Background
A 54 year old woman developed florid complex regional pain syndrome (CRPS) within 3 weeks of minor skin surgery to the plantar foot. This was complicated by wound dehiscence that progressed to a large chronic wound. Management was extremely challenging due to the severity of pain & allodynia, requiring several inpatient admissions for debridement under general anaesthetic.
After 18-months of multi-modal management but failure to progress, the consensus decision to offer amputation was made.
Intervention
Above knee amputation was performed as a multi-specialty procedure. A fish-mouth incision was marked with equal length anterior & posterior skin flaps proximal to the level of skin change and CRPS pain, as recommended in the recent literature. The sciatic nerve was cut cleanly and the stump buried inside an adductor muscle, and both transposed away from the femoral stump to reduce irritation. A sciatic nerve catheter was placed, and a lidocaine PCA was provided for post-op use. The wound was closed in layers with PDS and subcuticular monocryl, and dressed with histoacryl glue and standard bandaging. The patient was able to be managed with oral analgesia by day 5, and was discharged on post-operative day 6.
Discussion
Despite the widely held understanding that amputation is contraindicated in CRPS, an increasing evidence base supports its use in select cases. There are no reported cases in the literature of limb amputation in CRPS with associated chronic wounds.
This patient was able to differentiate between different types of pain, and reported complete resolution of the chronic wound pain that had been the most difficult aspect of her condition to manage. She reported intermittent phantom limb pain & sensation, which she described as manageable. SF-36 questionnaires pre- and post-op demonstrate clear patient-reported improvements in pain, global physical health and mental health.