Reflex Sympathetic Dystrophy of the Knee

We retrospectively reviewed the cases of fourteen patients who had reflex sympathetic dystrophy of the knee. All fourteen were hospitalized, and epidural block anesthesia was instituted with an indwelling catheter for an average of four days, during which continuous passive motion, manipulation (as necessary), stimulation of muscles, and alternating hot and cold soaks were used. The average length of follow-up was thirty-two months. Eleven patients had complete resolution of the symptoms, two had sufficient intermittent aching with changes in the weather to need medication, and one had no relief. The diagnosis was confirmed if the symptoms were relieved by a lumbar sympathetic block Pain that was out of proportion to the severity of the injury was the most consistent finding, being present in all fourteen patients. However, variation in clinical severity is characteristic of the syndrome. Eleven of the fourteen patients had had a previous patellar operation. After the onset of the symptoms, nine patients had two or more arthroscopic examinations, without notable findings. All fourteen patients had had extensive physical therapy and medical treatment before the epidural block was performed. The literature contains few reports on reflex sympathetic dystrophy of the knee, which is considered a rare entity 9”825. In 1984, Schutzer and Gossling defined the syndrome as an excessive or an exaggerated response to an injury of an extremity, manifested by four more-or-less constant characteristics: (1) intense or unduly prolonged pain, (2) vasomotor disturbances, (3) delayed functional recovery, and (4) various associated trophic changes. The clinical presentation varies and the clinical course is difficult to predict. Some authors have described the syndrome as selflimited5’9, but many have asserted that complete spontaneous resolution is rare”’925. In 1983, Poplawski et al. reported that most patients who did not have treatment were symptomatic after ten years of follow-up. The clinical findings in reflex sympathetic dystrophy * No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject ofthis article. No funds were received in support of this study. t University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284. Please address requests for reprints to Dr. DeLee. of the knee have been described previously59”25. Tietjen emphasized that all affected patients have pain that seems out of proportion to the severity of the original injury or to the operation that preceded the syndrome. Stiffness, mechanical complaints, atrophy, and diffuse tenderness were also consistently present in his patients. However, none had an effusion. The changes in the skin, burning sensations, and loss of motion that are usual when the syndrome affects the upper extremity were only variably present. Ogilvie-Harris and Roscoe, as well as Katz and Hungerford, emphasized that the patellofemoral joint is consistently involved when the syndrome affects the knee. Katz and Hungerford reported more favorable results in patients who were treated within one year after the appearance of symptoms compared with patients who were treated after a longer interval. Ogilvie-Harris and Roscoe found that treatment within six months was necessary for a favorable outcome. However, both pairs of authors expressed frustration with the treatment of this disorder, and no single treatment protocol has been reported to be consistently beneficial59 8.25 We are reporting the cases of fourteen patients who had a confirmed diagnosis of reflex sympathetic dystrophy of the knee and who were treated in the hospital with epidural block anesthesia. The anesthesia was administered with an indwelling catheter. During the treatment, continuous passive motion, manipulation (as necessary), stimulation of muscles, and alternating hot and cold soaks were used. Our results were more favorable than those that have been previously reported9”25.