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

Postoperative pain relief after total knee arthroplasty: A Bayesian network meta-analysis and systematic review of analgesic strategies based on nerve blocks

STUDY OBJECTIVE

A Bayesian network meta-analysis was performed to compare the analgesic efficacy of the following nerve block techniques: femoral nerve block (FNB), adductor canal block (ACB), infiltration between the popliteal artery and the capsule of the posterior knee (iPACK), and genicular nerve block (GNB) following total knee arthroplasty (TKA).

DESIGN

Systematic review and network meta-analysis (NMA).

PATIENTS AND MEASUREMENTS

We searched the Web of Science, PubMed, EMBASE, and Cochrane Library databases until September 20, 2022. Patients who were treated by any of the above four nerve block techniques (alone or in combination) after TKA were included. Patients who underwent minimally invasive knee surgery were excluded. The indicators included pain scores during rest and mobilization, opioid consumption after surgery, postsurgical mobilization function (ROM [range of motion], TUG [Timed-Up-and-Go] test) at 24 h and 48 h, and length of hospital stay. The risk of bias was assessed by the Cochrane risk of bias tool.

RESULTS

Forty-two studies involving 2857 patients were eligible for this study. This NMA suggested that ACB + iPACK was the most efficacious option for improving ambulation ability and shortening the length of hospital stay. Furthermore, ACB + iPACK was the best regimen for resting-pain and movement-pain relief (78% and 87%, respectively) and for reducing opioid consumption (90%) at 48 h. However, FNB + iPACK was the most efficacious option for relief of resting pain (42%) and reducing opioid consumption (68%) at 24 h; GNB was the most efficacious option for movement pain relief at 24 h (94%).

CONCLUSION

Considering both pain control and knee functional recovery, ACB + iPACK may be the optimal analgesic regimen for patients after TKA. At the same time, it significantly reduces pain and opioid consumption at 48 h. However, ACB + iPACK is not the recommended technique for short-term (24 h) pain control.

CLINICAL TRIAL REGISTRATION

PROSPERO (CRD42022362322).

Acute postoperative pain and catastrophizing in unicompartmental knee arthroplasty: a prospective, observational, single-center, cohort study

BACKGROUND AND OBJECTIVES

Pain catastrophizing is associated with acute pain after total knee arthroplasty. However, the association between pain catastrophizing and acute pain after unicompartmental knee arthroplasty (UKA) remains unclear.

METHODS

We investigated the incidence of predicted high-pain and low-pain responders, based on a preoperative Pain Catastrophizing Scale score >20 or ≤20, respectively, and the acute postoperative pain course in both groups. Patients undergoing UKA were consecutively included in this prospective observational cohort study. Pain at rest and during walking (5 m walk test) was evaluated preoperatively, at 24 hours postoperatively, and on days 2-7 using a pain diary.

RESULTS

125 patients were included, with 101 completing the pain diary. The incidence of predicted high-pain responders was 31% (95% CI 23% to 40%). The incidence of moderate to severe pain during walking at 24 hours postoperatively was 69% (95% CI 52% to 83%) in predicted high-pain responders and 66% (95% CI 55% to 76%) in predicted low-pain responders; OR 1.3 (95% CI 0.5 to 3.1). The incidence of moderate to severe pain at rest 24 hours postoperatively was 49% (95% CI 32% to 65%) in predicted high-pain responders and 28% (95% CI 19% to 39%) in predicted low-pain responders; OR 2.6 (95% CI 1.1 to 6.1; p=0.03). Pain catastrophizing was not associated with increased cumulated pain during walking on days 2-7.

CONCLUSIONS

The incidence of predicted high-pain responders in UKA was slightly lower than reported in total knee arthroplasty. Additionally, preoperative pain catastrophizing was not associated with acute postoperative pain during walking.

Effects of Dexamethasone on Postoperative Glycemic Control in Patients After Primary Total Joint Arthroplasty: A Randomized Double-Blind Controlled Trial

BACKGROUND

In patients undergoing total joint arthroplasty, the use of dexamethasone (DEX) may cause perioperative blood glucose (BG) disorders, leading to complications even in patients who do not have diabetes. We aimed to evaluate the effects of different DEX doses on perioperative BG levels.

METHODS

A total of 135 patients who do not have diabetes were randomized into three groups: preoperative intravenous (IV) injection of normal saline (Group A, the placebo group), preoperative IV injection of 10 mg DEX (Group B), and preoperative IV injection of 20 mg DEX (Group C). Postoperative fasting BG (FBG) levels were designated as the primary outcome, while postoperative postprandial BG (PBG) levels were assigned as the secondary outcome. The incidence of complications was recorded. We also investigated the risk factors for FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL.

RESULTS

The FBG levels were higher in Groups B and C than in Group A on postoperative days (PODs) 0 and 1. The PBG levels were lower for Groups A and B compared to Group C on POD 1. No differences in FBG or PBG were detected beyond POD 1. Elevated preoperative glycosylated hemoglobin A1c levels increased the risk of FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL, respectively. However, preoperative IV injection of DEX was not associated with FBG ≥ 140 mg/dL or PBG ≥ 180 mg/dL. No differences were found in postoperative complications among the three groups.

CONCLUSIONS

The preoperative IV administration of 10 or 20 mg DEX in patients who do not have diabetes showed transient effects on postoperative BG after total joint arthroplasty. The preoperative glycosylated hemoglobin A1c level threshold (regardless of the administration or dosage of DEX) that increased the risk for the occurrence of FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL was 5.75 and 5.85%, respectively.

