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Gettleman BS, Liu KC, Yoshida B, Vega AN, Kusnezov N, Lieberman JR, Heckmann ND. Perioperative Dexamethasone is Associated with a Decreased Risk of Pulmonary Embolism and Deep Vein Thrombosis Following Total Joint Arthroplasty: An Analysis of 70,000 High-Risk Patients. J Arthroplasty 2024:S0883-5403(24)00453-4. [PMID: 38735549 DOI: 10.1016/j.arth.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Dexamethasone (DEX) has demonstrated promise with respect to decreasing postoperative thromboembolic complications following total joint arthroplasty (TJA). Therefore, the aim of this study was to investigate the effects of perioperative intravenous DEX on rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) after primary TJA in patients who have a history of venous thromboembolism (VTE). METHODS Patients who have a history of VTE who underwent primary, elective TJA from 2015 to 2021 were identified using a commercial healthcare database. Patients were divided based on receipt of perioperative intravenous DEX [DEX(+) versus DEX(-)] on the day of index TJA. Patient demographics and hospital factors were collected. The 90-day risk of postoperative complications, readmission, and in-hospital mortality were compared. RESULTS Overall, 70,147 patients who had a history of VTE underwent TJA, of which 40,607 (57.89%) received DEX and 29,540 (42.11%) did not. The DEX(+) patients were younger (67 ± 9.8 versus 68 ± 9.9 years, P < 0.001) and had a significantly shorter length of stay compared to the DEX(-) patients (1.8 ± 1.6 versus 2.2 ± 1.8 days, P < 0.001). The DEX(+) patients demonstrated lower rates of PE (1.37 versus 1.75%, P < 0.001) and DVT (2.37 versus 3.01%, P < 0.001) compared to DEX(-) patients. The DEX(+) patients experienced a lower risk of PE (adjusted odds ratio [aOR] 0.78, 95% confidence interval [95%-CI]: 0.66 to 0.93, P = 0.006) and DVT (aOR: 0.84, 95%-CI: 0.74 to 0.95, P = 0.006) compared to DEX(-) patients. The DEX(+) patients demonstrated no differences in the odds of surgical site infection, periprosthetic joint infection, or sepsis compared to the DEX(-) patients (P > 0.05). CONCLUSION The administration of DEX was associated with a decreased risk of PE and DVT in patients who have a history of VTE who underwent TJA. These data warrant further study investigating the postoperative benefits of perioperative DEX administration for high-risk patients undergoing TJA.
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Affiliation(s)
- Brandon S Gettleman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kevin C Liu
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon Yoshida
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Andrew N Vega
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nicholas Kusnezov
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California.
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Zhang G, Tian C, Liang T, Chi H, Wu A, Li J, Yao X, Wang Q, Zhu C, Lin N. The analgesic properties of Yu-Xue-Bi tablets in the inflammatory pain mice: By the inhibition of CCL3-mediated macrophage transmigration into the spinal cord. JOURNAL OF ETHNOPHARMACOLOGY 2022; 289:115051. [PMID: 35101573 DOI: 10.1016/j.jep.2022.115051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 06/14/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Until now, inflammatory pain, especially ones with central sensitization in the spinal cord, is far from effectively treated. Yu-Xue-Bi Tablets (YXB) is a patented medicine, which has been widely applied for inflammatory pain. However, its therapeutic characteristics and mechanism remain unknown. AIM OF THE STUDY This study is designed to evaluate the analgesic characteristics and explore the underlying mechanism of YXB in the inflammatory pain model induced by Complete Freund's Adjuvant (CFA). MATERIALS AND METHODS The analgesic effects were measured by Von Frey test. The expression of calcitonin gene-related peptide (CGRP) was quantified by immunofluorescence. The expression of immune factors was analyzed via Luminex assay. The further quantifications of C-C Motif chemokine ligand 3 (CCL3) were verified by Enzyme-linked immunosorbent assay (ELISA). The transmigration of macrophage and activation of microglia were evaluated by immunofluorescence. Spinal injections of purified CCL3, CCR1 antagonist (J113863) and CCR5 antagonist (Maraviroc) were used to clarify roles of CCL3 assumed in the pharmacological mechanism of YXB. RESULTS In CFA mice, YXB ameliorated the mechanical allodynia in dose and time dependent way, suppressed the central sensitization in dose dependent way. In the L5 spinal cord, YXB downregulated the expression of macrophage M1 pro-inflammatory factors TNFRI and CCL3, inhibited the transmigration of circulating macrophage and the activation of microglia. Purified CCL3 led to the transmigration of macrophage, activation of microglia, central sensitization, and mechanical allodynia in the Sham mice. Inhibitors of CCR1 and CCR5 attenuated above symptoms in CFA mice. Purified CCL3 blocked YXB mediated down regulation of CCL3, inhibition of macrophage transmigration, but not activation of microglia. CONCLUSION YXB exerts the analgesic effects by inhibiting CCL3-mediated peripheral macrophage transmigrate into spinal cord. This study provided a novel approach for inflammatory pain treatment and new insight into the pharmacological action of YXB.
