Pre-operative intravenous steroid improves pain and joint mobility after total knee arthroplasty in Chinese population: a double-blind randomized controlled trial

Intraoperative intravenous versus periarticular injection of glucocorticoids in improving clinical outcomes after total knee arthroplasty: A prospective, randomized and controlled study

BACKGROUND

Glucocorticoids have been widely used in perioperative period for postoperative pain relief after total knee arthroplasty (TKA). However, the optimal administration protocols of glucocorticoids remain controversial. This study aims to compare the efficacy of glucocorticoids between intravenous and periarticular injection on clinical outcomes.

METHODS

A total of 114 patients were randomly assigned to intravenous (IV) group (n = 57) and periarticular injection (PI) group (n = 57). The IV group received 10 mg dexamethasone intravenously and the PI group received periarticular injection of 10 mg dexamethasone during the procedure. The clinical outcomes were assessed using visual analogue scale (VAS), knee society score (KSS), range of motion (ROM), knee swelling, inflammation markers and complications after TKA.

RESULTS

The VAS score during walking at 2nd day postoperatively was lower in the PI group compared with the IV group (2.08 ± 1.45 vs 2.73 ± 1.69, p = .039), and there was no significant difference at the other time points of VAS score in two groups. The inflammation markers, knee swelling, knee ROM and KSS score were not statistically different. Vomiting and other complications occurrence were not significantly different between the two groups.

CONCLUSIONS

Intraoperative periarticular injection of glucocorticoids has similar analgesic effect compared to intravenous in the postoperative period following TKA and may be even more effective on the second postoperative day. In addition, periarticular injection of glucocorticoids does not impose an excess risk or complication on patients.

High dose glucocorticoids for treatment of postoperative pain: A systematic review of the literature and meta-analysis

STUDY OBJECTIVE

Glucocorticoids as a component of multimodal analgesia have been studied for many years and their post-operative analgesic effects appear to be dose-dependent. We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the evidence of peri-operative high dose corticosteroid therapy in comparison to placebo (placebo drug) or control group (no treatment) for improving the quality of post-operative analgesia as indicated by a reduction of 10 mm in 100 mm Visual Analogue Scale (VAS) or reduction of 1 point in a 0-10 point VAS scale, or a reduction of 1 point in an 11-point Numerical Rating Scale (NRS) score, or reduction of rescue opioid analgesia, in patients undergoing all types of surgery.

DESIGN

Systematic review of RCTs with meta-analysis.

SETTING

Acute postoperative pain treatment in non-obese adult population.

INTERVENTIONS

Perioperative administration of high dose of Dexamethasone (≥ 0,2 mg/Kg or ≥ 15 mg), or a corresponding dose of a systemic glucocorticoid.

MEASUREMENTS

Primary outcomes were postoperative pain measured in 0-100 mm VAS score at 24 h after surgery upon rest and movement. Secondary outcomes were postoperative pain 0-100 mm VAS score 48 h after surgery, postoperative rescue analgesic requirement, postoperative nausea and vomiting (PONV), relevant adverse events.

MAIN RESULTS

47 RCT's were included (3943 patients). The Mean Difference (MD) of 100 mm VAS scores for pain at rest 24 h after surgery was -6.18 mm 95% CI [-8.53, -3.83], at motion -8.86 mm 95% CI [-11.82, -5.89]. Opioid analgesic requirements evaluated in Oral Morphine Equivalents (OME) was -10.00 mg 95% CI [-13.65, -6.34]. PONV events Odds Ratio of 0.29 95%CI [0.24, 0.36]. Major adverse events OR was 0.88 95% CI [0.65, 1.19]. Minor adverse events OR 1.29 95% CI [0.86, 1.92].

CONCLUSION

High doses of glucocorticoids are one of the many possible tools available in multimodal postoperative analgesia, possibly reducing opioids consumption and recurrence of PONV but with no relevant effects in terms of reduction of postoperative VAS score. Available data show a safe therapeutic profile, without increase adverse events.

PROTOCOL REGISTRATION

CRD42020137119.

The efficacy and safety of perioperative glucocorticoid for total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

An increasing number of individuals undergo total knee arthroplasty (TKA), which can result in pain, limited motor function and adverse complications such as infection, nausea and vomiting. Glucocorticoids have been shown anti-inflammatory and antiemetic effects, but can also elevate blood glucose levels and increase the risk of wound infection. Thus, it is essential to investigate the efficacy and safety of glucocorticoid usage in TKA.

