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Zamour S, Dumontier C. Complications in nail surgery and how to avoid them. HAND SURGERY & REHABILITATION 2024:101648. [PMID: 38244695 DOI: 10.1016/j.hansur.2024.101648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/22/2024]
Abstract
Complications in nail surgery are not that frequent. Apart from complications that are common to every hand procedure, intense pain is the major issue with nail surgery. To prevent complications, good knowledge of anatomy and physiology is required to avoid misdiagnosis or inappropriate technique. However, some complications, such as postoperative nail dystrophy, are unavoidable, and must be known and discussed with the patient prior to the procedure in order to prevent disappointment that may lead to medico-legal cases. This paper will discuss the most frequent complications encountered.
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Affiliation(s)
- Sarah Zamour
- Clinique Les Eaux Claires, ZAC Moudong Sud, 97122 Baie-Mahault, Guadeloupe, France.
| | - Christian Dumontier
- Clinique Les Eaux Claires, ZAC Moudong Sud, 97122 Baie-Mahault, Guadeloupe, France.
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Del Piñal F. Diagnosis and Outcomes of 225 Consecutive Cases of Complex Regional Pain Syndrome of the Hand. Plast Reconstr Surg 2023; 152:807-816. [PMID: 36952596 DOI: 10.1097/prs.0000000000010454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND The lack of specific tests and potential diagnostic inaccuracy may be behind the stunning figures of complex regional pain syndrome (CRPS) cases. The author tested the hypothesis that patients diagnosed with CRPS at referral could be assigned to recognized conditions and treated accordingly. METHODS From January of 2018 to April of 2021, 225 consecutive patients attended the author's office having been diagnosed with and treated for CRPS for an average of 16 ± 26 months. There were 180 women and 45 men; no patient was excluded. RESULTS All patients could be allocated in named conditions: 79 had a wrong diagnosis; seven had a true causalgia; 16 were dystonic-psychogenic hands; 20 presented a flare reaction; and 90 had an "irritative" carpal tunnel syndrome. The remaining 13 patients had a miscellany of symptoms within a substandard management setting. Surgery was offered to 175 with a correctable cause; 50 (20 of whom had a tangible cause responsible for their pain) declined, and their outcome is unknown. The remaining 125 were operated on and tracked for an average of 20 ± 9 months. In the operated group, pain dropped 7.5 ± 2.2 points ( P < 0.0001) on a numerical rating scale of 0 to 10. Disabilities of the Arm, Shoulder, and Hand questionnaire scores fell from 80 to 16 ( P < 0.0001). Patients who were operated on rated their satisfaction on a scale of 0 to 10 as 8.9 ± 1.9. CONCLUSIONS Unlike with CRPS, all patients in this series had a true, diagnosable condition explaining their clinical picture. Most patients who agreed to be operated on had a favorable outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Limerick G, Christo DK, Tram J, Moheimani R, Manor J, Chakravarthy K, Karri J, Christo PJ. Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments. Curr Pain Headache Rep 2023; 27:269-298. [PMID: 37421541 DOI: 10.1007/s11916-023-01130-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/10/2023]
Abstract
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.
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Affiliation(s)
- Gerard Limerick
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Dana K Christo
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jennifer Tram
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | | | - John Manor
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Jay Karri
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.
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Bahm J. Additions Required. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:485. [PMID: 37661320 PMCID: PMC10487678 DOI: 10.3238/arztebl.m2023.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Jörg Bahm
- *Klinik für Plastische, Hand- und Verbrennungschirurgie am Universitätsklinikum Aachen
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5
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Hobby J, Ring D, Larson D. The mind and the hand. J Hand Surg Eur Vol 2023; 48:269-275. [PMID: 36638068 DOI: 10.1177/17531934221143502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Symptoms are determined in large part by mindsets. Feelings of distress and unhelpful thoughts (misinterpretations) of symptoms account for much of the variability in comfort and capability with the severity of the underlying pathophysiology making a more limited contribution. Incorporating this experimental evidence into the daily practice of hand surgery will help us find ways to develop healthy mindsets, to prioritize the alleviation of distress and the gentle redirection of unhelpful thoughts, to avoid unnecessary surgery, and to provide better psychological and social support for people recovering from injury and surgery.
