Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study

Effect of high-dose dexamethasone on morphine use after periacetabular osteotomy for hip dysplasia: a randomized double-blind placebo-controlled single center trial

BACKGROUND AND PURPOSE

 Periacetabular osteotomy (PAO) for hip dysplasia is associated with intensive pain and high opioid consumption. High doses of dexamethasone may reduce this. We aimed to compare the effect of 1 or 2 doses of dexamethasone 24 mg, relative to placebo, on postoperative morphine consumption after PAO.

METHODS

 A 3-group, randomized, double-blind, placebo-controlled trial was undertaken on patients ≥ 18 years, undergoing PAO (ClinicalTrials.gov: NCT03874936). Randomization Group A received 1 preoperative dose of dexamethasone 24 mg and placebo 24 hours later; Group B received 1 dose of intravenous dexamethasone 24 mg preoperatively and a repeated dose 24 hours postoperatively; and Group C received placebo at both time points. The primary endpoint was the difference in least squares mean cumulative postoperative morphine consumption between the combined dexamethasone groups and placebo within 48 hours from baseline. Key secondary outcomes included postoperative pain intensity, nausea and vomiting, antiemetic consumption and Timed Up and Go at 24 and 48 hours postoperatively, and cumulative morphine consumption from 48 hours to day 14 post-operation.

RESULTS

 90 patients were randomized to dexamethasone groups (n = 60) and placebo (n = 30); 58 and 28, respectively, completed the trial. Mean age was 31 years and 71 (79%) were females. In the combined dexamethasone group the mean cumulated postoperative morphine consumption within 48 hours was 92 mg vs 95 mg in the placebo group, corresponding to a between-group difference of -3 mg (95% confidence interval -27 to 21; P = 0.8). There were no differences observed between groups for any of the secondary outcomes.

CONCLUSION

 High-dose dexamethasone did not reduce postoperative morphine use or improve any of the secondary outcomes after PAO.

The influence of preoperative methylprednisolone bolus on edema in lower leg fractures: A prospective randomized controlled trial

INTRODUCTION

Lower limb fractures are often associated with significant soft tissue damage, leading to edema and unfavorable conditions for wound healing. This study investigates the efficacy of a preoperative bolus of methylprednisolone (MP) in reducing edema and improving postoperative function in patients undergoing ankle or tibial fracture surgery.

HYPOTHESIS

We hypothesized that the cohort receiving the steroid would experience faster edema reduction and improved functional outcomes.

MATERIAL AND METHODS

A monocentric, prospective, randomized, double-blind, controlled trial was conducted from May 2019 to June 2023, including 104 patients. The experimental group (n = 51) received a 2 mg/kg bolus of MP in 100 ml of saline, while the control group (n = 51) received 100 ml of saline prior to surgery. Data were collected on the intervention day and postoperatively at days 2, 7, 15, 45, and at 3 and 6 months. Leg circumference ratio, pain intensity, wound healing, complications, LEFS scores, and work and sport resumption were recorded.

RESULTS

There were no significant differences in edema reduction between the two groups, except on day 15, where the MP group showed a significantly lower leg circumference ratio compared to the placebo group (P = 0.015). No differences were found in pain scores, functional recovery, or return to work. Both groups had comparable complication rates, with no evidence of adverse effects associated with the steroid treatment.

CONCLUSION

The injection of a bolus of MP had a slight positive impact on lower leg edema without apparent risk of adverse event. The long-term monitoring (6 months) and the low rate of lost to follow-up let us affirm that a single 2 mg/kg MP bolus does not impede wound healing or functional recovery.

LEVEL OF EVIDENCE

II; prospective randomized controlled trial.

Dexamethasone vs. placebo modulation of the perioperative blood immune proteome in patients undergoing total knee arthroplasty

BACKGROUND

Pre- and post-operative immune status has gained interest in recent years, as it has been shown to be related to postoperative complications and recovery. The change in immune status has also been known to constitute a large part of the surgical stress response, and it has been speculated that immunomodulatory treatment by glucocorticoids may impact it. Profiling of the impact of specific surgeries and medications on immune status are therefore needed.

METHODS

We characterized the postoperative blood immune proteome in 83 patients receiving either placebo (n = 20) or IV 24 mg dexamethasone (n = 60) preoperative before total knee arthroplasty (TKA). The primary outcome was the effect of dexamethasone on total knee arthroplasty surgical stress by comparing postoperative immune proteome in the dexamethasone group and the placebo group. Secondary outcomes were the surgical stress by total knee arthroplasty by comparing pre- to postoperative immune proteome in the placebo group, and the combined effect of surgical stress and dexamethasone by comparing pre- to postoperative immune proteome in the dexamethasone group. Characterization was performed with the Olink Explorer Inflammation panel on blood samples from the biobank for future research collected during the randomized, clinical DEX-2-TKA Trial. Protein change was reported as log2-fold-change and p-values were corrected a.m. Benjamini-Hochberg.

RESULTS

The surgical stress (placebo) was characterized by a 4.7 log2-fold-change of IL6 (adjusted p-value < 0.01) and up-regulation of central immune signaling pathways and bone marrow mobilization. The combined effect of surgery and dexamethasone showed a less pro-inflammatory profile: IL6 2.5 log2-fold-change (adjusted p-value < 0.01), with decreased signaling for osteoclast activity and innate, immune cell reaction. The effect of dexamethasone showed upregulation of CSF3 (1.55 log2-fold-change, adjusted p-value < 0.01) and an inhibitory effect on both innate and adaptive immune response, immune cell reactivity and formation of extracellular matrix.

CONCLUSIONS

Preoperative dexamethasone indicated anti-inflammatory properties on both innate and adaptive immune response, while surgery was pro-inflammatory. the combination of total knee arthroplasty and dexamethasone inhibited pathways for osteoclast-activity, indicating possible implications on aseptic prosthesis loosening. Dexamethasone showed strong modulation of the surgical stress response following total knee arthroplasty and future studies must explore the clinical associations of these findings.

TRIAL REGISTRATION

NCT03506789.

Comparison of Dexamethasone at Three Doses Administered Postoperatively for Improving Pain Control and Sleep Quality in Patients Who Underwent Total Knee Arthroplasty: A Triple Blind Randomized Controlled Trial

BACKGROUND

Dexamethasone has been shown to alleviate pain, yet the optimal dosing and safety profiles remain unclear. This study aimed to evaluate the analgesic efficacy and impact on sleep quality of three different doses of intravenous dexamethasone in patients undergoing total knee arthroplasty (TKA).

METHODS

In this randomized, triple-blind, clinical trial, we assessed the analgesic effects of three doses of intravenous dexamethasone (four, eight, and 16 mg) in adult patients who underwent TKA. Pain was measured using the visual analog scale at one, 12, 24, and 48 hours postoperatively, and sleep quality was assessed two weeks postsurgery.

