A systematic review and meta-analysis of intravenous glucocorticoids for acute pain following total hip arthroplasty

Impact of Perioperative Dexamethasone Administration on Infection and Implant Osseointegration in a Preclinical Model of Orthopedic Device-Related Infection

Glucocorticoids may be given prior to major orthopedic surgery to decrease postoperative nausea, vomiting, and pain. Additionally, many orthopedic patients may be on chronic glucocorticoid therapy. The aim of our study was to investigate whether glucocorticoid administration influences Orthopedic-Device-Related Infection (ODRI) in a rat model. Screws colonized with Staphylococcus epidermidis were implanted in the tibia of skeletally mature female Wistar rats. The treated groups received either a single shot of dexamethasone in a short-term risk study, or a daily dose of dexamethasone in a longer-term interference study. In both phases, bone changes in the vicinity of the implant were monitored with microCT. There were no statistically significant differences in bacteriological outcome with or without dexamethasone. In the interference study, new bone formation was statistically higher in the dexamethasone-treated group (p = 0.0005) as revealed by CT and histopathological analysis, although with relatively low direct osseointegration of the implant. In conclusion, dexamethasone does not increase the risk of developing periprosthetic osteolysis or infection in a pre-clinical model of ODRI. Long-term administration of dexamethasone seemed to offer a benefit in terms of new bone formation around the implant, but with low osseointegration.

Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations

PURPOSE

Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways.

SOURCE

We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature.

PRINCIPAL FINDINGS

Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen.

CONCLUSION

Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

Dexamethasone Is Associated With a Statistically Significant Increase in Postoperative Blood Glucose Levels Following Primary Total Knee Arthroplasty

Background

Dexamethasone has the potential to cause a transient increase in blood glucose levels. Recent evidence has suggested the potential for a linearly increased risk of periprosthetic joint infection beginning at blood glucose levels of ≥115 mg/dL and an optimal cutoff of 137 mg/dL. We designed the following study to determine (1) what percentage of our patients had postoperative day 1 (POD1) glucose levels above 137 mg/dL and (2) if the administration of dexamethasone further increased this risk.

Methods

All primary total knee arthroplasties performed from 1998 to 2021 at our institution were identified and retrospectively reviewed. Patient demographics, dexamethasone administration, and perioperative glucose levels were recorded. Outcomes included POD1 glucose levels, infection rate, and all-cause reoperations and revisions.

Results

The average POD1 glucose level for the entire cohort (n = 5353) was 138.7 mg/dL. The percentage of patients with a glucose level of 137 mg/dL or higher was significantly greater in patients that received dexamethasone (55.2% vs 37.7%; P < .0001). Significantly higher glucose levels were seen with dexamethasone administration in both diabetic (187.7 vs 173.4 mg/dL; P < .0001) and nondiabetic patients (137.7 vs 128.0 mg/dL; P < .0001). Dexamethasone use was associated with a nonstatistically significant increase in infection rates (1.7% vs 1.0%; P = .177).

Conclusions

Administration of dexamethasone is associated with a statistically significant increase in POD1 glucose levels, regardless of diabetic status. Dexamethasone use should continue to be closely monitored given the potential risks of elevated postoperative glucose levels and the potential for periprosthetic infection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Repeat Dose of Perioperative Dexamethasone Can Effectively Reduce Pain, Opioid Requirement, Time to Ambulation, and In-Hospital Stay After Total Hip Arthroplasty: A Prospective Randomized Controlled Trial

BACKGROUND

The ideal dose of intravenous glucocorticoids to control pain in total hip arthroplasty (THA) remains unclear. This randomized controlled trial compared postoperative pain and tramadol requirement in patients undergoing unilateral primary THA who received one versus two perioperative doses of dexamethasone.

METHODS

Patients consented to undergo blinded, simple randomization to either one (at anesthetic induction [1D-group]: 54 patients) or two (with an additional dose 8 hours after surgery [2D-group]: 61 patients) perioperative doses of 8-mg intravenous dexamethasone. Pain was evaluated with visual analog scale at 8, 16, and 24 hours postoperatively and with tramadol requirement. The secondary outcomes included postoperative nausea and vomiting, time to ambulation, and length of stay.

