Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies

Dexamethasone, Glycemic Control, and Outcomes in Patients With Type 2 Diabetes Mellitus Undergoing Elective, Primary Total Joint Arthroplasty

Background

Dexamethasone (DEX) has been shown to reduce pain and postoperative nausea and vomiting for patients undergoing elective total joint arthroplasty (TJA). We investigated the impact of DEX on glycemic control and outcomes in patients with type 2 diabetes mellitus undergoing elective primary TJA.

Methods

All patients with type 2 diabetes mellitus undergoing primary elective TJA between January 2016 and December 2021 at 4 sites within 1 hospital system were identified. Propensity scores were calculated to match patients receiving or not receiving DEX. Primary outcomes were perioperative blood glucose levels and the incidence of hyperglycemia. Secondary outcomes were the amount of insulin administered, the occurrence of 30-day postoperative surgical site infections, hospital readmission, and mortality.

Results

After matching, we identified 1372 patients. DEX administration was associated with a significant increase in mean blood glucose levels in mg/dL on postoperative days (PODs) 0 to 2: POD 0 (28.4, 95% confidence interval [CI]: 24.6-32.1), POD 1 (14.4, 95% CI: 10.1-18.8), POD 2 (12.4, 95% CI: 7.5-17.2) when comparing patients who did or did not receive DEX. Additionally, patients receiving DEX, compared to patients who did not receive DEX, had increased odds of experiencing hyperglycemia on POD 0 (odds ratio: 4.0, 95% CI: 3.1-5.2). DEX was not associated with a significant difference in insulin administration, surgical site infections, hospital readmission, or mortality.

Conclusions

In our review of 1372 patients with propensity-matched type 2 diabetes mellitus undergoing elective, primary TJA, we found that DEX administration was associated with an increased risk of elevated mean glucose on POD 0-2, hyperglycemia on POD 0, but was not associated with an increase in total insulin dose administered nor occurrence of surgical site infections, hospital readmission, or mortality within 30 days of surgery in patients who received DEX compared to patients who did not receive DEX.

Level of Evidence

IV.

Oral Prednisone Use Following Primary Total Knee Arthroplasty Does Not Increase Infections, but can be Associated With Higher Risk for Medical and Surgical Complications

BACKGROUND

Postoperative use of oral prednisone to augment the effect of multimodal pain regimens after total knee arthroplasty (TKA) has increased in popularity. However, data on the risks of its utilization, especially as it relates to infection, have been lacking. We tested the null hypothesis that perioperative prednisone use is not associated with the incidence of surgical and medical complications after TKA.

METHODS

Using a national administrative claims database, we identified 949,555 patients undergoing primary TKA. We excluded patients who filled oral prednisone prescriptions within 90 days prior to surgery or between 90 and 364 days after surgery. Patients who had acute prednisone use were defined as those who filled prednisone prescriptions only within 30 days after surgery. Outcomes consisted of surgical and medical complications after TKA. Multivariable logistic regression models were used to evaluate the association between acute prednisone use and complications, adjusting for age, sex, region, insurance plan, and Elixhauser comorbidities.

RESULTS

Patients in the acute prednisone cohort had greater adjusted odds of subsequent manipulation under anesthesia (adjusted odds ratio [OR] = 1.23 [95% confidence interval {CI}: 1.09 to 1.38]; P < .001) and lysis of adhesions (adjusted OR = 1.58 [95% CI: 1.02 to 2.33]; P = .03) compared to patients who did not have acute prednisone use. Patients who had acute prednisone use also had greater adjusted odds of acute kidney injury (adjusted OR = 1.47 [95% CI: 1.25 to 1.71]; P < .001) and pneumonia (adjusted OR = 4.04 [95% CI: 3.53 to 4.59]; P < .001). There was no increased incidence of infection.

CONCLUSIONS

Prednisone use shortly following TKA may be associated with a higher incidence of certain surgical and medical complications, but without increased risk for infection. However, given these risks, the optimal patient profile for postoperative prednisone use remains to be defined.

