Mr Shakir Hussain, Consultant Orthopaedic Surgeon at the Royal Orthopaedic Hospital Birmingham, performs total hip replacement for rheumatoid hip disease that has failed medical therapy.
What is rheumatoid arthritis of the hip?
Rheumatoid arthritis (RA) is a chronic autoimmune disease in which the body's immune system mistakenly attacks the synovial lining of the joints. In the hip, this causes synovitis, pannus formation, and progressive destruction of the cartilage and bone. It is distinct from osteoarthritis (wear-and-tear cartilage loss) and from avascular necrosis (interruption of blood supply to bone).
The hip is a ball-and-socket joint between the femoral head (the top of the thigh bone) and the acetabulum (the socket in the pelvis). Each joint surface is lined by a thin membrane called the synovium, which produces the fluid that lubricates the joint.
In rheumatoid arthritis, the immune system targets this synovium. Inflamed synovial tissue thickens into an aggressive layer called pannus, which invades the cartilage and erodes the underlying bone. Over time, the joint space narrows symmetrically, the femoral head can migrate medially through the acetabular floor (protrusio acetabuli), and the hip becomes painful, stiff, and progressively destroyed.
The hip is involved in 15 to 28 per cent of rheumatoid arthritis patients. It is rarely the only joint affected; in most patients the hands and feet show signs first, with the hips and knees following as the disease progresses.
What does rheumatoid arthritis of the hip feel like?
Rheumatoid arthritis of the hip typically causes groin pain combined with prolonged morning stiffness lasting more than 30 minutes, often in patients who already have inflammation in other joints (hands, feet, knees). Systemic symptoms such as fatigue, low-grade fever, and weight loss are common. The pattern is usually bilateral and symmetrical, distinguishing RA from osteoarthritis.
The hip joint in RA is rarely the first joint to declare itself. Most patients are diagnosed with rheumatoid arthritis years before the hips become involved. When hip symptoms do develop, they often appear during a flare of disease activity or as joint damage accumulates from years of inflammation.
Morning stiffness over 30 minutes
The hallmark feature of inflammatory arthritis. Stiffness on waking that takes more than half an hour to settle, often lasting one to two hours in active disease. Compare with osteoarthritis, where stiffness eases within 30 minutes.
Bilateral and symmetrical joint involvement
Both hips often affected together, alongside the same joints on both sides of the body (both hands, both wrists). One-sided RA hip is unusual and prompts re-evaluation of the diagnosis.
Groin pain
Deep aching pain in the groin, often spreading to the thigh. The pain is inflammatory in character, worse on getting going, easing somewhat with gentle movement, returning with rest.
Systemic features
Fatigue, low-grade fever, weight loss, and a general feeling of being unwell during disease flares. These are part of the RA process and rarely seen in osteoarthritis.
Walking difficulty
Reduced walking distance and a noticeable limp as cartilage erosion progresses. Multi-joint involvement compounds the difficulty when knees, ankles, and feet are also affected.
Disease flares
Periods of increased pain, swelling, and stiffness lasting days to weeks, often triggered by stress, infection, or missed medication. Flares are managed jointly by you and your rheumatologist.
What causes rheumatoid arthritis?
Rheumatoid arthritis is an autoimmune disease with both genetic and environmental triggers. Genes in the HLA-DRB1 family create susceptibility; smoking is the single strongest modifiable risk factor; female sex, age 40 to 60, and family history all increase the likelihood. Recent research has linked oral and gut microbiome disruption, particularly gum disease, to disease onset.
Why the immune system turns on the body's own joints is not fully understood, but a clear picture has emerged of who is at risk. RA is multifactorial: a genetic susceptibility carried by certain immune-system genes makes the joints potentially vulnerable, and environmental triggers tip vulnerable people into active disease.
The most important risk factors are:
- Female sex. Women are affected two to three times more often than men, suggesting a hormonal contribution to disease activity.
- Age 40 to 60 at onset. RA can begin at any age but is most often diagnosed in middle adulthood.
- Family history of rheumatoid arthritis. First-degree relatives of patients with RA have a measurably higher risk than the general population.
- HLA-DRB1 shared epitope alleles. A group of immune-system gene variants that strongly predispose to RA and to more severe disease. Testing is occasionally helpful but not routinely needed.
- Smoking. The single strongest modifiable risk factor, particularly in patients carrying the HLA-DRB1 alleles and in those whose blood tests show anti-CCP antibodies.
- Periodontal disease. Recent immunology research has implicated chronic gum infection as a trigger for the citrullination of self-proteins that prompts the autoimmune response.
- Obesity. A weaker but consistent risk factor, also worsens response to treatment.
How is rheumatoid arthritis of the hip diagnosed?
