Complex Regional Pain Syndrome after Total Knee Arthroplasty is Rare and Misdiagnosis Potentially Hazardous—Prospective Study of the New Diagnostic Criteria in 100 Patients with No Cases Identified

Abstract

Previous studies suggest that complex regional pain syndrome (CRPS) occurs in up to 21% of patients following total knee arthroplasty (TKA). However, this diagnosis has a substantial impact on the patient's management if it is incorrect. We aimed to identify cases, using updated internationally accepted criteria, while investigating potential causes of misdiagnosis.

We prospectively studied a consecutive series of 100 primary TKA patients. Each patient was assessed 6-week post-TKA. Pain levels were recorded with the presence of symptoms and signs of CRPS (Budapest Diagnostic Criteria) assessed in those with excessive pain. An alternative diagnosis was sought, in these patients, including the presence of neuropathic pain.

We found no cases of CRPS (no patients had symptoms or signs in greater than two of four subgroups). Seventeen patients had excessive pain levels (nine had an alternative diagnosis explaining this). The commonest signs were sensory and sudomotor, whereas motor/trophic changes were not seen. Using a previous definition (Orlando Criteria), eight patients may have been diagnosed with CRPS. Over half of the patients with unexplained excessive pain had evidence of neuropathic pain.

CRPS is a rare diagnosis following TKA using modern criteria. Isolated signs and symptoms may lead to the overdiagnosis of CRPS in the presence of unexplained pain following TKA. New diagnostic criteria, with strict definitions and treatment algorithms, are now accepted. Delays in managing more common causes (such as neuropathic pain) may negatively affect the patient's outcome.

Keywords

complex regional pain syndrome - total knee arthroplasty - pain - neuropathic pain - diagnostic criteria

• References

• 1 Hawker GA. Who, when, and why total joint replacement surgery? The patient's perspective. Curr Opin Rheumatol 2006; 18 (05) 526-530
• 2 Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open 2012; 2 (01) e000435
• 3 Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. ; National Joint Registry for England and Wales; Data from the National Joint Registry for England and Wales. The role of pain and function in determining patient satisfaction after total knee replacement. J Bone Joint Surg Br 2007; 89 (07) 893-900
• 4 Toms AD, Mandalia V, Haigh R, Hopwood B. The management of patients with painful total knee replacement. J Bone Joint Surg Br 2009; 91 (02) 143-150
• 5 Lindenfeld TN, Bach BR, Wojtys EM. Reflex sympathetic dystrophy and pain dysfunction in the lower extremity. J Bone Joint Surg Am 1996; 78-A: 1936-1944
• 6 Dowd GS, Hussein R, Khanduja V, Ordman AJ. Complex regional pain syndrome with special emphasis on the knee. J Bone Joint Surg Br 2007; 89 (03) 285-290
• 7 Harden RN, Bruehl SP. Diagnosis of complex regional pain syndrome: signs, symptoms, and new empirically derived diagnostic criteria. Clin J Pain 2006; 22 (05) 415-419
• 8 Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med 2007; 8 (04) 326-331
• 9 Cooper DE, DeLee JC. Reflex sympathetic dystrophy of the knee. J Am Acad Orthop Surg 1994; 2 (02) 79-86
• 10 Katz MM, Hungerford DS. Reflex sympathetic dystrophy affecting the knee. J Bone Joint Surg Br 1987; 69 (05) 797-803
• 11 Harden RN, Bruehl S, Stanos S. , et al. Prospective examination of pain-related and psychological predictors of CRPS-like phenomena following total knee arthroplasty: a preliminary study. Pain 2003; 106 (03) 393-400
• 12 Burns AWR, Parker DA, Coolican MR, Rajaratnam K. Complex regional pain syndrome complicating total knee arthroplasty. J Orthop Surg (Hong Kong) 2006; 14 (03) 280-283
• 13 Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: what is moderate pain in millimetres?. Pain 1997; 72 (1-2): 95-97
• 14 Phillips JR, Hopwood B, Arthur C, Stroud R, Toms AD. The natural history of pain and neuropathic pain after knee replacement: a prospective cohort study of the point prevalence of pain and neuropathic pain to a minimum three-year follow-up. Bone Joint J 2014; 96-B [phone]
• 15 Freynhagen R, Baron R, Gockel U, Tölle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin 2006; 22 (10) 1911-1920
• 16 Justins D. Reflex sympathetic dystrophy. Has been renamed complex regional pain syndrome. BMJ 1995; 311 (7008): 812
• 17 Atkins RM. Complex regional pain syndrome. J Bone Joint Surg Br 2003; 85 (08) 1100-1106
• 18 Jänig W, Baron R. Complex regional pain syndrome: mystery explained?. Lancet Neurol 2003; 2 (11) 687-697
• 19 Jänig W, Baron R. Experimental approach to CRPS. Pain 2004; 108 (1-2): 3-7
• 20 Hogan CJ, Hurwitz SR. Treatment of complex regional pain syndrome of the lower extremity. J Am Acad Orthop Surg 2002; 10 (04) 281-289
• 21 Birklein F, Riedl B, Claus D, Neundörfer B. Pattern of autonomic dysfunction in time course of complex regional pain syndrome. Clin Auton Res 1998; 8 (02) 79-85
• 22 Harden RN, Bruehl S, Galer BS. , et al. Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive?. Pain 1999; 83 (02) 211-219
• 23 van Velzen GA, Perez RS, van Gestel MA. , et al. Health-related quality of life in 975 patients with complex regional pain syndrome type 1. Pain 2014; 155 (03) 629-634
• 24 O'Brien SJ, Ngeow J, Gibney MA, Warren RF, Fealy S. Reflex sympathetic dystrophy of the knee. Causes, diagnosis, and treatment. Am J Sports Med 1995; 23 (06) 655-659
• 25 Cadambi A, Jones RE. Reflex sympathetic dystrophy occurring after total knee arthroplasty. Orthop Trans 1992; 26: 74
• 26 Cameron HU, Park YS, Krestow M. Reflex sympathetic dystrophy following total knee replacement. Contemp Orthop 1994; 29 (04) 279-281
• 27 Nielsen S, Hvid I, Sneppen O. Total condylar knee arthroplasty. A report of 2-year follow-up on 247 cases. Arch Orthop Trauma Surg 1985; 104 (04) 227-232
• 28 No authors listed. National Institute for Health and Clinical Excellence: NICE guideline 96: Neuropathic pain: The pharmacological management of neuropathic pain in adults in non-specialist settings, March 2010. Available at: http://guidance.nice.org.uk/CG96.htm . Accessed February 13, 2017
• 29 Royal College of Physicians. Complex regional pain syndrome in adults - UK guidelines for diagnosis, referral and management in primary and secondary care. 2012. Available at: https://www.rcplondon.ac.uk/file/1589/download?token=li_hqRc0 . Accessed February 12, 2017
• 30 Freynhagen R, Bennett MI. Diagnosis and management of neuropathic pain. BMJ 2009; 339: b3002
• 31 Ogilvie-Harris DJ, Roscoe M. Reflex sympathetic dystrophy of the knee. J Bone Joint Surg Br 1987; 69 (05) 804-806
• 32 Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH. Algorithm for neuropathic pain treatment: an evidence based proposal. Pain 2005; 118 (03) 289-305