RESULTS

A total of 90 participants were enrolled in the study, with 30 participants in each dosing group. The mean visual analog scale scores at 12, 24, and 48 hours postoperatively showed significant improvement from baseline in all groups. Notably, the 16 mg and eight mg dexamethasone groups demonstrated significantly greater pain reduction compared to the four mg group (P < 0.05). Additionally, sleep quality significantly improved in the 16 mg and eight mg groups (P < 0.05).

CONCLUSIONS

Dexamethasone at doses of four, eight, and 16 mg effectively reduces pain and enhances sleep quality in patients undergoing TKA, with the 16 mg dose showing the most pronounced effects at 12, 24, and 48 hours postoperatively.

Effect of perioperative methylprednisolone administration on postoperative pleural effusion in older patients with non-small cell lung cancer

BACKGROUND

It remains uncertain whether the utilization of methylprednisolone during surgery effectively mitigates the occurrence of adverse outcomes. To examine the association between perioperative methylprednisolone administration and postoperative pleural effusion and pneumonia in older patients with non-small cell lung cancer.

METHODS

A retrospective cohort study included non-small cell lung cancer patients aged 65 years or older undergoing thoracic surgery between January 2012 and December 2019 in China. Primary outcome was pleural effusion. Secondary outcome was postoperative pneumonia. Multivariate logistic regression models assessed the independent effects of various factors on pleural effusion and pneumonia. Propensity score matching (PSM) method reduced selection bias enhancing causal inference validity. Subgroup analyses identified potential effect heterogeneity in specific sub-populations.

RESULTS

A total of 1951 older patients with non-small cell lung cancer were included. The incidence of postoperative pleural effusion in the methylprednisolone group before and after PSM matching was significantly lower than that in the control group (before PSM: 9.4% vs. 19.2, P < 0.001; after PSM: 9.8% vs. 18.2%, P < 0.001). There was no statistically significant difference in the incidence of postoperative pneumonia between the two groups before and after matching. After adjusting all the variables and PSM, we found that intraoperative methylprednisolone was associated with a reduction in postoperative pleural effusion in older patients with non-small cell lung cancer [odds ratio (OR) = 0.48, P < 0.001; OR = 0.47, P < 0.001]. Perioperative methylprednisolone showed consistent protective effects in all sub-populations of gender, age, surgery duration, and smoking (P all < 0.05). Logistic regression models and PSM found that methylprednisolone was not associated with postoperative pneumonia and long-term survival in older patients with non-small cell lung cancer.

CONCLUSION

Perioperative methylprednisolone was associated with reducing the occurrence of postoperative pleural effusions in older patients with non-small volume lung cancer, but it was not associated with pneumonia or long-term survival outcomes.

Perioperative intravenous dexamethasone did not reduce the severity of persistent postsurgical pain after total knee arthroplasty: a prospective, randomized, double-blind, placebo-controlled trial

BACKGROUND

Even with the great advancements in recent years in total knee arthroplasty (TKA), some patients continue to have persistent postsurgical pain (PPSP). The advantages of systemic corticosteroids in the perioperative context have been further supported by previously published trials. However, the impact of dexamethasone on the intensity of post-TKA PPSP is still unclear. We aimed to investigate its effect on the degree of PPSP and compare that with a placebo.

METHODS

In this randomized, double-blind, placebo-controlled study, 48 patients undergoing unilateral TKA were given intravenous dexamethasone 10 mg or saline just before spinal anesthesia was induced, and they also received two additional doses of dexamethasone 10 mg or saline 24 and 48 h after surgery. A standardized, multimodal analgesic regimen was administered to each patient. The modified WOMAC pain scores at 12 weeks postoperative were the main outcome. The secondary outcomes included pain during a walk of five meters, pain during active knee flexion at 45 degrees, maximum pain at rest during the previous 24 h, nausea visual analogue scale values, and use of rescue opioid and antiemetic medications.

RESULTS

There was no difference in modified WOMAC pain scores 12 weeks after surgery between patients who received and did not receive perioperative dexamethasone. At 24, 30, 48, 54, and 72 h following surgery, the dexamethasone group experienced considerably less pain during a five-meter walk and during 45 degrees active knee flexion (p < 0.01). At postoperative 0-24, 24-48, and 48-72 h, the dexamethasone group experienced less maximal pain at rest (p < 0.01). The dexamethasone group also had less visual analogue scale scores for nausea at 6, 24, 30, 48, and 54 h after surgery (p < 0.02). During the first 0-24 and 24-48 h, the dexamethasone group consumed fewer opioids and antiemetic medications (p < 0.01). All patients showed no signs of wound complications.

CONCLUSIONS

When compared to a placebo at 12 weeks after TKA, intravenous dexamethasone did not reduce PPSP. Nevertheless, early postoperative pain was relieved by perioperative intravenous dexamethasone, which also decreased the need for opioid and antiemetic medications and decreased postoperative nausea and vomiting.

TRIAL REGISTRATION

NCT02760459.

A Single Preoperative Low Dose of Dexamethasone Is Efficacious in Improving Early Postoperative Pain, Function, Nausea, and Vomiting After Primary Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

The primary objective was to evaluate a single preoperative low-dose (8 mg) dexamethasone (DXM) efficacy in relieving postoperative pain in patients undergoing total knee arthroplasty (TKA). The secondary objectives were to assess its effect on postoperative nausea and vomiting (PONV), C-reactive protein (CRP) levels, and early wound complications incidence.

METHODS

This was a single-center, double-blind, randomized controlled trial. We included 86 unilateral primary TKA divided equally into two groups (placebo [Group A] and DXM [Group B], as a single intravenous dose given after anesthesia). Postoperative pain was assessed as the primary outcome at rest and while walking using a visual analog scale (VAS). Secondary outcomes included PONV evaluated using VAS for postoperative nausea. The following variables were evaluated: the Time Up and Go test, serum CRP, quadriceps muscle power, and wound complications. All outcomes were reported in the first three days and at 14 days follow-up visit.

RESULTS

Both groups' baseline data were comparable. Group B reported significantly less pain at rest and walking throughout all time points (P < 0.001). Group B had fewer vomiting episodes on postoperative days one and two (P = 0.195 and 0.747, respectively) and no difference in PONV VAS score. Group B had significantly lower Time Up and Go test scores for postoperative days one and two (P = 0.029 and 0.016, respectively) and significantly better quadriceps muscle power on postoperative days two and three (P = 0.042 and 0.019, respectively). The Serum CRP levels were significantly less in Group B throughout all follow-up time points (P < 0.001) except on day three (P = 0.302). No wound complications were reported in any patient.

CONCLUSIONS

Preoperative single low dose (eight mg) DXM intravenous in patients undergoing unilateral TKA is safe (early postoperatively) and effective for reducing postoperative pain scores, improving early mobility, and reducing inflammatory markers. However, the effect on PONV was less evident.

