Vitamin C prevention of complex regional pain syndrome after foot and ankle surgery: a prospective randomized study of three hundred and twenty nine patients

The influence of high doses of vitamin C on functional recovery and postoperative pain in patients with trochanteric fracture after intramedullary nailing during a three-month follow-up: a full-scale study

PURPOSE

To determine the effects of high peri- and postoperative doses of vitamin C administration on severity of pain in postoperative period and functional outcome of the patients with trochanteric fracture treated with intramedullary nailing during a three-month follow-up.

METHODS

A prospective, randomised, full-scale study included 74 patients who were randomly divided into vitamin C (intervention) and control groups. In the intervention group, patients received vitamin C perioperatively by intravenous route for 2 days, and oral vitamin C for 38 days postoperatively. Baseline characteristics, postoperative metamizole consumption, visual analogue scale (VAS) score, Harris hip score (HHS) value, and the prevalence of complications were evaluated in both groups.

RESULTS

No significant differences were noted between the groups regarding age, gender, length of hospitalisation, and distribution in fracture type as well as in postoperative HHS values. Postoperative metamizole consumption was notably higher in the control group compared to the vitamin C group (p = 0.003). Postoperative VAS scores were higher in the control group than in the vitamin C group at all time follow-ups (p < 0.05). The group variable significantly contributed to VAS score, and age and gender variables significantly contributed to HHS value.

CONCLUSION

Significant reduction of subjective pain levels and lower analgesic consumption was found in patients who received vitamin C, suggesting that it should be considered as an adjuvant agent for analgesia in patients with hip fracture.

Clinical and Molecular Barriers to Understanding the Pathogenesis, Diagnosis, and Treatment of Complex Regional Pain Syndrome (CRPS)

Complex regional pain syndrome (CRPS) is an idiopathic, highly debilitating chronic disorder with persistent regional pain accompanied by a combination of sensory, motor, and autonomic abnormalities. It is not only difficult to treat but also difficult to study. This scoping review aimed to identify the key clinical and molecular challenges encountered in CRPS research and to examine the assessment tools currently employed. A comprehensive search was conducted across PubMed/Medline, Science Direct, Scopus, Wiley Online Library, and Google Scholar using a combination of free text and MeSH terms related to CRPS, clinical and molecular aspects, neuroinflammation, biomarkers, and research challenges. We analyzed 55 original clinical research papers on CRPS and 17 studies of immunological/biochemical/molecular aspects of CRPS. A significant degree of heterogeneity was observed in the methodologies employed across the reviewed studies. The most frequently reported challenges included difficulties in participant recruitment and controlling confounding factors (reported in 62% of studies), such as the heterogeneity of the patient population, the influence of pain coping strategies and psychological factors, and the impact of sociocultural factors (reported in 62% of studies). Research into diagnostic and prognostic markers for CRPS also faces numerous challenges. Recruiting participants is difficult due to the rarity of the condition, resulting in small sample sizes for studies. In vitro models often fail to replicate the complexity of in vivo inflammation, limiting their applicability. Findings from early CRPS stages may not generalize to chronic CRPS because of differing pathophysiological mechanisms and symptom profiles. Additional obstacles include the disorder's heterogeneity, difficulties in controlling confounding factors, variability in treatment approaches, and the lack of standardized tools and baseline comparisons. These issues hinder the development of reliable biomarkers and evidence-based treatments. Due to these difficulties, the exact cause of CRPS is still not fully understood, making it difficult to develop effective, specific treatments and conduct targeted research.

The effect of intravenous vitamin C administration on postoperative pain and intraoperative blood loss in older patients after intramedullary nailing of trochanteric fractures

PURPOSE

The purpose of this study was to determine the effects of peri and postoperative intravenous vitamin C administration on severity of postoperative pain and intraoperative blood loss in patients with trochanteric fracture treated with intramedullary nailing.

METHODS

A prospective, single-blinded, controlled, randomised clinical study was conducted. It included 60 patients who were randomly divided into the Vitamin C and Control groups. Baseline characteristics, haemoglobin levels, number of Red Blood Cell (RBC) units transfusion, and metamizole consumption were noted in each group. Visual Analogue Scale (VAS) score was evaluated at 24 and 48 h postoperatively.

RESULTS

There were no differences between the groups concerning age, gender, length of hospitalisation, fracture type distribution, preoperative and postoperative haemoglobin levels. Postoperative metamizole consumption was higher in the Control group than in the Vitamin C group, with statistically significant difference (p = 0.003). The median VAS scores were higher in the Control group compared to the Vitamin C group at 24 and 48 h postoperatively with significant differences (p = 0.001 and p < 0.0005, respectively). Multivariate logistic regression analysis revealed two independent predictors of postoperative blood transfusion: unstable fracture pattern (OR = 0.065, 95% CI 0.007-0.571, p = 0.014), and preoperative haemoglobin level (OR = 903, 95% CI 0.846-0.965, p = 0.003).

CONCLUSION

The results showed significant reduction of subjective pain levels and lower analgesic consumption in patients who received intravenous vitamin C, suggesting that it could be considered as an adjuvant agent for analgesia in older patients with hip fracture. Unstable fracture pattern and preoperative haemoglobin levels significantly contributed to postoperative blood transfusion requirement.

