CRPS and Elective Surgery

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Would you do an elective surgery for someone with history of upper extremity CRPS

  • Yes

    Votes: 7 36.8%
  • No

    Votes: 12 63.2%
  • Other, write your response in comments

    Votes: 0 0.0%

  • Total voters
    19
  • Poll closed .

Steveington

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Here's the scenario: 65 year old female with history of upper extremity CRPS after wrist surgery 5 years ago. Still is painful, managed with opioids. She has painful hallux rigidus, best treated with fusion of the MTPJ. She's done some conservative treatment for it: shoes, carbon fiber splint, injections, but still having pain. She was turned away by another podiatrist for surgery, comes to see you asking about surgery. What would you do?

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CRPS is a risk of any surgery and is not something you'll be sued over if you consent the patient properly. Failure to recognize the disease is another reason you can be sued (we'll skip gross negligence as well). I am assuming she had countless other surgeries without CRPS in her life. She got wrist surgery and unfortunately for whatever reason it didn't go well. If she is willing to risk CRPS again and whatever went into treating that condition, then that's all you can do. 1st MTPJ fusion has low risk of nerve injury since there is no major nerve in the surgical area. I say proceed.


Here is a refresher in case you want to talk to a pain management provider and see what can be done even if she already passed the "cool down" phase.
 
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It is an unnecessary risk here. This is an elective procedure. There is no infection, no unstable fracture, no deformity that won't fit in shoes, etc.

I will do an infected ingrown or ulcerating deformity or trauma stuff for CRPS patients (even with that extremity involved), "uncontrolled" diabetics, alcoholics, morbidly obese, fibromyalgia, etc since those are a major debility or threat which will progress quickly. Joint pain is not those situations. You have to consider the reason that the Morton ext, injects, topicals, better shoes, etc do not relieve her 1st MPJ pain is the CRPS... so how will any surgery fix that component?

It's always a case-by-case basis, so it's ultimately up to you. Some CRPS (and non) patients are anxious lunatics, and some are pretty mellow normal folks with just local involvement. Do at least a few visits and figure out which type of CRPS and which type of personality you are dealing with. Personally, I'd do the conservative care with good pt counseling in the process ("surgery could definitely do more harm than good, and I don't want that for you"). We often forget our role as health counselor/advisor and assume surgical skill can compensate for patients with questionable mental health, physical health, compliance ability, etc (it seldom can). If she is set on surgery, you can send her to a competitor for another opinion (I usually don't do that to someone in my group or someone I like). If you decide to do an elective case for any CRPS pt (I almost certainly would not), then make sure to get neuro/pain consult from her specialist regarding risk.

As someone who has been sued over "causing CRPS," it is never a good thing (case was dismissed nuisance since the pt was on video waking in flip flops when she was supposedly crippled, but still not fun). Any post-op nerve pain will be blown up by the plaintiff attorneys as being new dx CRPS or exacerbation of it. It is just generally stuff you don't want to get involved with if you can avoid it. There is no reason to be a hero and many other patients to operate on. That is definitely one thing I am better at now than I was 10 or even 5yrs ago... detecting the crazies and the anxious ("CRPS-prone") and the unrealistic expectations in pre-op visits. I will often say "you can probably find another foot doc who will do the surgery for you, but I am not going to be the one as I do not believe it's in your best interest" (used if pt wants ultra-fast recovery, can't be NWB, almost any nerve surgery, MPJ implant, ankle implant, salvage when amp is clearly best move, various anxious or unrealistic expectations or unhealthy pt, etc). Again, sometimes with infection or trauma, you have no choice, but in elective recon, you always do. Don't roll the dice when there is no reason to.
 
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I might do the surgery, but there will be a lot of talking and a minimum of two visits before scheduling. That said, I will not do the case if the patient appears to have CRPS at the surgery site -BEFORE- the surgery.

The two worst cases of my life both had clear warning signs before hand.
(a) one was a ...unclean older male smoker who cussed at my office manager during the scheduling
(b) the other patient had no formal diagnosis but had nerve pain at an arthritis surgery site and wouldn't tolerate examination.

I've read on other forums about patients who scream and cuss are really just frightened, but we terminate anyone who screams/curses at the staff even if they are scheduled for surgery.
 
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CRPS after wrist surgery 5 years ago. Still is painful, managed with opioids. She has painful hallux rigidus, best treated with fusion of the MTPJ.
Just say NO . I personally like doing 1st MPJ fusion. I would say it is my favorite procedure but then again I won't get over my head and get too confident in doing surgery on the wrong candidate. A surgeon is only as good as the patient following the right post-op instructions. Hallux limitus pain is not life threatening or an emergency regardless of what patients tell you. Don't try to be a hero.
 
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No way am I doing elective surgery on someone with a H/O CRPS. Manage with injections. Someone else can have this nightmare.
 
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Just to add, these patients are going to be super sweet pre-op and act very understanding. However when the post-op nightmare starts, they turn into a different persona. All the consent form that they signed pre-op is now forgotten. Think about when you drilled into a patients head that post-op edema could last up to 6-9 months (I tell all my patients a year) then 2 months post-op they start complaining about how their surgical foot is still swollen.

I have seen patients come to me for a "second opinion" for post-op swelling 2 months after initial surgery even when x-ray and surgery site is 100% fine and healed. Then they claim the doctor never told them the swelling last this long. In this cases, I always defend the initial surgeon and won't believe what the patient is telling me. I want to look out for my fellow colleagues at all cost even when I don't know them. The customer is not always right.
 
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I don't cut on CRPS patients.

In residency I saw 2 or 3 patients with CRPS and their entire legs were blotchy and blue and purple with allodynia and hyperaesthesias. They were in constant pain similar to fibromyalgia patients but with a legitimate and obvious reason for their symptoms. No thank you. I would send a kind referral to the unfriendly ortho or DPM across town.
 
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"but with a legitimate reason" :lol:
 
  • Haha
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