Exploring the need for reconsideration of trial design in perioperative outcomes research: a narrative review

"Enhanced recovery after surgery" is a multimodal effort to control perioperative pathophysiology and improve outcome. However, despite advances in perioperative care, postoperative complications and the need for hospitalisation and prolonged recovery continue to be challenging. This is further complicated by procedure-specific and patient-associated risk factors, given the increase in the number of elderly and frail patients with multiple comorbidities undergoing surgery. This paper is a critical assessment of current methodology for trials in perioperative medicine. We make a plea to reconsider the design of future interventional trials to improve surgical outcome, based upon studies of potentially effective interventions, but often without improvements in recovery. The complexity of perioperative pathophysiology necessitates a procedure- and patient-specific approach whenever outcome is assessed or interventions are planned. With improved understanding of perioperative pathophysiology, the way to improve outcomes looks promising, provided that knowledge and established enhanced recovery programmes are integrated in trial design.

Funding

None.

Effect of Perineural or Intravenous Betamethasone on Femoral Nerve Block Outcomes in Knee Arthroplasty: A Randomized, Controlled Study

OBJECTIVES

Despite the use of multimodal analgesia, patients undergoing knee arthroplasty still encounter residual moderate pain. The addition of betamethasone to local anesthetic has been shown to improve postoperative pain. However, it remains uncertain whether the positive effects of perineural or intravenous administration of betamethasone on analgesia outcomes lead to better early mobility and postoperative recovery.

METHODS

Between June 2022 and February 2023, a total of 159 patients who were undergoing knee arthroplasty were included in this study. These patients were allocated randomly into three groups: (i) the NS group, received ropivacaine 0.375% and intravenous 3mL 0.9% normal saline; (ii) the PNB group, received ropivacaine 0.375% plus perineural betamethasone (12mg) 3mL and intravenous 3mL 0.9% normal saline; and (iii) the IVB group, received ropivacaine 0.375% and intravenous betamethasone (12mg) 3mL.

RESULTS

Both perineural and intravenous administration of betamethasone led to improved median (IQR) numeric rating scale (NRS) scores on the 6-meter walk test, with a score of 1.0 (1.0-2.0) for both groups, compared with 2.0 (1.0-2.0) for the NS group (p = 0.003). Compared to the NS group, both the PNB and IVB groups showed significant reductions in NRS scores at 24 and 36 h after surgery, along with a significant increase in ROM at 24, 36, and 48 h post-operation. Additionally, it exhibited lower levels of cytokine IL-1β and TNF-α in fluid samples, as well as lower level of HS-CRP in blood samples in the PNB and IVB groups compared to the NS group.

CONCLUSION

The administration of perineural and intravenous betamethasone demonstrated an enhanced analgesic effect following knee arthroplasty. Furthermore, it was associated with reduced levels of IL-1β, TNF-α, and HS-CRP, as well as enhanced knee ROM, which is conducive to early ambulation and postoperative rehabilitation after knee arthroplasty.

Associations of dexamethasone's effect on morphine consumption after total knee arthroplasty-Subgroup analyses

The DEXamethasone twice for pain treatment after Total Knee Arthroplasty (DEX-2-TKA) trial showed that adding one and two doses of 24 mg intravenous dexamethasone to paracetamol, ibuprofen and local infiltration analgesia, reduced morphine consumption (primary outcome) within 48 h after TKA. We aimed to explore the differences in the effect of dexamethasone on morphine consumption in different subgroups. Quantile regression adjusted for site was used to test for significant interaction between the predefined dichotomised subgroups and treatment group. The subgroups were defined based on baseline data: sex (male/female), age (≤65 years/>65 years), American Society of Anaesthesiologists (ASA)-score (ASA I + II/III), visual analogue score of preoperative pain at rest (≤30 mm/>30 mm), pain during mobilisation (≤30 mm/>30 mm), type of anaesthesia (spinal anaesthesia/general anaesthesia and spinal converted to general anaesthesia), and prior daily use of analgesics (either paracetamol and/or NSAID/neither). These analyses were supplemented with post hoc multivariate linear regression analyses. Test of interaction comparing sex in the pairwise comparison between DX2 (dexamethasone [24 mg] + dexamethasone [24 mg]) versus placebo (p = .02), showed a larger effect of dexamethasone on morphine consumption in male patients compared to females. Test of interaction comparing age in the pairwise comparison between DX1 (dexamethasone [24 mg] + placebo) versus placebo (p = .04), showed a larger effect of dexamethasone on morphine consumption in younger patients (≤65 years) compared to older. All remaining subgroup analyses showed no evidence of a difference. The supplemental multivariate analyses did not support any significant interaction for sex (p = .256) or age (p = .730) but supported a significant interaction with the type of anaesthesia (p < .001). Our results from the quantile regression analyses indicate that the male sex and younger age (≤65 years) may be associated with a larger analgesic effect of dexamethasone than the effects in other types of patients. However, this is not supported by post-hoc multivariate linear regression analyses. The two types of analyses both supported a possible interaction with the type of anaesthesia.

Combining various acupuncture therapies with multimodal analgesia to enhance postoperative pain management following total knee arthroplasty: a network meta-analysis of randomized controlled trials

Objective

This study aims to evaluate the efficacy and safety of various acupuncture treatments in conjunction with multimodal analgesia (MA) for managing postoperative pain and improving knee function in patients undergoing total knee arthroplasty (TKA), based on the findings from clinical research indicating the potential benefits of acupuncture-related therapies in this context.

Methods

We searched Web of Science, PubMed, SCI-hub, Embase, Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Data, and Chinese Scientific Journal Database (VIP) to collect randomized controlled trials of acupuncture-related therapies for post-TKA pain. After independent screening and data extraction, the quality of the included literature was evaluated. The potential for bias in the studies incorporated in the analysis was assessed according to the guidelines outlined in the Cochrane Handbook 5.1. Network meta-analysis (NMA) was conducted using RevMan 5.4 and Stata 16.0 software, with primary outcome measures including visual analog scale (VAS), pain pressure threshold (PPT), hospital for special surgery knee score (HSS), and knee joint range of motion (ROM). Furthermore, the interventions were ranked based on the SUCRA value.

