Addressing Surgical Complications of the Patient With Fibromyalgia

Diagnosing fibromyalgia in a patient requiring foot and ankle surgery is challenging.  Fibromyalgia is a complex chronic pain syndrome associated with diffuse musculoskeletal pain as well as chronic fatigue, sleep ailments, and depressionanxiety.^1,2 Fibromyalgia affects approximately 2 to 4 percent of the US population with slightly more afflicted worldwide, of which an estimated 85 to 90 percent are female.^1,2 Though diagnosis relies on a thorough history and physical examination, patients must meet criterion formed by the American College of Rheumatology, which includes a widespread pain index (WPI) score of 7 or greater and a symptom severity scale (SS) of 5 or greater, widespread pain lasting greater than 3 months, and excluding other diagnoses.² Though there is no cure for this disease, management can vary from pain medications and antidepressants, to physical therapy and cognitive behavioral therapy.³ Challenges in both diagnosis and treatment lead to a recommendation for multi-disciplinary care, which is also relevant when operating on patients with fibromyalgia.

Fibromyalgia is common amongst patients with rheumatoid arthritis, axial spondylarthritis, psoriatic arthritis and osteoarthritis.¹ Of those, osteoarthritis shows the most common indication for joint replacement surgery. Multiple risk factors, including musculoskeletal pain and depression, have shown to influence surgical outcomes.² Consequently, some hypothesize that fibromyalgia is associated with poor outcomes in orthopedic surgery.

D’Onghia and colleagues systemically reviewed a number of studies which focused on surgical outcomes in fibromyalgia patients. The studies reported that the prevalence of patients with fibromyalgia who underwent hipknee surgery was 4.1 percent, 10.1 percent for elbow and shoulder surgery and 20.1 percent for spinal surgery.² After compiling the data, the authors reported that fibromyalgia was a significant risk factor for higher pain, worse functional outcome scores, increased postoperative opioid prescriptions, and a higher rate of medical and surgical complications.2 Donnally and team reported that within the first 30 postop days from lumbar spine fusions, those with fibromyalgia had significantly higher readmission rates and acute post-hemorrhagic anemia. They also noted higher rates of pneumonia and hospital charges within 90 days postop.⁴

O’Hara and colleagues performed a literature review relating major depressive disorder and complications of surgery as well as increased morbidity and mortality, showing depression as a strong predictor and correlate of chronic postsurgical pain and morbidity.⁵ Consequently, there may be an association between fibromyalgia and surgical complications related to depression. D’Apuzzo and team reviewed patients with fibromyalgia undergoing total knee arthroplasties to determine the level of postoperative pain and satisfaction, the incidence of postop complications, and revision rates.⁶ Forty-four percent of patients had continued pain after surgery, where 82 percent of patients were satisfied with the results. The most common complications were arthrofibrosis and symptomatic instability. The reported revision rate was 6 percent. These authors concluded that though patients with fibromyalgia undergoing a primary total knee arthroplasty have a high prevalence of complications and pain, the majority of patients in this study expressed satisfaction with the results and reported outcomes.⁶

Brummett and coworkers’ study stated fibromyalgia characteristics predict poorer pain outcomes in total knee and hip arthroplasties.⁷ Fibromyalgia is often comorbid with knee osteoarthritis.⁸ Sodhi and team performed a study examining fibromyalgia patients and their likelihood of developing surgical complications after total knee arthroplasty.⁸ When compared to those without fibromyalgia, patients with fibromyalgia had increased odds of developing surgical complications, including weight-bearing and periprosthetic osteolysis. Patients also had significantly greater chances of developing tibial insert or mechanical loosening, infection, inflammation, or dislocations.⁸

It is also crucial for surgeons and the health care team to properly diagnose and treat patients with fibromyalgia. A questionnaire in a study by Bloom and colleagues evaluated the awareness and skills of orthopedic surgeons when diagnosing and treating patients with fibromyalgia.⁹ After performing a multivariable statistical analysis, 91 percent of responders reported that they recognized the disease.⁹

Fibromyalgia is a very complex condition and patients can suffer greatly when undergoing orthopedic surgeries unless closely monitored. The literature reports several instances where patients with fibromyalgia suffered physical or emotional postoperative complications. While there is still a risk, surgery may sometimes be the only option to help patients with certain orthopedic conditions.^1,2 Surgeons and patients should be aware of the increased risks and possible benefits, coupled with continued monitored, multidisciplinary care in order to clinically and surgically manage those with fibromyalgia. It is imperative that surgeons discuss that despite the most successful radiographic and clinical outcomes of foot and ankle surgery, the patient may have persistent pain that remains problematic despite deformity and/or pathology mitigation.

Dr. Miller is a Fellow of the American College of Foot and Ankle Surgeons. He is the Director of the Pennsylvania Intensive Lower Extremity Fellowship in Malvern, PA, and the Podiatric Residency Program at Phoenixville Hospital in Phoenixville, PA.

Dr. Capuzzi is a current Fellow of the Pennsylvania Intensive Lower Extremity Fellowship in Malvern, PA.

Dr. Mullapudi is a current fourth-year student at Temple University School of Podiatric Medicine in Philadelphia.

References

1. Boyd M. Narrative review: the pathophysiology of fibromyalgia. Yearbook of Medicine. 2009;2009:39-40. doi:10.1016s0084-3873(09)79346-0

2. D’Onghia M, Ciaffi J, McVeigh JG, et al. Fibromyalgia syndrome – a risk factor for poor outcomes following orthopaedic surgery: A systematic review. Sem Arthrit Rheum. 2021;51(4):793-803. doi:10.1016j.semarthrit.2021.05.016

3. Häuser W. Fibromyalgia syndrome—classification, diagnosis, and treatment: in reply. Deutsches Aerzteblatt Online. Published online October 30, 2009. doi:10.3238arztebl.2009.0729b

4. Donnally CJ, Vakharia RM, Rush AJ, et al. Fibromyalgia as a predictor of increased postoperative complications, readmission rates, and hospital costs in patients undergoing posterior lumbar spine fusion. Spine. 2019;44(4):E233-E238. doi:10.1097brs.0000000000002820

5. Ghoneim MM, O’Hara MW. Depression and postoperative complications: an overview. BMC Surgery. 2016;16(1). doi:10.1186s12893-016-0120-y

6. D’Apuzzo MR, Cabanela ME, Trousdale RT, Sierra RJ. Primary total knee arthroplasty in patients with fibromyalgia. Orthopedics. Published online February 17, 2012. doi:10.392801477447-20120123-18

7. Brummett CM, Urquhart AG, Hassett AL, et al. Characteristics of fibromyalgia independently predict poorer long‐term analgesic outcomes following total knee and hip arthroplasty. Arthrit Rheumatol. 2015;67(5):1386-1394. doi:10.1002art.39051

8. Sodhi N, Moore T, Vakharia RM, et al. Fibromyalgia increases the risk of surgical complications following total knee arthroplasty: a nationwide database study. J Arthroplasty. 2019;34(9):1953-1956. doi:10.1016j.arth.2019.04.023

9. Bloom S, Ablin JN, Lebel D, et al. Awareness of diagnostic and clinical features of fibromyalgia among orthopedic surgeons. Rheumatol Int. 2012;33(4):927-931. doi:10.1007s00296-012-2488-z