Wrist Arthroscopy in Juvenile Idiopathic Arthritis: A Review of Current Literature and Future Implications

Examination of Physical Functions, Activity and Participation in Children with Juvenile Idiopathic Arthritis

AIMS

To examine physical functions, activity, and participation level, and associated factors with participation in children with juvenile idiopathic arthritis (JIA) across the International Classification of Functioning Disability and Health-Children and Youth.

METHODS

49 children (Girl/Boy:28/21) aged between 7 and 18 years (Mean: 13.4 ± 3.3) were included. To evaluate body structure/functioning; pain, fatigue, disease activity, and motor functions were assessed. Childhood Health Assessment Questionnaire and Juvenile Arthritis Biopsychosocial and Clinical Questionnaire were used to determine activity level. Child and Adolescent Scale of Participation was used to assess participation.

RESULTS

Mild level of pain (2.0 ± 2.3), disease activity (2.0 ± 2.3), and fatigue (4.1 ± 4.0) were recorded. Decrease in motor functions was determined in 75% of children, while 61% of whom had activity-related disability. There was mild to moderate participation restrictions, and participation was significantly associated with age (r = -0.29), pain severity (r = -0.31), disease activity (r = -0.39), motor functions (r = 0.33), and activity level (r = -0.43), (p ˂ 0.05).

CONCLUSIONS

Majority of children with JIA have deteriorations in physical functions, activity, and participation. Age, pain, disease activity, motor functions and activity level were associated with participation level. Children with JIA should be regularly evaluated multi-directional and they should be referred to rehabilitation programs to increase functionality and participation.

Arthroscopic Capsular Shrinkage Is Safe and Effective in the Treatment of Midcarpal Instability in a Pediatric Population: A Single-Center Experience of 51 Cases

Objective  Treatment of palmar midcarpal instability (PMCI) remains controversial and children can develop PMCI from asymptomatic hypermobility. Recently, case series have been published regarding the use of arthroscopic thermal shrinkage of the capsule in adults. Reports of the use of the technique in children and adolescents are rare, and there are no published case series. Methods  In a tertiary hand center for children's hand and wrist conditions, 51 patients were treated with arthroscopy for PMCI between 2014 and 2021. Eighteen out of 51 patients carried additional diagnosis of juvenile idiopathic arthritis (JIA) or a congenital arthritis. Data were collected including range of movement, visual analog scale (VAS) at rest and with load, and grip strength. Data were used to determine the safety and efficacy of this treatment in pediatric and adolescent patients. Results  Mean follow-up was 11.9 months. The procedure was well tolerated and no complications were recorded. Range of movement was preserved postoperatively. In all groups VAS scores at rest and with load improved. Those who underwent arthroscopic capsular shrinkage (ACS) had significantly greater improvement in VAS with load, compared with those who underwent arthroscopic synovectomy alone ( p  = 0.04). Comparing those treated with underlying JIA versus those without, there was no difference in postoperative range of movement, but there was significantly greater improvement for the non-JIA group in terms of both VAS at rest ( p  = 0.02) and VAS with load ( p  = 0.02). Those with JIA and hypermobility stabilized postoperatively, and those with JIA with signs of early carpal collapse and no hypermobility achieved improved range of movement, in terms of flexion ( p  = 0.02), extension ( p  = 0.03), and radial deviation ( p  = 0.01). Conclusion  ACS is a well-tolerated, safe, and effective procedure for PMCI in children and adolescents. It improves pain and instability at rest and with load, and offers benefit over open synovectomy alone. This is the first case series describing the usefulness of the procedure in children and adolescents, and demonstrates effective use of the technique in experienced hands in a specialist center. Level of Evidence  This is a Level IV study.

Role of Wrist Arthroscopy in Juvenile Inflammatory Arthritis

Background and Purposes  The wrist is the fourth most common joint to be involved in juvenile inflammatory arthritis (JIA), which is a common rheumatological condition affecting children. Wrist arthroscopy is well established in rheumatoid arthritis, but remains unexplored in JIA. The aim of this study is to investigate the role of wrist arthroscopy in JIA, with focus on those who are refractory to medical management. Methods  This is a prospective observational study, including consecutive patients with JIA undergoing arthroscopy between January 2016 and December 2020. Those over the age of 18 years and those with other rheumatological diagnoses were excluded. Data including pre-, intra-, and postoperative variables, demographics, and patient-reported outcomes were collated and are reported using standard measures. Results  A total of 15 patients underwent arthroscopy ( n  = 20 wrists). Synovitis was noted in all wrists on arthroscopy and synovectomy was performed in all cases. Other procedures were performed as indicated during the procedure. The median follow-up duration was 11.3 (interquartile range [IQR] 8.1-24.2) months. Median reduction of 4 (IQR 2.25-6) points on the Visual Analogue Score for pain on loading was noted postoperatively. Grip strength was improved in n  = 11/20 wrists and functional improvement was noted in n  = 18/20 wrists. Restriction of range of motion was achieved with a shrinkage procedure in patients with hypermobile joints. There were no postoperative complications, and no patients were lost to follow-up. Conclusion  In experienced hands, wrist arthroscopy is feasible, safe, and efficacious in the management of JIA, among patients who are refractory to medical management. Level of Evidence  This is a Level II study.

Arthroscopic Synovectomy of the Wrist in Patients With Rheumatoid Arthritis: A Systematic Review of the Current Literature

BACKGROUND

Rheumatoid arthritis (RA) of the wrist can lead to loss of wrist function and progressive joint destruction if inadequately treated. Arthroscopic synovectomy of the wrist may prove a valuable treatment for local inflammation.

OBJECTIVE

The aim of this study was to perform a systematic review evaluating functional outcomes and pain following arthroscopic synovectomy of the wrist in RA patients.

METHODS

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines. MEDLINE, EMBASE, The Cochrane Library, Web of Science, and Google Scholar were searched for studies describing pain or functional outcomes following arthroscopic synovectomy of the wrist in RA patients (CRD42021270846). Risk of bias was assessed using the Methodological Index for Non-Randomized Studies. Data collection included patient characteristics, pain scores, wrist function questionnaires, secondary surgery, and complications.

RESULTS

Six noncomparative cohort studies were included, with a total of 153 arthroscopic synovectomies. Disease duration of RA ranged from 32 to 89 months, and radiographic progression was mild to moderate. The Methodological Index for Non-Randomized Studies scores ranged from 8 to 10 out of 16. Mean follow-up ranged from 21 to 95 months. Improvements were seen in pooled mean visual analog scale pain score (from 7.7 to 2.2, p < 0.05), pooled mean Modified Mayo Wrist Score (from 43.3 to 70.4, p < 0.05), and the Disability of the Arm, Shoulder, and Hand (from 67.5 to 36.5, p < 0.05). Two complications occurred, and 5 patients required secondary surgery.

CONCLUSIONS

There is limited evidence suggesting that arthroscopic synovectomy of the wrist improves wrist function and pain in patients with RA, with few complications. In centers with arthroscopic expertise, it can be considered as a treatment option.