Elbow Arthroplasty in a patient with Juvenile Idiopathic Arthritis

Martins, P; Moura, DL; Ferreira, J; Reis, A; Capelão, M; Fonseca, F

http://hdl.handle.net/10400.4/1836

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Introduction: Juvenile Idiopathic Arthritis (JIA) is an autoimmune systemic chronic inflammatory disease that affects the joints as a chronic inflammatory synovitis. It appears before the 16 years old and there are many disease types, like the oligoarticular, polyarticular, systemic, etc. The orthopedic treatment and prognosis are defined by the joint sequelae grades, affecting mostly the hips, knees, ankles, elbows and wrists. Objectives: Case report of a patient with JIA which conservative treatment was ineffective. A new stage of treatment was proposed, with bone preservation total elbow prosthesis. A good function, increasing range of motion and pain relief was achieved. Methods: We present a clinical case of a 35 year-old female with diagnosis of a polyarticular JIA with evolution of 30 years. The disease stadium is the articular sequelae phase, affecting the vertebral column, hips, knees, shoulders, elbows and hands. The patient is referred to our centre because of intense pain and progressive amplitudes loss of the left elbow, with 5 years evolution. The plain radiograph of the left elbow shows bone erosions and diffuse osteopenia, signs of inflammatory active process at this joint. At this time, the patient is treated non surgically with disease modifying anti-rheumatoid, anti-inflammatory and pain killer drugs. After six months, the elbow pain and stiffness are worse, so the patient is submitted to a surgical arthrolisis, with no improvement. After 6 months, it is performed another arthrolisis, with the same unsuccessful results. The symptoms became incapacitating, with intense pain and crepitation of the joint, and severe limitation of the daily activities. The Mayo Score was 15. The movement arc was 90º of flexion and 20º of extension. At this time, the x-ray shows a grade 4 elbow arthrosis, with numerous osteophytes and an almost complete disappearance of the interarticular space. Being aware of the age of the patient and the severe limitation and prejudice on the life quality, it is performed a total elbow arthroplasty. The intraoperative findings were extense synovitis and aderences and a total juxtaposition of the articular surfaces, conditioning severe joint stiffness. It was used a bone preservation total elbow prosthesis. Results: The surgery had no intercurrences and during the first 3 weeks it was done a cast immobilization with 90º elbow flexion. After this time, the patient began psychiatric rehabilitation programs that lead to progressive gain of joint amplitudes. One month after the joint replacement, the patient has 120º flexion and 15º extension, with no signs of joint instability and pain only at the movement limits. The patient was satisfied with the recuperation and at the third postoperative month the Mayo Sore was 100. Conclusions: JIA can result in extreme situations of incapacitating osteoarthosis, frequently of the elbow joint. This disease affecting a young active patient is an indication to total elbow arthroplasty, that in the inflammatory arthritis generally results in pain relief and an important function recuperation of the joint amplitudes movements.