Effects of Postoperative Oral Corticosteroids on Infection Rates in Upper Extremity Surgery

BACKGROUND

The recent trend in administering postoperative oral corticosteroids has proven effective in alleviating pain and improving surgical outcomes for hand and upper extremity procedures. However, concerns persist regarding potential infection risks despite a lack of supporting evidence in the current literature. We propose that a 6-day regimen of low-dose postoperative oral corticosteroids is safe and does not increase the likelihood of surgical site infections (SSIs) in adult upper extremity surgeries.

METHODS

A retrospective study of all adult patients who underwent clean, upper extremity surgery, including both soft tissue and hardware implantation cases, between November 2021 and November 2023, performed at a single institution were included in the study. Primary outcome measures were diagnosis of SSI by 14 days and 30 days. Categorical variables were compared using χ2 tests, and continuous variables were compared using Wilcoxon rank-sum tests. A P value less than .05 was considered statistically significant.

RESULTS

A total of 813 cases were included for analysis-196 received a 6-day course of postoperative oral steroids (methylprednisolone) and 617 did not. Both groups had similar SSI rates of 4.1% and 3.1%, respectively, with no statistical differences between the groups at any postoperative time. Subgroup analysis of patients diagnosed with an SSI identified no statistically different demographic factors or medical comorbidities when comparing patients who received postoperative oral corticosteroids versus those who did not.

CONCLUSIONS

Low-dose, postoperative oral steroid use following adult upper extremity surgery is safe and does not increase the risk of SSI. Further investigations with prospective studies on postoperative oral corticosteroids would prove advantageous.

Determining factors on length of stay in primary total knee arthroplasty patients using enhanced recovery protocol after surgery (ERAS) pathway

INTRODUCTION

There is an increase in degenerative arthropathies because of the increase in the longevity of world's population, making primary knee arthroplasties a procedure to recover quality of life without pain. There are factors associated with the length of hospital stay after this procedure.

OBJECTIVE

To determine the risk factors influencing the hospital stay during the postoperative period of patients undergoing primary total knee arthroplasty with an enhanced recovery after surgery protocol (ERAS).

METHODS

A retrospective study is carried out on patients undergoing primary total knee arthroplasty at an University Hospital in the period 2017-2020 using the ERAS protocol, during which 957 surgeries were performed.

RESULTS

Average age of 71.7±8.2years, 62.4% were women and the 77.3% were classified as ASAII. The significantly associated factors to an increased length of stay are: age (P=.001), ASA scale (P=.04), day of surgery (P<.001), blood transfusion (P<.001), postoperative hemoglobin level at 48-72h (P<.001), the time of first postoperative mobilization to ambulate and climb stairs (P<.001), the need for analgesic rescues (P=.003), and the presence of postoperative nausea and vomiting (P=.008).

CONCLUSIONS

There are statistically significant and clinically relevant factors associated with hospital stay. Determining these factors constitutes an advantage in hospital management, in the development of strategies to improve and optimize the quality of care and available health resources.

Adjuvant Analgesics in Acute Pain - Evaluation of Efficacy

PURPOSE OF THE REVIEW

Acute postoperative pain impacts a significant number of patients and is associated with various complications, such as a higher occurrence of chronic postsurgical pain as well as increased morbidity and mortality.

RECENT FINDINGS

Opioids are often used to manage severe pain, but they come with serious adverse effects, such as sedation, respiratory depression, postoperative nausea and vomiting, and impaired bowel function. Therefore, most enhanced recovery after surgery protocols promote multimodal analgesia, which includes adjuvant analgesics, to provide optimal pain control. In this article, we aim to offer a comprehensive review of the contemporary literature on adjuvant analgesics in the management of acute pain, especially in the perioperative setting. Adjuvant analgesics have proven efficacy in treating postoperative pain and reducing need for opioids. While ketamine is an established option for opioid-dependent patients, magnesium and α2-agonists have, in addition to their analgetic effect, the potential to attenuate hemodynamic responses, which make them especially useful in painful laparoscopic procedures. Furthermore, α2-agonists and dexamethasone can extend the analgesic effect of regional anesthesia techniques. However, findings for lidocaine remain inconclusive.

[Translated article] Determining factors on length of stay in primary total knee arthroplasty patients using enhanced recovery protocol after surgery (ERAS) pathway

INTRODUCTION

There is an increase in degenerative arthropathies because of the increase in the longevity of world's population, making primary knee arthroplasties a procedure to recover quality of life without pain. There are factors associated with the length of hospital stay after this procedure.

OBJECTIVE

To determine the risk factors influencing the hospital stay during the postoperative period of patients undergoing primary total knee arthroplasty with an enhanced recovery after surgery protocol (ERAS).

METHODS

A retrospective study is carried out on patients undergoing primary total knee arthroplasty at an University Hospital in the period 2017-2020 using the ERAS protocol, during which 957 surgeries were performed.

RESULTS

Average age of 71.7±8.2years, 62.4% were women and the 77.3% were classified as ASA II. The significantly associated factors to an increased length of stay are: age (p=.001), ASA scale (p=.04), day of surgery (p<.001), blood transfusion (p<.001), postoperative haemoglobin level at 48-72h (p<.001), the time of first postoperative mobilisation to ambulate and climb stairs (p<.001), the need for analgesic rescues (p=.003), and the presence of postoperative nausea and vomiting (p=.008).

CONCLUSIONS

There are statistically significant and clinically relevant factors associated with hospital stay. Determining these factors constitutes an advantage in hospital management, in the development of strategies to improve and optimise the quality of care and available health resources.

Perioperative systemic corticosteroids in primary unilateral total knee arthroplasty: a systematic review

Main reasons for prolonged hospital stay after total knee arthroplasty (TKA) are postoperative nausea and vomiting (PONV) and pain. Having a positive effect on both PONV and pain, perioperative administration of corticosteroids might improve rehabilitation and reduce length of hospital stay (LOS) after TKA. Aim of this review is to determine the effect of different corticosteroid dosages on PONV, pain, and LOS in TKA. A systematic search for articles comparing dosage effects of corticosteroids regarding PONV, pain, and LOS after primary unilateral TKA was conducted using EMBASE, PubMed publisher, MEDLINE, Cochrane, Google scholar, and Web-of-Science for articles published from inception to March 17, 2022. 16 studies were included involving 2352 TKA procedures. Most studies showed reduced pain scores in corticosteroid groups and some described better pain reduction in high-dose groups. All studies showed reduced PONV in the corticosteroid groups. LOS was similar in most studies comparing placebo and perioperative corticosteroids. Only one study reported increased infection rates and intramuscular venous thrombosis in the corticosteroid group. Concluding, current literature on corticosteroids use in TKA is highly variable in type, dosage, and timing of administering medication. Overall, corticosteroids mostly reduce pain and PONV with limited effects on LOS after TKA. Only minimal statistically significant and clinically relevant benefits were found in perioperative high-dose corticosteroids compared to low-dose. Given the short follow-up in most studies, it is not possible to evaluate safety of high-dose corticosteroids.

Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner

BACKGROUND

Perioperative corticosteroids have shown potential as nonopioid analgesic adjuncts for various orthopedic pathologies, but there is a lack of research on their use in the postoperative setting after total shoulder arthroplasty (TSA). The purpose of this study was to assess the effect of a methylprednisolone taper on a multimodal pain regimen after TSA.

METHODS

This study was a randomized controlled trial (clinicaltrials.gov NCT03661645) of opioid-naive patients undergoing TSA. Patients were randomly assigned to receive intraoperative dexamethasone only (control group) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group). All patients received the same standardized perioperative pain management protocol. Standardized pain journal entries were used to record visual analog pain scores (VAS-pain), VAS-nausea scores, and quantity of opioid tablet consumption during the first 7 postoperative days (POD). Patients were followed for at least one year postoperatively for clinical evaluation, collection of patient-reported outcomes, and observation of complications.

RESULTS

A total of 67 patients were enrolled in the study; 32 in the control group and 35 in the treatment group. The groups had similar demographics and comorbidities. The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 POD. Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively. There were no differences in Europe Quality of Life, shoulder subjective value (SSV), at any time point between groups, although American Shoulder and Elbow Surgeons questionnaire scores showed a slight improvement at 6-weeks in the treatment group. At mean follow-up, (control group: 23.4 months; treatment group:19.4 months), there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. No other complications were reported.

CONCLUSIONS

A methylprednisolone taper course shows promise in reducing acute pain and opioid consumption as part of a multimodal regimen following TSA. As a result of this study, we have included this 6-day methylprednisolone taper course in our multimodal regimen for all primary shoulder arthroplasties. We hope this trial serves as a foundation for future studies on the use of low-dose oral corticosteroids and other nonnarcotic modalities to control pain after shoulder surgeries.

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

STUDY OBJECTIVE

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

DESIGN

Systematic review of RCTs with meta-analysis.

SETTING

Acute postoperative pain treatment in non-obese adult population.

INTERVENTIONS

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

MEASUREMENTS

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

MAIN RESULTS

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

CONCLUSION

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

PROTOCOL REGISTRATION

CRD42020137119.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Does spinal anesthesia for total hip or knee arthroplasty entail longer operating room occupancy compared to general anesthesia? Case-control study of 337 spinal versus 243 general anesthesias

BACKGROUND

Treatment protocols, including anesthesia, are constantly progressing to improve rapid early postoperative recovery in lower-limb arthroplasty. To the best of our knowledge, however, no studies compared general versus spinal anesthesia (GA vs. SA) in the surgical pathway of patients undergoing total knee or hip arthroplasty (TKA, THA). Better knowledge of the processes should improve efficacy in theater and optimize surgical planning. The present study comparing GA and SA in the operating room aimed to assess (1) theater occupancy times, and (2) times for each step in a surgery day according to type of anesthesia.

HYPOTHESIS

SA leads to longer theater occupancy than GA in TKA and THA.

METHODS

A single-center retrospective case-control study analyzed data for the period January 2019 to December 2020 in 303 TKAs (100 GA, 203 SA) and 277 THAs (143 GA, 134 SA), comparing times for all perioperative steps and particularly theater occupancy.

RESULTS

In TKA, occupancy did not differ between GA and SA: 98±16min versus 98±14min respectively; Δ=0min (p=0.78). In THA, occupancy was shorter with SA than GA: 117±23min versus 123±26min respectively; Δ=-6min (p=0.02). In THA, time to perform SA was longer than induction of GA: 28±13min versus 23±12min respectively; Δ=+5min (p<0.001). In TKA, time to leaving the operating room was shorter with SA than GA: 8±5min versus 14±7min respectively; Δ=-6min (p<0.001).

DISCUSSION/CONCLUSION

SA did not involve longer mean theater occupancy than GA for TKA, and reduced it by 6minutes for THA.

LEVEL OF EVIDENCE

III; case-control study.

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.

Prolonged effects of dexamethasone following total knee arthroplasty: A pre-planned sub-study of the DEX-2-TKA trial

OBJECTIVES

The DEX-2-TKA trial demonstrated that one and two doses of 24 mg intravenous dexamethasone reduced opioid consumption and pain after total knee arthroplasty (TKA). We aimed to investigate the prolonged effects of dexamethasone after the 48-h intervention period.

DESIGN

This was a prospective, pre-planned questionnaire follow-up on postoperative days 3-7 of patients in the DEX-2-TKA trial that randomly received: DX1 (dexamethasone 24 mg + placebo), DX2 (dexamethasone 24 mg + dexamethasone 24 mg), and placebo (placebo + placebo) perioperatively and 24 h later.

SETTING

A multicenter trial performed at five Danish hospitals.

PARTICIPANTS

We analyzed 434 of 485 adult participants enrolled in the DEX-2-TKA trial.

OUTCOME MEASURES

Primary outcome was difference between groups in average of all numerical rating scale (NRS) pain scores reported in the morning, at bedtime, and the daily average pain on postoperative days 3-7. Secondary outcomes were sleep quality and patient satisfaction.

RESULTS

The median (interquartile range) pain intensity levels for postoperative days 3-7 were: DX2 3.2 (2.1-4.3); DX1 3.3 (2.3-4.1); and placebo 3.3 (2.5-4.7). Hodges-Lehmann median differences between groups were: 0 (95% confidence interval - 0.54 to 0.2), P = 0.38 between DX1 and placebo; 0.1 (-0.47 to 0.33), p = .87 between DX1 and DX2; and 0.1 (-0.6 to 0.13), p = .20 between DX2 and placebo. We found no relevant differences between groups on sleep quality on postoperative days 3-7 nor for patient satisfaction with the analgesic treatment.

CONCLUSIONS

We found that neither one nor two doses of 24 mg intravenous dexamethasone demonstrated prolonged effects on overall pain or sleep quality on postoperative days 3-7 after total knee arthroplasty. We also found that dexamethasone had no effect on patient satisfaction.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT03506789 (main result trial).

Effects of combined dexamethasone and tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomized clinical trials

PURPOSE

To evaluate the effectiveness of combined Tranexamic acid (TXA) and dexamethasone (DEX) in total hip and knee arthroplasty.

METHODS

PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched for randomized studies that utilized TXA and DEX administration of TXA in THA or TKA.

RESULTS

A total of three randomized studies enrolling 288 patients were eligible for qualitative and quantitative analysis. DEX + TXA group demonstrated statistical significantly lesser usage of oxycodone (OR: 0.34, p < 0.0001), metoclopramide (OR: 0.21, p < 0.00001), lesser incidence of postoperative nausea and vomiting (OR: 0.27, p < 0.0001), better postoperative range of motion (MD: 2.30, p < 0.00001) and shorter length of hospital stay (MD: 0.31, p = 0.03). Comparable results were seen in total blood loss, transfusion rate and postoperative complications.