METHOD

A comprehensive systematic search of PubMed, Medline, EMBASE, Cochrane databases, to identify relevant randomized controlled trials (RCTs) of glucocorticoid application in TKA. The primary outcomes assessed were the postoperative pain assessment. Secondary outcomes included the range of motion in knee joint, levels of inflammatory cytokines, adverse complications, and the length of hospital stay.

RESULTS

Thirty-six randomized controlled trials were included in the final analysis. The glucocorticoid group exhibited significant reduction in the resting VAS scores on postoperative days 1, 2 (POD1, 2)and postoperative 3 months (POM3), as well as decreased morphine consumption on POD1 and increased range of motion (ROM) in knee joint on POD1, 3. Additionally, the glucocorticoid group exhibited decreased levels of postoperative inflammatory cytokines and the incidence of PONV along with a shorter length of hospital stay. The blood glucose concentration was significantly increased in the glucocorticoid group on POD1 compared with the control group. While the blood glucose on POD2 and occurrence of postoperative adverse complications were similar between two groups including wound infection and venous thrombosis. The periarticular injection analgesia (PIA) group demonstrated lower VAS scores on POD2 comparing to the systemic administration (SA) group according to two studies. However, there was no significant difference of the resting VAS on POD1 and POD2 between PIA and SA group across all studies.

CONCLUSION

Perioperative glucocorticoids treatment in TKA significantly reduced short-term pain score and opioid-use which was probably not patient relevant. The application of glucocorticoids in TKA implied a beneficial trend in analgesic, anti-inflammatory, and antiemetic effects, as well as improved range of motion and shortened hospital stay. While it will not increase the risk of continued high glucose, postoperative wound infection and venous thrombosis.

Clinical utilization of methylprednisolone in conjunction with tranexamic acid for accelerated rehabilitation in total hip arthroplasty

PURPOSE

This study aimed to evaluate the efficacy and safety of combined methylprednisolone (MP) and tranexamic acid (TXA) in promoting accelerated rehabilitation following total hip arthroplasty (THA). We further investigated effective strategies for rapid rehabilitation post-THA.

METHODS

Conducted as a randomized controlled trial involving 80 patients, the study allocated subjects into two groups. The control group received saline and TXA, whereas the experimental group was administered with an additional dose of MP. Several clinical parameters, including markers of inflammation, pain, nausea, and coagulation factors, were meticulously assessed in both groups.

RESULTS

It was observed that the group receiving the MP + TXA treatment showcased significant reductions in postoperative levels of CRP and IL-6, as well as an alleviation in pain scores. Furthermore, this group demonstrated lower incidences of postoperative nausea and fatigue, facilitating enhanced hip joint mobility. Interestingly, this group did exhibit blood glucose fluctuations within the first 24 h postoperatively. However, there was no notable difference between the groups concerning transfusion rate, postoperative hospital stay duration, and coagulation profile, and no severe complications were reported.

CONCLUSION

The findings suggest that the combined administration of MP and TXA can appreciably enhance postoperative recovery, by reducing inflammatory markers, alleviating pain, reducing nausea and fatigue, and improving hip mobility, without leading to an increased risk of severe perioperative complications. This highlights the potential role of this combined therapy in facilitating improved postoperative patient experiences.

Systemic glucocorticoids as an adjunct to treatment of postoperative pain after total hip and knee arthroplasty: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Postoperative analgesic effects of systemic glucocorticoids given as an adjunct to treatment are largely undetermined in alloplastic procedures.

OBJECTIVES

To investigate the beneficial and harmful effects of peri-operative systemic glucocorticoid treatment for pain after total hip arthroplasty (THA) or total knee arthroplasty (TKA).

DESIGN

A systematic review of randomised clinical trials (RCTs) with meta-analyses, trial sequential analyses and GRADE. Primary outcome was 24 h intravenous (i.v.) morphine (or equivalent) consumption with a predefined minimal important difference (MID) of 5 mg. Secondary outcomes included pain at rest and during mobilisation (MID, VAS 10 mm), adverse and serious adverse events (SAEs).