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Affiliation(s)
- Guoxin Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Congmin Tian
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Tingjun Liang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Hongyu Chi
- School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Anguo Wu
- Sichuan Key Medical Laboratory of New Drug Discovery and Druggability Evaluation, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, School of Pharmacy, Southwest Medical University, Luzhou, 646000, China
| | - Jiahao Li
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Xuemin Yao
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Qi Wang
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Chunyan Zhu
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China.
| | - Na Lin
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China; Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
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Central nervous system monoaminergic activity in hip osteoarthritis patients with disabling pain: associations with pain severity and central sensitization. Pain Rep 2022; 7:e988. [PMID: 35097309 PMCID: PMC8789209 DOI: 10.1097/pr9.0000000000000988] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/08/2021] [Accepted: 12/17/2021] [Indexed: 12/19/2022] Open
Abstract
In patients with osteoarthritis undergoing total hip arthroplasty, higher cerebrospinal fluid concentrations of serotonin and dopamine metabolites are associated with increased pain severity and central sensitization. Introduction: Objectives: Methods: Results: Conclusions:
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Zhong C, He R, Lu X, Zhong L, Lin DK, Liu J, Guo D. Would high-dose corticosteroid addition to multimodal cocktail periarticular injection contribute to prolonged pain control and better recovery following total knee arthroplasty?: study protocol for a randomized controlled trial. Trials 2021; 22:703. [PMID: 34654469 PMCID: PMC8518286 DOI: 10.1186/s13063-021-05655-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/24/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Enhanced recovery following total knee arthroplasty (TKA) has been advocated to enhance postoperative recovery. Multimodal cocktail periarticular injection (MCPI) use for pain control in TKA has gained wide acceptance. MCPI-containing corticosteroids are believed to be an effective solution owing to their local anti-inflammatory effects and ability to reduce the local stress response postoperatively. However, there is conflicting evidence regarding its benefits. This trial aims to compare MCPI with a high dose of corticosteroid, normal dose of corticosteroid, and non-corticosteroid during TKA, to assess the effectiveness of MCPI containing corticosteroids in postoperative pain relief, functional improvement, rescue analgesia, and side effects and provide evidence that high-dose corticosteroids result in prolonged pain control and better recovery following TKA. METHODS This is a double-blinded, randomized, placebo-controlled study. A total of 234 patients scheduled for TKA will be recruited. During surgery, before wound closure, 80 ml of the cocktail analgesic will be injected into the muscle and joint capsule for local infiltration analgesia; the participants will be randomly assigned to three groups to receive a high dose of betamethasone MCPI (group H), normal dose of betamethasone MCPI (group N), and non-betamethasone MCPI (group C). The following indices will be recorded and analyzed: the strongest knee pain experienced during 90° flexion at 6 h, 24 h, 48 h, 72 h, 5 days, 14 days, and 30 days after surgery; 1 min walking ability; and circumference around the patella at 2, 5, 14, and 30 days after surgery; Knee Society knee score at 14 days and 30 days after surgery; C-reactive protein and blood sedimentation; blood sugar 2, 5, 14, and 30 days following surgery; rescue analgesic consumption; and adverse events. If any participant withdraws from the trial, an intention-to-treat analysis will be performed. DISCUSSION The results of this study will provide clinical evidence on the effectiveness of MCPI-containing corticosteroids in postoperative pain relief, functional improvement, rescue analgesia, and adverse events, as well as provide evidence on the efficacy of high-dose corticosteroids in prolonged pain control and better recovery following TKA. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2000038671 . Registered on September 27, 2020.
