Comparison of synovectomy and no synovectomy in patients with juvenile rheumatoid arthritis. A 24-month controlled study

Surgical Treatment of Juvenile Idiopathic Arthritis in the Era of Novel Drug Therapies

Juvenile idiopathic arthritis is the most common chronic rheumatic disease encountered in children under the age of sixteen and causes significant impairments in daily life. Over the last two decades, the introduction of new drug treatments (including disease-modifying antirheumatic drugs and biologics) has changed the course of this disease, thus reducing the indication for surgery. However, some patients fail to respond to drug therapy and thus require personalized surgical management, e.g., the local reduction of joint effusion or a synovial pannus (via intra-articular corticosteroid injections, synovectomy, or soft tissue release), and management of the sequelae of arthritis (such as growth disorders and joint degeneration). Here, we provide an overview of the surgical indications and outcomes of the following interventions: intra-articular corticosteroid injections, synovectomy, soft tissue release, surgery for growth disorders, and arthroplasty.

Synovectomy in juvenile idiopathic arthritis: A systematic review and meta-analysis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is an inflammatory arthropathy with onset in children younger than 16 years. Treatment is primarily medical; however, surgical interventions, such as arthroscopic or open synovectomy, can be beneficial. Many studies have investigated synovectomy in JIA, but the results of these studies have not been synthesized to our knowledge. Therefore, we performed a systematic review of the literature reporting synovectomy as a treatment for JIA to provide clinical recommendations regarding its risks and benefits.

METHODS

On March 8, 2022, we searched the Cochrane Library, Embase, PubMed, Scopus, and Web of Science for studies evaluating clinical outcomes of open or arthroscopic synovectomy to treat JIA in patients younger than 18 years. We included only studies published in English and excluded studies of synovectomy to treat other arthropathies, septic arthritis, hemophilia, or foreign body arthropathy. The level of evidence for included studies was determined by using the Oxford Centre for Evidence-Based Medicine criteria. We qualitatively analyzed clinical outcomes data, including patient-reported pain relief, rates of symptom recurrence, and postoperative complications.

RESULTS

Of 428 articles assessed, 14 were included in our analysis. One was a randomized trial, 1 was a case-control study, and all others were case-series. Studies consistently reported that synovectomy was associated with improved function and decreased pain postoperatively. However, comparisons with modern medical therapy were lacking. Rates of arthritis recurrence varied, with increasing symptom recurrence with longer follow-up and re-synovectomy rates up to 15%. Oligoarticular disease and early disease course were associated with better response to synovectomy, whereas systemic and polyarticular disease were associated with poor response. Stiffness requiring manipulation under anesthesia was the most common complication (4% of all included patients).

CONCLUSION

Although synovectomy is associated with positive functional outcomes and pain reduction postoperatively, there was inadequate comparison thus inadequate evidence to recommend it over modern medical therapy. The current literature suggests that synovectomy should be offered only to patients for whom medical management has failed, while noting the risks of decreased range of motion and symptom recurrence over time.

Juvenile Idiopathic Arthritis for the Pediatric Orthopedic Surgeon

Juvenile idiopathic arthritis includes conditions characterized by joint inflammation of unknown etiology lasting longer than 6 weeks in patients younger than 16 years. Diagnosis and medical management are complex and best coordinated by a pediatric rheumatologist. The mainstay of therapy is anti-inflammatory and biologic medications to control pain and joint inflammation. Orthopedic surgical treatment may be indicated for deformity, limb length inequality, or end-stage arthritis. Evaluation of the cervical spine and appropriate medication management in consultation with a patient's rheumatologist are essential in perioperative care. Preoperative planning should take into account patient deformity, contracture, small size, osteopenia, and medical comorbidities.

[Treatment options in juvenile idiopathic arthritis : Part 2: Orthopedics und surgery]

In most cases of juvenile idiopathic arthritis (JIA), disease remission can be achieved by a multidisciplinary approach using modern medication. However, JIA is currently incurable An interdisciplinary concept is therefore needed for long-term development of affected joints and tendons. Only early interdisciplinary treatment strategies can improve long-term outcomes in patients with a complicated disease course or persistent disease activity, thereby delaying or even avoiding joint replacement. An early interdisciplinary assessment and treatment planning according to surgical orthopedic rheumatology aspects is now state of the art and will continue to be in the future, especially in treatment-refractory disease courses.

[Long-term results of synovectomy in the rheumatoid ankle joint]

Inflammatory rheumatic ankle joint destruction endangers the mobility of the rheumatic patient by pain and loss of function. In the presented patient population, 29 patients with a mean preoperative history of 14.3 years of rheumatoid arthritis and 7.6 years manifestation of ankle arthritis underwent open synovectomy of the ankle joint optionally combined with accompanying tenosynovectomy. Disease duration and the prevalence of radiological alterations (81% LDE 2-3) characterize the procedures as late synovectomies. The rate of 93% of additional tenosynovectomies and the prevalence of radiological alteration in the adjacent rear foot joints indicate a panarticular pathology of the rheumatic disease. A progression of the Larsen, Dale and Eek (LDE) grade was found in 62% of the ankle joints. The significant gain in the Kofoed ankle score (42.4 versus 55.9 points, p=0.042) was mainly caused by pain reduction and gain of mobility, whereas a decline of function was detected. Both genders showed comparable outcomes. The mean pain level on a visual analogue scale decreased from 7.6 to 3.3 (p<0.001) and 81.5% of the patients assessed the results of the synovectomy as good or very good.

