Role of Wrist Arthroscopy in Juvenile Inflammatory Arthritis

Abstract

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.

Juvenile inflammatory arthritis (JIA) is a common chronic rheumatic condition in children which is of unknown etiology and encompasses a group of arthritides having onset before 16 years of age and persisting for 6 weeks or longer in duration. ¹

The International League of Associations for Rheumatology classification of JIA includes the following eight subtypes: systemic-onset arthritis, oligoarthritis, extended oligoarthritis, polyarthritis (rheumatoid factor [RF] negative), polyarthritis RF-positive arthritis, psoriatic arthritis, enthesitis-related arthritis, and undifferentiated arthritis. ²

The most prevalent of these subtypes is oligoarthritis (50%) with typical female preponderance and with a peak age of onset between 2 and 4 years of age. The wrist joint is the fourth most commonly affected joint in JIA, with early involvement being cited as a poor prognostic factor in JIA outcome. ^{3 4} The inability to control disease with conventional drug treatment may result in significant morbidity, presenting as joint contracture, persistent inflammation, chronic pain, and permanent joint destruction. Comprehensive clinical as well as radiological assessment by means of ultrasound (US) or magnetic resonance imaging (MRI) is of utmost importance to guide management. MRI being the most sensitive imaging modality for detecting subclinical synovitis has led to the development of MRI scoring systems to assess disease activity, most importantly in the knee and wrist. ⁵ The limitation however being unable to differentiate anatomical variants from an inflammatory background in the pediatric age group owing to the nature of a growing skeleton. ^{6 7} The benefits of US in the target population is the ease of performance and noninvasive technique, the disadvantage being operator dependence and less specific as compared with MRI. ⁷

The role of wrist arthroscopy and assisted procedures in JIA wrist evaluation is unclear and only has been sparsely described within other pathologies. ⁸ Procedures of direct imaging of the wrist joint with arthroscopy and arthroscopy-assisted synovectomy (AAS), have become well-established techniques in adults with rheumatoid arthritis (RA) with positive outcome by means of pain relief, improvement of function, and long-term control of synovitis in 75% of patients not responding to medication. ^{9 10}

Studies on the outcomes of wrist surgery in children and adolescents are sparse compared with the adult RA. ¹¹ The goals of surgical management are to prevent joint degeneration and alleviate symptoms. In children, those interventions are limited to procedures which will not affect the epiphyseal plates during growth. ¹² A limited number of case studies have shown advantages of open synovectomy of the wrist in children and adolescents with JIA, including pain relief, decreased swelling, and better range of motion (ROM). A recent systematic review, reported no literature on the use of wrist arthroscopy in JIA patients. ¹³ In addition to being a safe procedure, advantages of arthroscopy over open procedures include reduced invasiveness, lower morbidity rates, and earlier functional recovery. ^{14 15}

The aim of this study was to assess the role of wrist arthroscopy in children and adolescents with JIA, resistant to medical management, focusing on pre- and intraoperative findings and postoperative outcomes.

Methods

The study was performed prospectively. Institutional audit approval was obtained (CARMS-30570). Ethical approval was not required due to the observational nature of the study. All patients were referred from a pediatric multidisciplinary team (MDT) clinic which included a hand surgeon, radiologist, rheumatologist, and occupational therapist. They were also evaluated by the same MDT postoperatively. Patients with other diagnoses and age over 18 years at the time of first presentation to the pediatric hand department were excluded. The study duration was between January 1, 2016 and December 31, 2020. The clinical decision to operate was made along the lines of the treatment algorithm listed in Table 1 , as agreed by the MDT.

Table 1. Treatment algorithm and decision-making process at the JIA MDT.