DATA SOURCES

We searched EMBASE, Cochrane CENTRAL, PubMed and Google Scholar up to October 2021.

ELIGIBILITY CRITERIA

RCTs investigating peri-operative systemic glucocorticoid versus placebo or no intervention, for analgesic pain management of patients at least 18 years undergoing planned THA or TKA, irrespective of publication date and language.

RESULTS

We included 32 RCTs with 3521 patients. Nine trials were at a low risk of bias. Meta-analyses showed evidence of a reduction in 24 h cumulative morphine consumption with glucocorticoids by 5.0 mg (95% CI 2.2 to 7.7; P  = 0.0004). Pain at rest was reduced at 6 h by 7.8 mm (95% CI 5.5 to 10.2; P  < 0.00001), and at 24 h by 6.3 mm (95% CI 3.8 to 8.8; P  < 0.00001). Pain during mobilisation was reduced at 6 h by 9.8 mm (95% CI 6.9 to 12.8; P  < 0.00001), and at 24 h by 9.0 mm (95% CI 5.5 to 12.4, P  < 0.00001). Incidence of adverse events was generally lower in the glucocorticoid treatment group. SAEs were rarely reported. The GRADE rated quality of evidence was low to very low.

CONCLUSION

Peri-operative systemic glucocorticoid treatment reduced postoperative morphine consumption to an individually relevant level following hip and knee arthroplasty. Pain levels were reduced but were below the predefined MID. The quality of evidence was generally low.

REGISTRATION

PROSPERO ID: CRD42019135034.

Perioperative Intravenous Glucocorticoids in Total Joint Arthroplasty: A Systematic Review

BACKGROUND

Total joint arthroplasties (TJAs) of the hip and knee are common orthopaedic procedures. Postoperative pain in TJA is managed with opioids, which carry notable adverse effects and are associated with high dependency rates. With newer multimodal pain control regimens, perioperative glucocorticoid administration has shown promise as a means of mitigating postoperative pain. The objective of this review was to identify the effects of perioperative intravenous glucocorticoid administration on postoperative outcomes in TJA.

MATERIALS AND METHODS

A systematic review was done. The EMBASE database was searched from inception through September 1, 2020, to identify studies of perioperative glucocorticoids in TJA. Primary outcomes were postoperative pain, nausea, and vomiting. Secondary outcomes included hospital length of stay, postoperative opioid utilization, antiemetic rescue medication use, and postoperative surgical complications.

RESULTS

Our search yielded 429 publications; 14 studies were ultimately included, incorporating 1704 patients. In 13 of 14 studies, pain scores improved with perioperative steroid administration. Regarding postoperative nausea and vomiting, most of the studies found a notable association between steroids and improved VAS-N (visual analogue scale for nausea) and decreased postoperative nausea and vomiting incidence. There were inconclusive data on the effects of perioperative steroids regarding postoperative length of stay, fatigue, and range of motion of the affected joint. In all 14 studies, no notable difference was found between study groups regarding postoperative surgical complications.

CONCLUSION

This systematic review supports the use of perioperative steroids in TJA for mitigating postoperative pain, nausea, and systemic inflammation. Additional randomized trials are needed to form a consensus on optimal dosing, delivery method, and timing of perioperative glucocorticoids in TJA.

The Efficacy and Safety of Corticosteroids in Total Joint Arthroplasty: A Direct Meta-Analysis

BACKGROUND

Corticosteroids are commonly used intraoperatively to treat pain and reduce opioid consumption and nausea associated with primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of corticosteroids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management.

METHODS

The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published before February 2020 on corticosteroids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of corticosteroids.

RESULTS

Critical appraisal of 1,581 publications revealed 23 studies regarded as the best available evidence for analysis. Intraoperative dexamethasone reduces postoperative pain, opioid consumption, and nausea and vomiting. Multiple doses lead to further reduction in pain, opioid consumption, nausea and vomiting. There is insufficient evidence on the risk of adverse events with perioperative dexamethasone in TJA.

CONCLUSION

Strong evidence supports the use of a single dose or multiple doses of intravenous dexamethasone to reduce postoperative pain, opioid consumption, nausea and vomiting after primary TJA. There is insufficient evidence on perioperative dexamethasone in primary TJA to determine the optimal dose, number of doses, or risk of postoperative adverse events.

