PurposeTotal knee arthroplasty (TKA) in patients with osteoarthritis (OA) are considered to be a successful procedure, but with little being known about outcomes in patients with rheumatoid arthritis (RA). The aim of this study was to compare the outcomes of TKA in patients with RA versus OA.MethodsData were obtained from PubMed, Cochrane Library, EBSCO and Scopus for all available studies comparing the outcomes of THA in RA and OA patients (From January 1, 2000 to October 15, 2022). Outcomes of interest included infection, revision, venous thromboembolism (VTE), mortality, periprosthetic fractures, prosthetic loosening, length of stay, and satisfaction. Two reviewers independently assessed each study for quality and extracted data. The quality of the studies was scored using the Newcastle-Ottawa scale (NOS).ResultsTwenty-four articles with a total 8,033,554 patients were included in this review. The results found strong evidence for increased risk of overall infection (OR = 1.61, 95% CI, 1.24–2.07;P= 0.0003), deep infection (OR = 2.06, 95% CI, 1.37–3.09;P= 0.0005), VTE (OR = 0.76, 95% CI, 0.61–0.93;P= 0.008), pulmonary embolism (PE) (OR = 0.84, 95% CI, 0.78–0.90;P<0.00001), periprosthetic fractures (OR = 1.87, 95% CI, 1.60–2.17;P<0.00001); and reasonable evidence for increased risk of deep venous thrombosis (DVT) (OR = 0.74, 95% CI, 0.54–0.99;P= 0.05), and length of stay (OR = 0.07, 95% CI, 0.01–0.14;P= 0.03) after TKA in patients with RA versus OA. There were no significant differences in superficial site infection (OR = 0.84,95% CI, 0.47–1.52;P= 0.57), revision (OR = 1.33,95% CI, 0.79–2.23;P= 0.28), mortality (OR = 1.16,95% CI, 0.87–1.55;P= 0.32), and prosthetic loosening (OR = 1.75, 95% CI, 0.56–5.48;P= 0.34) between the groups.ConclusionOur study demonstrated that patients with RA have a higher risk of postoperative infection, VTE, periprosthetic fracture, and lengths of stay, but did not increase revision rate, prosthetic loosening and mortality compared to patients with OA following TKA. In conclusion, despite RA increased incidence of postoperative complications, TKA should continue to be presented as an effective surgical procedure for patients whose conditions are intractable to conservative and medical management of RA.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12891-023-06601-9.