Shoulder and Elbow Surgery in Juvenile Idiopathic Arthritis

Abstract

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory arthropathy that manifests itself prior to the age of sixteen years with symptoms lasting six weeks or longer. As JIA frequently effects the upper extremities, activities of daily living become compromised during the stages of development when young adults are striving for independence. Symptomatology includes ankylosing, pain and early growth plate closure. Patients with joint involvement prior to growth plate closure have the most destruction in terms of joint abnormality and surgical complexity.Medical management of JIA has allowed for better non-surgical management, yet, there is a continued need to understand the appropriate surgical intervention and order for the greatest functional gains. Comparative studies have shown that varied results as to whether the shoulder replacement should supersede the elbow replacement or should that be reversed or both joint replacements done simultaneously. Our experience found a more significant functional improvement after total elbow replacement due to the unpredictable nature from the shoulder replacement outcomes and an inability for patients to do simple tasks such as bringing a cup to their mouths or handling a toothbrush. The exception to this occurs if the ipsilateral shoulder joint is severely limited to the point that the stressors placed on the elbow due to compensation will lead to early loosening or failure of the elbow joint replacement.Various methods for performing joint replacement of the shoulder and elbow in the JIA population will be discussed. Soft tissue integrity including the functional status of the rotator cuff will be a consideration for which surgical procedure should be considered. Surgical approaches for the elbow present fewer options for improving pain and function in this patient population. Pre, peri and postoperative management is reviewed as careful attention to irregular bony dimensions and dysmorphic anatomy precludes the use of standard implants.Total shoulder and total elbow arthroplasty should be considered in the JIA population where pain and significant functional compromise are present. The order of procedures is dependent on multiple factors and expected outcomes. Educating patients on postoperative expectations over the lifespan is an important part of surgical management for patients with JIA.