Paracetamol, ibuprofen and dexamethasone for pain treatment after total hip arthroplasty: protocol for the randomised, placebo-controlled, parallel 4-group, blinded, multicentre RECIPE trial

INTRODUCTION

Multimodal analgesia with paracetamol, non-steroidal anti-inflammatory drug and glucocorticoid is recommended for hip arthroplasty, but with uncertain effects of the different combinations. We aim to investigate benefit and harm of different combinations of paracetamol, ibuprofen and dexamethasone following total hip arthroplasty.

METHODS AND ANALYSIS

RECIPE is a randomised, placebo-controlled, parallel 4-group, blinded trial with 90-day and 1-year follow-up performed at nine Danish hospitals. Interventions are initiated preoperatively and continued for 24 hours postoperatively. Eligible participants undergoing total hip arthroplasty are randomised to:group A: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous placebo; group B: oral paracetamol 1000 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group C: oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group D: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg.Primary outcome is cumulative opioid consumption at 0-24 hours. Secondary outcomes are pain at rest, during mobilisation and during a 5 m walk and adverse events. Follow-up includes serious adverse events and patient reported outcome measures at 90 days and 1 year. A total of 1060 participants are needed to demonstrate a difference of 8 mg in 24-hour morphine consumption assuming an SD of 24.5 mg, a risk of type I errors of 0.0083 and a risk of type 2 errors of 0.2. Primary analysis will be a modified intention-to-treat analysis.With this trial we aim to verify recommendations for pain treatment after total hip arthroplasty, and investigate the role of dexamethasone as an analgesic adjuvant to paracetamol and ibuprofen.

ETHICS AND DISSEMINATION

This trial is approved by the Region Zealand Committee on Health Research Ethics (SJ-799). Plans for dissemination include publication in peer-reviewed journals and presentation at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT04123873.

Effect of dexamethasone as an analgesic adjuvant to multimodal pain treatment after total knee arthroplasty: randomised clinical trial

OBJECTIVE

To investigate the effects of one and two doses of intravenous dexamethasone in patients after total knee arthroplasty.

DESIGN

Randomised, blinded, placebo controlled trial with follow-up at 90 days.

SETTING

Five Danish hospitals, September 2018 to March 2020.

PARTICIPANTS

485 adult participants undergoing total knee arthroplasty.

INTERVENTION

A computer generated randomised sequence stratified for site was used to allocate participants to one of three groups: DX1 (dexamethasone (24 mg)+placebo); DX2 (dexamethasone (24 mg)+dexamethasone (24 mg)); or placebo (placebo+placebo). The intervention was given preoperatively and after 24 hours. Participants, investigators, and outcome assessors were blinded. All participants received paracetamol, ibuprofen, and local infiltration analgesia.

MAIN OUTCOME MEASURES

The primary outcome was total intravenous morphine consumption 0 to 48 hours postoperatively. Multiplicity adjusted threshold for statistical significance was P<0.017 and minimal important difference was 10 mg morphine. Secondary outcomes included postoperative pain.

RESULTS

485 participants were randomised: 161 to DX1, 162 to DX2, and 162 to placebo. Data from 472 participants (97.3%) were included in the primary outcome analysis. The median (interquartile range) morphine consumptions at 0-48 hours were: DX1 37.9 mg (20.7 to 56.7); DX2 35.0 mg (20.6 to 52.0); and placebo 43.0 mg (28.7 to 64.0). Hodges-Lehmann median differences between groups were: -2.7 mg (98.3% confidence interval -9.3 to 3.7), P=0.30 between DX1 and DX2; 7.8 mg (0.7 to 14.7), P=0.008 between DX1 and placebo; and 10.7 mg (4.0 to 17.3), P<0.001 between DX2 and placebo. Postoperative pain was reduced at 24 hours with one dose, and at 48 hours with two doses, of dexamethasone.

CONCLUSION

Two doses of dexamethasone reduced morphine consumption during 48 hours after total knee arthroplasty and reduced postoperative pain.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03506789.

Is intraoperative corticosteroid a good choice for postoperative pain relief in total joint arthroplasty? A meta-analysis of 11 randomized controlled trials

BACKGROUND

Effective postoperative analgesia is of great significance for postoperative rehabilitation. This meta-analysis aimed to investigate the efficacy of corticosteroid on pain following total joint arthroplasty.