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Affiliation(s)
- Jonathan Hobby
- Department of Trauma and Orthopaedics, North Hampshire Hospital, Basingstoke, UK
| | - David Ring
- University of Texas at Austin Dell Medical School, Austin, TX, USA
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Melf-Marzi A, Böhringer B, Wiehle M, Hausteiner-Wiehle C. Modern Principles of Diagnosis and Treatment in Complex Regional Pain Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:879-886. [PMID: 36482756 PMCID: PMC10011717 DOI: 10.3238/arztebl.m2022.0358] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 04/21/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Background: Complex regional pain syndrome (CRPS) is a relatively common complication, occurring in 5% of cases after injury or surgery, particularly in the limbs. The incidence of CPRS is around 5-26/100 000. The latest revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) now categorizes CRPS as a primary pain condition of multifactorial origin, rather than a disease of the skeletal system or the autonomic nervous system. METHODS Method: Based on a selective search of the literature, we summarize current principles for the diagnosis and treatment of CRPS. RESULTS Results: Regional findings in CRPS are accompanied by systemic symptoms, especially by neurocognitive disorders of body perception and of symptom processing. The therapeutic focus is shifting from predominantly passive peripheral measures to early active treatments acting both centrally and peripherally. The treatment is centered on physiotherapy and occupational therapy to improve sensory perception, strength, (fine) motor skills, and sensorimotor integration/ body perception. This is supported by stepped psychological interventions to reduce anxiety and avoidance behavior, medication to decrease inflammation and pain, passive physical measures for reduction of edema and of pain, and medical aids to improve functioning in daily life. Interventional procedures should be limited to exceptional cases and only be performed in specialized centers. Spinal cord and dorsal root ganglion stimulation, respectively, are the interventions with the best evidence. CONCLUSION Conclusion: The modern principles for the diagnosis and treatment of CRPS consider both, physiological and psychological mechanisms, with the primary goal of restoring function and participation. More research is needed to strengthen the evidence base in this field.
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Affiliation(s)
- Alexandra Melf-Marzi
- Department for BG Rehabilitation; Outpatient CRPS Clinic; BG Trauma Center Murnau; Department for Anesthesiology, Intensive Care Medicine and Pain Therapy; Multimodal Pain Therapy; BG Trauma Center Murnau; Department for Neurology, Clinical Neurophysiology and Stroke Unit; BG Trauma Center Murnau; Clinic and Polyclinic for Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich
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Outcomes of Carpal Tunnel Release in Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy/Sudeck Disease Patients. Plast Reconstr Surg 2022; 150:93-101. [PMID: 35536771 DOI: 10.1097/prs.0000000000009243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The clinical features of classic carpal tunnel syndrome are well known. However, some patients who display atypical symptoms and signs of pain and dysesthesias in the hand, worsening of symptoms at night, and above all, inability to make a full fist, respond equally well to carpal tunnel release. This same clinical picture was shared by some patients labeled as having complex regional pain syndrome. Because of the poor outcome of complex regional pain syndrome patients with current regimens, the authors tested the hypothesis that carpal tunnel release could be effective on them. The purpose of this article is to report the outcome of carpal tunnel release in complex regional pain syndrome patients who presented the above signs and symptoms. METHODS Fifty-three patients with an average age of 55 years presenting the above cluster of symptoms were operated on. All were unilateral cases, had sustained trauma, and were treated for complex regional pain syndrome before referral for an average of 16 months. All patients underwent carpal tunnel release. RESULTS At a minimum of 6 months' follow-up, pain dropped 7.5 points on a numerical rating scale of 0 to 10 ( p < 0.001). Disabilities of the Arm, Shoulder and Hand scoring fell from 82 to 17 ( p < 0.001). Six patients had an unsatisfactory result. CONCLUSIONS Some patients with complex regional pain syndrome may respond successfully to a carpal tunnel release operation. Recognition of this possibility is crucial, as the symptoms and signs might lead the clinician away from the proper diagnosis and treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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8