Results

We conducted an analysis of 41 qualifying studies encompassing 3,003 patients, examining the efficacy of four acupuncture therapies (acupuncture ACU, electroacupuncture EA, transcutaneous electrical acupoint stimulation TEAS, and auricular acupoint therapy AAT) in conjunction with multimodal analgesia (MA) and MA alone. The VAS results showed no significant difference in efficacy among the five interventions for VAS-3 score. However, TEAS+MA (SMD: 0.67; 95%CI: 0.01, 1.32) was more effective than MA alone for VAS-7 score. There was no significant difference in PPT score among the three interventions. ACU + MA (SMD: 6.45; 95%CI: 3.30, 9.60), EA + MA (SMD: 4.89; 95%CI: 1.46, 8.32), and TEAS+MA (SMD: 5.31; 95%CI: 0.85, 9.78) were found to be more effective than MA alone for HSS score. For ROM score, ACU + MA was more efficacious than EA + MA, TEAS+MA, and AAT + MA, MA. Regarding the incidence of postoperative adverse reactions, nausea and vomiting were more prevalent after using only MA. Additionally, the incidence of postoperative dizziness and drowsiness following ACU + MA (OR = 4.98; 95%CI: 1.01, 24.42) was observed to be higher compared to that after AAT + MA intervention. Similarly, the occurrence of dizziness and drowsiness after MA was found to be significantly higher compared to the following interventions: TEAS+MA (OR = 0.36; 95%CI: 0.18, 0.70) and AAT + MA (OR = 0.20; 95%CI: 0.08, 0.50). The SUCRA ranking indicated that ACU + MA, EA + MA, TEAS+MA, and AAT + MA displayed superior SUCRA scores for each outcome index, respectively.

Conclusion

For the clinical treatment of post-TKA pain, acupuncture-related therapies can be selected as a complementary and alternative therapy. EA + MA and TEAS+MA demonstrate superior efficacy in alleviating postoperative pain among TKA patients. ACU + MA is the optimal choice for promoting postoperative knee joint function recovery in TKA patients. AAT + MA is recommended for preventing postoperative adverse reactions.

Systematic review registration

https://www.crd.york.ac.uk/, identifier (CRD42023492859).

Bibliometric and visual analysis of research on analgesia and total knee arthroplasty from 1990 to 2022

Background

In recent decades, there have been notable advancements in the field of analgesia and total knee arthroplasty (TKA). This study aims to employ bibliometric analysis to elucidate the prevailing research focal points and trends within analgesia and TKA from 1990 to 2022.

Material and methods

Relevant publications were retrieved from the Web of Science Core Collection. CiteSpace, VOSviewer, and Scimago Graphica were used for visualization and bibliometric analysis of countries, institutions, authors, journals, references, and keywords.

Results

A total of 2776 publications on analgesia and TKA were identified, with the United States having the highest number of publications. The University of Copenhagen was the most productive institution, and Kehlet, Henrik was the most prolific author. The Journal of Arthroplasty had the most publications and citations. The most common keywords were "TKA," "pain management," "postoperative pain," "Total hip arthroplasty (THA)," and "postoperative management." Keyword burst detection demonstrated that adductor canal block (ACB) was a recent research hotspot.

Conclusion

Our study revealed a sharp increase in global publications on analgesia and TKA, and this trend is expected to continue. Further research is necessary to determine the optimal regimen for multimodal analgesia, the ideal location and volume of ACB, and their clinical significance.

The effect of preoperative different dexamethasone regimens on postoperative glycemic control in patients with type 2 diabetes mellitus undergoing total joint arthroplasty: a retrospective cohort study

BACKGROUND

Concerns have been raised regarding the impact of preoperative intravenous dexamethasone on postoperative glycemic control in diabetic patients undergoing total joint arthroplasty (TJA). This study aimed to determine relationships between preoperative different dexamethasone regimens and postoperative fasting blood glucose (FBG), as well as to identify risk factors for postoperative FBG ≥ 200 mg/dl in diabetic patients undergoing TJA.

METHODS

This retrospective study included 1216 diabetic patients undergoing TJA and categorized into group A (dexamethasone = 0 mg), group B (dexamethasone = 5 mg), and group C (dexamethasone = 10 mg). All dexamethasone was administered before skin incision. FBG levels were monitored until postoperative day (POD) 3. Analyses were conducted for periprosthetic joint infection (PJI) and wound complications during 90 days postoperatively. And the risk factors for postoperative FBG ≥ 200 mg/dl were identified.

RESULTS

Preoperative dexamethasone administration resulted in a transiently higher FBG on POD 0 and POD 1 (all P < 0.001). However, no differences were observed on POD 2 (P = 0.583) and POD 3 (P = 0.131) among three groups. While preoperative dexamethasone led to an increase in postoperative mean FBG and postoperative maximum FBG (all P < 0.001), no differences were found in wound complications (P = 0.548) and PJI (P = 1.000). Increased HbA1c and preoperative high FBG, but not preoperative dexamethasone, were identified as risk factors for postoperative FBG ≥ 200 mg/dl. Preoperative HbA1c level of ≥ 7.15% was associated with an elevated risk of postoperative FBG ≥ 200 mg/dl.

CONCLUSIONS

Although preoperative intravenous administration of 5 mg or 10 mg dexamethasone in diabetic patients showed transient effects on postoperative FBG after TJA, no differences were found in the rates of PJI and wound complications during 90 days postoperatively. Notably, patients with a preoperative HbA1c level of ≥ 7.15% and elevated preoperative FBG may encountered postoperative FBG ≥ 200 mg/dl.