Efficacy of vitamin C supplementation in preventing and treating complex regional pain syndrome type I (CRPS-I) in Orthopedic patients: A systematic review and meta-analysis

AIM

Complex regional pain syndrome type I (CRPS-I) is a specific type of persistent pain which is often caused by fracture and surgery. There is no effective curative therapy available. However some studies have indicated that Vitamin C (VC) can reduce the incidence of CRPS-I. This study's objective is to investigate the effectiveness VC in preventing and treating CRPS-I.

DESIGN

An Systematic review and Meta-analysis was done.

DATA SOURCES

Primary research studies from PubMed, Scopus, Web of Science, ProQuest, Embase database, and Cochran Library, and Google Scholar were reviewed. This search was conducted until March 27, 2024. This study was conducted without any language, place, and time restrictions. Study results were meta-analyzed with using effect sizes. To evaluate heterogeneity, we employed the Cochrane Q test and the I2 index.

RESULTS

In our systematic review, 3947 articles were initially identified, with 3939 excluded for not meeting inclusion criteria, resulting in 8 studies being critically evaluated using Cochran's risk of bias checklist. The meta-analysis revealed that VC supplementation have effect on reducing CRPS-I post-limb surgery but this result shows that the pooled effect size is not statistically significant. The heterogeneity of the studies was low (I2 = 26.28%, p = 0.22). Publication bias was detected, indicating asymmetry in the funnel plot.

CONCLUSION

The results of our study showed the positive effect of VC supplementation in reducing the prevalence of CRPS-I after limb surgery.

Efficacy of N-acetylcysteine in reducing inflammation and oxidative stress to prevent complex regional pain syndrome type 1

This study aimed to evaluate the effectiveness of N-acetylcysteine (NAC) in preventing complex regional pain syndrome type 1 (CRPS-1) by reducing proinflammatory cytokines and oxidative stress markers in patients with distal radius fractures. A retrospective single-center study at Bursa City Hospital involves patients over 50 years of age with distal radius fractures treated between January 2021 and December 2023. A total of 60 patients (mean age, 62.8 ± 5.1 years; 26 males and 34 females) were analyzed. Patients were divided into 2 groups: the NAC group (31 patients receiving 600-mg NAC daily for 3 months) and the control group (29 patients with no prophylactic medication). CRPS-1 diagnosis was based on Budapest criteria during multiple follow-up visits. Serum levels of interleukin (IL)-1 beta, IL-6, tumor necrosis factor-alpha (TNF-α), total oxidant status (TOS), and total antioxidant status (TAS) were measured at baseline and study end point. CRPS-1 positive patients had significantly higher levels of IL-6, TNF-α, and IL-1 (P < .001 for all), higher TOS (P < .001) and oxidative stress index (P < .001), and lower TAS (P < .001) compared with CRPS-1 negatives. The incidence of CRPS-1 was significantly lower in the NAC group (9.7%) compared with the control group (31.0%; P = .039). Logistic regression indicated a 78% reduction in CRPS-1 odds ratio with NAC treatment (odds ratio, 0.219 [95% confidence interval, 0.053-0.895]; P = .0322). NAC significantly reduced end-point levels and changes in IL-6 (P < .001), TNF-α (P < .001), and IL-1 (P = .038) and improved oxidative stress markers, showing higher TAS (P < .001), lower TOS (P < .001), and oxidative stress index (P < .001) compared with controls. NAC significantly reduced the risk of developing CRPS-1 by decreasing levels of proinflammatory cytokines and oxidative stress. This study highlights NAC's potential as a preventive treatment for CRPS-1 and emphasizes the importance of early intervention.

Chronic regional pain syndrome following calcaneal fractures: what causes it and how may Vitamin C aid?

The purpose of the current study is to determine which variables influence the onset of chronic regional pain syndrome (CRPS) following Sanders type 1 calcaneal fractures, which are treated conservatively, and to discover how Vitamin C (VC) supplementation, which is often mentioned in the literature, affects the outcomes of these fractures. The study incorporated individuals who had a Sanders type 1 fracture that was both closed and non-displaced and were treated with conventional plaster. The current study retrospectively reviewed medical records to gather demographic data, duration of immobilization, smoking habits, administration of VC supplementation, and presence of diabetes mellitus (DM). The Budapest criteria were employed to make the clinical diagnosis of CRPS. The study cohort comprised 258 (75.9%) males and 82 (24.1%) females aged between 18 and 90 years who had sustained Sanders type 1 calcaneal fractures and were managed non-operatively. CRPS was detected in 42 (12.4%) of the 340 subjects. CRPS patients had a statistically higher immobilization duration than those without CRPS (p<0.05). Smoking and DM were more common among patients with CRPS (p<0.05) and CRPS patients had a much lower rate of VC consumption (4.8%) (p<0.05). The current study is the first to examine risk variables for CRPS after calcaneal fractures. Long periods of immobility, female gender, and lack of VC supplementation increase the risk of CRPS. CRPS also increases with diabetes and smoking.