Propensity score-matched analysis of enhanced recovery after surgery in total hip arthroplasty for displaced femoral neck fractures

OBJECTIVE

The concept of enhanced recovery after surgery (ERAS) has been proposed in recent years, which indeed bring about evident convenience for the patients. This prospective cohort study was aimed to investigate the impact of ERAS on the clinical outcome of patients who undergoing total hip arthroplasty due to displaced femoral neck fractures.

METHODS

Patients in two periods were included in our research, before ERAS (n = 194) and after ERAS (n = 65). The clinical outcome, such as patient statistics, details of perioperative management, length of stay (LOS), pain, Harris hip score, in-hospital complications, and interim postoperative survival were collected. This retrospective observational study addressed confounding bias using propensity score matching (PSM) analysis.

RESULTS

With PSM, 55 pairs of well-matched patients were generated for comparison (conventional vs. ERAS). LOS decreased to 13.0 ± 3.2 days for the ERAS group, compared to 15.7 ± 3.5 days in the conventional group. VAS pain scores decreased significantly in both groups, and the decrease in the ERAS group was more significant than that in the conventional group at 3, 7, and 14 days postoperatively. The Harris scores of both groups significantly improved, but were better for the ERAS group than the conventional group at 7 and 14 days and 1 month postoperatively. However, no significant difference was observed at 6 months postoperatively. Additionally, the incidence of complications during hospitalization was lower in the ERAS group than that in the conventional group. No significant difference was observed in the medium-term survival between the two groups.

CONCLUSIONS

ERAS apparently benefit patients in early rehabilitation by reducing complications and shortening hospital stays but not for the long-term hip function or survival.

Overview of systematic reviews of risk factors for prosthetic joint infection

BACKGROUND

Prosthetic joint infection is one of the most serious complications in orthopedics. Prognostic systematic reviews (SR) detecting and assessing factors related to prosthetic joint infection, allow better prediction of risk and implementation of preventive measures. Although prognostic SR are increasingly frequent, their methodological field presents some knowledge gaps.

PURPOSE

To carry out an overview of SR assessing risk factors for prosthetic joint infection, describing and synthesizing their evidence. Secondarily, to assess the risk of bias and methodological quality.

MATERIAL AND METHODS

We conducted a bibliographic search in 4databases (May 2021) to identify prognostic SR evaluating any risk factor for prosthetic joint infection. We evaluated risk of bias with the ROBIS tool, and methodological quality with a modified AMSTAR-2 tool. We computed the overlap degree study between included SR.

RESULTS

Twenty-three SR were included, studying 15 factors for prosthetic joint infection, of which, 13 had significant association. The most frequently studied risk factors were obesity, intra-articular corticosteroids, smoking and uncontrolled diabetes. Overlapping between SR was high for obesity and very high for intra-articular corticoid injection, smoking and uncontrolled diabetes. Risk of bias was considered low in 8SRs (34.7%). The modified AMSTAR-2 tool showed important methodological gaps.

CONCLUSIONS

Identification of procedural-modifiable factors, such as intra-articular corticoids use, can give patients better results. Overlapping between SR was very high, meaning that some SR are redundant. The evidence on risk factors for prosthetic joint infection is weak due to high risk of bias and limited methodological quality.

[Translated article] Overview of systematic reviews of risk factors for prosthetic joint infection

BACKGROUND

Prosthetic joint infection is one of the most serious complications in orthopedics. Prognostic systematic reviews (SRs) detecting and assessing factors related to prosthetic joint infection, allow better prediction of risk and implementation of preventive measures. Although prognostic SRs are increasingly frequent, their methodological field presents some knowledge gaps.

PURPOSE

To carry out an overview of SR assessing risk factors for prosthetic joint infection, describing and synthesizing their evidence. Secondarily, to assess the risk of bias and methodological quality.

MATERIAL AND METHODS

We conducted a bibliographic search in 4 databases (May 2021) to identify prognostic SR evaluating any risk factor for prosthetic joint infection. We evaluated risk of bias with the ROBIS tool, and methodological quality with a modified AMSTAR-2 tool. We computed the overlap degree study between included SR.