CONCLUSION

In this meta-analysis, the combination of TXA and DEX has positive impacts on the usage of oxycodone and metoclopramide, postoperative range of motion, postoperative nausea and vomiting and reduces the length of hospital stay.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Adjuvants for balanced anesthesia in ambulatory surgery

Balanced anesthesia relies on the simultaneous administration of different drugs to attain an anesthetic state. The classic triad of anesthesia is a combination of a hypnotic, an analgesic, and a neuromuscular blocker. It is predominantly the analgesic pillar of this triad that became more and more supported by adjuvant therapy. The aim of this approach is to evolve into an opioid-sparing technique to cope with undesirable side effects of the opioids and is fueled by the opioid epidemic. The optimal strategy for balanced general anesthesia in ambulatory surgery must aim for a transition to a multimodal analgesic regimen dealing with acute postoperative pain and ideally reduce the most common adverse effects patients are faced with at home; sore throat, delayed awakening, memory disturbances, headache, nausea and vomiting, and negative behavioral changes. Over the years, this continuum of "multimodal general anesthesia" adopted many drugs with different modes of action. This review focuses on the most recent evidence on the different adjuvants that entered clinical practice and gives an overview of the different mechanisms of action, the potential as opioid-sparing or hypnotic-sparing drugs, and the applicability specifically in ambulatory surgery.

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.

Effect of Adding Perineural Methylprednisolone to Peripheral Nerve Blocks Combined With Intravenous Dexamethasone for Prolonged Postdischarge Analgesia After Fast-track Total Knee Arthroplasty: A Randomized Controlled Trial

OBJECTIVES

Patients undergoing total knee arthroplasty (TKA) may experience moderate-to-severe subacute pain after hospital discharge that may be undermanaged. We aimed to evaluate the effect of methylprednisolone added to ultrasound-guided peripheral nerve blocks (PNBs) combined with multimodal analgesia including intravenous dexamethasone for prolonged analgesia after early discharge.

MATERIALS AND METHODS

We randomized 80 patients who underwent fast-track TKA into 2 groups. All patients received a periarticular injection, PNBs, and multiple doses of intravenous dexamethasone. The methylprednisolone group received 140 mg methylprednisolone in PNBs, while the nonmethylprednisolone group did not. The primary outcome was the incidence of moderate-to-severe pain (Numerical Rating Scale ≥4) during the first 12 postdischarge days. The secondary outcomes included pain scores until 3 postoperative months, incidence of rebound pain, functional performances, patient satisfaction, and adverse events.

RESULTS

No significant between-group differences were noted in the incidence of moderate-to-severe pain during the first 12 postdischarge days (nonmethylprednisolone vs. methylprednisolone groups: 70% vs. 69.2%, P=0.941). However, this incidence was significantly higher in the methylprednisolone group between 2 weeks and 1 month (P=0.015) and between 1 and 3 months (P=0.004) postoperatively. No between-group differences in the Numerical Rating Scale scores at the postdischarge time points, incidence of rebound pain, and functional performance results were noted.

DISCUSSION

Adding perineural methylprednisolone to ultrasound-guided PNBs for multimodal analgesia with intravenous dexamethasone did not prolong analgesia and improved the functional ability after fast-track TKA within 12 postdischarge days. However, the incidence moderate-to-severe pain may increase between the 2-week and 3-month follow-up.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

RESULTS

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

CONCLUSION

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

REGISTRATION

PROSPERO ID: CRD42019135034.

Pain treatment after total hip arthroplasty: Detailed statistical analysis plan for the RECIPE randomised clinical trial

BACKGROUND

The RECIPE trial systematically investigates the effects of different combinations of paracetamol, ibuprofen and dexamethasone for pain treatment after total hip arthroplasty. To preserve transparency, minimise risk of bias and to prevent data-driven analysis, we present this detailed statistical analysis plan.

METHODS

The RECIPE trial is a randomised, blinded, parallel four-group multicenter clinical trial for patients undergoing planned primary total hip arthroplasty. Interventions are initiated preoperatively and continued for 24 h postoperatively. Primary outcome is total opioid consumption 0-24 h after end of surgery. Primary analysis will be performed in the modified intention to treat population of all patients undergoing total hip arthroplasty, and all analyses will be stratified for site. We will perform pairwise comparisons between each of the four groups. The primary outcome will be analysed using the van Elteren test and we will present Hodges-Lehmann median differences and confidence intervals. Binary outcomes will be analysed using logistic regression. To preserve a family-wise error rate of <0.05, we will use a Bonferroni-adjusted alfa of 0.05/6 = 0.0083 for all six pairwise comparisons between groups when analysing the primary outcome. We will systematically assess the underlying statistical assumptions for each analysis. Data will be analysed by two blinded independent statisticians, and we will write abstracts covering all possible combinations of conclusions, before breaking the blind.

DISCUSSION

The RECIPE trial will provide important information on benefit and harm of combinations of the most frequently used non-opioid analgesics for pain after primary hip arthroplasty.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL TRIAL REGISTRATION

NCT03758170 (first registration 29-11-2018).

Postoperative systemic inflammatory dysregulation and corticosteroids: a narrative review

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

Effect of 24 mg dexamethasone preoperatively on surgical stress, pain and recovery in robotic-assisted laparoscopic hysterectomy

Background

Robotic-assisted hysterectomy is an alternative to laparoscopic surgery as part of a minimal invasive regimen. Several treatment strategies are followed to improve the overall outcome and minimize surgical stress. Glucocorticoids provide significant analgesic and antiemetic effects but their role in reducing inflammatory stress in a fast-track, multi-modal setting in patients undergoing minimally invasive surgery remains to be investigated in details.

Methods

This study will evaluate in a randomized trial the effect of a single dose of 24 mg dexamethasone on 100 women undergoing robotic-assisted hysterectomy with regard to surgical stress, measured by c-reactive protein as primary outcome and, further, other stress markers like white blood cell subtypes. The postoperative recovery will be registered in validated charts and questionnaires for pain and analgesic use, quality of recovery, incontinence, sexual and work life. Furthermore, in a sub-analysis, transcriptional profiling will be performed to explore the mechanism of systemic innate and adaptive immune system perturbation induced by surgical stress.

Conclusion

The study will provide solid evidence on markers of immunomodulation biomarkers and in addition the subjective effects and underlying mechanisms of perioperative glucocorticoid in women undergoing robotic hysterectomy. These include important aspects of life quality like pain, fatigue, freedom of medications, resuming work and sexual activities.