RESULTS

Age (mean, 66 ± 13 years), body mass index (mean, 29 ± 5), gender (60% female), and history of diabetes were similar between groups (P >.05). Pain was higher at 16 (4 [interquartile range {IQR} 3-5] vs 2 [IQR 1-3]; P <.001) and 24 (2.5 [IQR 2-3] vs 1 [IQR 0-1] P <.001) hours postoperatively in the 1D-group patients. 1D-group patients had significantly more tramadol consumption (50 [IQR 50-100] vs 0 [IQR 0-50]; P = .01), as well as postoperative nausea and vomiting (18 [33.3%] vs 5 [8.2%]; P = .001). Fifty-five (90%) patients in the 2D-group and 32 (59%) in the 1D-group ambulated on postoperative day 0 (P = .0002). Fifty-eight (95%) patients in the 2D-group and 37 (68%) in the 1D-group were discharged on postoperative day 1 (P = .0002).

CONCLUSION

An additional dose of dexamethasone at 8 hours postoperatively significantly reduced pain, tramadol consumption, time to ambulation, and length of stay after primary THA.

PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations

The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.

Perioperative dexamethasone administration reduces 'on-demand' opioid requirements in bilateral total hip arthroplasty

BACKGROUND

Bilateral joint arthroplasty is currently not common, but its usage is expected to increase in the future. This may result in larger amounts of opioids being consumed by patients due to anticipated increased pain and prolonged recovery from this procedure.

AIM

We describe the impact of perioperative steroid administration in a cohort of bilateral total hip arthroplasties (THAs) (44 hips) in relation to post-operative opioid consumption.

METHODS

We report a single-surgeon consecutive case series of simultaneously performed bilateral THAs. Nine patients received two doses of 8 mg IV dexamethasone in the perioperative setting. There were 13 patients in the control group that received no dexamethasone. The primary outcome measure was post-operative analgesic requirements (mg/mcg). Secondary outcomes included post-operative pain according to the visual analogue score (VAS), anti-emetic requirements (mg) and length of stay (days).

RESULTS

The mean 'on-demand' Oxynorm® (IR oxycodone) usage in the 'steroid' group was lower than the 'non-steroid' group (47 mg vs 111 mg) (p = 0.005). There was also a significant decrease in the mean consumption of pregabalin in the 'steroid' group when compared with the 'non-steroid' group-464 mg versus 570 mg (p = 0.000). There was no reduction in the requirement of 'regularly' prescribed opioid analgesic medications. VAS analysis demonstrated no significant difference between the two groups at any timepoint. The 'steroid' group did have a trend towards a lower total LOS at 4.6 days compared with 5.5 days in the 'non-steroid' group (p = 0.0503).

CONCLUSIONS

We recommend the use of perioperative steroids in bilateral THA to reduce the consumption of potentially problematic opioid-based analgesics.

Is a split-dose intravenous dexamethasone regimen superior to a single high dose in reducing pain and improving function after total hip arthroplasty? A randomized blinded placebo-controlled trial

Aims

Intravenous dexamethasone has been shown to reduce immediate postoperative pain after total hip arthroplasty (THA), though the effects are short-lived. We aimed to assess whether two equivalent perioperative split doses were more effective than a single preoperative dose.

Methods

A total of 165 patients were randomly assigned into three groups: two perioperative saline injections (Group A, placebo), a single preoperative dose of 20 mg dexamethasone and a postoperative saline injection (Group B), and two perioperative doses of 10 mg dexamethasone (Group C). Patients, surgeons, and staff collecting outcome data were blinded to allocation. The primary outcome was postoperative pain level reported on a ten-point Numerical Rating Scale (NRS) at rest and during activity. The use of analgesic and antiemetic rescue, incidence of postoperative nausea and vomiting (PONV), CRP and interleukin-6 (IL-6) levels, range of motion (ROM), length of stay (LOS), patient satisfaction, and the incidence of surgical site infection (SSI) and gastrointestinal bleeding (GIB) in the three months postoperatively, were also compared.