Mechanisms inherent in acute-to-chronic pain after surgery - risk, diagnostic, predictive, and prognostic factors

PURPOSE OF REVIEW

Pain is an expected consequence of a surgery, but it is far from being well controlled. One major complication of acute pain is its risk of persistency beyond healing. This so-called chronic post-surgical pain (CPSP) is defined as new or increased pain due to surgery that lasts for at least 3 months after surgery. CPSP is frequent, underlies a complex bio-psycho-social process and constitutes an important socioeconomic challenge with significant impact on patients' quality of life. Its importance has been recognized by its inclusion in the eleventh version of the ICD (International Classification of Diseases).

RECENT FINDINGS

Evidence for most pharmacological and non-pharmacological interventions preventing CPSP is inconsistent. Identification of associated patient-related factors, such as psychosocial aspects, comorbidities, surgical factors, pain trajectories, or biomarkers may allow stratification and selection of treatment options based on underlying individual mechanisms. Consequently, the identification of patients at risk and implementation of individually tailored, preventive, multimodal treatment to reduce the risk of transition from acute to chronic pain is facilitated.

SUMMARY

This review will give an update on current knowledge on mechanism-based risk, prognostic and predictive factors for CPSP in adults, and preventive and therapeutic approaches, and how to use them for patient stratification in the future.

Chronic Pain and Functional Outcome 3 years After Total Knee Arthroplasty and Perioperative Dexamethasone: A Follow-Up of the Randomized, Clinical DEX-2-TKA Trial

BACKGROUND

Perioperative dexamethasone as an adjunct to multimodal analgesia, has an opioid-sparing and pain alleviating effect after total knee arthroplasty (TKA), however, the 3-year effects are unknown. We aimed to investigate the 3-year effect of 1 (DX1) or 2 (DX2) intravenous doses of 24 mg dexamethasone or placebo on pain, physical function, and health-related quality of life after TKA.

METHODS

Patients who participated in the Dexamethasone Twice for Pain Treatment after TKA (DEX-2-TKA) were invited to physical tests and questionnaires (self-reported characteristics, Oxford Knee Score, EuroQol-5Dimensions-5Levels (EQ5D5L), and PainDetect). The tests were 40-meter Fast Paced Walk (40FPW) test, Timed Up and Go (TUG), 30 Second Chair Stand test (30CST), Stair Climb Test (SCT), bilateral knee Range of Motion, and knee extension torque. For each test the peak pain intensity was registered on a 0 to 100 mm Visual Analogue Scale. Primary outcome was average peak pain intensity during the 40FPW, TUG, 30CST and SCT. Secondary outcomes were the tests and questionnaires. Out of 252 eligible patients, 133 (52.8%) underwent the tests and 160 (63.5%) answered the questionnaires. Mean follow-up time was 33 months (range, 23 to 40).

RESULTS

Median (interquartile range) peak pain intensity was 0 (0 to 65) for the DX2 group, 0 (0 to 51) for DX1 group and 0 (0 to 70) for the placebo group (P = .72). No differences in secondary outcomes were identified.

CONCLUSION

One or 2 intravenous doses of 24 mg dexamethasone did not impact chronic pain development or physical function 3 years after TKA.

Psychological predictors of acute postoperative pain after total knee and hip arthroplasty: A systematic review

BACKGROUND

Identifying patients at high risk of acute postoperative pain after total knee or hip arthroplasty (TKA/THA) will facilitate individualized pain management and research on the efficacy of treatment options. Numerous studies have reported that psychological patient factors may influence acute postoperative pain, but most reviews have focused on chronic pain and functional outcomes. This systematic review aims to evaluate which psychological metrics are associated with acute postoperative pain after TKA and THA.

METHODS

A systematic search was conducted using the databases PubMed, EMBASE, Web of Science, and Cochrane Library until June 2022. Full-text articles reporting associations of preoperative psychological factors with acute pain within 48 h of TKA or THA surgery were identified. Quality was assessed using the Quality in Prognostic Studies tool.

RESULTS

Eighteen studies containing 16 unique study populations were included. TKA was the most common procedure, and anxiety and depression were the most evaluated psychological metrics. Several different anesthetic techniques and analgesic regimens were used. The studies were generally rated as having a low to moderate risk of bias. Catastrophizing was associated with acute pain in six studies (of nine), mainly after TKA. In contrast, three studies (of 13) and two studies (of 13) found anxiety and depression, respectively, to be associated with acute postoperative pain.

CONCLUSION

Pain catastrophizing seemed to be the most consistent psychological predictor of acute postoperative pain after TKA. The results for other psychological factors and THA were inconsistent. However, the interpretation of results was limited by considerable methodological heterogeneity.

Days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in the era of enhanced recovery

BACKGROUND

Days alive and out of hospital is proposed as a valid and patient-centred quality measure for perioperative care. However, no procedure-specific data exist after pulmonary wedge resection. The aim of this study was to assess the first 90 days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in an optimized enhanced recovery programme.

METHODS

A retrospective analysis of prospectively collected data of consecutive patients undergoing enhanced recovery thoracoscopic wedge resections from January 2021 to June 2022 in a high-volume centre was carried out. All factors leading to hospitalization, readmission, and death were evaluated individually. A logistic regression model was used to evaluate predictors. Additionally, a sensitivity analysis was performed.