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Affiliation(s)
- Chengfan Zhong
- Department of Orthopedic Surgery, People's Hospital of Gaozhou, No. 89, Xiguan Road, Gaozhou City, 525200, Guangdong, China
| | - Rong He
- Department of Orthopedic Surgery, Maoming People's Hospital, No.101, Weimin Road, Maoming City, 525000, Guangdong, China
| | - Xiaomin Lu
- Clinical Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong, China
| | - Lilun Zhong
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China
| | - Ding-Kun Lin
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China
| | - Jun Liu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China
| | - Da Guo
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China.
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5
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Zhang LK, Zhu FB, Gao HH, Zhang L, Quan RF. Is intraoperative corticosteroid a good choice for postoperative pain relief in total joint arthroplasty? A meta-analysis of 11 randomized controlled trials. Medicine (Baltimore) 2021; 100:e27468. [PMID: 34622874 PMCID: PMC8500626 DOI: 10.1097/md.0000000000027468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 09/18/2021] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Lu-kai Zhang
- Department of Orthopaedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People's Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Fang-bing Zhu
- Department of Orthopaedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People's Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Huan-huan Gao
- Department of Orthopaedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People's Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Lei Zhang
- Department of Orthopaedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People's Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Ren-fu Quan
- Department of Orthopaedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People's Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People's Republic of China
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Kazarian GS, Anthony CA, Lawrie CM, Barrack RL. The Impact of Psychological Factors and Their Treatment on the Results of Total Knee Arthroplasty. J Bone Joint Surg Am 2021; 103:1744-1756. [PMID: 34252068 DOI: 10.2106/jbjs.20.01479] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ There is a growing body of evidence implicating psychosocial factors, including anxiety, depression, kinesiophobia, central sensitization, and pain catastrophizing, as negative prognostic factors following total knee arthroplasty (TKA). ➤ Symptoms of anxiety and depression likely represent risk factors for negative outcomes in patients undergoing TKA. However, few studies have assessed the impact of preoperative interventions for these conditions on postoperative outcomes. ➤ The Tampa Scale of Kinesiophobia and the Central Sensitization Inventory have demonstrated value in the diagnosis of kinesiophobia and central sensitization. Higher preoperative indices of kinesiophobia and central sensitization predict worse patient-reported outcomes postoperatively. ➤ Although evidence is limited, cognitive-behavioral therapy for kinesiophobia and duloxetine for central sensitization may help to diminish the negative impact of these preoperative comorbidities. It is important to note, however, that outside the realm of TKA, cognitive-behavioral therapy has been recognized as a more effective treatment for central sensitization than medical treatment. ➤ Awareness of these issues will allow surgeons to better prepare patients regarding postoperative expectations in the setting of a comorbid psychosocial risk factor. Further research into the role of preoperative assessment and possible treatment of these conditions in patients undergoing TKA is warranted.
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Affiliation(s)
- Gregory S Kazarian
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY.,Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Christopher A Anthony
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri.,Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles M Lawrie
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Robert L Barrack
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
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Bjurström MF, Bodelsson M, Irwin MR, Orbjörn C, Hansson O, Mattsson-Carlgren N. Decreased pain sensitivity and alterations of cerebrospinal fluid and plasma inflammatory mediators after total hip arthroplasty in patients with disabling osteoarthritis. Pain Pract 2021; 22:66-82. [PMID: 34143556 DOI: 10.1111/papr.13051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/05/2021] [Accepted: 06/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Proinflammatory mechanisms are implicated in pain states. Recent research indicates that patients with osteoarthritis (OA) with signs of central sensitization exhibit elevated cerebrospinal fluid (CSF) levels of interferon gamma-induced protein 10 (IP-10), Fms-related tyrosine kinase 1 (Flt-1), and monocyte chemoattractant protein 1 (MCP-1). METHODS The current prospective cohort study, including 15 patients with OA, primarily aimed to evaluate associations among alterations in CSF IP-10, Flt-1, MCP-1, and pain sensitization following total hip arthroplasty (THA). Participants provided CSF and blood samples for analysis of 10 proinflammatory mediators, and underwent detailed clinical examination and quantitative sensory testing, immediately preoperative and 18 months after surgery. RESULTS Neurophysiological measures of pain showed markedly reduced pain sensitivity long-term postoperative. Increases in remote site pressure pain detection thresholds (PPDTs) and decreased temporal summation indicated partial resolution of previous central sensitization. Compared to preoperative, CSF concentrations of IP-10 were increased (p = 0.041), whereas neither Flt-1 (p = 0.112) nor MCP-1 levels changed (p = 0.650). Compared to preoperative, plasma concentrations of IP-10 were increased (p = 0.006), whereas interleukin (IL)-8 was decreased (p = 0.023). Subjects who exhibited increases in arm PPDTs above median showed greater increases in CSF IP-10 compared to those with PPDT increases below median (p = 0.028). Analyses of plasma IP-10 and IL-8 indicated higher levels of peripheral inflammation were linked to decreased pressure pain thresholds (unadjusted β = -0.79, p = 0.006, and β = -118.1, p = 0.014, respectively). CONCLUSIONS THA leads to long-term decreases in pain sensitivity, indicative of resolution of sensitization processes. Changes in CSF and plasma levels of IP-10, and plasma IL-8, may be associated with altered pain phenotype.