Rheumatoid arthritis is diagnosed using the 2010 ACR/EULAR criteria, which combine joint involvement, blood tests (rheumatoid factor and anti-CCP antibodies), inflammatory markers (CRP and ESR), and symptom duration into a single score. The diagnosis is made by a rheumatologist. Hip involvement is then confirmed on imaging, with X-ray and MRI used to grade joint damage.
Most patients are already under rheumatology care by the time hip symptoms develop. If hip pain is the presenting feature in a patient not yet diagnosed with RA, blood tests and a rheumatology referral are the first step. The orthopaedic surgeon's role is to assess and treat the hip damage rather than diagnose the underlying disease.
Investigations used in rheumatoid arthritis of the hip:
- Rheumatoid factor (RF) and anti-CCP antibodies. The two key blood markers. Anti-CCP is more specific for RA. About 70 to 80 per cent of patients are positive for one or both.
- Inflammatory markers (CRP and ESR). Used to assess disease activity and response to treatment over time.
- Ultrasound of the joints. Highly sensitive for synovitis and early erosions, including in the hip when accessibility allows. Useful in early disease before X-ray changes appear.
- MRI. The most sensitive imaging for early hip disease and for showing bone marrow oedema, an indicator of active inflammation.
- AP pelvic X-ray. Shows late changes: concentric (uniform) joint space narrowing, periarticular osteopenia, marginal erosions, and protrusio acetabuli (medial migration of the femoral head). The concentric pattern is a key feature distinguishing RA from the superolateral wear of osteoarthritis.
- Cervical spine X-ray. Mr Hussain checks this before recommending general anaesthesia because RA can cause atlanto-axial subluxation in the neck, with a prevalence of 3 to 44 per cent in long-standing disease.
How is rheumatoid arthritis treated medically?
Rheumatoid arthritis is managed by rheumatologists using a treat-to-target approach aimed at remission or low disease activity. First-line therapy is conventional disease-modifying anti-rheumatic drugs (DMARDs), particularly methotrexate. If response is inadequate, biologic agents such as anti-TNF drugs, IL-6 inhibitors, and rituximab are added. JAK inhibitors are now positioned after biologics following 2025 EULAR guidance.
Medical therapy for RA has been transformed over the last two decades. Early aggressive treatment can suppress disease activity, prevent joint damage, and allow many patients to live full and active lives. Mr Hussain works closely with rheumatologists to time any surgery so that medical therapy is optimised before and after.
The treat-to-target approach uses these drug groups:
- Conventional DMARDs (csDMARDs). Methotrexate is the first-line drug, often combined with sulfasalazine, hydroxychloroquine, or leflunomide. Short courses of oral or intramuscular steroids are used to control flares while DMARDs take effect (usually 6 to 12 weeks).
- Biologic DMARDs (bDMARDs). Added when csDMARDs alone do not control disease. Anti-TNF agents (adalimumab, etanercept, infliximab, golimumab, certolizumab); IL-6 inhibitors (tocilizumab, sarilumab); B-cell depleting therapy (rituximab); T-cell costimulation modulator (abatacept).
- Targeted synthetic DMARDs (JAK inhibitors). Tofacitinib, baricitinib, upadacitinib, filgotinib. The 2025 EULAR update repositioned these after biologics because of cardiovascular and malignancy risk signals.
- Treat-to-target. Disease activity is measured every three months using scores such as DAS28. Treatment is escalated until remission (DAS28 below 2.6) or low disease activity is achieved.
- Physiotherapy and exercise. Tailored programmes preserve joint function and slow the muscle wasting that accompanies chronic inflammation.
Medical therapy slows or stops disease progression but cannot reverse existing joint damage. When the hip has been destroyed by long-standing disease, total hip replacement becomes the right next step.
If you are taking prescribed medication for rheumatoid arthritis, please review Mr Hussain's patient guide on medications to pause before hip or knee surgery. The perioperative plan is agreed jointly with your rheumatologist following the 2022 American College of Rheumatology and American Association of Hip and Knee Surgeons guideline.
When should I consider hip replacement for rheumatoid arthritis?
NICE guidance (NG100) recommends referral for joint replacement when joint damage causes persistent pain or functional limitation despite optimal medical therapy. Crucially, NICE recommends earlier referral rather than waiting until long-standing deformity, instability, or tendon damage develops. Early consultation gives the best surgical outcome.
The traditional approach of "wait until it gets really bad" has been replaced by earlier surgical referral for RA. Long-standing untreated joint damage produces soft-tissue contractures, muscle wasting, and bone loss that make eventual surgery more complex and recovery slower.