RESULTS

A total of 433 patients were included (21.7% (n = 94) with non-small cell lung cancer, 47.6% (n = 206) with metastasis, 26.8% (n = 116) with benign nodules, and 3.9% (n = 17) with other lung cancers). The median duration of hospital stay was 1 day. The median of postoperative 30 and 90 days alive and out of hospital was 28 and 88 days respectively. Air leak (112 patients) and pain (96 patients) were the most frequent reasons for reduced days alive and out of hospital from postoperative day 1 to 30, whereas treatment of the original cancer or metastasis (36 patients) was the most frequent reason for reduced days alive and out of hospital from postoperative day 31 to 90. Male sex, reduced lung function, longer dimension of resection margin, pleural adhesions, and non-small cell lung cancer were independent risks, confirmed by a sensitivity analysis.

CONCLUSION

Days alive and out of hospital within 90 days after enhanced recovery thoracoscopic wedge resection was only reduced by a median of 2 days, mainly due to air leak and pain.

The effect of dexamethasone on functional pain following Transoral Robotic Surgery: a randomized double blinded clinical trial

BACKGROUND

Pain is prevalent after most TransOral Robotic Surgery (TORS) procedures and may limit function i.e. swallowing. Currently, there is limited knowledge regarding optimal pain treatment in TORS.

AIMS/OBJECTIVES

This clinical trial randomized patients to either a high-dose dexamethasone or low-dose dexamethasone treatment in addition to a multimodal basic analgesic protocol. The aim of the trial was to investigate the pain intensity during rest and swallowing using the Visual Analogue Scale (VAS) after TORS lingual tonsillectomy. Secondary outcomes were acceptable food consistency, nausea, vomiting, opioid rescue usage, length of hospitalization, feeding tube placements, readmissions, blood glucose levels and postoperative complications.

METHODS

The trial was conducted between August 2020 and October 2022. Eligible patients were patients scheduled for TORS-L treatment of obstructive sleep apnea syndrome or as part of the diagnostic work-up of head and neck carcinoma of unknown primary.

RESULTS

Eighteen patients were and randomized 1:1. There were overall no significant differences between groups in the reported VAS scores during rest or swallowing (p ≥ .05). Overall, there were no differences in the secondary outcomes.

CONCLUSION

There were no differences in the pain intensity in the two treatment groups allocated to a basic multimodal analgesic package and either high-dose dexamethasone or low-dose dexamethasone treatment. The trial is the first RCT to include pain measurement during a procedure-relevant activity, thus creating a platform for future recovery studies.

Prognostic models for chronic postsurgical pain-Current developments, trends, and challenges

PURPOSE OF REVIEW

Prognostic models for chronic postsurgical pain (CPSP) aim to predict the likelihood for development and severity of CPSP in individual patients undergoing surgical procedures. Such models might provide valuable information for healthcare providers, allowing them to identify patients at higher risk and implement targeted interventions to prevent or manage CPSP effectively. This review discusses the latest developments of prognostic models for CPSP, their challenges, limitations, and future directions.

RECENT FINDINGS

Numerous studies have been conducted aiming to develop prognostic models for CPSP using various perioperative factors. These include patient-related factors like demographic variables, preexisting pain conditions, psychosocial aspects, procedure-specific characteristics, perioperative analgesic strategies, postoperative complications and, as indicated most recently, biomarkers. Model generation, however, varies and performance and accuracy differ between prognostic models for several reasons and validation of models is rather scarce.

SUMMARY

Precise methodology of prognostic model development needs advancements in the field of CPSP. Development of more accurate, validated and refined models in large-scale cohorts is needed to improve reliability and applicability in clinical practice and validation studies are necessary to further refine and improve the performance of prognostic models for CPSP.

Transoral robotic surgery - time for consensus on pain assessment. A review

BACKGROUND

In Head and Neck surgery Transoral Robotic Surgery (TORS) is evolving as a key treatment option for benign and malignant lesions in the oropharynx. Even so, postoperative pain is one of the primary early complaints following TORS. Well established evidence-based procedure specific pain treatment guidelines are available for a variety of other surgical specialties. However, there are no guidelines for TORS.

AIM

This review describes the available data of early pain intensity following TORS during rest and procedure related activity.

METHODS

Literature concerning pain in the immediate postoperative phase following TORS were obtained from two literature databases.

RESULTS

Most data on pain intensity following TORS are based upon a numeric rating scale, e.g. the Visual Analogue Scale and/or analgesic demands. Only one randomized clinical trial is available reflecting that the literature is mainly based on retrospective and a few prospective studies. Only one study analyzed pain during relevant functionality, i.e. swallowing. Overall, the studies suffer from a non-standardized approach and there is a need for transparent information concerning the timing of pain ratings and methodology.

CONCLUSIONS

The evidence for optimal pain control is limited, particularly during surgical relevant activity. Postoperative pain rating during activity is a fundamental element in pain trials in order to enhance recovery thereby calling for future consensus on assessment methodology.

High dose dexamethasone in high pain responders undergoing total hip arthroplasty: A randomized controlled trial

BACKGROUND

Postoperative pain after total hip arthroplasty (THA) may delay postoperative mobilization and discharge. Postoperative pain has been shown to be higher in pain catastrophisers and patients receiving opioids. A single dose of glucocorticoid reduces pain after THA, and an increased dose of glucocorticoids has been found to be effective in patients at high risk of postoperative pain after total knee arthroplasty (TKA), however, the ideal dose in THA remains unknown.

OBJECTIVE

To evaluate the effect of a high dose (1 mg kg -1 ) vs. intermediate dose (0.3 mg kg -1 ) of dexamethasone on pain after THA.

DESIGN

A randomized double-blind controlled study.

SETTING

A two-centre study including two large arthroplasty sites in Denmark was conducted from February 2019 to August 2020.

PATIENTS

A total of 160 patients undergoing THA by neuraxial block with multimodal analgesia, having a Pain Catastrophising Scale score >20 and/or preoperative opioid use were included.

INTERVENTION

Patients were randomly assigned to receive dexamethasone 1 mg kg -1 or 0.3 mg kg -1 before THA.

