Is surgery to remove metal hardware in the hand recommended for a person with Complex Regional Pain Syndrome (CRPS)?

Surgery for Metal Hardware Removal in CRPS Patients

Surgery to remove metal hardware in the hand of a person with Complex Regional Pain Syndrome (CRPS) is generally not recommended as it may worsen symptoms and lead to further pain and disability.

Understanding CRPS and Surgical Intervention

CRPS is a chronic pain condition characterized by:

• Pain disproportionate to the inciting event
• Sensory, vasomotor, sudomotor/edema, and motor/trophic changes
• Classification into Type I (without nerve injury) and Type II (with identifiable nerve damage) 1

Evidence Against Hardware Removal Surgery

Research indicates significant concerns with surgical intervention in CRPS patients:

• Surgical procedures in patients with established CRPS can exacerbate symptoms and worsen pain outcomes 2
• A retrospective study of 55 CRPS patients found that 22 out of 27 patients (81%) who underwent orthopedic surgery after their initial injury reported worsening of pain 2
• Trauma, including surgical trauma, is a known trigger for CRPS development and can potentially worsen existing CRPS 3

Current Treatment Recommendations for CRPS

Instead of surgery, guidelines recommend a multimodal approach:

1. First-line treatments:

   • Physical and occupational therapy to maintain function 1
   • Pain management with medications (anticonvulsants, antidepressants, NSAIDs) 1
   • Patient education and self-management strategies 1

2. Interventional approaches when conservative treatment fails:

   • Sympathetic nerve blocks to facilitate physical therapy participation 4, 1
   • Spinal cord stimulation for persistent pain 4
   • Botulinum toxin for specific indications 4

3. Advanced therapies for refractory cases:

   • Neuromodulation techniques including peripheral nerve stimulation 4
   • Immune-modulatory treatments for selected cases 5

Special Considerations

Hardware Removal Decision Algorithm

If hardware removal is being considered despite CRPS:

1. Determine if hardware is definitively causing mechanical issues (not just pain)
2. Assess duration since CRPS onset (longer duration correlates with worse surgical outcomes)
3. Evaluate response to conservative treatments and nerve blocks
4. Consider CRPS severity and extent of autonomic features
5. Assess psychological readiness and expectations

Risk Mitigation If Surgery Is Unavoidable

If hardware must be removed due to mechanical failure or infection:

• Ensure CRPS symptoms are optimally controlled before surgery
• Consider prophylactic treatment with vitamin C, gabapentinoids, or ketamine
• Use regional anesthesia techniques when possible
• Plan for aggressive post-operative pain control
• Implement immediate post-operative physical therapy

Conclusion

The evidence strongly suggests avoiding surgical intervention, including hardware removal, in patients with established CRPS whenever possible. Early diagnosis and non-surgical management remain the cornerstone of CRPS treatment, with a focus on physical therapy, pain management, and interventional procedures when necessary.