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Affiliation(s)
- Martin F Bjurström
- Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Norman Cousins Center for Psychoneuroimmunology, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Mikael Bodelsson
- Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Michael R Irwin
- Norman Cousins Center for Psychoneuroimmunology, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Camilla Orbjörn
- Clinical Memory Research Unit, Faculty of Medicine, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Oskar Hansson
- Clinical Memory Research Unit, Faculty of Medicine, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden.,Memory Clinic, Skåne University Hospital, Malmö, Sweden
| | - Niklas Mattsson-Carlgren
- Clinical Memory Research Unit, Faculty of Medicine, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden.,Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.,Department of Neurology, Skåne University Hospital, Lund University, Lund, Sweden
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Differential expression of cerebrospinal fluid neuroinflammatory mediators depending on osteoarthritis pain phenotype. Pain 2021; 161:2142-2154. [PMID: 32384383 PMCID: PMC7431139 DOI: 10.1097/j.pain.0000000000001903] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/21/2020] [Indexed: 12/15/2022]
Abstract
Supplemental Digital Content is Available in the Text. Distinct cerebrospinal fluid neuroinflammatory profiles may be associated with different objective characteristics of persistent pain in osteoarthritis patients undergoing total hip arthroplasty. Neuroinflammation is implicated in the development and maintenance of persistent pain states, but there are limited data linking cerebrospinal fluid (CSF) inflammatory mediators with neurophysiological pain processes in humans. In a prospective observational study, CSF inflammatory mediators were compared between patients with osteoarthritis (OA) who were undergoing total hip arthroplasty due to disabling pain symptoms (n = 52) and pain-free comparison controls (n = 30). In OA patients only, detailed clinical examination and quantitative sensory testing were completed. Cerebrospinal fluid samples were analyzed for 10 proinflammatory mediators using Meso Scale Discovery platform. Compared to controls, OA patients had higher CSF levels of interleukin 8 (IL-8) (P = 0.002), intercellular adhesion molecule 1 (P = 0.007), and vascular cell adhesion molecule 1 (P = 0.006). Osteoarthritis patients with central sensitization possibly indicated by arm pressure pain detection threshold <250 kPa showed significantly higher CSF levels of Fms-related tyrosine kinase 1 (Flt-1) (P = 0.044) and interferon gamma-induced protein 10 (IP-10) (P = 0.024), as compared to subjects with PPDT above that threshold. In patients reporting pain numerical rating scale score ≥3/10 during peripheral venous cannulation, Flt-1 was elevated (P = 0.025), and in patients with punctate stimulus wind-up ratio ≥2, CSF monocyte chemoattractant protein 1 was higher (P = 0.011). Multiple logistic regression models showed that increased Flt-1 was associated with central sensitization, assessed by remote-site PPDT and peripheral venous cannulation pain, and monocyte chemoattractant protein-1 with temporal summation in the area of maximum pain. Multiple proinflammatory mediators measured in CSF are associated with persistent hip OA-related pain. Pain phenotype may be influenced by specific CSF neuroinflammatory profiles.
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Previtali D, Di Laura Frattura G, Filardo G, Delcogliano M, Deabate L, Candrian C. Peri-operative steroids reduce pain, inflammatory response and hospitalisation length following knee arthroplasty without increased risk of acute complications: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2021; 29:59-81. [PMID: 31494685 DOI: 10.1007/s00167-019-05700-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/28/2019] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Davide Previtali
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Giorgio Di Laura Frattura
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland.