Decision-making—Arthroscopic treatment in JIA
1. Synovitis: (including joint effusion, bone edema, bone synovial cysts)    a. with painful wrist: ASC ± AAS    b. without pain:     i. erosions/debris: ASC ± AAS     ii. early signs of carpal collapse: ASC ± AAS ± shrinkage
2. No synovitis:    a. with painful wrist:     i. erosions/debris: ASC ± AAS     ii. signs of carpal collapse: ASC ± AAS ± arthroscopic shrinkage       iii. diagnostic ASC (±proceed if other pathologies not identified in MRI)    b. without pain:     i. erosions/debris: ASC ± AAS     ii. signs of carpal collapse: ASC ± AAS ± shrinkage     iii. none of above: nonoperative
3. Advanced carpal collapse / erosions:    a. with painful wrist:     i. arthroscopic synovectomy, removal of loose bodies       ii. salvage procedures (denervation, fusion)    b. without pain: nonoperative
Note: Conditions for consideration for surgery:  • Patients are on optimal medical treatment for JIA before surgery  • Patients have preoperative MRI imaging Intraoperative:  • Synovial biopsies can be obtained in unclear diagnosis

Abbreviations: AAS, arthroscopic-assisted synovectomy; ASC, arthroscopy; JIA, juvenile inflammatory arthritis; MDT, multidisciplinary team; MRI, magnetic resonance imaging.

Data Collection

The data were stored and collated in a prospectively maintained database that allowed for multiple variables to be analyzed. These included demographics such as age, gender, and laterality. Preoperative variables collected included indication for surgery, Visual Analogue Score (VAS; 0–10) for pain, ROM of affected wrist, grip strength (measured on a dynamometer), and imaging findings on MRI scan. The images were reviewed in the MDT prior to consideration for arthroscopy. Intraoperative variables included date of surgery and significant intraoperative findings (e.g., synovitis, chondromalacia, ligament laxity, triangular fibrocartilage complex [TFCC] tears, etc.). Postoperative follow-up was at 6 months with assessment of similar factors to the preoperative scores and need for additional medical management (steroid injections) after the operation. All the evaluations were performed under the care of a hand surgeon and hand therapist. The first follow-up assessment was performed at 2 weeks after surgery to allow for acute perioperative changes to settle down and to allow immunosuppression to resume. At the clinical assessment, objective parameters such VAS for pain, range of movement, grip strength along with subjective patient-reported outcomes and Disabilities of the Arm, Shoulder and Hand (DASH) scores were recorded. The patients were then followed up at regular intervals.

Surgical Technique

Wrist arthroscopy was performed as a day case procedure. A 1.9- or 2.5-mm arthroscope was used with standard arthroscopy theater setup and traction tower (ConMed). Standard 3–4 and 4–5 radiocarpal (between the 3rd and 4th extensor compartment and between 4th and 5th compartments, respectively), radial, and ulnar midcarpal portals were used. Irrigation was performed with normal saline and outflow was achieved using the 6R or 6U (radial or ulnar to the 6th compartment) portals. Systematic evaluation of the radiocarpal and midcarpal joints was performed. Debridement of synovitis was undertaken using a 2.0- or 2.5-mm shaver (ConMed). Shrinkage of the midcarpal and/or radiocarpal joints was performed if significant joint laxity was noted using a 30-degree angle bipolar arthroscopic radiofrequency system (EDGE/ConMed). This was assessed by comparing preoperative midcarpal laxity on physical examination with identified laxity of the volar wrist ligaments under traction perioperatively. Shrinkage was also performed if there were further signs of carpal collapse with laxity of the scapholunate and lunotriquetral ligaments. At the end of the procedure, patients were placed in a volar wrist slab.

Data Analysis

Descriptive details were used to measure outcomes. Categorical variables are presented as numbers and continuous variables are presented as median ± interquartile range (IQR). Due to a small sample size, statistical analysis was not performed on the present data.

Results

Patient and Wrist Demographics

A total of 106 patients with diagnosed JIA were referred to the MDT clinic during the study period. The median age was 13.8 years (IQR 12.2–16.1) at the time of operation, the youngest patient was an 8-year-old girl. As a part of medical management, all patients in the study cohort had received methotrexate and intra-articular steroid injections. Further biological immunomodulatory agents (e.g., anti-tumor necrosis factor-α agents like etanercept, infliximab, or adalimumab) were added on if a lack of response to other previously mentioned methods was observed. Nine of the 15 patients in the present cohort needed biological immunomodulatory agents for medical treatment optimization prior to surgery.

