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.

Keywords: arthroscopy; juvenile inflammatory arthritis; pain; range of motion; synovectomy; synovitis; wrist.

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.

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).

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.

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).

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.