MAIN OUTCOME MEASURES

Primary outcome was percentage of patients experiencing moderate to severe pain (visual analogue scale, VAS > 30 mm on a 0 to 100 mm scale) on ambulating 24 h after surgery. Secondary outcomes included cumulated pain scores, C-reactive protein (CRP), opioid use, postoperative recovery scores, length of stay, complications, and re-admission within 30 and 90 days.

RESULTS

No difference was found in percentage of VAS >30 mm 24 h after surgery in the 5-m walk test (VAS > 30/VAS ≤ 30%); 33/42 (44%) vs. 32/43 (43%), relative risk = 1.04 (95% confidence interval 0.72-1.51; P  = 0.814) in 1 mg kg -1vs. 0.3 mg kg -1 respectively. No differences were found in CRP and opioid use between groups. Also, no intergroup differences were found in recovery scores, re-admissions, or complications.

CONCLUSION

1 mg kg -1vs. 0.3 mg kg -1 dexamethasone improved neither postoperative pain nor recovery in THA in a cohort of predicted high pain responders.

TRIAL REGISTRATION

ClinicalTrials.gov ID-number NCT03763760 and EudraCT-number 2018-2636-25.

Anti-Inflammatory Effect of Vitamin C during the Postoperative Period in Patients Subjected to Total Knee Arthroplasty: A Randomized Controlled Trial

Vitamin C, a potent reducing and antioxidant agent, plays an important role in the body, aiding in the growth of cartilage and bones. It is also involved in mechanisms that help reduce inflammation and its effects on the body. In addition, vitamin C decreases pro-inflammatory cytokines, such as IL-6, which produce acute-phase proteins such as CRP and influence inflammatory markers such as ESR. We carried out a study with 110 patients who underwent total knee replacement surgery. We divided the patients into two groups, in which the intervention group received 15 g of parenteral vitamin C during the immediate postoperative period while the control group did not. Patients who received 15 g of vitamin C after total knee replacement surgery had decreased inflammatory markers, specifically CRP and ESR. Overall, administering vitamin C in the post-surgical period results in improved management of inflammation, as evidenced by a decrease in CRP and ESR values. This leads to faster recovery and better healing outcomes for patients undergoing total knee replacement surgery. Furthermore, the beneficial effects of vitamin C in reducing proinflammatory cytokines, reducing the need for opioid analgesics, and its mild adverse effects make it a promising adjuvant in managing postoperative recovery.

Benefits versus harm of intraoperative glucocorticoid for postoperative nausea and vomiting prophylaxis

Intraoperative use of glucocorticoids is effective for postoperative nausea and vomiting prophylaxis and can also provide early postoperative analgesic effects, but the consequences for chronic post-surgical pain are debatable. In a secondary analysis of the large pragmatic Perioperative Administration of Dexamethasone and Infection trial (n=8478), the primary outcome of pain at the surgical wound at 6 months after surgery was increased in subjects receiving dexamethasone 8 mg i.v. for postoperative nausea and vomiting prophylaxis, a dose not associated with the detrimental effect of surgical site infection in the original study. In contrast, a more detailed assessment of chronic post-surgical pain after exclusion of patients with preoperative pain at the surgical site showed no differences with or without intraoperative dexamethasone regarding chronic post-surgical pain characteristics (intensity and neuropathic features). Because of several confounding factors especially regarding surgical details, these unexpected findings call for more well-designed studies about the potential risk of intraoperative treatments, such as glucocorticoids, on late post-surgical pain.

Oral Dexamethasone Following Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial

BACKGROUND

Intravenous dexamethasone has been shown to reduce pain in total joint arthroplasty. This double-blind, randomized, placebo-controlled trial investigated the postoperative effects and safety of oral dexamethasone as a potential augment to multimodal pain management in outpatient knee arthroplasty.

METHODS

The authors prospectively randomized 109 consecutive patients undergoing primary total knee arthroplasty. Patients were assigned to Group A (57 patients) received 4 mg of dexamethasone by mouth twice per day starting postoperative day (POD) one for four days and Group B received placebo capsules. All healthcare professionals and patients were blinded to group allocation. The primary outcome was defined as postoperative pain scores. Secondary outcomes included 90-day postoperative complications, nausea and vomiting, daily opioid usage, assistance for ambulation, difficulty sleeping, and early patient reported outcomes. Demographics were similar between groups.

RESULTS

The patients who received dexamethasone had statistically significant decrease in VAS scores when averaging POD 1 to 4 (P=0.01). The average VAS scores among individual days were significantly lower with dexamethasone on POD 2, 3, and 4. While taking dexamethasone, morning and mid-day VAS scores were significantly lower. There was no difference between the groups with opioid use, nausea or vomiting, 90-day complications, ability to walk with/without assistance, difficulty sleeping, and early patient reported outcomes.

CONCLUSION

This double-blind, randomized, placebo-controlled trial demonstrated that oral dexamethasone following primary total knee arthroplasty can reduce postoperative pain. This may be a beneficial option in ambulatory surgery where intravenous limitations exist, but larger series are needed to further evaluate the safety profile in this population.