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Bharwani KD, Kersten AB, Stone AL, Birklein F, Bruehl S, Dirckx M, Drummond PD, Gierthmühlen J, Goebel A, Knudsen L, Huygen FJPM. Denying the Truth Does Not Change the Facts: A Systematic Analysis of Pseudoscientific Denial of Complex Regional Pain Syndrome. J Pain Res 2021; 14:3359-3376. [PMID: 34737631 PMCID: PMC8558034 DOI: 10.2147/jpr.s326638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 09/03/2021] [Indexed: 12/31/2022] Open
Abstract
Purpose Several articles have claimed that complex regional pain syndrome (CRPS) does not exist. Although a minority view, it is important to understand the arguments presented in these articles. We conducted a systematic literature search to evaluate the methodological quality of articles that claim CRPS does not exist. We then examined and refuted the arguments supporting this claim using up-to-date scientific literature on CRPS. Methods A systematic search was conducted in MEDLINE, EMBASE and Cochrane CENTRAL databases. Inclusion criteria for articles were (a) a claim made that CRPS does not exist or that CRPS is not a distinct diagnostic entity and (b) support of these claims with subsequent argument(s). The methodological quality of articles was assessed if possible. Results Nine articles were included for analysis: 4 narrative reviews, 2 personal views, 1 letter, 1 editorial and 1 case report. Seven points of controversy were used in these articles to argue that CRPS does not exist: 1) disagreement with the label “CRPS”; 2) the “unclear” pathophysiology; 3) the validity of the diagnostic criteria; 4) CRPS as a normal consequence of immobilization; 5) the role of psychological factors; 6) other identifiable causes for CRPS symptoms; and 7) the methodological quality of CRPS research. Conclusion The level of evidence for the claim that CRPS does not exist is very weak. Published accounts concluding that CRPS does not exist, in the absence of primary evidence to underpin them, can harm patients by encouraging dismissal of patients’ signs and symptoms.
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Affiliation(s)
- K D Bharwani
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - A B Kersten
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - A L Stone
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - F Birklein
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - S Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Dirckx
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - P D Drummond
- Discipline of Psychology, College of Science, Health, Engineering and Education, Murdoch University, Perth, WA, Australia
| | - J Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - A Goebel
- Director of the Pain Research Institute Reader in Pain Medicine, University of Liverpool Honorary Consultant in Pain Medicine, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - L Knudsen
- The National Rehabilitation Centre for Neuromuscular Diseases, Aarhus, Denmark
| | - F J P M Huygen
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Groenveld TD, Boersma EZ, Blokhuis TJ, Bloemers FW, Frölke JPM. Decreasing incidence of complex regional pain syndrome in the Netherlands: a retrospective multicenter study. Br J Pain 2021; 16:214-222. [PMID: 35419200 PMCID: PMC8998521 DOI: 10.1177/20494637211041935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Complex regional pain syndrome type I (CRPS) is a symptom-based diagnosis of which the reported incidence varies widely. In daily practice, there appears to be a decrease in incidence of CRPS after a distal radius fracture and in general. Questions/purposes: The aim of this study was to assess the trend in the incidence of CRPS after a distal radius fracture and in general in the Netherlands from 2014 to 2018. Methods: The incidence of CRPS after a distal radius fracture was calculated by dividing the number of confirmed cases of CRPS after distal radius fracture by the total number of patients diagnosed with a distal radius fracture. Medical records of these patients were reviewed. Hospital-based data were used to establish a trend in incidence of CRPS in general. A Dutch national database was used to measure the trend in the incidence of CRPS in the Netherlands by calculating annual incidence rates: the number of new CRPS cases, collected from the national database, divided by the Dutch mid-year population. Results: The incidence of CRPS after distal radius fracture over the whole study period was 0.36%. Hospital data showed an absolute decrease in CRPS cases from 520 in 2014 to 223 in 2018. National data confirmed this with a decrease in annual incidence from 23.2 (95% CI: 22.5–23.9) per 100,000 person years in 2014 to 16.1 (95% CI: 15.5–16.7) per 100,000 person years in 2018. Conclusion: A decreasing trend of CRPS is shown in this study. We hypothesize this to be the result of the changing approach towards CRPS and fracture management, with more focus on prevention and the psychological aspects of disproportionate posttraumatic pain. Level of Evidence: level 3 (retrospective cohort study).