A total of 15 patients underwent arthroscopy with a combined diagnostic and therapeutic approach. Bilateral arthroscopic procedures were required in 5 patients leading altogether to 20 wrist arthroscopies. All patients underwent arthroscopy by the same surgeon. The indications for surgery were stratified according to the algorithm ( Table 1 ) and ranged from a painful wrist with synovitis noted on MRI to severe articular destruction in 4/20 wrists. Preoperative pain, on VAS was noted to be 0 (0–2.25) at rest and 6 (2.25–7.75) with loading. Synovitis was noted preoperatively on MRI in 18/20 wrists ( Fig. 1 ).

Fig. 1.

Magnetic resonance imaging (MRI; T1W coronal and T1W sagittal views) of 11-year-old girl, left wrist with destructive and active inflammatory synovitis.

Arthroscopic Intraoperative Findings

All wrists were seen to have synovitis at arthroscopy ( n  = 20/20) ( Fig. 2 ; Table 2 ). In addition, there were arthroscopic findings of ligament laxity, chondromalacia, and loose intra-articular bodies ( Fig. 3 ), which were removed, TFCC tears, which were debrided ( Fig. 4 ; Table 2 ).

Fig. 2.

Arthroscopic views of radiocarpal joints: ( A ) Chronic synovitis (9-year-old girl, right wrist). ( B ) Acute synovitis (14-year-old girl, right wrist). ( C ) Chronic and acute synovitis (10-year-old girl, right wrist). ( D ) Chronic synovitis in the midcarpal joint (capitate on top, lunate in the bottom). ( E ) Synovectomy of the two-dimensional (2D) chronic synovitis (11-year-old boy, left wrist).

Table 2. Arthroscopic findings ( n  = 20) .

Intraoperative findings	Number of wrists: out of all 20
Synovitis ( Fig. 2 )	20
Ligament laxity ( Figs. 5 and 6 )	11
Chondromalacia	9
TFCC pathology ( Fig. 4 )	9
Loose bodies ( Fig. 3 )	3

Abbreviation: TFCC, triangular fibrocartilage complex.

Fig. 3.

Arthroscopic view of multiple loose, “rice-grain” bodies typical for juvenile inflammatory arthritis.

Fig. 4.

Arthroscopic view of triangular fibrocartilage complex wear and tear (16-year-old girl, left wrist) seen in this patient with juvenile inflammatory arthritis, but with arthroscopic appearance like a pediatric patient.

The exact nature of procedure was dependent on intraoperative findings ( Table 2 ). Synovectomy was performed as a “baseline” to excise the foundation for the destructive synovitis in these JIA patients. It was done in the radiocarpal and ulnocarpal joints as well as in the center of the midcarpal joint, but rarely in the scaphotrapeziotrapezoidal joint. This was the case in all wrists ( Fig. 2 ). A diagnostic biopsy was performed in 16/20 wrists. Shrinkage was performed in addition to synovectomy in 11/20 wrists, when hypermobility was observed with associated above intraoperative findings like ligament laxity ( Figs. 5 and 6 ; Table 2 ). The shrinkage was primarily done in the fossa Poiret in the midcarpal joint as well as toward the ulnocarpal ligaments in the “radiocarpal and ulnocarpal” joint as the instability is of palmar ulnar nature. Depending on the severity of destruction and/or hypermobility they were supported by a plaster in between 2 and 6 weeks postoperatively.

Fig. 5.

Midcarpal synovitis combined with ligament laxity. ( A ) Midcarpal joint with synovitis, head of capitate on top. ( B ) Midcarpal joint (with bipolar probe) after synovectomy and shrinkage (16-year-old girl, right wrist).

Fig. 6.

Arthroscopic view of midcarpal joint: ( A ) Fossa Poirier view with acute and chronic synovitis. ( B ) Midcarpal view of gapping of scapholunate interval (SL ligament laxity). ( C ) Midcarpal view of palmar aspect of the SL interval after synovectomy and shrinkage (11-year-old girl, left wrist).

