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Juvenile Arthritis

Juvenile arthritis
Objectives
  1. Describe a classification of juvenile arthritis
  2. Discuss the prognosis and its relation to age of onset and type of arthritis
  3. Describe the pathophysiology of joints affected with juvenile arthritis
  4. Discuss current treatment of juvenile arthritis

Discussion point
  1. How often is the orthopaedist the first specialist contacted for patients with juvenile arthritis?
  2. Why are ophthalmologists involved with this condition?

Discussion
Juvenile arthritis is a relatively common disease affecting children. Terminologies have varied through the last 25 years. The International League against Rheumatism has proposed a classification which that organization hopes will clarify communication between Europe and North America. At the present time, there is still some discussion about classification, but the ILAR will be presented here. Categories listed include systemic arthritis, oligoarthritis (persistent), oligoarthritis (extended), polyarticular arthritis (rheumatoid-factor negative), polyarticular arthritis (rheumatoid-factor positive), enthesitis arthritis, psoriatic arthritis, and unclassified. North American clinicians will find some of these terms unfamiliar, the last 3 categories are not juvenile arthritis; and terminology in North America has been pauciarticular, polyarticular, and systemic. With such a heterogeneous group of disorders, a single etiology is obviously not at play, there appears to be a combination of autoimmune activity with other local factors, such as cytokine activity and growth factors. Systemic arthritis can begin anytime in childhood, characterized by high fever, rash, intense musculoskeletal pain, and a number of other clinical and laboratory findings. These children do not generally present to the orthopaedist, but children with pauci (or oligoarthritis) do, in a recent study 62% were referred to an orthopaedist before seeing a rheumatologist. Joints most often affected with pauciarticular arthritis are knees, ankles, fingers, toes, wrists, elbows, and hips respectively. Although children with pauciarticular arthritis are generally thought to do well, rheumatologists are identifying subsets of pauciarticular arthritis with less good prognoses. Medical management of juvenile arthritis has evolved considerably over the past decade, with more frequent intra-articular steroid usage, less systemic steroid administration, methotrexate, and bone marrow transplant for serious situations. Uveitis, which formerly led to the blinding of a number of children because of its silent progression, appears to be affected in incidence to some degree by race, white children particularly susceptible.

Growth disturbance, systemic or regional, accompanies juvenile arthritis. Leg length discrepancy is common in the oligoarticular subset, which can easily be managed by standard measures. The need for synovectomy appears greatly reduced as a result of better medical management. However, the orthopaedist still has a great role in prevention or management of contracture, and monitoring functional recovery (as persistent weakness is common).

References
  1. Ansell BM. Prognosis in juvenile arthritis. Advances in Experimental Medicine & Biology 1999; 455: 27-33.
  2. Cassidy JT, Hillman LS. Abnormalities in skeletal growth in children with juvenile rheumatoid arthritis. Rheumatic Diseases Clinics of North America 1997; 23( 3): 499-522.
  3. Chmell MJ, Scott RD, Thomas WH, Sledge CB. Total hip arthroplasty with cement for juvenile rheumatoid arthritis. Results at a minimum of ten years in patients less than thirty years old. Journal of Bone & Joint Surgery -American Volume 1997; 79( 1): 44-52.
  4. Connor PM, Morrey BF. Total elbow arthroplasty in patients who have juvenile rheumatoid arthritis. Journal of Bone & Joint Surgery -American Volume 1998; 80( 5): 678-88.
  5. Cuesta IA, Kerr K, Simpson P, Jarvis JN. Subspecialty referrals for pauciarticular juvenile rheumatoid arthritis. Archives of Pediatrics & Adolescent Medicine 2000; 154( 2): 122-5.
  6. Foeldvari I, Bidde M. Validation of the proposed ILAR classification criteria for juvenile idiopathic arthritis. International League of Associations for Rheumatology. Journal of Rheumatology 2000; 27( 4): 1069-72.
  7. Guillaume S, Prieur AM, Coste J, Job-Deslandre C. Long-term outcome and prognosis in oligoarticular-onset juvenile idiopathic arthritis. Arthritis & Rheumatism 2000; 43( 8): 1858-65.
  8. Guzman J, Burgos-Vargas R, Duarte-Salazar C, Gomez-Mora P. Reliability of the articular examination in children with juvenile rheumatoid arthritis: interobserver agreement and sources of disagreement. Journal of Rheumatology 1995; 22( 12): 2331-6.
  9. Haber D, Goodman SB. Total hip arthroplasty in juvenile chronic arthritis: a consecutive series. Journal of Arthroplasty 1998; 13( 3): 259-65.
  10. Lindehammar H, Sandstedt P. Measurement of quadriceps muscle strength and bulk in juvenile chronic arthritis. A prospective, longitudinal, 2 year survey. Journal of Rheumatology 1998; 25( 11): 2240-8.
  11. Mink van der Molen AB, Hall MA, Evans DM. Ulnar lengthening in juvenile chronic arthritis. Journal of Hand Surgery -British Volume 1998; 23( 4): 438-41.
  12. Rydholm U, Brattstrom H, Bylander B, Lidgren L. Stapling of the knee in juvenile chronic arthritis. Journal of Pediatric Orthopedics 1987; 7( 1): 63-8.
  13. Sharma S, Sherry DD. Joint distribution at presentation in children with pauciarticular arthritis [see comments]. Journal of Pediatrics 1999; 134( 5): 642-3.
  14. Sherry DD, Mosca VS. Juvenile rheumatoid arthritis and seronegative spondyloarthropathies. In: Morrissy RT, Weinstein SL, editors. Pediatric Orthopaedics. Philadelphia: Lippincott-Raven; 1996. p. 393-421.
  15. Sherry DD, Stein LD, Reed AM, Schanberg LE, Kredich DW. Prevention of leg length discrepancy in young children with pauciarticular juvenile rheumatoid arthritis by treatment with intraarticular steroids. Arthritis & Rheumatism 1999; 42( 11): 2330-4.
  16. Vostrejs M, Hollister JR. Muscle atrophy and leg length discrepancies in pauciarticular juvenile rheumatoid arthritis. American Journal of Diseases of Children 1988; 142( 3): 343-5.
  17. Witt JD, McCullough CJ. Anterior soft-tissue release of the hip in juvenile chronic arthritis. Journal of Bone & Joint Surgery -British Volume 1994; 76( 2): 267-70.
  18. Woo P, Wedderburn LR. Juvenile chronic arthritis. Lancet 1998; 351( 9107): 969-73.

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