O’Palko S, Burbelo A, Murphy A, Bullock M. Painful arthroplasty with disproportionate pain: Recognition and management of complex regional pain syndrome. World J Orthop 2026; 17(10): 126605 [DOI: 10.5312/wjo.126605]
Corresponding Author of This Article
Alexander Burbelo, BS, Research Fellow, Department of Orthopaedic Surgery, Marshall University, Joan C Edwards School of Medicine, 1600 Medical Center Drive - Suite G500, Huntington, WV 25701, United States. burbelo@marshall.edu
Research Domain of This Article
Orthopedics
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review-article
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O’Palko S, Burbelo A, Murphy A, Bullock M. Painful arthroplasty with disproportionate pain: Recognition and management of complex regional pain syndrome. World J Orthop 2026; 17(10): 126605 [DOI: 10.5312/wjo.126605]
World J Orthop. Oct 18, 2026; 17(10): 126605 Published online Oct 18, 2026. doi: 10.5312/wjo.126605
Painful arthroplasty with disproportionate pain: Recognition and management of complex regional pain syndrome
Stephanie O’Palko, Alexander Burbelo, Andrew Murphy, Matthew Bullock
Stephanie O’Palko, Alexander Burbelo, Andrew Murphy, Matthew Bullock, Department of Orthopaedic Surgery, Marshall University, Joan C Edwards School of Medicine, Huntington, WV 25701, United States
Author contributions: O’Palko S and Burbelo A were responsible for writing the original draft of the manuscript; Murphy A and Bullock M were responsible for editing the manuscript. All authors read and approved the final manuscript.
AI contribution statement: No artificial intelligence tools were used in the preparation of this manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Alexander Burbelo, BS, Research Fellow, Department of Orthopaedic Surgery, Marshall University, Joan C Edwards School of Medicine, 1600 Medical Center Drive - Suite G500, Huntington, WV 25701, United States. burbelo@marshall.edu
Received: August 10, 2026 Revised: August 30, 2026 Accepted: October 12, 2026 Published online: October 18, 2026 Processing time: 69 Days and 12.7 Hours
Abstract
Persistent pain following total hip arthroplasty and total knee arthroplasty is most commonly attributed to periprosthetic joint infection, aseptic loosening, instability, or other mechanical complications. However, complex regional pain syndrome (CRPS) represents an uncommon but important cause of disproportionate postoperative pain that is frequently underrecognized, highlighting the importance of timely and accurate diagnosis and management. This narrative review summarizes the current evidence regarding the epidemiology, pathophysiology, diagnosis, and management of CRPS following total joint arthroplasty, with particular emphasis on challenges unique to the arthroplasty population. The Budapest criteria remain the primary clinical framework for diagnosis after exclusion of infection and mechanical failure. Current management emphasizes early recognition, multidisciplinary rehabilitation, physical therapy, and multimodal pharmacologic treatment. Although sympathetic nerve blocks are commonly incorporated into treatment algorithms and may provide temporary diagnostic or therapeutic benefit in selected patients, contemporary systematic reviews demonstrate limited high-quality evidence supporting sustained clinical efficacy. Available arthroplasty-specific literature consists primarily of case reports and small observational studies. Orthopaedic surgeons should maintain a high index of suspicion for CRPS in patients with persistent pain that is disproportionate to expected recovery after total hip arthroplasty or total knee arthroplasty, particularly when standard diagnostic evaluation is unrevealing. Early recognition and appropriate evaluation may facilitate timely management of CRPS following arthroplasty. Further prospective studies are needed to define optimal diagnostic pathways and clarify the role of sympathetic nerve blocks in arthroplasty-associated CRPS.
Core Tip: Complex regional pain syndrome is an underrecognized cause of persistent pain after total hip and knee arthroplasty, with features that overlap with normal recovery, infection, and mechanical complications. This review provides a systematic diagnostic approach and clarifies that sympathetic nerve blocks offer only limited, temporary benefit.