Postoperative Outcomes

The median follow-up duration was 11.3 (IQR 8.1–24.2) months. No patients were lost to follow-up. There were no intra- or postoperative complications.

Postoperative pain relief measured as a difference in the VAS for pain showed a median reduction of 0 (0–2.25) points at rest and 4 (2.25–6) points on loading. Further steroid injection was needed in one patient only.

Functional Improvement

Postoperative changes in range of movement showed that 13/20 wrists had improved or unchanged range on the extension/flexion axis and 13/20 wrists had improved or unchanged range on the radial/ulnar deviation axis. Of the 7/20 patients, who had decreased ROM for both extension/flexion axis and radial/ulnar deviation axis, were those patients who had undergone shrinkage (11/20 wrists) as a part of the AAS procedure. They had as expected a reduced range on the extension-flexion axis which accounted for 4/7 wrists and reduced range in radial/ulnar deviation axis in 5/7 wrists ( Table 3 ). Postoperative measurements in grip strength were improved in 11/20 wrists with the others showing stability in symptoms. No patients reported worsening grip strength.

Table 3. Overview of postoperative outcomes.

Objective and subjective measurements N  = 20 wrists		Overview of postoperative outcomes
		Improved or no change	Decreased
ROM 11/20 wrists with shrinkage 9/20 wrist no shrinkage	Extension	13	7 (4 after shrinkage)
	Flexion	14	6 (4 after shrinkage)
	Radialduction	15	5 (all after shrinkage)
	Ulnaduction	11	9 (6 after shrinkage)
Grip strength		11/20 improved	9/20 no change
VAS	Rest	median reduction 0 (0–2.25) points
	Loading	median reduction 4 (2.25–6) points
Subjective experience of ADL		13/15 patients improved (18/20 wrists)	2/15 patients no improvement

Abbreviations: ADL, activity of daily living; ROM, range of motion; VAS, Visual Analogue Scale.

Note: As the purpose of shrinkage was to limit the increased joint hypermobility the decrease in ROM for those cases is an expected and good outcome.

Thirteen of 15 patients (18/20 wrists) reported subjective improvement in function and symptoms. Patients without completed data for grip strength reported subjective improvement in the ability to carry on with day-to-day activities. Subjective improvement was also noted on DASH scores with a median postoperative score of 20 (15–25) ( Table 3 ).

Discussion

AAS is recognized as a safe and reliable procedure with minimal postoperative morbidity and is used in the adult setting for diagnosis and treatment of various arthritides. Its use in the pediatric population is relatively new and is associated with relative paucity of high-quality evidence to support its use. ¹³ Indeed, its use in JIA is limited to a few case series and a systematic review by the authors of this article. ¹³

JIA predominates in the female population which was shown in the study population described. Majority of patients in this cohort were noted to be negative for RF and had polyarthritis, which is somewhat in contradiction to previous case series wherein RF positivity and oligoarthritis were commoner. ¹³

In adults with RA, wrist arthroscopy and AAS are associated with pain relief, increased ROM, and improvement in general function. ^{9 10} Our patients demonstrated improvement in function assessed with improvement in the VAS for pain, ROM, and grip strength. DASH scores also correlated with positive outcome of surgery. Five of the 15 children underwent similar procedure on the contralateral side after noting sustained improvement and symptomatic benefit from the first procedure.

Early recognition and diagnosis are imperative to avoiding long-term disability in these patients. ¹¹ Adequate imaging of patients with JIA is of utmost importance as silent (pain-free) joint destruction is common in this population and may demonstrate intra-articular synovitis despite a lack of typical symptoms. Limited ROM of the wrist may be a late sign of intra-articular destruction and carpal collapse, without significant pain as an early sign of destruction. Not uncommonly, limited ROM might be the only initial sign as the child may simply lack “normal” wrist function prior to being referred to a hand surgeon or a rheumatologist. Dynamic contrast-enhanced MRI is a novel tool which may help evaluate the disease load in children with JIA and wrist involvement. ¹⁶

Synovitis detected clinically correlated with MRI findings in most cases (18/20 wrists; Fig. 1 ). However, arthroscopy improved the overall diagnosis and accurately staged severity of the condition by finding synovitis in the remaining 2/20 wrists ( Fig. 2 ). Furthermore, arthroscopy found chondromalacia, loose bodies ( Fig. 3 ), and ligament involvement of intercarpal ligaments as well as TFCC which could be dealt with by removing lose bodies and debridement of involved structures.

