When Surgery Is Necessary for Your Child
While surgery is less common in children with arthritis these days, sometimes it is necessary. Here's what you need to know.
By Charlotte Huff
In the last two decades, surgery has been pushed to the back burner of juvenile arthritis treatment. 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.
By combining medication with other tools, your child’s joints can be protected for a longer period of time and functioning challenges may be reduced or, ideally, eliminated. Drugs aren’t the only method for alleviating juvenile arthritis symptoms and avoiding surgery. For example, regular stretching and exercise can help prevent joint contractures, in which healthy connective tissue becomes scarred and inflexible, preventing movement. Assistive devices, such as splints, can be used to support or reposition weakened joints.
Still, surgery and even hospitalization can become unavoidable, typically for one of two reasons. Either an effective medication regimen couldn’t be identified to stem the progression of joint damage in your child, 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
Over time, inflammation can weaken your child’s joints and surrounding tissues in a number of ways. The synovium — the tissue that lines the joint capsule and makes lubrication for your joint — can become inflamed and enlarged, invading and damaging nearby cartilage and bone. Inflammation also can weaken muscles, ligaments and tendons, leaving them unable to support the joint properly.
Surgical procedures can provide several potential benefits, including reducing pain and increasing your child’s ability to move and use her joint. Depending on the procedure, an orthopedic surgeon may remove inflamed tissue or replace an entire joint.
If your child’s doctor does recommend surgery, keep in mind that advances in surgical techniques make it more feasible than ever for the procedure to be performed on an outpatient basis, allowing your child to go home for the night. One significant advance is arthroscopy, in which a thin, lighted tube helps the surgeon examine your child’s joints or perform some procedures. Through the tube, which is connected to a closed-circuit TV, the surgeon can take a biopsy, remove overgrown synovial lining or a loose piece of cartilage, or smooth an area that’s become rough.
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:
Epiphysiodesis: Occasionally arthritis of the knee can cause increased growth in the growth centers of the distal femur (the portion of the upper leg bone closest to the knee) and the proximal tibia (the portion of the lower leg bone closest to the knee), resulting in a discrepancy in leg lengths. Epiphysiodesis is an operation that involves surgically closing one of the growth centers of the longer limb, allowing the shorter limb gradually to catch up in length.
Why it’s done: To correct a difference in leg lengths that may be caused by accelerated 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): In this procedure, also called bone fusion, the surgeon removes the cartilage from the ends of two bones that form a joint and then positions the bones together and holds them immobile, often with a pin or a rod. Over time, the two bones fuse to form a single solid unit.
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 never again be able to bend it. Fusing one joint can place stress on nearby joints and increase the risk of fracture in the bones that are fused.
Joint replacement (arthroplasty): This surgery involves removing a damaged joint and replacing it with an artificial joint made of metal, ceramics and/or plastics.
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, wrist 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.
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 limit excess synovial lining that isn’t helped by treatments, including intra-articular corticosteroid injections. The procedure most often is done on the knee and occasionally the wrist.
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. 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.
Procedures Performed Less Often Than Children
Osteotomy: Corrects a bone deformity by cutting and repositioning the bone and then resetting it in a better position.
Why it’s done: Osteotomy is used primarily to fix deformities. By correcting the bone deformities that lead to unusual forces on a joint, and perhaps joint instability and damage, osteotomy also may eliminate or at least delay the need for total joint replacement. The joints it can help include the knee, hip and joints of the foot.
What else you should know: In general, osteotomy is less successful than total joint replacement. Osteotomy can increase stiffness in the hip. Children who have osteotomy to reposition the hip or knee may need totaljoint replacement later. New bone growth takes several weeks.
Soft tissue release: In this procedure, a surgeon cuts and repairs tissues that have tightened about a joint (contracture), often due to inflammation of the joint lining.
Why it’s done: To improve the position of a malaligned joint due to shortening and tightening of the tendons that support it. If not corrected, contractures can cause pain and joint damage and can affect a child’s ability to walk and function. Soft tissue release can improve motion and reduce pain. Results tend to be best for the hip and knee, though your child’s doctor may recommend it for other joints.
What else you need to know: Soft tissue release is most effective when joint destruction is not severe.