When Your Child With JIA Needs Surgery

By Mary Anne Dunkin | Updated April 27, 2022

In the last few decades, the need for surgery for juvenile idiopathic arthritis (JIA) has been dramatically reduced. Thanks to the emergence and more aggressive use of powerful drugs, your child faces a much lower risk of developing joint damage that’s substantial enough to require some type of surgical intervention. “We used to see children with severe joint destruction of multiple joints including both hips and knees, but now we rarely see those patients. The patients we do see typically are older than before and have oligoarticular disease-affecting one or two joints,” says Mark P. Figgie, MD, chief emeritus of the Surgical Arthritis Service at Hospital for Special Surgery (HSS).

By combining medication with other tools — such as regular stretching and exercise to prevent joint contractures, and assistive devices, such as splints, to support or reposition weakened joints — your child’s joints can be protected for a longer period of time and functional challenges reduced or prevented.

Still, surgery sometimes becomes unavoidable usually for one of two reasons: Either medication couldn’t stop the progression of joint damage, or your child was diagnosed later in the disease after significant damage had occurred. In such cases, surgery may provide pain relief and restore function.

The following tend to be the most commonly performed surgical procedures on children with arthritis.

Epiphysiodesis

The knee joint has growth plates that increase the length of the leg as kids grow. Arthritis can sometimes cause too much or too little growth in the growth centers of the leg bones, leading to a discrepancy in leg lengths. Epiphysiodesis is a surgery that stops or slows growth in the longer leg, allowing the shorter leg to catch up over time.

Why it’s done: To correct a difference in leg lengths.

How it’s done: There are several ways to perform epiphysiodesis. Some are permanent and others are temporary (called hemiepiphysiodesis) and reversible. A common surgery uses metal plates to temporarily halt bone growth in the longer leg. Permanent epiphysiodesis removes part of the growth plate. Both types of surgery require precise timing and the ability to correctly predict how much more the longer leg will grow.

What else you need to know: Epiphysiodesis usually is reserved for children whose anticipated leg-length discrepancy is greater than 2 centimeters (or almost an inch) and who have at least one to two years of growth remaining. The recovery period is brief, with few complications, though the screws used to fasten the metal plates can loosen, and a temporarily corrected leg can sometimes revert to its previous length. Epiphysiodesis can also cause kids to be slightly shorter than without the surgery.

Joint Fusion (arthrodesis)

In this procedure, also called bone fusion, the surgeon removes damaged cartilage from the ends of two bones that form a joint and then positions the bones together and holds them in place with a pin or rod. Over time, the two bones fuse to form a single unit, much as a broken bone fuses when it heals.

Why it’s done: The main goal is to relieve severe pain by stopping the joint from moving.  Arthrodesis can also make a joint more stable and help it bear weight better. It’s usually performed on joints in the foot and ankle, hand and wrist, or spine.

What else you need to know: Once a joint is fused, your child will not be able to bend it. Sometimes the bones may not fuse or the wound might not heal properly. Arthritis can also develop in nearby joints because of increased stress from the fusion. The surgery is painful and it may take months to fully recover. Be sure you and your child understand the risks and benefits of this type of surgery.

Synovectomy

This procedure removes excess synovial tissue. The synovium is normally a thin membrane that lines the joint capsule. With chronic inflammation of this lining (as occurs with juvenile arthritis), it not only produces extra fluid, but grows much thicker and can affect joint structure and function. The vast majority of synovectomies are performed by arthroscopy, a procedure in which surgical tools are inserted through a few small incisions, eliminating the need to open the joint.

Why it’s done: Synovectomy is designed to remove excess synovial lining that isn’t responding to treatments, including corticosteroid injections into the joint. The procedure is usually performed on the knee and occasionally the wrist and elbow.

What else you need to know: Although synovectomy can relieve pain and swelling, it doesn’t stop progression of the disease. In most cases, the synovium grows back in a matter of months or years, depending on the response to medications. For some children, joint pain and swelling are so severe that surgery is worthwhile for even a short period of relief. If it’s successful, the procedure can be repeated when the synovium grows back.

Osteotomy

This surgery helps correct a bone deformity by cutting and repositioning the bone and then resetting it in a better position. It’s usually performed on the knee, hip, foot and temporomandibular joint (TMJ) in the jaw.

Why it’s done: Correcting bone deformities helps maintain the proper anatomy and function of the joint. For kids with TMJ disease, osteotomy can improve facial structure and self-confidence and make eating and chewing easier. Small studies of outcomes in TMJ surgery have shown positive results in kids whose facial growth is complete — 15 years for girls and 17 to 18 years for boys. Performing surgery sooner is likely to lead to repeat operations.

What else you need to know: Osteotomy is generally low-risk and safer than total hip or knee replacement. Post-surgery recovery for kids with jaw deformities can be rough; they wear elastic bands to support the jaw, use a palatal splint and eat a soft diet for a few months. But for most, the life-altering changes they experience are worth it.

Total joint replacement (arthroplasty)

This surgery involves removing a damaged joint and replacing it with an artificial ceramic or plastic joint.

Why it’s done: Although common in older adults, this surgery is considered a last-ditch option for kids with JA. It’s usually reserved for joints that are so severely damaged, painful and stiff that they interfere with a child’s functioning and quality of life. The most commonly replaced joint is the hip, followed by the knee.

What else you need to know: Total joint replacement in children tends to have a number of drawbacks and complications. Replacing joints can stunt growth, and the longevity of prosthetic joints is limited. Although doctors delay the surgery as long as possible for young people, one or more repeat surgeries are usually needed. Second and third surgeries are far more challenging and less successful than the original joint replacement. Complications can include premature failure of the synthetic joint, deep infections that could potentially require more surgery, bone perforation and joint dislocation.