The Effect of Dexamethasone on Postoperative Pain Management in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

Objective The objective of this study was to evaluate the effectiveness of dexamethasone in treating postoperative pain in patients undergoing total knee arthroplasty (TKA). Methodology This randomized controlled trial (RCT) was completed over the course of two years (September 7, 2015, to September 6, 2017). In the course of their treatment for osteoarthritis of the knee, all of the patients who had primary unilateral total knee replacement (TKR) participated in the research. Under spinal anesthesia, each patient had medial para-patellar approach medial orthopedic surgery. Patients were assigned to group A or group B based on a random selection. Each of the groups consisted of 79 individuals. Group A was given dexamethasone through intravenous administration at a dose of 0.1 mg/kg before the operation. During the subsequent period of 24 hours, no more treatment was administered (control group). On a predesigned questionnaire, postoperative pain was measured using the visual analog scale (VAS) for pain. Functional results, duration of hospital stay, and complications were all recorded on the questionnaire (VAS). Analysis of data was carried out using the Statistical Package for the Social Sciences (SPSS) version 23 (IBM SPSS Statistics, Armonk, NY, USA). Results There were 158 patients in total in the study, out of which 98 were females and 60 were males in the group. The patients' average body mass index (BMI) was 26.94 ± 3.14 kg/m². Patients in group A had lower postoperative analgesic and antiemetic needs and higher VAS scores and spent less time in the hospital than patients in group B. There were no postoperative problems in either group. Conclusion In patients undergoing TKA, the use of dexamethasone during and after surgery decreases pain, the need for analgesics, and the duration of hospital stay.

Study protocol for discharge on day of surgery after hip and knee arthroplasty from the Center for Fast-track Hip and Knee Replacement

BACKGROUND AND PURPOSE

Limited data exists on the implementation process and safety of discharge on the day of surgery after primary hip and knee arthroplasty in a multicenter setting. We report our study protocol on the investigation of the feasibility, safety, and socioeconomic aspects following discharge on day of surgery after hip and knee arthroplasty across 8 fast-track centers.

PATIENTS AND METHODS

This is a study protocol for a prospective cohort study on discharge on day of surgery from the Center for Fast-track Hip and Knee Replacement. The collaboration includes 8 centers covering 40% of the primary hip and knee arthroplasty procedures undertaken in Denmark. All patients scheduled for surgery are screened for eligibility using well-defined inclusion and exclusion criteria. Eligible patients fulfilling discharge criteria will be discharged on day of surgery. We expect to screen 9,000 patients annually. Duration and outcome: Patients will be enrolled over a 3-year period from September 2022 and reporting of results will run continuously until December 2025. We shall report the proportion of eligible patients and patients discharged on day of surgery as well as limiting factors. Readmissions and complications within 30 days are recorded with real-time follow-up by research staff. Furthermore, patient-reported information on willingness to repeat discharge on day of surgery, contacts with the healthcare system, complications, and workability is registered 30 days postoperatively. EQ-5D, Oxford Knee Score, and Oxford Hip Score are completed preoperatively and after 3 months and 1 year. Finally, outcome data will be used in the development of a prediction model for successful discharge on the day of surgery.

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).

Peripheral nerve-blocks and associations with length of stay and readmissions in fast-track total hip and knee arthroplasty

BACKGROUND

Peripheral nerve blocks (PNB) have recently been recommended in total hip (THA) and knee (TKA) arthroplasty as they may reduce pain, morphine consumption, length of stay (LOS) and complications. However, whether PNBs are associated with early discharge within an enhanced recovery protocol including multimodal analgesia is uncertain.

METHODS

An observational multicenter study from January to August 2017 in six Danish Arthroplasty Centers with established fast-track protocols. Prospective recording of preoperative characteristics and information on PNB, LOS and readmissions through the Danish National Patient Registry and medical records. Multiple logistic regression was used to investigate associations between PNB and a LOS >1 day, LOS >4 days, and 30-days readmissions. We also reported on mobilization, pain, opioid and fall-related complications leading to LOS >4 days or readmissions.

RESULTS

A total of 2027 (58.6%) THA and 1432 (41.4%) TKAs with a median LOS of 1 day (IQR 1-2) and 5.3% (CI:4.6-6.1) 30-days readmission rate were identified. PNB was used in 40.7% (CI:38.2-43.3) of TKA and 2.7% (CI:2.0-3.5) of THA, but with considerable interdepartmental variation (0.0-89.0% for TKA). There was no association between PNB and LOS >1 day (OR:1.19 CI:0.82-1.72; p = .354), LOS >4 days (OR:1.4 CI:0.68-2.89; p = .359) or 30-days readmissions (OR:1.02 CI:0.63-1.65; p = .935) in TKA. Logistic regression in THA was not possible due to limited use of PNB. In TKA there were 12 (2.1% CI:1.2-3.6) with and 1 (0.1% CI:0.02-0.7) without a PNB, who had mobilization, pain or opioid-related complications, and 5 (0.9% CI:0.4-2.0) versus 4 (0.5% CI:0.2-1.2) who fell. Correspondingly, 2 (3.7% CI:1.0-12.6) and 11 (0.6% CI:0.3-1.0) of THA patients had these complications, while 0 (0.0% CI:0.0-6.6) and 17 (0.8% CI:0.5-1.3) fell.

CONCLUSION

Routine use of peripheral nerve blocks was not associated with early discharge or 30-days readmissions in fast-track THA and TKA. Future studies should focus on benefits of PNB in high-risk patients.

A 20 mg dose of dexamethasone does not reduce the proportion of joint replacement patients needing rescue analgesia: a matched cohort study

Background

Consistent pain control after total joint replacement (TJR) has not yet been reached in all patients managed with a multimodal analgesia regime. Questions remain on dosage and timing of analgesics. Glucocorticoids such as dexamethasone are considered most powerful in reducing the surgery-induced inflammatory response with most pain studies using a 6-12 mg dose. Reviews agree that additional glucocorticoids may provide more analgesia, but a dose-finding analysis is limited. The primary aim of this study was to determine if a high, single preoperative dose of dexamethasone resulted in a reduced need for rescue analgesics during the first 24 hours after TJR when compared to a standard 8 mg dose of dexamethasone.