Opioid consumption and non-opioid multimodal analgesic treatment in pain management trials after hip and knee arthroplasties: A meta-epidemiological study

BACKGROUND

The leading principle in peri-operative pain management is multimodal analgesia, which reduces opioid requirements and associated adverse effects. Pragmatic pain trials should optimally test interventions in addition to multimodal non-opioid analgesics and interventions to ensure clinical relevance and baseline levels of opioid consumption that reflect clinical settings. We aimed to investigate opioid consumption and use of non-opioid analgesics administered adjunct to interventions in post-operative pain trials after total hip and knee arthroplasty.

METHODS

A systematic literature search was conducted 7 January 2020 in The Cochrane Library's CENTRAL, PubMed, and EMBASE. Trials investigating analgesic interventions for post-operative pain in adults undergoing total hip or knee arthroplasty were included. The primary outcome was the aggregated median 0-24 h post-operative opioid consumption. Further, we assessed the use of paracetamol, non-steroidal anti-inflammatory drugs, gabapentinoids, high-dose glucocorticoids, local infiltration analgesia and nerve blocks administered as co-interventions equally to all participants. We assessed trends over time for all outcomes.

RESULTS

Of 14,200 records, 570 trials were included. Median 0-24 h opioid consumption was 21 and 22 mg iv morphine equivalents in hip and knee arthroplasty trials, respectively. Meta-regression showed no overall linear correlation between opioid consumption and publication year. The use of multimodal non-opioid analgesia increased over time, though only 48% of trials published from 2010 to 2020 administered two or more non-opioid analgesics. Applying more non-opioid analgesics was associated with lower opioid consumption in intervention groups.

CONCLUSION

Post-operative 0-24 h morphine consumption was median 21-22 mg. The demonstrated differences in non-opioid multimodal analgesic regimens between research and clinical settings, can potentially diminish the demonstrated opioid-sparing effects of trial interventions when such are implemented in a clinical context.

Effect of Dexamethasone on Myocardial Injury After Total Knee Arthroplasty: A Substudy of the Randomized Clinical DEX-2-TKA Trial

BACKGROUND

Myocardial injury after noncardiac surgery (MINS) carries a high postoperative mortality. In this preplanned, subgroup analysis of the randomized DEX-2-TKA Trial, we investigated the effect of dexamethasone versus placebo on the concentration of cardiac troponin I and T (TnI and TnT) on the first postoperative morning after total knee arthroplasty. In addition, frequency of MINS, myocardial infarction, and major adverse cardiovascular events where evaluated.

METHODS

We included 290 patients who received either 24 mg of dexamethasone intravenously (given perioperatively) or placebo. Blood samples were analyzed as either TnI or T depending on trial site.

RESULTS

A total of 236 samples were eligible for analysis of TnI and 38 samples for TnT on the first postoperative morning. The median (IQR) TnI concentration was 4.6 ng/L (0-7.2 ng/L) in the dexamethasone group and 4.5ng/l (0-7.0 ng/L) in the placebo group (P = .96) on the first postoperative morning. The median TnT was 9 ng/L (6-11 ng/L) in the dexamethasone group and 8 ng/L (5-10 ng/L) in the placebo group (P = .68). The frequencies of MINS, myocardial infarction, and major adverse cardiovascular events were similar in the compared groups, but these analyses were underpowered.

CONCLUSION

We found no effect of dexamethasone on postoperative concentration of troponin I or T on the first postoperative morning after total knee arthroplasty.

Management of perioperative pain after TKA

Postoperative pain is the prime obstacle to recovery of motion and return to activity after total knee arthroplasty (TKA). Combating pain is a key point in enhanced recovery after surgery (ERAS) protocols. Outcome depends on the efficacy of pain relief, making it a major issue. The pain originates locally in the knee and also remotely via neural pathways. Regression can be slow, over several months. Pain may sometimes be definitive, to a varying degree. Pain should be managed at each step of ERAS, from the preoperative period to the last follow-up consultation, and most especially during the perioperative phase. Pain needs to be anticipated and limited for as long as necessary. The impact of analgesics should be enhanced by means of potentiators. Some are administered by general route, sometimes preoperatively; others are applied locally, directly in the surgical site by local injection, or close to the nerves, to reduce painful stimuli. The two main principles of pain management are preventive analgesia and multimodal analgesia associating various molecules and routes.

The application of low-dose dexamethasone in total knee arthroplasty: finding out the best route and dosage schedule

BACKGROUND

The use of dexamethasone as additive to multimodal analgesic regimen in total knee arthroplasty has been well established, but the most suitable route, effectiveness, safety and dose schedule of low-dose dexamethasone is not known.

METHODS

We conducted a prospective, randomized, double-blinded trial to investigate and compare the analgesic and antiemetic effects and safety of low-dose (8 mg) dexamethasone introduced as periarticular injection or intravenous (as a single dose or in two divided doses of 4 mg separated by 24 h) in unilateral total knee arthroplasty patients.

RESULTS

The single dose intravenous administration as well as the periarticular administration of dexamethasone had similar mean visual analogue scores which were significantly lower than divided dose group at 24 and 48 h postoperatively. The rate of postoperative nausea and vomiting was lowest among single intravenous dose group and highest among interval dose group at 24 h, while no difference was noted at 48 h. No significant differences were noted in terms of knee flexion angle at 48 h and modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 6 weeks.

CONCLUSION

Single low-dose intravenous dexamethasone is the most appropriate dose which can safely be given to TKA patients and is only moderately associated with rise in blood sugar not causing any significant complication. Alternatively, periarticular infiltration of low-dose dexamethasone can produce equivalent analgesic effect as SDIV in first 24 h without causing significant blood sugar rise and wound complications, but its antiemetic effect remains subtle. Therefore, it is recommended to further study the combination of intraoperative periarticular and postoperative intravenous dexamethasone for their possible additive effect.

Perioperative Intravenous Glucocorticoids in Total Joint Arthroplasty: A Systematic Review

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Systemic Effects of Perineural Glucocorticoids on Fasting Serum Glucose, Potassium, and White Blood Cell Count in Total Hip Arthroplasty

Purpose

Glucocorticoids are commonly used as regional anesthesia adjuvants to improve blockade quality and duration. There are limited data in the literature regarding the potential systemic effects and safety of perineural glucocorticoids. This study examines the effects of perineural glucocorticoids on serum glucose, potassium, and white blood cell count (WBC) in the immediate postoperative period after primary total hip arthroplasty (THA).

Patients and Methods

A retrospective cohort study was carried out at a tertiary academic medical center utilizing electronic health records of 210 patients who underwent THA, for which patients received either a periarticular local anesthetic injection alone (PAI, N=132) or additional peripheral nerve blocks (PNB, N=78) containing 10 mg dexamethasone and 80 mg methylprednisolone acetate (PAI+PNB). The primary outcome was change in serum glucose from a preoperative baseline on postoperative days (POD) 1, 2, and 3. Secondary outcomes included changes in WBC and serum potassium.