Published literature has demonstrated the importance of a MDT approach in the management of JIA. Nonsteroidal anti-inflammatory drugs are the standard first line of therapy. Second-line therapy of antirheumatic drugs may be used early for progressive disease. Intra-articular corticosteroid injections are considered to preserve joint mobility and muscle strength when medical treatment fails to control synovitis or when marked functional impairment exists. ¹⁷ Depending on the course of disease, children may require further medical intervention or steroid injections following surgery. It is worthwhile to note that in the present study, only one of the patients required steroid injections following surgery. Subjective improvement was noted in almost all patients in the current cohort. Among children with bilateral wrist AAS, patient decision to proceed with an operation on the second wrist was made on the basis of symptomatic improvement and better function on the first operated wrist.

The regenerative, or sometimes remodeling, potential in the pediatric population is well known, not just for patients with JIA. Following synovectomy, one child in this series showed recovery of cystic and osteolytic changes on follow-up MRI, demonstrating that AAS might improve bone stock and maintain wrist integrity during time of growth, probably in combination with medical treatment ( Fig. 7 ).

Fig. 7.

Case example of complete resolution of cystic erosions after arthroscopy-assisted synovectomy (AAS) in juvenile inflammatory arthritis (JIA). ( A , B ) Magnetic resonance imaging (MRI) images (T1W coronal + T1W sagittal views) of 9-year-old girl, right wrist before synovectomy demonstrate large synovitic cyst in the scaphoid and synovitis in the radiocarpal and midcarpal joints. ( C ) Arthroscopic view of acute synovitis in the radiocarpal joint. ( D ) Acute synovitis in radial recess with proximal pole of scaphoid (top) and radial styloid (bottom). ( E ) Arthroscopic midcarpal view of fossa Poirier after synovectomy. ( F , G ) MRI images (right wrist T1W coronal + T1W sagittal views) after AAS: complete resolution of cystic degeneration in the scaphoid and no synovitis.

The main limitation of this study is that it explores arthroscopy in a limited cohort of 20 wrists in 15 patients. This limited sample size prevents the use of statistical analysis and is not powered to provide definite conclusions regarding the efficacy of the procedure itself. It is also limited by being restricted to a high-volume setting, thereby reducing the ability to generalize the findings from this study. The other limitation is the need for an objective measure in children, similar to the DASH score in adults. The current study quotes DASH scores, with the knowledge that it is not well validated in children and, therefore, these must be interpreted with caution.

Our ability to reassess the patients and follow them up during the year 2020 was limited due to the COVID-19 pandemic. Due to this, in some patients we had to rely on subjective methods of evaluation through video consultation rather than objective in-person measurements.

Conclusion

JIA is a multifaceted disease where some children cannot be sufficiently treated medically even with the most modern and aggressive anti-inflammatory medication. We have demonstrated in this limited cohort that:

• AAS is a safe procedure with very low to no complications in experienced hands.

• Arthroscopy can improve diagnosis and additional pathologies not visible on MRI alone and give those children improved wrist function regarding ROM, grip strength, and pain.

• We could further demonstrate the potential of a complete resolution of significant wrist destruction ( Fig. 7 ).

• In further long-term outcome studies it will be seen, if in arthroscopically assisted treatment of early carpal collapse further destruction can be delayed to maintain wrist function.

• Within our follow-up period after AAS the need for steroid injections was significantly reduced.

It is our conclusion that arthroscopy should be considered in a JIA affected child where it is difficult to reduce the inflammatory activity with medication alone.

Funding Statement

Funding None.