Recurrent complex regional pain syndrome after minor hip surgery

Abstract

Complex regional pain syndrome (CRPS) Type I, a chronic pain disorder, occurs in the sequel of certain predisposing conditions. Recurrence may be observed in 4%–10% of cases in the same or another limb. There are no specific parameters to prevent CRPS after surgery or trauma. However, some authors have reported several recommendations about surgical techniques and Vitamin C supplementation. We report a case who had CRPS Type I history before and developed recurrent CRPS Type I in the lower limb due to surgery for osteonecrosis of the hip. We observed significant improvement with physical therapy and medication.

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© 2021 Journal of Orthopaedics, Traumatology and Rehabilitation | Published by Wolters Kluwer - Medknow 61
Abstract
Case Report
IntRoductIon
Complexregionalpainsyndrome(CRPS)Type I is a
chronicpaindisorderwhich occursafter somepredisposing
conditionsincludingtrauma,infection,surgery, cervical
radiculopathy,soft‑tissue contusions, fractures, tendon
ruptures,andmyocardialinfarction.[1,2]Symptomsandndings
arecharacterizedbypain,allodynia,edema,trophicand
vasomotorchangesintheaffectedlimb.Aswellasthepain
isnot limitedto aspecic nervedistributionordermatome,
itisnotassociatedwiththeseverityofinjuryeither.CRPSis
clinicallyseparatedintothreephasesasacute,dystrophic,and
atrophic.According to extremelyvariousdurationsofeach
period,separationofthesephasesisnotpossibleunlikely.
Thepathophysiologyisnotclear,and some theories are
suggestedsuchasirregularsympatheticsystem,neurogenic
inammation,andimmobilization.Furthermore,psychological
featuresareaccusedasapredisposingfactor.[3,4]CRPScanbe
reactivatedafteradisease‑freeperiodwithfurthertraumaor
anotheroperationinthesameoranotherlimb.[5]
Wereportacase,whohadCRPSTypeIhistoryinthelower
limbafterminortrauma,withrecurrentCRPSTypeIin
anotherlimbduetocoredecompressionandbonegraftingfor
osteonecrosisofthehip.
case RepoRt
A47‑year‑oldmalehadahistoryofCRPSTypeIafterleft
footfourthngersoft‑tissueinjury,duetothespreadofthe
complaintstothefeetandankle,andprolongedhissymptoms
throughout3months.Hehadbeenimplemented45sessions
ofphysicaltherapyprogramandmedicaltreatmentinour
departmentbecauseof leftlower‑limbCRPSTypeI.Then,
hehadcompletelyameliorated.Oneyearlater,thepatienthad
feltpaininhisrighthipandhehadappliedtoorthopaedist.
Inthesequel,osteonecrosisoftherightfemoralheadhad
beenidentifiedbymagneticresonanceimaging(MRI).
Havingbeenoperatedduetoosteonecrosisandperformed
coredecompressionandbonegraftingfortherighthipbyan
orthopedist,hehadbeenadvisedimmobilizationthroughout
2monthsbecauseofcastingaftersurgery.Alongwith
mobilization,thepatientbegantofeelpaininhisrightfoot.
Complexregionalpainsyndrome(CRPS)TypeI,achronicpaindisorder,occursinthesequelofcertainpredisposingconditions.Recurrence
maybeobservedin4%–10%ofcasesinthesameoranotherlimb.TherearenospecicparameterstopreventCRPSaftersurgeryortrauma.
However,someauthorshavereportedseveralrecommendationsaboutsurgicaltechniquesandVitaminCsupplementation.Wereportacase
whohadCRPSTypeIhistorybeforeanddevelopedrecurrentCRPSTypeIinthelowerlimbduetosurgeryforosteonecrosisofthehip.We
observedsignicantimprovementwithphysicaltherapyandmedication.
Keywords:Complexregionalpainsyndrome,hipsurgery,recurrentcomplexregionalpainsyndrome
Address for correspondence: Dr. Hüseyin Kaplan,
Department of Physical Medicine and Rehabilitation, School of Medicine,
Education and Research Hospital, Aksaray University, Aksaray, Turkey.
E‑mail: hkaplan_87@hotmail.com
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Recurrent Complex Regional Pain Syndrome after Minor Hip
Surgery
Hüseyin Kaplan, Emel Güler1, Mehmet Kırnap2
Department of Physical Medicine and Rehabilitation, School of Medicine, Education and Research Hospital, Aksaray University, Aksaray, 1Department of Physical
Medicine and Rehabilitation, Division of Algology, Kayseri City Hospital, 2Department of Physical Medicine and Rehabilitation, School of Medicine, Erciyes University,
Kayseri, Turkey
How to cite this article: KaplanH,GülerE,KirnapM.Recurrentcomplex
regionalpainsyndromeafterminorhipsurgery.JOrthopTraumatolRehabil
2021;13:61‑3.