RESULTS

Twenty-three SRs were included, studying 15 factors for prosthetic joint infection, of which, 13 had significant association. The most frequently studied risk factors were obesity, intra-articular corticosteroids, smoking and uncontrolled diabetes. Overlapping between SR was high for obesity and very high for intra-articular corticoid injection, smoking and uncontrolled diabetes. Risk of bias was considered low in 8 SRs (34.7%). The modified AMSTAR-2 tool showed important methodological gaps.

CONCLUSIONS

Identification of procedural-modifiable factors, such as intra-articular corticoids use, can give patients better results. Overlapping between SR was very high, meaning that some SRs are redundant. The evidence on risk factors for prosthetic joint infection is weak due to high risk of bias and limited methodological quality.

Comparison of Perioperative Outcomes and Early Complications Between a Direct Anterior Approach or Posterolateral Approach in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Study

Background: Controversies remain on the best surgical approaches for unilateral total hip arthroplasty (THA). There are little data on simultaneous bilateral THA via direct anterior approach (SimBDAA-THA) or posterolateral approach (SimBPA-THA). Purpose: We sought to assess differences in perioperative outcomes and early medical and surgical complications between SimBDAA-THA and SimBPA-THA. Methods: This retrospective study involved patients who underwent either SimBDAA-THA in a supine position (n = 73) or SimBPA-THA in a lateral position (n = 162) at our institution from January 2015 to November 2021. The 2 groups were compared in terms of clinical and demographic characteristics, surgical parameters, and complications during 6-months of follow-up. Results: There were no differences in clinical and demographic characteristics between the 2 groups prior to surgery. Simultaneous bilateral THA via direct anterior approach significantly shortened the length of both the operation (117.50 ±19.42 vs 143.97 ± 32.20 min) and the hospitalization (140.64 ± 43.22 vs 156.24 ± 56.64 h) but increased perioperative loss of hemoglobin (3.28 ± 1.01 vs 3.21 ± 2.26 g/dL). There were no significant differences between the two groups in transfusion rate; levels of interleukin-6, C-reactive protein or creatine kinase; or complications. Conclusion: This retrospective study of patients at a single institution found minimal differences in perioperative outcomes or early medical and surgical complications between SimBDAA-THA and SimBPA-THA except operative time and length of hospitalization. Larger studies with longer follow-up should be conducted to identify whether a direct anterior approach is superior to a posterolateral one.

High-dose dexamethasone in low pain responders undergoing total knee arthroplasty: a randomised double-blind trial

BACKGROUND

Postoperative pain after total knee arthroplasty (TKA) is a continuing problem despite optimised multimodal analgesia. Previous studies have shown preoperative glucocorticoids to reduce postoperative pain, but knowledge about specific doses and effects in specific patient groups is lacking.

METHODS

A two-centre, double-blind, two-arm study comparing preoperative dexamethasone (1 mg kg^-1vs 0.3 mg kg^-1 i.v.) on postoperative pain in 160 planned TKA subjects with low preoperative pain catastrophising and no opioid use. Subjects received multimodal analgesia with paracetamol, cyclooxygenase-2 inhibitors, local anaesthetic infiltration analgesia, and rescue opioids. The primary outcome was percentage of subjects experiencing moderate to severe pain (visual analogue scale >30 mm) upon ambulation at 24 h. Secondary outcomes included pain scores, postoperative inflammation (C-reactive protein), opioid and antiemetics use, and 'Quality of Recovery-15' and 'Opioid-Related Symptom Distress Scale', length of stay, readmissions, and complications up to Day 90.

RESULTS

A total of 157 subjects (80 vs 77) were included. No difference was found between groups in the incidence of subjects experiencing visual analogue scale >30 on ambulation 24 h after surgery (56% vs 53%, relative risk =1.07, confidence interval: 0.8-1.4, P=0.65). No differences in other pain outcomes or use of rescue opioids and antiemetics, in Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, length of stay, readmissions, or complications. C-reactive protein values were comparable at 24 h (13 [6-25] mg L^-1vs 16 [9-38] mg L^-1, P = 0.07), but lower at 48 h (26 [9-52] mg L^-1vs 50 [30-72] mg L^-1, P<0.01) in the high-dose group.