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Affiliation(s)
- Tjitske D Groenveld
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Emily Z Boersma
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Taco J Blokhuis
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Jan Paul M Frölke
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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10
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Chang C, McDonnell P, Gershwin ME. Complex regional pain syndrome - Autoimmune or functional neurologic syndrome. J Transl Autoimmun 2020; 4:100080. [PMID: 33490941 PMCID: PMC7804982 DOI: 10.1016/j.jtauto.2020.100080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 12/23/2022] Open
Abstract
Complex regional pain syndrome (CRPS) purports to explain extremity pain accompanied by a variety of subjective complaints, including sensitivity to touch, fatigue, burning sensations, allodynia and signs consistent with voluntary immobilization, including skin changes, edema and trophic changes. By its own definition, CRPS pain is disproportionate to any inciting event or underlying pathology, which means that the syndrome describes non-anatomic and exaggerated symptoms. Although CRPS was coined in the early 1990s, physicians have described unexplained exaggerated pain for centuries. Before a small group of researchers assigned this historical phenomenon with the name CRPS, other physicians in various subspecialties investigated the existence of a common pathophysiologic mechanism but found none. The literature was searched for evidence of a reproducible pathologic mechanism for CRPS. Although some have suggested that CRPS is an autoimmune disease, there is a paucity of evidence to support this. While cytokines such as IL-1β, IL-6 and TNF-α have been detected during the early phases of CRPS, this cannot lead to the conclusion that CRPS is an autoimmune disease, nor that it is an autoinflammatory disorder. Moreover, intravenous immunoglobulin has showed inconsistent results in the treatment of CRPS. On the other hand, CRPS has been found to meet at least three out of four criteria of malingering, which was previously a DSM-IV diagnosis; and its diagnostic criteria are virtually identical to current DSM-5 Functional Neurological Disorder ("FND"), and proposed ICD-11 classification, which includes FND as a distinct neurological diagnosis apart from any psychiatric condition. Unfortunately, the creation of CPRS is not merely misguided brand marketing. It has serious social and health issues. At least in part, the existence of CRPS has led to the labeling of many patients with a diagnosis that allows the inappropriate use of invasive surgery, addictive opioids, and ketamine. The CRPS hypothesis also ignores the nature and purpose of pain, as a symptom of some organic or psychological process. Physicians have long encountered patients who voice symptoms that cannot be biologically explained. Terminology historically used to describe this phenomenon have been medically unexplained symptoms ("MUS"), hysterical, somatic, non-organic, psychogenic, conversion disorder, or dissociative symptoms. The more recent trend describes disorders where there is a functional, rather than structural cause of the symptoms, as "functional disorders." Physicians report high success treating functional neurological symptoms with reassurance, physiotherapy, and cognitive behavior therapy measured in terms of functional improvement. The CRPS label, however, neither leads to functional improvement in these patients nor resolution of symptoms. Under principles of evidence-based medicine, the CRPS label should be abandoned and the syndrome should simply be considered a subset of FNDs, specifically Functional Pain Disorder; and treated appropriately.