Results

The pain scores at rest were significantly lower in Groups B and C than in Group A on postoperative days 1 and 2. The dynamic pain scores and CRP and IL-6 levels were significantly lower for Groups B and C compared to Group A on postoperative days 1, 2, and 3. Patients in Groups B and C had a lower incidence of PONV, reduced use of analgesic and antiemetic rescue, improved ROM, shorter LOS, and reported higher satisfaction than in Group A. Patients in Group C had significantly lower dynamic pain scores and IL-6 and CRP levels on postoperative days 2 and 3, and higher ROM and satisfaction on postoperative day 3 than in Group B. No SSI or GIB occurred in any group.

Conclusion

Perioperative dexamethasone provides short-term advantages in reducing pain, PONV, and inflammation, and increasing range of motion in the early postoperative period after THA. A split-dose regimen was superior to a single high dose in reducing pain and inflammation, and increasing ROM, with better patient satisfaction. Level of evidence: I Cite this article: Bone Joint J 2020;102-B(11):1497–1504.

DEX-2-TKA-DEXamethasone twice for pain treatment after Total Knee Arthroplasty: A protocol for a randomized, blinded, three-group multicentre clinical trial

BACKGROUND

Multimodal analgesia is considered the leading principle for post-operative pain treatment, but no gold standard after total knee arthroplasty (TKA) exists.

AIM

To investigate the beneficial and harmful effects of one or two doses of 24 mg intravenous dexamethasone (DXM) as part of a multimodal analgesic regimen (paracetamol, NSAID and perioperative local infiltration analgesia) after TKA. We hypothesize that addition of DXM will reduce post-operative opioid consumption.

METHODS

DEXamethasone twice for pain treatment after TKA is a randomized, blinded, three-group multicentre clinical trial. Participants will be randomized to one of three groups: placebo, single dose of DXM or two consecutive doses of DXM. Participants, treatment providers and investigators will be blinded to the allocated intervention. The primary outcome is total opioid consumption (units of morphine equivalents) 0-48 hours post-operatively.

INCLUSION CRITERIA

unilateral, primary TKA; age ≥18 years; American Society of Anesthesiologists-Score 1-3; Body Mass Index ≥18 and ≤40; for women-not pregnant; and written informed consent.

EXCLUSION CRITERIA

allergy or contraindications against trial medication; daily use of high dose opioid and/or use of methadone/transdermal opioids; daily use of systemic glucocorticoids; dysregulated diabetes; and patients suffering from alcohol and/or drug abuse. Four-hundred-and-eighty-six eligible participants are needed to detect or discard a difference of 10 mg morphine equivalents 0-48 hours post-operatively maintaining a familywise error rate of 0.05 and a power of 90% for the three possible pairwise comparisons.

DISCUSSION

Recruiting is planned to commence September 2018 and expected to finish March 2020.

TRIAL REGISTRATION

EudraCT: 2018-001099-39 (08/06-18); ClinicalTrials.gov: NCT03506789 (24/04-2019). Editorial Comment This is the protocol for the largest randomized clinical trial investigating the effect of one or two doses of dexamethasones on pain treatment after total knee arthroplasty. Due to the pragmatic and rigerous design this study will deliver results of high quality and external validity.

Can Preoperative Intravenous Corticosteroids Administration Reduce Postoperative Pain Scores Following Spinal Fusion?: A Meta-Analysis

