When Your Child With JIA Needs Surgery
While surgery is less common in children with arthritis, sometimes it is necessary. Here's what you need to know.
By Mary Anne Dunkin
In the last two 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,” observed Mark P. Figgie, MD, chief 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 functioning challenges may be reduced or, ideally, eliminated.
Still, surgery sometimes becomes unavoidable, typically for one of two reasons. Either an effective medication regimen couldn’t be identified to stop the progression of joint damage, or your child may have been diagnosed later in the disease process, after significant inflammatory fallout already has occurred. Surgery, in such cases, can provide relief and restore function.
Seeking Surgical Relief
Surgical procedures can provide several potential benefits, including reducing pain and increasing your child’s ability to move and use her joint(s). Depending on the procedure, an orthopedic surgeon may remove inflamed tissue or replace an entire joint.
Procedure by Procedure
The following surgical procedures tend to be the most commonly performed on children with arthritis; the more frequent surgical interventions are ranked closer to the top:
Types of Procedures
Epiphysiodesis
Why it’s done: To correct a difference in leg lengths that may be caused by disrupted growth of the limb with arthritis.
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 two years of growth remaining. The recovery period is brief, and there are few complications.
Joint Fusion (arthrodesis)
Why it’s done: Arthrodesis can correct joint deformity. It can make the joint more stable, help it bear weight better and relieve pain. It’s most likely to be done on specific joints, including the foot/ankle, hand/wrist and spine.
What else you need to know: Once a joint is fused, your child will not be able to bend it. Fusing one joint can place stress on nearby joints, so major joints including hips and knees are rarely fused.
Joint Replacement (arthroplasty)
Why it’s done: Total joint replacement can often dramatically reduce pain and improve motion, mobility and function. It is usually reserved as the final option for joints that are so severely damaged, painful and stiff that they interfere with the child’s functioning and quality of life. The most commonly replaced joint due to JIA is the hip, followed by the knee; rarely is the ankle, elbow or shoulder replaced.
What else you need to know: Total joint replacement does have some drawbacks. Replacing joints can stunt growth, and the longevity of prosthetic joints is limited. Most doctors delay the surgery as long as possible for young people. Complications can include premature failure of the synthetic joint or an infection that could potentially necessitate additional surgery. Frequently implants need to be custom made for the JIA patient due to bone size and deformity.
Synovectomy
Why it’s done: Synovectomy is designed to remove excess synovial lining that isn’t responding to treatments, including intra-articular corticosteroid injections. The procedure most often is done 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.
Less Common Procedures
Osteotomy
Soft Tissue Release
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