SLR - January 2022 - Aseem Saini

Vitamin C Prevention of Complex Regional Pain Syndrome After Foot and Ankle Surgery: A Prospective Randomized Study of Three Hundred and Twenty-Nine Patients

Reference: Hernigou, Jacques, et al. “Vitamin C Prevention of Complex Regional Pain Syndrome after Foot and Ankle Surgery: A Prospective Randomized Study of Three Hundred and Twenty-Nine Patients.” International Orthopaedics, vol. 45, no. 9, 2021, pp. 2453–2459.,

Level of Evidence: II

Scientific Literature Review

Reviewed By: Aseem Saini, DPM
Residency Program: John Peter Smith Hospital - Fort Worth, TX

Podiatric Relevance: As the field of Podiatry continues to expand as a well recognized surgical sub-speciality, practitioners within the field will inevitably encounter postoperative/ post traumatic Chronic Regional Pain Syndrome (CRPS) on a more frequent basis. CRPS, if left untreated or undiagnosed, can have devastating consequences to a patient’s quality of life and functionality. While physical therapy remains the gold standard to address CRPS, there are few options available for Foot and Ankle Surgeons to prophylactically treat patients for CRPS. Vitamin C may be a tool that Foot and Ankle Surgeons may implement to prophylax against postoperative/post-traumatic CRPS.

Methods: Three hundred twenty-nine patients were randomized in one of two groups. The control group consisted of those who received a placebo, while the experimental group consisted of patient’s who received Vitamin C postoperatively. Surgeries were categorized into two anatomical regions (foot and ankle) and two conditions (traumatic vs elective surgery). Ninety-one percent of patient’s in the study had a tourniquet placed and inflated during surgery. Patients with postoperative infections, fibromyalgia, and psychiatric disorders were excluded from the study. A previous history of CRPS prior to surgery was also an exclusion criteria given previous history of CRPS increased risk of postoperative CRPS by 10 fold. One hundred twenty-one patients were placed in the experimental group, and 208 were placed in the control group. Experimental group patient’s received 1 gram of oral Vitamin C per day for 40 days. Diagnosis of CRPS was based on Budapest criteria and three phase bone scintigraphy at six months after the surgery.

Results: The percentage of patients who presented with CRPS in the Vitamin C group was 4.9 percent of patients (six patients). The percentage of patients who presented with CRPS in the control group was 11.5 percent (24 patients). This was found to be a statistically significant difference (p=0.039). Factors that were associated with higher risk of CRPS included alcohol abuse and cast immobilization. Among the 30 patients with CRPS, nine patients (30 percent) had alcohol abuse, as compared to patients without  CRPS, where only 10 percent had alcohol abuse. For cast immobilization, 53 percent (16 cases) of patients with CRPS had a postoperative cast, while only 33 percent (99 cases) of the patient’s without CRPS had a postoperative cast. Increased time in a cast was not linked with increased risk of CRPS.

Conclusions: While physical therapy should continue to be the gold standard for treatment of CRPS, Foot and Ankle Surgeons should not discount the use of Vitamin C as a viable means for prevention of CRPS after both elective surgeries and trauma requiring surgery.

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