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Informed Decision-Making Regarding Amputation for Complex Regional Pain Syndrome Type I
Marlies I. Bodde, MD; Pieter U. Dijkstra, PhD; Ernst Schrier, MSc; Jan J. van den Dungen, PhD; Wilfred F. den Dunnen, PhD; Jan H. Geertzen, PhD
J Bone Joint Surg Am, 2014 Jun 04;96(11):930-934.
Background: Literature on complex regional pain syndrome type I (CRPS-I) discussing the decision to amputate or not, the level of amputation, or the timing of the amputation is scarce. We evaluated informed decision-making regarding amputation for CRPS-I.
Methods: We describe our findings in a retrospective study of the decision-making process of thirty-six patients who underwent amputation for CRPS-I at our university medical center from 2000 to 2012. Additionally, we present the incidents preceding the CRPS-I, the reasons for and the levels of the amputation, and the outcomes after the amputations.
Results: Team members and the patient decided together whether or not to amputate and the level of amputation. Issues such as level of pain or allodynia, infection, desired length of the residual limb, joint range of motion, strength of all extremities, ability to use walking aids, and psychological “green, yellow, and red flags” were weighed in this process. There were no complications during the amputation surgery, a 22% rate of complications (infection in all but one patient) immediately postoperatively (reamputation not required), a 72% rate of phantom pain immediately after or within the first three months after the amputation, and a 77% rate of phantom pain more than one year after the amputation.
Conclusions: Informed decision-making regarding amputation for CRPS-I remains a complex process for which little evidence is available to support patient choices; patient-specific outcomes are not predictable. However, amputation should not be ignored as a treatment option for long-standing therapy-resistant CRPS-I.
Investigation performed at the Department of Rehabilitation Medicine, Center for Rehabilitation, and the Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, the Netherlands