Results

The change in serum glucose from baseline was found to be significantly higher in the PAI+PNB group compared to the PAI group on POD 1 (mean difference 19.87 mg/dL, 95% CI [12.42, 27.32]; P<0.001) and POD 2 (mean difference 17.5 mg/dL, 95% CI [9.66, 25.44], P<0.001). No significant difference was found on POD 3 (mean difference -8.18 mg/dL, 95% CI [-19.07, 2.70], P=0.14). Statistically significant but clinically insignificant differences were detected in serum potassium in the PAI+PNB group compared to the PAI group on POD1 (mean difference 0.16 mEq/L, 95% CI [0.02, 0.30], P=0.03) and WBC on POD 2 (mean difference 3.18 × 1000/mm³, 95% CI [2.14, 4.22], P<0.001).

Conclusion

Patients who underwent THA and received PAI+PNB with glucocorticoid adjuvants demonstrated higher elevations in serum glucose for the first two PODs compared to patients who received PAI alone. These differences resolved by a third POD and are likely to be of no clinical significance.

Steroids Significantly Decrease Postoperative Postural Hypotension in Total Knee Replacement

Total knee replacement (TKR) is one of the most common orthopaedic procedures performed, and enhanced recovery after surgery (ERAS) has been developed and incorporated into inpatient surgical pathways to improve patient outcomes. Under ERAS recommendations, multimodal prophylaxis has been used to help manage postoperative nausea and vomiting (PONV) following TKR. Dexamethasone is one of the commonly used for this and the anti-inflammatory properties could depress vagal activity, reducing postural hypotension (PH). The hypothesis of this study is that postoperative dexamethasone use is associated with lower rates of early postoperative PH following TKR surgery. In our institution, patients who undergo elective primary TKR are admitted on the day of surgery and follow a standardized ERAS protocol. Data on patients who underwent elective primary TKR under a single adult reconstruction team from September 2017 to March 2020 were reviewed and analyzed. A review of demographic characteristics, surgical data, postoperative medications, and postoperative notes was performed. Binary logistic regression was used to assess the effect of the use of dexamethasone on PH, with an adjusted odds ratio (OR) calculated after accounting for potential confounders. Of the 149 patients were included in the study, 78 had dexamethasone postoperatively, and 71 did not. Patients who had received dexamethasone were statistically less likely to suffer from PH (OR = 0.31, p = 0.03) and less likely to develop PONV (OR = 0.21, p = 0.006). Patients who had received dexamethasone were more likely able to participate in early physiotherapy (OR = 2.42, p = 0.14), and this result was statistically insignificant. The use of postoperative intravenous dexamethasone is significantly associated with lower rates of postoperative PH after TKR. However, more studies are required to assess the optimal dosing amount and frequency, as well as to assess other factors which can enhance early postoperative patient mobilization as part of our goals for ERAS. This therapeutic study reflects level of evidence III.

Can intra-operative methylprednisolone application be effective for post-operative pain, nausea and vomiting in laparoscopic cholecystectomy operations?

Background/Aim: Post-operative nausea, vomiting (PONV), and pain are common symptoms after laparoscopic cholecystectomy (LC) that is performed under general anesthesia. These symptoms lead to prolongation of post-operative recovery and hospital stay. In this study, the efficacy of intra-operative methylprednisolone (MP) administration on post-operative pain and PONV was investigated in patients undergoing LC under general anesthesia. Methods: This study was conducted at Uşak University Faculty of Medicine Hospital. Patients who underwent LC under general anesthesia between 01.11.2018 and 01.06.2019 were evaluated using the prospective cohort method. While intra-operative MP was administered to one group of patients who underwent LC (MP group), MP was not administered to the second group (non-MP). The pain was evaluated using the Visual Analog Scale (VAS) while PONV was evaluated with the Verbal Descriptive Scale (VDS in patients at post-operative hours 0, 1, 2, 6, 12, 18, and 24. On the first post-operative day, patient satisfaction was assessed. Results: The study cohort consisted of 76 patients. The VAS was used to measure post-operative pain, and it was discovered that the MP group had significantly reduced VAS values at post-operative hours 0, 1, 2, 6, 12, 18, and 24 (P < 0.001). In the VDS evaluation, no difference between the two groups only at post-operative hour 12 (P = 0.52) was found, while the VDS value was found to be lower in the MP group than in the non-MP group at post-operative hours 0, 1, 2, 6, 18, and 24 (P ˂ 0.001). The mean total analgesic use at post-operative hour 48 was 69.08 (26.91) mg in the MP group and 96.71 (42.38) mg in the non-MP group. The difference was statistically significant (P ˂ 0.001). Conclusion: PONV and discomfort incidence decreased after intra-operative MPadministration. The decrease in these symptoms was positively reflected in post-operativepatient satisfaction.

Sleep Disturbances and Disorders in Patients with Knee Osteoarthritis and Total Knee Arthroplasty

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There is increasing evidence that patient-reported outcomes following total knee arthroplasty (TKA) are associated with psychosocial factors and pain catastrophizing. Sleep disturbance, pain, and mental health have a complex interaction, which, if unrecognized, can be associated with impaired patient-reported outcomes and dissatisfaction following TKA.

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The gold standard of objective sleep assessment is polysomnography, which is not feasible to use routinely for TKA patients. Wearable devices are a validated and less costly alternative.

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Subjective sleep measures, such as the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, or Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive test sleep domains, are simple to administer and provide additional insight into sleep disturbance. Although objective and subjective measures do not correlate precisely, they can be informative together.

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Sleep disturbances in the elderly population are common and multifactorial in etiology, stemming from the interplay of sleep disorders, medication side effects, and pain. Commonly prescribed medications following TKA as well as postoperative pain can exacerbate underlying sleep disturbances.

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Obstructive sleep apnea (OSA) is prevalent in patients seeking TKA. In the setting of OSA, postoperative opioids can cause respiratory depression, resulting in consequences as severe as death. A standardized multimodal pain protocol including anti-inflammatories and gamma-aminobutyric acid (GABA) analogues may allow for decreased reliance on opioids for pain control.

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Surgeons should reassure patients that postoperative sleep disturbance is common and transient, collaborate with the patient's primary care doctor to address sleep disturbance, and avoid prescription of pharmaceutical sleep aids.

A Prospective Randomized Controlled Trial of Methylprednisolone for Postoperative Pain Management of Surgically Treated Distal Radius Fractures

PURPOSE

Perioperative glucocorticoids have been effectively used as a pain management regimen for reducing pain after hand surgery. We hypothesize that a methylprednisolone taper (MPT) course following surgery will reduce pain and opioid consumption in the early postoperative period.