Submission: 01.12.2019 Revision: 19.08.2020
Acceptance:11.04.2021 Web Publication:16.06.2021
[Downloaded free from http://www.jotr.in on Thursday, July 8, 2021, IP: 181.215.86.152]

Kaplan, et al.: Recurrent CRPS
Journal of Orthopaedics, Traumatology and Rehabilitation ¦ Volume 13 ¦ Issue 1 ¦ January-June 2021
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Ontheoccasionofprolongedcomplaints,hehadapplied
tohissurgeon. InconsequenceofX‑rays and MRI,hehad
beendiagnosedrightlower‑limbCRPSTypeI.Hehadbeen
performedphysicaltherapyinanotherhospitalthroughout
21sessions.However,he was consulted in our department
byhisorthopedistforcontinuingcomplaints.Thepatient
presentedwithcomplaintsofdifcultyinwalking,swelling
intherightfootandankle,paininthecourseof mobility,
andresting.Onphysicalexamination,ininspection,he
mobilizedwithtwocrutch,hisrightfootandanklewere
edematousandalittle red.Also, elongation andthickening
wereobservedinhairofrightfoot.Onpalpation,therewere
prominentlytenderness,allodynia,andparesthesiaonthe
rightankle.Furthermore,he had alimitedrangeofmotion
ontheankle.TheNumericRatingScalewas8outof10.In
laboratoryexamination,erythrocytesedimentationratewas7
mm/h(3–20),C‑reactiveprotein(CRP)was3.98mg/L(0–6),
andrheumatoidfactorwasnegative.Triple‑phasebonescan
wascompatiblewithCRPS[Figure1].Regionalosteoporosis
wasseeninhisankleonroutineX‑rayexamination[Figure2].
MRIoftherightfootshowedthat therewasacompression
fractureinthetalus[Figure3].Hewasusingsomedrugs
includingibuprofen1200mg/day, pregabalin 150 mg/day,
andcalciumcarbonate andVitamin D3.Hewasundergone
physicaltherapy(transcutaneouselectricalnervestimulation,
whirlpool,rangeofmotionexercises,andpartialweightingon
thelimb).Hismedicaltreatmentwasreadjusted(pregabalin
300mg/day,ibuprofen1600mg/day,andcalciumcarbonate
plusVitaminD3).Asignicantimprovementwasobserved
followingninesessionsofphysicaltherapyandmedication.
Inadditiontothis,theNumericRatingScaledecreasedtothe
levelof1efciently.
dIscussIon
CRPSTypeI,aposttraumaticdisorder,commonlyassociated
withsurgeryincludingextremities,isascarcelycomplex
clinicalentityforclinicians.Theincidencehasbeenreported
1%–37%afterdistalradiusfracture.Somesynonymsarealso
usedtodescribeCRPSsuchasreexsympatheticdystrophy
syndrome,Sudeck’satrophy,andalgodystrophy.[3]The
BudapestcriteriaforthediagnosisofCRPS,modiedversion
ofOrlandocriteria,haveagreaterspecicityandalsoinclude
motorfeaturesofthesyndrome[Table1].[1]
Whileithasagoodprognosiswithearlydiagnosisand
treatment,prolongedmisdiagnosisandlackoftreatment
resultinchronicdisability.Recurrenceisobservedin4%–
10%ofcases3monthsto20yearsaftertheinitialevent.[6]
Therearenospecicparameterswhichareknowntoprevent
CRPSaftersurgeryortrauma.Butstill,anumberofauthors
havereportedseveralrecommendations including careful
operativetechnique,knowledgeofanatomy, avoidance
ofnerve traction,andproperpostoperativecaretoreduce
thefrequencyofthisdisorder.Physical therapies, mirror
visualfeedback,medication(oral/topicalmedicationor
injections),andsurgery maybeeffectivesolutions inthe
processoftreatment.Vitamin C supplementationafter
surgeryisassociatedwithreducingtheriskofdeveloping
CRPS.Althoughoptimaldoseisnotclear,500–1000mg/
daydosesarecommonlytaughttobeeffectivethanlower
doses.Typically,a 500 mg/daydoseisused for 50 days.
Furthermore,earlymobilizationafterlimbsurgerieshasbeen
reportedtopreventCRPS.[5,7,8]Paralleltothisinformation,
inasequelof2‑monthimmobilizationperiod,ourcaseeven
developedCRPSTypeI.