CONCLUSION

Use of 1 mg kg^-1vs 0.3 mg kg^-1 i.v. dexamethasone in low pain responders after TKA did not improve early postoperative pain or other outcomes in contrast to benefits in a high pain responder population.

CLINICAL TRIAL REGISTRATION

NCT03758170 (first registration 29-11-2018).

Postoperative systemic inflammatory dysregulation and corticosteroids: a narrative review

In some patients, the inflammatory-immune response to surgical injury progresses to a harmful, dysregulated state. We posit that postoperative systemic inflammatory dysregulation forms part of a pathophysiological response to surgical injury that places patients at increased risk of complications and subsequently prolongs hospital stay. In this narrative review, we have outlined the evolution, measurement and prediction of postoperative systemic inflammatory dysregulation, distinguishing it from a healthy and self-limiting host response. We reviewed the actions of glucocorticoids and the potential for heterogeneous responses to peri-operative corticosteroid supplementation. We have then appraised the evidence highlighting the safety of corticosteroid supplementation, and the potential benefits of high/repeated doses to reduce the risks of major complications and death. Finally, we addressed how clinical trials in the future should target patients at higher risk of peri-operative inflammatory complications, whereby corticosteroid regimes should be tailored to modify not only the a priori risk, but also further adjusted in response to markers of an evolving pathophysiological response.

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.

Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations

BACKGROUND

The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery.

OBJECTIVE

To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA.

DESIGN

A narrative review based on published systematic reviews, using modified PROSPECT methodology.

DATA SOURCES

A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA.

ELIGIBILITY CRITERIA

Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance.

RESULTS

A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 μg) may be considered in hospitalised patients only in rare situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified.

CONCLUSION

The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.

Same-Day Outpatient Lower-Extremity Joint Replacement: A Critical Analysis Review

➢ The economics of transitioning total joint arthroplasty (TJA) to standalone ambulatory surgery centers (ASCs) should not be capitalized on at the expense of patient safety in the absence of established superior patient outcomes. ➢ Proper patient selection is essential to maximizing safety and avoiding complications resulting in readmission. ➢ Ambulatory TJA programs should focus on reducing complications frequently associated with delays in discharge. ➢ The transition from hospital-based TJA to ASC-based TJA has substantial financial implications for the hospital, payer, patient, and surgeon.

High-dose steroids in high pain responders undergoing total knee arthroplasty: a randomised double-blind trial

Background

Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain despite multimodal opioid-sparing analgesia. Pain catastrophising or preoperative opioid therapy is associated with increased postoperative pain. Preoperative glucocorticoid improves pain after TKA, but dose-finding studies and benefit in high pain responders are lacking.

Methods

A randomised double-blind controlled trial with preoperative high-dose intravenous dexamethasone 1 mg kg⁻¹ or intermediate-dose dexamethasone 0.3 mg kg⁻¹ in 88 patients undergoing TKA with preoperative pain catastrophising score >20 or regular opioid use was designed. The primary outcome was the proportion of patients experiencing moderate-to-severe pain (VAS >30) during a 5 m walk 24 h postoperatively. Secondary outcomes included pain at rest during nights and at passive leg raise, C-reactive protein, opioid use, quality of sleep, Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, readmission, and complications.

Results

Moderate-to-severe pain when walking 24 h postoperatively was reduced (high dose vs intermediate dose, 49% vs 79%; P<0.01), along with pain at leg raise at 24 and 48 h (14% vs 29%, P=0.02 and 12% vs 31%, P=0.03, respectively). C-reactive protein was reduced in the high-dose group at both 24 and 48 h (both P<0.01). Quality of Recovery-15 was also improved (P<0.01).

Conclusions

When compared with preoperative dexamethasone 0.3 mg kg⁻¹ i.v., dexamethasone 1 mg kg⁻¹ reduced moderate-to-severe pain 24 h after TKA and improved recovery in high pain responders without apparent side-effects.

Clinical trial registration

NCT03763734.

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.