Juvenile rheumatoid arthritis manifesting in only limping due to flexion contraction of the knee

Juvenile rheumatoid arthritis (JRA) is a relatively uncommon condition. The damage to the cartilaginous tissue is often irreversible and responsible for much of the morbidity. Timely diagnosis and appropriate aggressive treatment of patients improve quality of life and outcome. A reported case of JRA is presented in which limping associated with flexion contraction of the knee developed without any systemic symptoms. Magnetic resonance imaging and arthroscopic examination were helpful with early diagnosis. Aspirin was effective. There have been no recurrence to date.

Total knee replacement in juvenile rheumatoid arthritis

In general, longer operative times and in some cases increased blood requirements can be expected with TKA in patients with juvenile rheumatoid arthritis. Complications also are more frequent. Pain relief is usually good to excellent, and function and deformity are significantly improved. Range of motion after TKA for juvenile rheumatoid arthritis is usually less than that obtained in osteoarthritis, but still allows for dramatic improvements in performing activities of daily living (Figure 3).

Arthroscopic synovectomy of the knee joint in early cases of rheumatoid arthritis: follow-up results of a multicenter study

A retrospective multicenter study on a total of 93 knee joints in 81 patients with early forms of rheumatoid arthritis treated by arthroscopic synovectomy was carried out. During the average follow-up period of 33 months, the patients' clinical state showed appreciable improvement. The Lysholm score modified by Klein and Jensen increased from 43.2 points preoperatively to 78.1 points at follow-up. Also, the Insall score (knee score and functional score) showed a highly significant increase of 25.7 and 25.2 points to 71.2 and 80.2 points, respectively. Patients receiving additional radiation synovectomy showed a highly significantly better result than those receiving synovectomy alone. Among the individual variables investigated, pain, swelling, and walking distance in particular were improved. Only radiologically was a mild worsening observed (from Larsen stage 1.57 preoperatively to 1.95 at follow-up). The follow-up examination revealed no synovitis in 80.6% of the patients. Subjectively, 76.4% of the patients assessed the results to be good or very good, with only 7.5% remaining unsatisfied. 90.3% of the patients declared themselves in retrospect willing to undergo the operation again.

Ulnar lengthening in juvenile chronic arthritis

Ten wrists in eight children with severe destructive changes in the wrist due to juvenile chronic arthritis underwent distraction lengthening of the ulna between 1983 and 1996 in an attempt to restore wrist alignment, which had not been preserved by previous splinting. Eight wrists in six patients (four female and two male) were evaluated. The average age at the time of operation was 13.8 years (range, 12-15.5). The average follow-up period was 70 months (range, 12-152). The average ulna minus deformity was between 8 and 9 mm. It was found that ulnar lengthening can be done safely and the procedure seems to stabilize the carpus, is likely to improve appearance, may improve function and in the majority of cases does eliminate the use of an external splint. Results seem to be stable for at least 3 to 5 years.

Arthroscopic synovectomy of the rheumatoid wrist

18 wrists in 16 patients with synovitis due to rheumatoid arthritis were treated with arthroscopic synovectomy. The surgical procedure and the results after surgery are described. Range of motion, grip strength, subjective experience of pain and level of activity were registered pre- and post-operatively. The operations were found to give good pain relief, increased grip strength, no post-operative stiffness and a short period of rehabilitation.

Monoarticular juvenile chronic arthritis of the shoulder. Report of a case and review of the literature

In 20% of the cases Juvenile Chronic Arthritis (JCA) has a monoarticular onset. Usually the inflammatory process spreads out to other joints with pauciarticular or polyarticular course. Very rarely the disease persists in one joint only and this is in about 70% of the cases, the knee. We describe a case of Monoarticular JCA with isolate and persistent involvement of the shoulder never reported in the literature. The clinical, pathologic features and different diagnoses are discussed.

Wrist synovectomy in juvenile chronic arthritis (JCA)

Synovectomy of 20 wrist joints in 15 patients with juvenile chronic arthritis (JCA) was performed and results were evaluated 3 (0.5-5) years after surgery. The surgical procedure consisted of synovectomy of the radiocarpal joint, around the ulnar head and in all intercarpal joints. Resection of the ulnar head was not performed. Results at follow-up showed that four wrist joints had been re-operated by arthrodesis because of persistent pain. In one case a spontaneous ankylosis had developed. These cases were not included in the re-examination. Of the remaining 15 cases, 12 were improved and 7 of these were totally pain-free. At follow-up, clinical examination revealed a mean improved grip strength (0.2 kp/cm2) and a mean decreased range of motion (10 degrees of flexion and extension, 16 degrees of pronation, supination unchanged). All wrist joints showed some radiographic changes preoperatively and at follow-up about half showed some further deterioration. This study indicates that the results of wrist synovectomy in patients with juvenile chronic arthritis do not differ significantly from results of wrist synovectomy in adult arthritic patients.