Methods

A cohort study in which 59 patients who received 20 mg dexamethasone intravenously just prior to incision were matched 1:1 to patients who received a standard 8 mg dose. Consecutive elective hip and knee replacement patients managed by one anaesthesiologist were included in the high dose group between June 2019 and March 2020. Patients were matched for arthroplasty type, gender, age, anaesthesia type and pre-operative pain. Patients with opioid use before surgery or with diabetes mellitus were excluded. Oxynorm rescues analgesics (number of times given and dosage) usage during hospitalization was retrieved from the electronic nursing files.

Results

There were no significant differences between groups in gender distribution, mean age and body mass index (BMI), in American Society of Anesthesiologists (ASA), type of arthroplasty, anaesthesia type and pre-operative pain score. In the 20 mg group 54 patients (91.5%) needed oxynorm during hospitalization versus 58 (98.3%) in the 8 mg group (P=0.09). High dose group patients received a median of 5 mg [interquartile range (IQR): 0] oxynorm versus 5 mg (IQR: 0) in the standard dose group (P=0.70).

Conclusions

In this matched cohort study there was no difference in the proportion of patients needing rescue analgesics during hospitalization between the group of patients who preoperatively received 20 mg dexamethasone and the group of patients who received 8 mg. Future blinded randomized controlled trials are needed to further investigate the effect of different glucocorticoids dosages on pain after joint replacement surgery.

Use of regional analgesia to prevent the conversion from acute to chronic pain

PURPOSE OF REVIEW

Chronic post-surgical pain (CPSP) prevalence has not changed over the past decades what questions the efficacy of preventive strategies. Regional analgesia is used to control acute pain, but preventive effect on CPSP remains debated. Failures and future application of regional analgesia to prevent transition from acute to chronic pain will be discussed.

RECENT FINDINGS

After thoracotomy, perioperative regional analgesia does not seem to prevent CPSP. After breast cancer surgery, paravertebral block might prevent CPSP intensity and impact on daily life up to 12 months, particularly in high catastrophizing patients. In knee arthroplasty, perioperative regional analgesia or preoperative genicular nerve neuroablation do not prevent CPSP, although current studies present several bias. The protective role of effective regional analgesia and early pain relief in trauma patients deserves further studies.

SUMMARY

Regional analgesia failure to prevent CPSP development should prompt us to reconsider its perioperative utilization. Patients' stratification, for example high-pain responders, might help to target those who will most benefit of regional analgesia. The impact of regional analgesia on secondary pain-related outcomes such as intensity and neuropathic character despite no difference on CPSP incidence requires more studies. Finally, the preventive effect of regional analgesia targeted interventions on CPSP in patients suffering from severe subacute pain deserves to be assessed.

Critical appraisal of randomised trials assessing regional analgesic interventions for knee arthroplasty: implications for postoperative pain guidelines development

Guidelines are increasingly being used for clinical decision-making. Such guidelines are usually based on meta-analyses, which are generally derived from RCTs. However, their interpretations are often hindered as they do not always consider current clinical relevance. Analyses of RCTs assessing analgesic efficacy of advanced regional analgesic techniques in knee arthroplasty show that the majority of trials do not include a package of basic analgesics such as paracetamol, NSAIDs or cyclooxygenase-2 specific inhibitors, dexamethasone, and local infiltration analgesia in the comparator group. Consequently, the current approach to analyse meta-analyses of pain interventions is not optimal, and may lead to inadequate or inappropriate conclusions and clinical guidance.

Post-cesarean section analgesia

Worldwide, the most performed surgical intervention is cesarean section. Hence, post-cesarean pain is a common problem with significant health and economic impact on the individual patient and society. Adequate treatment of post-cesarean pain is necessary to facilitate enhanced recovery, improve neonatal outcome by improving breastfeeding success and bonding between mother and child, and reduce pain-induced side effects. Therefore, optimal pain relief is important, but in the obstetric population, this is often complex due to the interplay of mother and neonate. To facilitate recovery and temper the side effects of potent analgesic drugs such as opioids, multimodal analgesia is currently advocated, and clear international guidelines and recommendations have recently been described. In the present overview, we will discuss the most recent guidelines and evaluate various analgesic interventions.

AHA STEROID trial, dexamethasone in acute high-risk abdominal surgery, the protocol for a randomized controlled trial

INTRODUCTION

Existing multimodal pathways for patients undergoing acute high-risk abdominal surgery for intestinal obstruction (IO) and perforated viscus (PV) have focused on rescue in the immediate perioperative period. However, there is little focus on the peri-operative pathophysiology of recovery in this patient group, as done to develop enhanced recovery pathways in elective care. Acute inflammation is the main driver of the perioperative pathophysiology leading to adverse outcomes. Pre-operative high-dose of glucocorticoids provides a reduction in the inflammatory response after surgery, effective pain relief in several major surgical procedures, as well as reduce fatigue and improving endothelial dysfunction.

AIM

To evaluate the effect of high-dose glucocorticoid on the inflammatory response, fluid distribution and recovery after acute high-risk abdominal surgery in patients with IO and PV.

METHODS

AHA STEROID trial is a sponsor-initiated single-center, randomized, double-blind placebo-controlled trial, assessing preoperative high-dose dexamethasone (1 mg/kg) versus placebo (normal saline) in patients undergoing emergency high-risk abdominal surgery. We plan to enroll 120 patients. Primary outcome is the reduction in C-reactive protein on postoperative day 1 as a marker of successful attenuation of the acute stress response. Secondary outcomes include perioperative changes in endothelial and other inflammatory markers, fluid distribution, pulmonary function, pain, fatigue, and mobilization. The statistical plan is outlined in the protocol.

DISCUSSION

The AHA STEROID trial will provide important evidence to guide the potential use of high-dose glucocorticoids in emergency high-risk abdominal surgery, with respect to different pathophysiologies.