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Affiliation(s)
- Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA.,Division of Immunology, Allergy and Rheumatology, Joe DiMaggio Children's Hospital and Memorial Healthcare System, 1131 N 35th Avenue, Suite 220, Hollywood, FL, 33021, USA
| | | | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA
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11
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Abstract
The main goals of treating severe crush injuries are debriding away devitalized tissue and filling any resultant dead space with vascularized tissue. In the authors' experience, the most ideal methods for soft tissue coverage in treating crush injuries are the iliac flap, the adipofascial lateral arm flap, and the gracilis flap. Accompanying bone defects respond very well to free corticoperiosteal flaps. Digital defects often require the use of complete or subtotal toe transfer to avoid amputation and restore function to the hand.
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12
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Russo MA, Fiore NT, van Vreden C, Bailey D, Santarelli DM, McGuire HM, Fazekas de St Groth B, Austin PJ. Expansion and activation of distinct central memory T lymphocyte subsets in complex regional pain syndrome. J Neuroinflammation 2019; 16:63. [PMID: 30885223 PMCID: PMC6423749 DOI: 10.1186/s12974-019-1449-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/28/2019] [Indexed: 02/07/2023] Open
Abstract
Background Complex regional pain syndrome (CRPS) is a debilitating condition where trauma to a limb results in devastating persistent pain that is disproportionate to the initial injury. The pathophysiology of CRPS remains unknown; however, accumulating evidence suggests it is an immunoneurological disorder, especially in light of evidence of auto-antibodies in ~ 30% of patients. Despite this, a systematic assessment of all circulating leukocyte populations in CRPS has never been performed. Methods We characterised 14 participants as meeting the Budapest clinical criteria for CRPS and assessed their pain ratings and psychological state using a series of questionnaires. Next, we performed immunophenotyping on blood samples from the 14 CRPS participants as well as 14 healthy pain-free controls using mass cytometry. Using a panel of 38 phenotypic and activation markers, we characterised the numbers and intracellular activation status of all major leukocyte populations using manual gating strategies and unsupervised cluster analysis. Results We have shown expansion and activation of several distinct populations of central memory T lymphocytes in CRPS. The number of central memory CD8+ T cells was increased 2.15-fold; furthermore, this cell group had increased phosphorylation of NFkB and STAT1 compared to controls. Regarding central memory CD4+ T lymphocytes, the number of Th1 and Treg cells was increased 4.98-fold and 2.18-fold respectively, with increased phosphorylation of NFkB in both populations. We also found decreased numbers of CD1c+ myeloid dendritic cells, although with increased p38 phosphorylation. These changes could indicate dendritic cell tissue trafficking, as well as their involvement in lymphocyte activation. Conclusions These findings represent the first mass cytometry immunophenotyping study in any chronic pain state and provide preliminary evidence of an antigen-mediated T lymphocyte response in CRPS. In particular, the presence of increased numbers of long-lived central memory CD4+ and CD8+ T lymphocytes with increased activation of pro-inflammatory signalling pathways may indicate ongoing inflammation and cellular damage in CRPS.
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Affiliation(s)
- Marc A Russo
- Hunter Pain Clinic, 91 Chatham Street, Broadmeadow, NSW, 2292, Australia.,Genesis Research Services, 220 Denison St, Broadmeadow, NSW, 2292, Australia
| | - Nathan T Fiore
- Discipline of Anatomy & Histology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Room E513, Anderson Stuart Building, Sydney, NSW, 2006, Australia
| | - Caryn van Vreden
- Ramaciotti Centre for Human Systems Biology, Charles Perkins Centre, The University of Sydney, Sydney, NSW, 2006, Australia.,Sydney Cytometry, Centenary Institute and the Charles Perkins Centre, John Hopkins Drive, Camperdown, NSW, 2050, Australia
| | - Dominic Bailey
- Genesis Research Services, 220 Denison St, Broadmeadow, NSW, 2292, Australia
| | | | - Helen M McGuire
- Ramaciotti Centre for Human Systems Biology, Charles Perkins Centre, The University of Sydney, Sydney, NSW, 2006, Australia.,Discipline of Pathology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Barbara Fazekas de St Groth
- Ramaciotti Centre for Human Systems Biology, Charles Perkins Centre, The University of Sydney, Sydney, NSW, 2006, Australia.,Discipline of Pathology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Paul J Austin
- Discipline of Anatomy & Histology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Room E513, Anderson Stuart Building, Sydney, NSW, 2006, Australia.