Figure 2: Regional osteoporosis on X‑ray
Figure 1: Triple‑phase bone scan was compatible with complex regional
pain syndrome for the right ankle (anterior‑posterior and posterior‑anterior
images, respectively)
Figure 3: Compression fracture in the talus on magnetic resonance
imaging of the right ankle
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Kaplan, et al.: Recurrent CRPS
Journal of Orthopaedics, Traumatology and Rehabilitation ¦ Volume 13 ¦ Issue 1 ¦ January-June 2021 63
Spinalcordstimulationmaybeperformed,ifsymptomsstill
persistafter3–4months.[1]However,itisreportedthat74%
ofpatientswithCRPSTypeIachieveresolutionofsymptoms
withearlytreatment.[9]Inourpatient,weachievedgreat
improvementwithphysicaltherapyandmedication.
Inconclusion,itcanbesuggestedthat people who will be
performedanysurgicalproceduresshouldbeevaluatedwith
regardtoCRPShistoryaheadofoperation.Thismaybe
fairlyimportanttotakeprecautionseitherduringsurgeryor
inpostoperativecaretopreventrecurrence.
Declaration of patient consent
Theauthorscertify thattheyhaveobtained allappropriate
patientconsentforms.Intheformthepatient(s)has/have
givenhis/her/theirconsentforhis/her/theirimagesandother
clinicalinformationtobereportedinthejournal.Thepatients
understandthattheirnamesandinitialswillnotbepublished
anddueeffortswill be  madetoconcealtheiridentity,but
anonymitycannotbeguaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
Therearenoconictsofinterest.
RefeRences
1. BussaM,GuttillaD,LuciaM,MascaroA,RinaldiS.Complexregional
pain syndrome type I: A comprehensive review. Acta Anaesthesiol
Scand2015;59:685‑97.
2. GencH,KaragozA,SaracogluM,SertE,ErdemHR.Complexregional
painsyndrometype‑Iafterrubellavaccine.EurJPain2005;9:517‑20.
3. DilekB,YemezB,KizilR,KartalE,GulbaharS,SariO, et al.Anxious
personality is a risk factor for developing complex regional pain
syndrometypeI.RheumatolInt2012;32:915‑20.
4. SaadA,KnollaR,GuptaK.Complexregionalpainsyndromefollowing
transfemoralcatheterization.JInvasiveCardiol2011;23:E267‑70.
5. Zyluk A. Complex regional pain syndrome type I. Risk factors,
preventionandriskofrecurrence.JHandSurgBr2004;29:334‑7.
6. AlbazazR,WongYT,Homer‑VanniasinkamS.Complexregionalpain
syndrome:Areview.AnnVascSurg2008;22:297‑306.
7. FieldJ. Complexregional painsyndrome:A review.JHand SurgEur
Vol2013;38:616‑26.
8. ShibuyaN,HumphersJM,AgarwalMR,JupiterDC.Efcacyandsafety
ofhigh‑dosevitaminConcomplexregionalpainsyndromeinextremity
traumaandsurgery‑systematicreviewandmeta‑analysis.JFootAnkle
Surg2013;52:62‑6.
9. KumarS,MackayC,O’CallaghanJ,De’AmbrosisB.Complexregional
pain syndrome after dermatological surgery. Australas J Dermatol
2008;49:242‑4.
Table 1: Budapest clinical diagnostic criteria for complex
regional pain syndrome
Continuingpain,whichisdisproportionatetoanyincitingevent
Mustreportatleastonesymptominthreeofthefourfollowingcategories
Sensory:Reportsofhyperalgesiaand/orallodynia
Vasomotor:Reportsoftemperatureasymmetry,and/orskincolor
changes,and/orskincolorasymmetry
Sudomotor/edema:Reportsofedema,and/orsweatingchanges,and/or
sweatingasymmetry
Motor/trophic:Reportsofdecreasedrangeofmotion,and/ormotor
dysfunction(weakness,tremor,anddystonia),and/ortrophic
changes(hair,nail,andskin)
Mustdisplayatleastonesign*attimeofevaluationintwoormoreofthe
followingcategories
Sensory:Evidenceofhyperalgesia(topinprick)and/orallodynia(to
lighttouch,and/ordeepsomaticpressure,and/orjointmovement)
Vasomotor:Evidenceoftemperatureasymmetry,and/orskincolor
changes,and/orasymmetry
Sudomotor/edema:Evidenceofedema,and/orsweatingchanges,and/or
sweatingasymmetry
Motor/trophic:Evidenceofdecreasedrangeofmotionand/ortrophic
changes(hair,nail,andskin)
Thereisnootherdiagnosisthatbetterexplainsthesignsandsymptoms
*Asigniscountedonlyifitobservedatthetimeofdiagnosis
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