Practical markers Mr Hussain looks for at consultation:
- Persistent groin pain despite optimised DMARD or biologic therapy
- Pain that wakes you at night, more than twice a week
- Imaging showing concentric joint space loss, marginal erosions, or protrusio acetabuli
- Reduced walking distance, difficulty climbing stairs or rising from a chair
- Restricted range of motion that interferes with dressing, bathing, or driving
- Multi-joint disease where the hips have become the dominant source of disability
- Failure to achieve sustained remission or low disease activity over 6 to 12 months despite optimal medical therapy
Mr Hussain coordinates the surgical timing directly with your rheumatologist so that disease activity is well-controlled at the time of operation. Biologic medications are usually held for one dosing interval before surgery, and recommenced once the wound is healed (around 14 days). Methotrexate and other conventional DMARDs are generally continued through surgery without interruption.
Private consultations with Mr Hussain are available at the Royal Orthopaedic Hospital, Priory Hospital Edgbaston, and Harborne Hospital. See the private consultation and surgery fees page for self-pay pricing and the list of recognised insurers, or book a consultation directly.
What surgical options are available for rheumatoid arthritis of the hip?
Total hip replacement is the standard surgical treatment for rheumatoid arthritis of the hip. Hip resurfacing is generally not recommended in RA because chronic inflammation and long-term steroid use weaken the femoral head bone, raising the risk of fracture and loosening. Mr Hussain selects implant fixation and bearing surfaces tailored to the bone quality typical of RA patients.
Mr Hussain trained in both hip replacement and hip resurfacing, and offers either where clinically appropriate. For rheumatoid arthritis specifically, the bone changes and pattern of joint destruction make total hip replacement the right choice in nearly all cases.
Total Hip Replacement
The damaged femoral head and the acetabular socket are both replaced with prosthetic components. For RA patients, implant choice typically favours uncemented fixation in younger patients with reasonable bone, or cemented fixation in older patients or those with very thin bone. Ceramic-on-ceramic or ceramic-on-polyethylene bearings are preferred for younger patients.
- The standard treatment for rheumatoid arthritis of the hip
- Inflamed synovial tissue is removed during surgery, treating the source of pain
- Bone graft is sometimes used to reconstruct an acetabulum with protrusio
- Comparable pain relief and function to osteoarthritis patients at follow-up
- Implant longevity continues to improve with modern bearings
Hip Resurfacing
Hip resurfacing relies on healthy femoral head bone, which is typically weakened in rheumatoid arthritis by chronic synovial inflammation and long-term corticosteroid exposure. Published series show RA resurfacing revision rates of around 9.5 per cent at 10 years versus 3 per cent in osteoarthritis. Resurfacing is also less attractive for RA patients because they typically have multi-joint disease, making bone preservation less relevant.
- Generally contraindicated in rheumatoid arthritis
- Higher risk of femoral neck fracture in inflammatory disease
- Higher aseptic loosening rates than in osteoarthritis
- Total hip replacement is the safer, more durable choice
For a deeper comparison of the two techniques across recovery, return to sport, and implant choice, read Mr Hussain's patient guide on hip resurfacing versus total hip replacement. Most RA patients should expect Mr Hussain to recommend hip replacement.
How successful is hip replacement for rheumatoid arthritis?
Total hip replacement delivers comparable pain relief and functional gain in rheumatoid arthritis patients to those seen in osteoarthritis. Complication rates are modestly higher in RA, driven by soft-tissue laxity, reduced bone density, and immunosuppression. With careful perioperative planning and coordination with rheumatology, modern results are excellent.
Patients with RA have historically been considered a higher-risk group for hip replacement. Contemporary data show pain and function results equal to those in osteoarthritis, with the main caveats being modestly higher rates of infection, dislocation, and revision. The 2025 Bone and Joint cohort analysis confirmed these patterns continue to apply, though the absolute risks remain low and have been falling year on year.
Expertise in rheumatoid arthritis hip treatment in Birmingham
Consultant at the Royal Orthopaedic Hospital
Mr Hussain practises at the Royal Orthopaedic Hospital Birmingham, one of the largest specialist orthopaedic hospitals in Europe, alongside Priory Hospital Edgbaston and Harborne Hospital.
3,000+ arthroplasty cases
From a total of more than 5,000 procedures performed, giving the operative volume and case complexity required for consistently excellent outcomes. Read more about Mr Hussain's training and background.
British Hip Society Travelling Fellowship
Trained at ENDO-Klinik Hamburg under Professor Thorsten Gehrke and Professor Mustafa Citak, the international reference centre for complex hip surgery.
Both hip replacement and hip resurfacing
Many surgeons offer only one technique. Mr Hussain trained in both, allowing the choice to be tailored to the individual patient rather than to a single technique.
Doctify Outstanding Patient Experience 2024, 2025, and 2026
Awarded in three consecutive years, recognising consistently high patient-reported outcomes and communication.
4.98 out of 5 from verified reviews on Doctify. Outstanding Patient Experience Award 2024, 2025, and 2026.
Frequently asked questions about rheumatoid arthritis of the hip
For more questions about surgery, recovery, fees, and what to expect, see the full frequently asked questions page or read recent patient testimonials.