Objective: This meta-analysis aimed to assess whether preoperative intravenous corticosteroids reduced postoperative pain in patients undergoing spinal fusion surgery. Methods: We systematically searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Google databases, from inception to March 29, 2018. Randomized controlled trials (RCTs) that compared preoperative intravenous glucocorticoids against a control treatment for the effect on pain following spinal fusion surgery were included. A meta-analysis was performed to generate a pooled risk ratio (RR) and weighted mean difference (WMD) with corresponding 95% confidence interval (CI) for discontinuous outcomes (the occurrence of postoperative nausea and vomiting [PONV] as well as surgical-site infections) and continuous outcomes (visual analog scale [VAS] scores at 12 h, 24 h, 48 h, and 72 h; total morphine consumption and the length of hospital stay), respectively. Results: Ten RCTs that compared intravenous corticosteroids versus placebo were included in our final meta-analysis. Compared with controls, intravenous corticosteroids were associated with a statistically significant reduction in pain VAS scores at 12 h, 24 h, 48 h, and 72 h. Additionally, intravenous corticosteroids decreased total morphine consumption, PONV, and the length of hospital stay. There was no significant difference between intravenous corticosteroids and controls, regarding the occurrence of infection (p > 0.05). Conclusions: In summary, our results indicated that intravenous corticosteroids not only reduce pain but also have anti-emetic effects. More studies should focus on the adverse effects of administering intravenous corticosteroids.

Infection safety of dexamethasone in total hip and total knee arthroplasty: a study of eighteen thousand, eight hundred and seventy two operations

PURPOSE

Dexamethasone has been shown to prevent post-operative nausea and vomiting (PONV) and seems to reduce post-operative pain. Both factors, which can extend the hospital stay, delay rehabilitation, and impact patient satisfaction. Because of the immunosuppressive and glucose-rising effects of dexamethasone, there has been concern of its safety in arthroplasty surgery. The purpose of our study was to examine infection safety of dexamethasone in arthroplasty surgery with enough large study material to reliably detect a possible, even small, difference in infection incidence.

METHODS

A total of 18,872 consecutive primary and revision hip and knee arthroplasties were analyzed with data gathered from clinical information databases and a surgical site infection surveillance database with prospective data collection. Also, emergency operations due to fractures were included except for hip hemiarthroplasties.

RESULTS

During the follow-up, 189 (1.0%) prosthetic joint infections (PJIs) occurred: 0.8% after primary arthroplasty and 1.9% after revision arthroplasty. Dexamethasone was used in 2922 (15.5%) operations. The PJI rate in the dexamethasone group was 1.1% (31/2922) and in the non-dexamethasone group 1.0% (161/15950), with no significant difference in the risk of PJI between the two groups (OR 1.052, 95% CI 0.715-1.548, P = 0.773).

CONCLUSIONS

In our study material, the use of a single 5-10 mg dose of dexamethasone did not increase the incidence of post-operative PJI. A low dose of dexamethasone may be safely used to prevent PONV and as part of multimodal analgesia on patients undergoing arthroplasty operation.

Intravenous glucocorticoid for pain control after spinal fusion: A meta-analysis of randomized controlled trials

OBJECTIVE

Postoperative pain was a common symptom after spinal surgery. This meta-analysis aimed to assess whether intravenous glucocorticoids has a beneficial role in reducing pain in patients following spinal fusion.

METHODS

We systematically searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and Google databases, from inception to March 2, 2018. Randomized controlled trials (RCTs) that comparing intravenous glucocorticoids with control treatment for spinal fusion were included. A meta-analysis was performed to generate pooled risk ratio (RR) and weighted mean difference with corresponding 95% confidence interval (CI) for discontinuous outcomes (the occurrence of nausea and infection) and continuous outcomes (visual analog scale [VAS] at 12, 24, and 48 h; total morphine consumption; and the length of hospital stay), respectively.

RESULTS

Eight clinical trials involving 918 patients (glucocorticoid group = 449, control group = 469) were finally included in this meta-analysis. Compared with control, intravenous glucocorticoids had significantly reduced VAS at 12, 24, and 48 hours with statistically significance (P < .05). Intravenous glucocorticoids can decrease the occurrence of nausea (RR = 0.42, 95% CI 0.29-0.62, P = .000; I = 0.0%) and the length of hospital stay. No difference was noticed in the occurrence of infection between glucocorticoids intravenous and control (P > .05).

CONCLUSION

Existing evidence indicated that intravenous glucocorticoids have a beneficial role in decreasing early pain and the occurrence of nausea after spinal fusion surgery. In consideration of the limitation in current meta-analysis, more high-quality RCTs were needed to identify the optimal dose of glucocorticoids in spinal fusion patients.