| | - Giuseppe Filardo
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
- ATRC, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Delcogliano
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Luca Deabate
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
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Zhang J, Huang JX. Administration with corticosteroid relieving pain following total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2020; 99:e23567. [PMID: 33371085 PMCID: PMC7748177 DOI: 10.1097/md.0000000000023567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 11/03/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND This meta-analysis compares the effectiveness of corticosteroid in relieving pain and inflammation in total knee arthroplasty (TKA) patients. METHOD Randomized controlled trials in PubMed (1996 to March 2020), Embase (1996 to March 2020), and the Cochrane Library (CENTRAL, March 2020) compared corticosteroid and placebo in pain in TKA patients were identified by a software and manual searching. The risk of bias and clinical relevance of the included studies were assessed. Sensitivity analysis was performed by omitting each study in turn. The major outcomes of the studies were analyzed by the Stata 12.0. RESULTS 13 randomized controlled trials that involved 193 patients were included in the present meta-analysis. The results of the study revealed a significantly lower visual analog scale (VAS) score of pain at rest in the corticosteroid group (12 hours: weighted mean difference (WMD)=-1.35, P = .005; 24 hours: WMD=-1.11, P = .000; 48 hours: WMD=-0.31, P = .000; 72 hours: WMD = -0.30, P = .000). And Postoperative VAS scores during mobilization at 12 hours and 24 hours were significantly lower at corticosteroid group when compared with control group (12 hours: WMD = -0.81, P = 0.000; 24 hours: WMD = -1.66, P = .018). Meta-analyses show that administration of corticosteroid can reduce the length of hospital stay, incidence nausea and the C-reactive protein level. While no significant difference was observed in the VAS scores during mobilization at 48 hours and 72 hours and total morphine consumption (P > .05). CONCLUSIONS Compared to the control group, intraoperative corticosteroid was benefit to the pain management in TKA. However, more high-quality studies are still warranted to further validate our findings, considering there are several limitations in this meta-analysis.
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Affiliation(s)
| | - Ji-xun Huang
- deputy director of Jingjiang people's hospital, Jingjiang, Tai Zhou city, Jiangsu province, China
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11
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Wu L, Si H, Li M, Zeng Y, Wu Y, Liu Y, Shen B. 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. Int J Surg 2020; 82:182-191. [PMID: 32877755 DOI: 10.1016/j.ijsu.2020.07.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/31/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Limin Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Haibo Si
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Mingyang Li
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yi Zeng
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yuan Liu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
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Tarasov DA, Lychagin AV, Yavorovkiy AG, Lipina MM, Tarasova IA. C-reactive protein as marker of post-operative analgesic quality after primary total knee arthroplasty. INTERNATIONAL ORTHOPAEDICS 2020; 44:1727-1735. [PMID: 32300831 DOI: 10.1007/s00264-020-04551-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
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Kehlet H, Joshi GP. The systematic review/meta‐analysis epidemic: a tale of glucocorticoid therapy in total knee arthroplasty. Anaesthesia 2019; 75:856-860. [DOI: 10.1111/anae.14946] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 11/29/2022]
Affiliation(s)
- H. Kehlet
- Section of Surgical Pathophysiology Rigshospitalet Copenhagen Denmark
| | - G. P. Joshi
- Department of Anesthesiology and Pain Management University of Texas Southwestern Medical Center Dallas TX USA
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Effect of Methylprednisolone on Pain Management in Total Knee or Hip Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin J Pain 2019; 34:967-974. [PMID: 29595528 DOI: 10.1097/ajp.0000000000000614] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Total joint arthroplasty (TJA) has been reported to be a successful strategy for patients with advanced osteoarthritis; however, early postoperative pain has become an unresolved issue. Perioperative methylprednisolone (MP) administration in TJA is an important and controversial topic. This study was conducted to assess the efficacy and safety of MP for pain management after total knee or hip arthroplasty (TKA/THA). MATERIALS AND METHODS PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials comparing MP versus placebo for patients undergoing TKA/THA. Related indicators that reflected the efficacy and safety for pain management were evaluated by meta-analysis. RESULTS Six randomized controlled trials involving a total of 350 patients met the inclusion criteria. The outcomes showed that intravenous MP significantly reduced pain scores at 6 and 24 hours during activity after TKA and THA but local use of MP had no clear benefit in reducing pain scores compared with the control group. There was no significant difference in VAS at 24 hours at rest and 48 hours during activity after TKA and THA. In addition, MP was associated with a reduction of morphine consumption at 24 hours after TKA. Furthermore, patients receiving MP had an obvious inflammatory control and improving postoperative nausea and vomiting and the use of MP was not associated with a significant increase in the risk of complications. There was no significant difference in the range of knee motion and length of hospital stay in both groups. CONCLUSIONS This study showed that intravenous MP significantly alleviated early postoperative pain and the incidence of postoperative nausea and vomiting after TKA and THA. For safety, intravenous MP as a promising strategy in rapid recovery to TJA.