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13
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A new hypothesis for the pathophysiology of complex regional pain syndrome. Med Hypotheses 2018; 119:41-53. [DOI: 10.1016/j.mehy.2018.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/18/2018] [Accepted: 07/27/2018] [Indexed: 12/21/2022]
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14
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Martínez-Lavín M, Amezcua-Guerra L. Serious adverse events after HPV vaccination: a critical review of randomized trials and post-marketing case series. Clin Rheumatol 2017; 36:2169-2178. [DOI: 10.1007/s10067-017-3768-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/10/2017] [Accepted: 07/13/2017] [Indexed: 01/30/2023]
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15
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Del Piñal F, Urrutia E, Klich M. Severe Crush Injury to the Forearm and Hand: The Role of Microsurgery. Clin Plast Surg 2017; 44:233-255. [PMID: 28340660 DOI: 10.1016/j.cps.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The main goals of treating severe crush injuries are debriding away devitalized tissue and filling any resultant dead space with vascularized tissue. In the authors' experience, the most ideal methods for soft tissue coverage in treating crush injuries are the iliac flap, the adipofascial lateral arm flap, and the gracilis flap. Accompanying bone defects respond very well to free corticoperiosteal flaps. Digital defects often require the use of complete or subtotal toe transfer to avoid amputation and restore function to the hand.
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Affiliation(s)
- Francisco Del Piñal
- Instituto de Cirugía Plástica y de la Mano, Private Practice, Hospital La Luz and Hospital Mutua Montañesa, Madrid/Santander, Spain.
| | - Esteban Urrutia
- Instituto de Cirugía Plástica y de la Mano, Private Practice, Hospital La Luz and Hospital Mutua Montañesa, Madrid/Santander, Spain; Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Maciej Klich
- Instituto de Cirugía Plástica y de la Mano, Private Practice, Hospital La Luz and Hospital Mutua Montañesa, Madrid/Santander, Spain; Department of Traumatology and Orthopedics, Clinical Hospital, Warsaw, Otwock, Poland
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16
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Erhard L. [Complex pain regional syndrome after distal radius fractures]. HAND SURGERY & REHABILITATION 2016; 35S:S144-S149. [PMID: 27890201 DOI: 10.1016/j.hansur.2016.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 03/07/2016] [Accepted: 03/30/2016] [Indexed: 10/20/2022]
Abstract
Complex regional pain syndrome (CPRS) greatly affects the outcomes of distal radius fractures in terms of functional recovery, time away from work and patient satisfaction. The diagnosis is sometimes difficult to make in the immediate post-injury period. The disproportionate nature of the pain in the absence of differential diagnoses and the presence of a pain-free interval should arouse suspicion. The natural history consists of spontaneous improvement except in some refractory forms. The treatment is multidisciplinary combining a physician specializing in pain, therapist and psychologist coordinated by the surgeon who must not abandon the patient. Treatment aims to improve the patient's comfort and quality of life. Recent treatment approaches aimed at improving cortical reorganization have demonstrated their effectiveness. Surgery has to be considered even in the acute phase to address any causes of pain that can be resolved and address secondary stiffness. Significant progress has to be made in our understanding of the pathogenesis of CPRS to improve treatment and shift this condition to a regional pain syndrome.
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Affiliation(s)
- L Erhard
- Institut chirurgical de la main et du membre supérieur, 17, avenue Condorcet, 69100 Villeurbanne, France.
