BIRMINGHAM, ENGLAND — Surgery can be an effective pain-relieving strategy for children with hip or knee joints severely disabled by juvenile idiopathic arthritis.
Total hip replacement is a good pain-relieving operation, and sometimes is indicated even in young patients, Dr. Johan Witt said at the annual meeting of the British Society for Rheumatology.
“Younger patients are better off getting a hip replacement while they still have bone to put this into,” said Dr. Witt, a consultant orthopedic surgeon at the University College of London Hospitals.
Joint replacements have the potential to last a long time, but close monitoring of the patients is warranted.
Synovectomy is an option that can help some patients with juvenile idiopathic arthritis (JIA), but it is used less and less frequently. “I've probably done one in the past year,” he said. “This requires intensive rehab to get anything out of it.”
Another option for a subgroup of patients is hip resurfacing. “There has been a push from patients over time, including a group of JIA patients,” he said. This procedure is indicated only for slightly older patients in whom the disease has largely resolved. “Some patients have an unrealistic view of what resurfacing can do. With some of the marketing around this, patients get confused.”
Another choice, osteotomy, rarely is indicated for patients with JIA. In this population, the joint is too stiff and severely involved, and the bone too osteopenic.
Hip involvement is the most common cause of limited mobility in JIA, affecting 30%–60% of patients. The ultimate results of nontreatment include a fixed flexion deformity, adduction, and greater internal than external hip rotation. Other potential consequences of hip deformity are excessive lumbar lordosis, fixed flexion deformity of the knees, genu valgum, and external tibial torsion.
Therefore, early identification of JIA is essential. “The younger you are when arthritis starts, the more likely it is to lead to persistent disability in later life,” he said.
Consider preoperative disease activity, upper limb involvement, and adjacent joint involvement, which can be important considerations for rehabilitation. Assess range of motion when a patient is under anesthesia.
In arthritic knees, Dr. Witt said that intra-articular steroids in combination with physiotherapy and rehabilitation are the front-line protocol. Surgery is a second-line option if the first interventions do not yield significant improvements.
Leg length discrepancies are common in children with knee involvement. A discrepancy or a valgus deformity can be corrected with epiphysiodesis.
“Remember this option,” Dr. Witt said. “It is a painless way of correcting this condition. It takes advantage of growth potential.”
Fixed flexion deformity (FFD) in combination with a valgus is a common presentation of an arthritic knee. “We are generally good at correcting the FFD. If it's a severe deformity, such as a 60-degree FFD, it may require some soft-tissue release in addition to knee replacement,” Dr. Witt commented.
In addition, “extreme osteoporosis is associated with active disease and is the enemy,” he said. “Many of these patients have been immobile for a long time, and immobility is bad for the skeleton.”
Total knee replacement studies in children with JIA all have had short follow-up. Studies of long-term outcomes of knee replacement are needed, Dr. Witt said.