Successful therapy of complex regional pain syndrome after hip arthroscopy for femoroacetabular impingement syndrome: a case report

BACKGROUND

Complex regional pain syndrome is a neuropathic pain disorder associated with ongoing pain that persists beyond the usual expected tissue healing time and that is disproportionate to the degree of tissue injury present. Complex regional pain syndrome after hip arthroscopy has not been reported before. Hip arthroscopy is a fast-growing domain that could lead to an increasing number of complex regional pain syndrome cases, probably owing to the high traction forces that are necessary.

CASE PRESENTATION

We report the case of a 30-year-old German female semiprofessional tennis player who presented with complex regional pain syndrome type I in the lower leg 3 weeks after hip arthroscopy for femoroacetabular impingement syndrome with suture anchor labral repair and femoroplasty. After 2 months of immediate multimodal conservative therapy including administration of gabapentin, prompt full weight-bearing, and intensified physiotherapy, complete recovery was achieved.

CONCLUSION

Complex regional pain syndrome does occur after elective hip arthroscopy. Disproportionate postoperative pain or other symptoms raising suspicion of complex regional pain syndrome should be promptly evaluated and treated through a multimodal approach. Postless hip arthroscopy may be advantageous.

Vitamins in neuropathy: pathophysiological and therapeutic roles

PURPOSE OF REVIEW

Vitamin deficiency is a risk factor in the development of peripheral neuropathy, which leads to complex and severe diseases. This review provides an update overview of the literature on the roles of vitamins in peripheral neuropathy, highlighting their pathophysiological and therapeutic roles.

RECENT FINDINGS

The importance and clinical manifestations and implications of the vitamins and vitamin deficiencies are further demonstrated in peripheral neuropathy and the associated diseases. Vitamin deficiency is common in various severe and complex diseases such as diabetes, chemotherapy, acute nutritional axonal neuropathy, dermatitis, complex regional pain syndrome, postherpetic neuralgia, carpal tunnel syndrome, and so forth and some rare clinical case reports. There is evidence that deficiencies of almost all vitamins are associated with diabetic neuropathy. Vitamin supplementation may serve as an effective therapeutic strategy.

SUMMARY

The vitamins play critical roles in maintaining physiological functions, and vitamin deficiencies cause peripheral neuropathy with various severe and complex diseases. The therapeutic benefits of vitamins and further understanding of the mechanisms for vitamin treatment effects should be emphasized and highlighted. More clinical trials are needed to establish optimal treatment strategies for vitamins in the various neuropathies. A large range of people/patients screening for vitamin deficiencies may be considered in order to provide early diagnosis and timely medical assistance.

The Classic Three-Month Post-Operative Adaptation Phase in Foot and Ankle Surgery-An Expert Perspective

Foot and ankle disorders are a common reason for orthopedic surgical intervention. After surgery, specific precautions such as partial weight bearing or complete unloading, and the use of walking aids, coupled with a period of rest, are usually implemented to ensure the surgical outcome. However, when these aids are discontinued and the patients resume load increase and normal daily activities, they may enter a transitional phase characterized by inflammation, swelling, and pain. We call this phenomenon the "classic three-month post-operative adaptation phase" (POAP). It is essential to differentiate this physiological transition phase from other conditions, such as from the immediate post-surgical inflammation, complex pain regional syndrome, or an infection. The objective of this expert opinion is to describe and raise medical awareness of this evidence-based phenomenon, which we commonly observe in our daily practice.

Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments

PURPOSE OF REVIEW

This review presents the most current information about the epidemiology of complex regional pain syndrome (CRPS), classification and diagnostic criteria, childhood CRPS, subtypes, pathophysiology, conventional and less conventional treatments, and preventive strategies.

RECENT FINDINGS

CRPS is a painful disorder with multifactorial pathophysiology. The data describe sensitization of the central and peripheral nervous systems, inflammation, possible genetic factors, sympatho-afferent coupling, autoimmunity, and mental health factors as contributors to the syndrome. In addition to conventional subtypes (type I and type II), cluster analyses have uncovered other proposed subtypes. Prevalence of CRPS is approximately 1.2%, female gender is consistently associated with a higher risk of development, and substantial physical, emotional, and financial costs can result from the syndrome. Children with CRPS seem to benefit from multifaceted physical therapy leading to a high percentage of symptom-free patients. The best available evidence along with standard clinical practice supports pharmacological agents, physical and occupational therapy, sympathetic blocks for engaging physical restoration, steroids for acute CRPS, neuromodulation, ketamine, and intrathecal baclofen as therapeutic approaches. There are many emerging treatments that can be considered as a part of individualized, patient-centered care. Vitamin C may be preventive. CRPS can lead to progressively painful sensory and vascular changes, edema, limb weakness, and trophic disturbances, all of which substantially erode healthy living. Despite some progress in research, more comprehensive basic science investigation is needed to clarify the molecular mechanisms of the disease so that targeted treatments can be developed for better outcomes. Incorporating a variety of standard therapies with different modes of action may offer the most effective analgesia. Introducing less conventional approaches may also be helpful when traditional treatments fail to provide sufficient improvement.