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Chai X, Liu H, You C, Wang C. Efficacy of Additional Corticosteroid in a Multimodal Cocktail for Postoperative Analgesia Following Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials. Pain Pract 2019; 19:316-327. [PMID: 30354013 DOI: 10.1111/papr.12740] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 07/27/2018] [Accepted: 08/21/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Xiping Chai
- Department of Orthopaedics; Traditional Chinese Medical Hospital of Gansu Province; Lanzhou China
| | - Haiping Liu
- Department of Orthopaedics; Traditional Chinese Medical Hospital of Gansu Province; Lanzhou China
| | - Congxin You
- Department of Orthopaedics; Traditional Chinese Medical Hospital of Gansu Province; Lanzhou China
| | - Changde Wang
- Department of Orthopaedics; Traditional Chinese Medical Hospital of Gansu Province; Lanzhou China
- Department of Geriatric Orthopedic; Shenzhen Pingle Orthopaedics Hospital Affiliated; Guangzhou University of traditional Chinese Medicine; Shenzhen China
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Wu Y, Lu X, Ma Y, Zeng Y, Bao X, Xiong H, Shen B. Perioperative multiple low-dose Dexamethasones improves postoperative clinical outcomes after Total knee arthroplasty. BMC Musculoskelet Disord 2018; 19:428. [PMID: 30501618 PMCID: PMC6271578 DOI: 10.1186/s12891-018-2359-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 11/22/2018] [Indexed: 02/05/2023] Open
Abstract
Background The purpose of this study was to investigate the efficacy and safety of multiple low-dose dexamethasones in primary total knee arthroplasty (TKA). Methods One hundred fifty patients were equally randomized into 3 groups: Group A (n = 50) received 2 doses of normal saline only; Group B (n = 50) received with 1 dose of intravenous dexamethasone and 1 dose of normal saline; Group C (n = 50) received with 2 doses of intravenous dexamethasone. The clinical outcomes and complications were assessed. Results The CRP and IL-6 were significantly lower in Group C and B than Group A at 24, 48, and 72 h postoperatively (P < 0.001 for all). The intensity of postoperative nausea and vomiting (PONV) in Group C was lower than Group A at 24 (P < 0.001, P = 0.002), 48 (P = 0.005, P = 0.041) and 72 h (P = 0.017, P = 0.031) postoperatively and Group B at 24 h (P = 0.027, P = 0.019) postoperatively. Pain were significantly less in Group C than Group A at 24 (P < 0.001), 48 h (P = 0.037) postoperatively and Group B 24 h (P = 0.030) postoperatively. Patients in Group C had better range of motion (ROM) and satisfaction than Group A (P < 0.001, P = 0.002) and B (P = 0.001, P = 0.043). No differences were found in complications. Conclusions The administration of 10 mg dexamethasone 1 h before the surgery, and repeated at 6 h postoperatively can significantly reduce the level of postoperative CRP and IL-6 and the incidence of PONV, relieve pain, achieve an additional analgesic effect, and improve the early ROM compared with the other two groups in TKA. Level of Evidence Therapeutic Level I. Trial registration The Chinese Clinical Trial Registry (ChiCTR1800017036). Registered on July 9, 2018.
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Affiliation(s)
- Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Xiaoxi Lu
- Department of Pediatrics, West China University Second Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Yimei Ma
- Department of Pediatrics, West China University Second Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Yi Zeng
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Xianchao Bao
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Huazhang Xiong
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, 610041, Sichuan Province, China.
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Recent advances in intra-articular drug delivery systems for osteoarthritis therapy. Drug Discov Today 2018; 23:1761-1775. [DOI: 10.1016/j.drudis.2018.05.023] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/17/2018] [Accepted: 05/16/2018] [Indexed: 02/07/2023]
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18
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Differences in 1‑year outcome after primary total hip and knee arthroplasty. DER ORTHOPADE 2018; 48:136-143. [DOI: 10.1007/s00132-018-3636-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Shen S, Gao Z, Liu J. The efficacy and safety of methylprednisolone for pain control after total knee arthroplasty: A meta-analysis of randomized controlled trials. Int J Surg 2018; 57:91-100. [DOI: 10.1016/j.ijsu.2018.07.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/24/2018] [Accepted: 07/27/2018] [Indexed: 11/25/2022]
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