METHOD

PubMed (1996-December 2020), Embase (1996-December 2020), and the Cochrane Library (CENTRAL, December 2020) were searched and a total of 11 randomized controlled trials met our inclusion criteria.

RESULTS

Eleven randomized controlled trials met the inclusion criteria. Pooled data indicated the corticosteroid group was effective compared to the control group in terms of the visual analogue scale at rest (P < .05) and movement (P < .05), the total morphine equivalent consumption (P < .05), and the length of stay (P < .05), without increasing the risk of periprosthetic joint infection (P = .74) and the length of stay (P = .32).

CONCLUSIONS

Compared to the control group, intraoperative corticosteroid was benefit to the pain management in total joint arthroplasty.

Peri-operative steroids reduce pain, inflammatory response and hospitalisation length following knee arthroplasty without increased risk of acute complications: a meta-analysis

PURPOSE

There is no consensus regarding the risks and benefits of peri-operative steroid supplementation in total knee arthroplasty (TKA). The aim of this meta-analysis is to compare TKA protocols implemented with or without steroids in terms of pain, inflammatory response, hospitalisation length, and complications.

METHODS

A systematic literature search was performed on July 2019 in PubMed, Medline, Embase, Web of Science, Cochrane library, and the grey literature for a meta-analysis of RCTs comparing peri-operative analgesia protocols implemented with or without steroids. Sub-analyses considering the administration route, steroid type, and dosage were performed. The inverse variance method and the Mantel-Haenszel test were used for pooling continuous variables and for dichotomous variables, respectively. Risk of bias and quality of evidence were defined according to the Cochrane guidelines.

RESULTS

Twenty articles were included. Steroid supplementation provides significantly lower post-operative pain from day 1 to day 4 (p < 0.05), with less opioid consumption (p = 0.05), less nausea and vomiting (p < 0.05), and greater knee range of motion (p < 0.001), thus resulting in a shorter hospitalisation length (p = 0.01). Moreover, lower C-reactive protein (p < 0.05), and IL-6 (p < 0.05) levels, but a higher blood glucose level at day 1 (p = 0.004), were documented. No significant differences were documented in all the outcomes after 4 days of follow-up. These results were achieved without an increased incidence of complications. According to the results of the sub-analyses, the intravenous administration of 200 steroid equivalents of a long-acting steroid was associated with better results.

CONCLUSION

Steroid supplementation of peri-operative drug protocols is effective in decreasing post-operative pain, opioid consumption, nausea and vomiting, range of motion limitation, and inflammatory markers without increasing short- and mid-term complications. Although these benefits last only the peri-operative period, steroid supplementation can reduce the length of hospitalisation after TKA.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level II.

The optimal dosage, route and timing of glucocorticoids administration for improving knee function, pain and inflammation in primary total knee arthroplasty: A systematic review and network meta-analysis of 34 randomized trials

PURPOSE

Glucocorticoids are a mainstay to control postoperative pain, inflammation, nausea and vomiting (PONV) in total knee arthroplasty (TKA). Understanding the optimal dose and route of glucocorticoids administration in TKA is of great significance in speedy functional recovery. We aimed to summarize, evaluate and rank order the efficacy of glucocorticoids regimens in TKA.

METHODS

Electronic databases (PubMed et al.) were systematically searched from inception up to April 30, 2020. The primary outcomes were visual analogue scale (VAS), range of motion (ROM) and knee society score (KSS). C-reactive Protein (CRP) and PONV were also evaluated. Multivariable Bayesian random effects models were used to synthesize and rank the comparative efficacy of glucocorticoids regimens.

RESULTS

A total of 34 eligible randomized controlled trials with 11 different glucocorticoids regimens were assessed. Overall inconsistency and heterogeneity were acceptable. Multiple medium dose perioperative intravenous injection (IV) ranked first in the analgesia network and a single high doses of preoperative IV ranked first in the inflammation and PONV network. There was no statistically significant increase in ROM or KSS in all the glucocorticoid formulations and doses compared with controls on postoperative day 30.

CONCLUSIONS

Glucocorticoid multiple intravenous injection was preferable to a single intravenous injection (preoperative and postoperative), periarticular injection and intra-articular injection in analgesia. Based on the available evidence, a medium dose of hydrocortisone of 2-4 mg/kg is optimal.