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17
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Borchers AT, Gershwin ME. The clinical relevance of complex regional pain syndrome type I: The Emperor's New Clothes. Autoimmun Rev 2016; 16:22-33. [PMID: 27666818 DOI: 10.1016/j.autrev.2016.09.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023]
Abstract
The management of patients with chronic pain is a nearly daily challenge to rheumatologists, neurologists, orthopedic surgeons, pain specialists and indeed a issue in nearly every clinical practice. Among the myriad of causes of pain are often included a unique syndrome, generally referred to as complex regional pain syndrome type I (CRPS). Unfortunately CRPS I has become a catch all phase and there are serious questions on whether it exists at all; this has led to an extraordinary number of poorly defined diagnostic criteria. It has also led to an etiologic quagmire that includes features as diverse as autoimmunity to simple trauma. These, in turn, have led to overdiagnosis and often overzealous use of pain medications, including narcotics. In a previous paper, we raised the issue of whether CRPS type I reflected a valid diagnosis. Indeed, the diagnostic criteria for CRPS I, and therefore the diagnosis itself, is unreliable for a number of reasons: 1) the underlying pathophysiology of the signs and symptoms of CPRS I are not biologically plausible; 2) there are no consistent laboratory or imaging testing available; 3) the signs and symptoms fluctuate over time without a medical explanation; 4) the definitions of most studies are derived from statistical analysis with little consideration to required sample size, i.e. power calculations; 5) interobserver reliability in the assessment of the signs and symptoms are often only fair to moderate, and agreement on the diagnosis of "CRPS I" is poor. Even physicians who still believe in the concept of "CRPS I" admit that it is vastly overdiagnosed and has become a diagnosis of last resort, often without a complete differential diagnosis and an alternative explanation. Finally, one of the most convincing arguments that there is no clinical entity as "CRPS I" comes from the enormous heterogeneity in sign and symptom profiles and the heterogeneity of pathophysiological mechanisms postulated. This observation is underscored by the diversity of responses among "CRPS I" patients to essentially all treatment modalities. It has even led to the concept that the signs and symptoms of CRPS can spread throughout the body, as if it is an infectious disease, without any medical plausible explanation. If true progress is to be made in helping patients with pain, it will require entirely new and different concepts and abandoning CRPS I as a legitimate diagnosis.
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Affiliation(s)
- Andrea T Borchers
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States.
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18
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Martínez-Lavín M. Hypothesis: Human papillomavirus vaccination syndrome—small fiber neuropathy and dysautonomia could be its underlying pathogenesis. Clin Rheumatol 2015; 34:1165-9. [DOI: 10.1007/s10067-015-2969-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 05/05/2015] [Accepted: 05/05/2015] [Indexed: 01/10/2023]
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19
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Sletten IN, Hellund JC, Olsen B, Clementsen S, Kvernmo HD, Nordsletten L. Conservative treatment has comparable outcome with bouquet pinning of little finger metacarpal neck fractures: a multicentre randomized controlled study of 85 patients. J Hand Surg Eur Vol 2015; 40:76-83. [PMID: 25427553 DOI: 10.1177/1753193414560119] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Current literature gives few guidelines regarding indication for operative treatment of little finger metacarpal neck fractures, and some surgeons choose operative treatment when the palmar angulation exceeds 30°. The objective of this study was to determine whether conservative treatment produces comparable outcomes with bouquet pinning in a randomized, controlled trial. Eighty-five patients with little finger metacarpal neck fractures with ≥30° palmar angulation in the lateral view were included. Patients were randomized to two groups: conservative treatment without reduction of the fracture (43 patients); and closed reduction and bouquet pinning (42 patients). After 1 year, there were no statistical differences between the groups in QuickDASH score, pain, satisfaction, finger range of motion, grip strength, or quality of life. There was a trend versus better satisfaction with hand appearance (p = 0.06), but longer sick leave (p < 0.001) and more complications (p = 0.02) in the operative group.
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Affiliation(s)
- I N Sletten
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - J C Hellund
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - B Olsen
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - S Clementsen
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway
| | - H D Kvernmo
- Division of Neurosciences and Orthopaedics, University Hospital of North Norway, Tromsø, Norway Department of Clinical Medicine, University of Tromsø - Arctic University of Norway, Tromsø, Norway
| | - L Nordsletten
- Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway Faculty of Medicine, University of Oslo, Blindern, Norway
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