METHODS

This study was a randomized controlled trial of patients undergoing surgical fixation for distal radius fracture. Before surgery, patients were randomly assigned to receive preoperative dexamethasone only or preoperative dexamethasone followed by a 6-day oral MPT. Patient pain and opioid consumption data were collected for 7 days after surgery using a patient-reported pain journal.

RESULTS

Our study consisted of 56 patients enrolled from November 2018 to March 2020. Twenty-eight patients each were assigned to the control and treatment groups. Demographic characteristics such as age, body mass index, the dominant side affected, smoking status, diabetes status, and current narcotic use were similar between the control and treatment groups. With a noticeable, significant reduction starting on postoperative day 2, patients who received an MPT course consumed substantially less opioids during the first 7 days (7.8 ± 7.2 pills compared with 15.5 ± 11.5 pills, a 50% reduction). These patients also consumed significantly fewer oral morphine equivalents than the control group (81.2 vs 41.2). A significant difference in the pain visual analog scale scores between the 2 groups was noted starting on postoperative day 2, with 48% of the treatment group reporting no pain by postoperative day 6. No adverse events, including infection or complications of wound or bone healing, were seen in either group.

CONCLUSIONS

There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT04123873.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

RESULTS

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

CONCLUSION

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

Effect of dexamethasone on intraoperative remifentanil dose in total knee arthroplasty surgery under general anaesthesia

Background

The effects of glucocorticoids may include both genomic and rapid nongenomic effects. The potential rapid analgesic effect during surgery has not previously been investigated. We aimed to explore the effect of dexamethasone on intraoperative infusion rate of remifentanil in patients undergoing total knee arthroplasty (TKA) surgery under general anaesthesia.

Methods

In this post hoc subgroup analysis, we included patients randomised in the DEX‐2‐TKA trial, who were operated under total intravenous anaesthesia with remifentanil and propofol. Trial medication, intravenous dexamethasone 24 mg or placebo, was administered immediately after anaesthesia onset. The primary outcome was the median weight‐corrected infusion rate of remifentanil during surgery. Secondary outcomes included median weight‐corrected infusion rate of propofol, median intraoperative bispectral index and time spent in the post‐anaesthesia care unit.

Results

Eighty‐seven patients were included in the analysis of the primary outcome. A significantly higher remifentanil infusion rate was observed in the dexamethasone group compared with the placebo group, p = .02. None of the secondary outcomes resulted in statistically significant differences between groups.

Conclusion

This explorative post hoc analysis of the randomised DEX‐2‐TKA trail showed that patients undergoing TKA surgery under general anaesthesia and who received dexamethasone seemed to have a higher remifentanil infusion rate compared with patients who received placebo. The clinical implications of the potentially increased remifentanil infusion rate need to be validated and explored further.

Clinical trial registration

ClinicalTrials.gov Identifier: NCT05002361 (12 August 2021).

Anterolateral minimally invasive hip approach offered faster rehabilitation with lower complication rates compared to the minimally invasive posterior hip approach-a University clinic case control study of 120 cases

INTRODUCTION

The surgical approach used in total hip arthroplasty (THA) has been identified as a factor affecting the outcome. In our University Hospital, the posterior surgical approach is the gold standard. The Rottinger approach is an anterolateral approach which is truly minimally invasive, as it does not vertically cut any muscle fibers. The objective of this study was to determine the difference in surgical outcomes between the posterior hip approach and the Rottinger approach which was newly adopted at our Hospital.

METHODS

In a retrospective study, a total of 120 patients underwent THA; 60 patients using the Rottinger approach by the young consultant surgeon and another 60 patients using the standard posterior approach by the senior orthopaedic surgeon. Patients have been controlled for age, gender, and ASA grades. All preoperative demographic data showed no significant difference between the control and study groups. The following parameters were analyzed: incision length, duration of the surgery, intraoperative blood loss, WOMAC index, Harris Hip Score, range of motion at 3 and 12 months after surgery, time of quitting the crutches, and willingness for the contralateral hip arthroplasty.

RESULTS

WOMAC index, surgical time, and incision lengths have been without significant difference in both approaches. Intraoperative blood loss was significantly lower in the Rottinger group (CI:  - 10.903,  - 0.064). Harris Hip score was significantly higher (CI: 4.564, 12.973) in the Rottinger group at 3 months, but similar (CI:  - 3.484, 2.134) at 12 months follow-up. At 3 months, active flexion and extension were significantly higher in the Rottinger group (CI: 0.595, 8.239; 2.487, 4.480, respectively), and active abduction and passive adduction (CI:  - 5.662,  - 0.338;  - 6.290,  - 1.410, respectively) in the posterior approach group. Patients in the Rottinger approach group on average quit crutches 3 weeks earlier and had no postoperative dislocations compared to 2 dislocations in the control group.

CONCLUSION

The Rottinger approach offered faster rehabilitation with less need for crutches and with lower complication rates.

Machine-learning model successfully predicts patients at risk for prolonged postoperative opioid use following elective knee arthroscopy

PURPOSE

Recovery following elective knee arthroscopy can be compromised by prolonged postoperative opioid utilization, yet an effective and validated risk calculator for this outcome remains elusive. The purpose of this study is to develop and validate a machine-learning algorithm that can reliably and effectively predict prolonged opioid consumption in patients following elective knee arthroscopy.

METHODS

A retrospective review of an institutional outcome database was performed at a tertiary academic medical centre to identify adult patients who underwent knee arthroscopy between 2016 and 2018. Extended postoperative opioid consumption was defined as opioid consumption at least 150 days following surgery. Five machine-learning algorithms were assessed for the ability to predict this outcome. Performances of the algorithms were assessed through discrimination, calibration, and decision curve analysis.

RESULTS

Overall, of the 381 patients included, 60 (20.3%) demonstrated sustained postoperative opioid consumption. The factors determined for prediction of prolonged postoperative opioid prescriptions were reduced preoperative scores on the following patient-reported outcomes: the IKDC, KOOS ADL, VR12 MCS, KOOS pain, and KOOS Sport and Activities. The ensemble model achieved the best performance based on discrimination (AUC = 0.74), calibration, and decision curve analysis. This model was integrated into a web-based open-access application able to provide both predictions and explanations.

CONCLUSION

Following appropriate external validation, the algorithm developed presently could augment timely identification of patients who are at risk of extended opioid use. Reduced scores on preoperative patient-reported outcomes, symptom duration and perioperative oral morphine equivalents were identified as novel predictors of prolonged postoperative opioid use. The predictive model can be easily deployed in the clinical setting to identify at risk patients thus allowing providers to optimize modifiable risk factors and appropriately counsel patients preoperatively.

LEVEL OF EVIDENCE

III.

Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review

Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting (N-methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials' and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.

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

OBJECTIVE

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

DESIGN

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

SETTING

Five Danish hospitals, September 2018 to March 2020.

PARTICIPANTS

485 adult participants undergoing total knee arthroplasty.

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

Clinicaltrials.gov NCT03506789.