Your child may need to have an operation to overcome more serious problems

The number amount to approximately ten per cent of those patients with JIA who are under paediatric rheumatology care. These children are very carefully selected, and often seen on a number of occasions by the surgeon before a final decision is made. These meetings are in conjunction with the paediatric rheumatologist, together with physiotherapists and others in the team. It then sometimes emerges that a child is not making satisfactory progress as one would have wished with the normal conservative regime of physiotherapy, splinting and drugs.
For instance a patient may continue to develop an increasing contracture of the joint, which cannot be  properly controlled, or alternatively the disease process may have been sufficiently bad over a period of time to irrevocably damage a joint, and further steps in the form of a surgical operation may be needed to rectify this state.
In general the indications for operation are pain, deformity, and loss of movement, either singularly or in combination. Operations may be performed on the soft tissues, or bones. By soft tissue we mean the muscles and tendons, and capsule which surrounds the joint, all of which may become tight in JIA thus preventing movement. Under these circumstances if physiotherapy has failed, it is possible to do a surgical operation in order to loosen these tight structures to allow the joint to regain its movement. This is called a Soft Tissue Release operation, and the results have been very encouraging in the majority of children where a joint deformity may be corrected, and also an increasing range of movement gained.
Another soft tissue operation is to remove the lining of the joint, which is known as the synovium, and the operation is called a synovectomy. There are some situations where it is clearly advisable to remove this lining, which in itself is causing some of the damage to the joint surface. For the most part however, intra-articular steroids may be sufficient to dampen down the activity of this inflamed lining. In the few patients where there is no satisfactory response to the injection, then a synovectomy may be indicated in order to relieve the symptoms of pain and swelling, and to prevent further joint damage. When steroid injections are given into a joint, the patient is some- times given a very light anaesthetic so that they feel no pain from what would otherwise be quite a painful injection. Whilst the patient is asleep the surgeon will take advantage of examining all the joints in this relaxed state in order to ascertain the movement possible at each site. This will give a target to both the patient and the physiotherapists when rehabilitation recommences.
Occasionally a bone becomes deformed during its growth in patients with JIA and under these circumstances it may be necessary to realign the bone by doing an operation called an osteotomy. This is simply an operation where the bone is reset by surgical means to the correct position. It is usually necessary to fix the osteotomy with some internal fixation device such as plate or screws, or possibly to hold the limb in plaster of Paris while the osteotomy unites.
Finally there is the possibility of replacing a badly affected joint. This is known as a total joint replacement, and is very similar to the operations performed in adults, but of course on a smaller scale in terms of size. Sometimes special joints have to be made for an individual patient. Whilst accepting that this is a major decision and a major operation, it has nevertheless transformed the lives of many children and young adults, and has allowed them to be integrated back into the school or place of education, and into the community as a result of regaining painless mobility.
The operation is performed under a general anaesthetic, and sometimes this is supplemented by introducing anaesthetic into the lower part of the spine in the case of leg or lower limb surgery. Modern anaesthetics have improved enormously over the past few years, and the patient’s recovery from such a procedure is most rapid and good. There are also very adequate means of completely controlling the pain so there is no need to be apprehensive of suffering following this, or indeed any form of surgical procedure.
In summary we have been very encouraged by the improvement in symptoms, and function, both locally at the site of operation, and as a consequence in the improvement of overall function following selected surgical procedures. The patients and their parents should be aware that the surgeon is only a member of the team, and will suggest, on occasions, an appropriate operation after full discussion. This will not only be with the team members, but the patient and the parents, so they can be fully aware of any complications, and of the expectations and the outcome of a surgical operation.
The patient will continue to be supported by the medical team and physiotherapists in the period around their admission for the operation, and of course this means that in all other respects the medication and physiotherapy continues both pre- and post-operatively. Following discharge the surgeon will arrange to see the patient in a combined clinic to assess progress and discuss any ongoing management. Continuity of care is thereby maintained.