Surgery for Juvenile Idiopathic Arthritis

Some 300,000 children ages 16 or younger have juvenile idiopathic arthritis (JIA), an umbrella term for various health conditions that can cause joint pain, swelling, stiffness, and loss of motion. Like other forms of arthritis, JIA starts when a child’s immune system becomes overactive, triggering an inflammatory response.

It’s not uncommon for JIA to be a long-term health condition, but there are many effective medications that can treat your child’s arthritis. Thanks to these drugs, inflammation is often brought under control before it reaches the point of causing joint damage. That means kids diagnosed with JIA today are much less likely to need surgery than in generations past.

Medication, along with active treatment tools like exercise and assistive devices such as splints, mean that your child’s joint pain can often be kept to a minimum.

Still, though considered a last resort, surgery may sometimes benefit some of the most severe cases of JIA. This could be either because medication is unable to stop the progression of joint damage, or your child was not diagnosed with JIA until after joint damage had already occurred. In these cases, surgery may offer pain relief with JIA and could also restore function to damaged joints.

Who Needs Surgery for JIA?

Step one, say experts, is to try and avoid invasive procedures for JIA kids. “We try to treat children aggressively with medication so we can preserve their joints and avoid surgery,” says Farzana Nuruzzaman, M.D., a pediatric rheumatologist at Stony Brook Children’s Hospital and clinical assistant professor at the Renaissance School of Medicine at Stony Brook University in Stony Brook, NY. “Unfortunately, in some cases the arthritis has caused so much damage that certain types of surgery are needed.” In those cases, if your child is not improving on medication and her quality of life is suffering, surgery may be an option.

If your child’s jaw is affected by arthritis pain, for instance, surgery might be recommended, says Beth Susan Gottlieb, M.D., chief of the division of pediatric rheumatology at Northwell Health in New Hyde Park, NY. “Arthritis in the jaw can slow down the growth of the lower jaw, which causes a smaller jaw,” Dr. Gottlieb explains. “Surgery can improve the appearance of the face and make the joint healthier.”

Types of JIA Surgery

If your child is a candidate for JIA surgery, it helps to know what to expect. The surgical procedures that may be recommended include:

Osteotomy

In an osteotomy, explains Dr. Nuruzzaman, a bone is cut and repositioned to fix a bone deformity. Then the bone is reset into a better position. An osteotomy could be performed on the foot, hip, knee, or the temporomandibular joint (TMJ) in the jaw. Jaw surgery can not only make eating and chewing easier but can improve a child’s facial structure and self-confidence. This procedure is considered low-risk and safer than a total knee or hip replacement, according to the American College of Rheumatology.

Joint Fusion (Arthrodesis)

In a joint fusion, “the surgeon removes the damaged cartilage from the ends of two bones that form a joint and then holds [the bones] in place with a pin or a rod,” Dr. Nuruzzaman explains. Over time, the two bones fuse to form a single unit, much as a broken bone fuses when it heals. While arthrodesis can stabilize a joint and help it bear weight better, the fusion of these bones will result in the loss of some mobility. It’s usually performed on joints in the foot and ankle, hand and wrist, or spine, per the Arthritis Foundation.

Synovectomy

The synovium is a thin membrane that lines the joint capsule, but when JIA causes chronic inflammation of this lining, it grows much thicker and can affect the structure and function of the joint. In this procedure, explains Dr. Nuruzzaman, the surgeon removes inflamed synovial lining that develops from chronic inflammation.A synovectomy alsocan be done arthroscopically, says Daniel Lovell, M.D., professor of pediatrics at the University of Cincinnati School of Medicine at the Cincinnati Children’s Hospital Medical Center. “The surgeon can go in using a scope and can also do an injection of steroids at the same time, which can reduce pain,” he says.

Epiphysiodesis

This procedure can help correct a difference in leg lengths, Dr. Nuruzzaman explains. (Leg-length discrepancy is a common symptom of JIA, per the American Academy of Orthopeadic Surgeons). Epiphysiodesis is usually is for children whose anticipated leg-length discrepancy is nearly an inch and who have a year or two of growth remaining. In a temporary epiphysiodesis, metal plates may be used to temporarily halt bone growth in the longer leg. With a permanent epiphysiodesis, part of the growth plate is removed.

“The growth plate of the longer leg is removed or replaced with a metal plate so the longer leg growth stops,” Dr. Nuruzzaman says. In addition, Dr. Lovell explains, if a leg has excessive angulation due to arthritis causing one side of the knee to grow faster, then a temporary epiphysiodesis may be used to straighten the leg by limiting the growth on the faster growing side of the knee joint.

Total Joint Replacement (Arthroplasty)

An arthroplasty “is when the damaged joint is removed and replaced with an artificial joint,” Dr. Nuruzzaman says. Considered a last-ditch option for children, it is usually reserved for a joint that is so damaged, painful, and stiff that it interferes with a child’s quality of life and ability to function. The hip is the joint that is most commonly replaced, followed by the knee. “Total joint replacement is usually done in later adolescence or young adulthood,” says Dr. Lovell.

The Pros and Cons of Surgery for JIA

All surgeries have a potential risk, and the surgeon should carefully explain both risks and benefits. And keep in mind: surgery is generally not a cure. “Surgeries do not protect against the progression of the underlying inflammatory disorder,” Dr. Nuruzzaman says.

Moreover, some surgeries may need to be repeated. For instance, performing TMJ surgery before facial growth is complete (15 years for girls and 17 to 18 years for boys) may mean that repeat operations may be necessary.

One con of joint fusion is that after the surgery, your child will not be able to bend the joint. And sometimes, the bone does not fuse, the wound may not properly heal, or arthritis develops in nearby joints due to stress from the fusion. It is important that you and your child understand both the benefits and risks of joint fusion.

Another consideration: Artificial joints cannot grow like natural joints so if the joint is replaced before growth is complete, then the growth in the area of the replaced joint will stop. In addition, an artificial joint does not last forever. For this reason, repeat surgeries are typically needed and can be more challenging to perform.

The main benefit of surgery for JIA is that for many children with juvenile arthritis, surgery can offer pain relief and improve their quality of life.

What You Can Expect After Surgery

Recuperation from surgery for JIA varies depending on the surgery, the joint, your child’s overall health, and more. Full recovery from a joint fusion may take months. After an epiphysiodesis, the recovery is brief and has few complications, per the Arthritis Foundation. One possible complication is that the metal plates could loosen, or a leg that is corrected temporarily could revert to its previous length.

Osteotomy procedures are generally low risk, but recovery can be rough: The Arthritis Foundation notes that for a few months after the procedure, kids have to wear elastic bands to support the jaw. They may also need to use a palatal splint and eat a soft diet.

After a synovectomy, symptoms like pain and swelling should get better. Usually, though, the synovium will grow back over time if there is not control of the inflammation in the joint with the medicines used to treat the arthritis, Dr. Lovell says. The synovectomy can be repeated if this happens.

Outlook for Children with JIA

The good news is that JIA is treatable, most children who have it can expect to live normal lives, and very few will need joint surgery, Dr. Lovell says. Some children will see their JIA go into remission.

And surgery can be a good option for some children with JIA. “We try to avoid surgery,” says Dr. Nuruzzaman. “But in some cases, it can improve a child’s quality of life.”