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Mo Y, Wang C, Yin D, Li F. Efficacy of Dexamethasone in Reducing Pain and Inflammation and Accelerating Total Hip Arthroplasty Postoperative Recovery: A Randomized Controlled Trial. J Perianesth Nurs 2024; 39:589-595. [PMID: 38219078 DOI: 10.1016/j.jopan.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/24/2023] [Accepted: 10/31/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE To evaluate the efficacy of dexamethasone in reducing pain and accelerating recovery after total hip arthroplasty (THA). DESIGN A prospective randomized controlled trial. METHODS A total of 98 patients who underwent THA received either low-dose (10 mg) dexamethasone (dexa group) or isotonic saline (placebo group). C-reactive protein and interleukin-6 levels were recorded at 24, 48, and 72 hours after surgery. Pain visual analog scale (VAS) score at rest and walking, the incidence of postoperative nausea and vomiting (PONV), nausea VAS score, postoperative identity-consequence fatigue scale rating, antiemetic use, postoperative length of stay (PLOS), and complications were also recorded and compared. FINDINGS Inflammatory marker (C-reactive protein and interleukin-6) levels at 24, 48, and 72 hours postoperatively in the dexa group were lower than that in the placebo group (P < .05). After 24 hours of rest, the dynamic pain VAS scores in the dexa group were lower than those in the placebo group (P < .05). The incidence of PONV, nausea VAS score, and identity-consequence fatigue scale score in the dexa group were lower than those in the placebo group (P < .05), and the dosages of analgesics and antiemetics were also lower (P < .05). In addition, PLOS in the dexa group was shorter than that in the placebo group (P < .05). No significant difference in perioperative complications between the two groups was observed (P > .05). CONCLUSIONS Low-dose dexamethasone in the THA perioperative period can effectively reduce inflammatory marker levels, pain, nausea, postoperative fatigue, opioid analgesic use, and shorten PLOS without increasing complications.
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Affiliation(s)
- Yingrong Mo
- Department of Pharmacy, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Chaoqun Wang
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Dong Yin
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Fulin Li
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China.
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Mackie M, Barton KI, Sokol-Randell D, Lanting B. The Use of Biomarkers to Quantify Clinical Response to Total Knee Arthroplasty Interventions: A Systematic Review. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202404000-00005. [PMID: 38547046 PMCID: PMC10977533 DOI: 10.5435/jaaosglobal-d-23-00202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/30/2024] [Accepted: 02/06/2024] [Indexed: 04/02/2024]
Abstract
The primary objective of this review was to determine whether the attenuation of the postoperative inflammatory response (PIR) after total knee arthroplasty (TKA) leads to a notable improvement in clinical outcome scores. The secondary objective of this review was to determine the optimal approach in using inflammatory biomarkers, clinical inflammatory assessments, and imaging to quantify the PIR. A systematic literature search of eight major databases was conducted using a predetermined search strategy. C-reactive protein (CRP), interleukin-6 (IL-6), erythrocyte sedimentation rate (ESR), knee surface temperature (KST), and clinical outcome data were collected and graphically displayed. Eighty-six percent of the studies that reported a statistically significant decrease in inflammatory biomarkers in their treatment group demonstrated a concordant notable improvement in clinical outcome scores. Mean CRP, IL-6, ESR, and KST values peaked on postoperative day (POD) 2, POD1, POD7, and POD 1-3, respectively. The PIR is correlated with early pain and function recovery outcomes. Future studies comparing TKA surgical methodologies and perioperative protocols should assess PIR by incorporating inflammatory biomarkers, such as CRP and IL-6, and clinical inflammatory assessment adjuncts, to provide a more comprehensive comparison.
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Affiliation(s)
- Mark Mackie
- From the Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (Mr. Mackie and Dr. Lanting); Orthopaedic Surgery, London Health Sciences Centre, London, ON, Canada (Dr. Barton and Dr. Lanting); School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON, Canada (Dr. Barton); Department of Neurology, Memorial University, Newfoundland, Canada (Dr. Sokol-Randell); Rorabeck Bourne Joint Replacement Clinic, London Health Sciences Centre, Western University, London, ON, Canada (Dr. Lanting)
| | - Kristen I. Barton
- From the Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (Mr. Mackie and Dr. Lanting); Orthopaedic Surgery, London Health Sciences Centre, London, ON, Canada (Dr. Barton and Dr. Lanting); School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON, Canada (Dr. Barton); Department of Neurology, Memorial University, Newfoundland, Canada (Dr. Sokol-Randell); Rorabeck Bourne Joint Replacement Clinic, London Health Sciences Centre, Western University, London, ON, Canada (Dr. Lanting)
| | - Darek Sokol-Randell
- From the Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (Mr. Mackie and Dr. Lanting); Orthopaedic Surgery, London Health Sciences Centre, London, ON, Canada (Dr. Barton and Dr. Lanting); School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON, Canada (Dr. Barton); Department of Neurology, Memorial University, Newfoundland, Canada (Dr. Sokol-Randell); Rorabeck Bourne Joint Replacement Clinic, London Health Sciences Centre, Western University, London, ON, Canada (Dr. Lanting)
| | - Brent Lanting
- From the Schulich School of Medicine and Dentistry, Western University, London, ON, Canada (Mr. Mackie and Dr. Lanting); Orthopaedic Surgery, London Health Sciences Centre, London, ON, Canada (Dr. Barton and Dr. Lanting); School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON, Canada (Dr. Barton); Department of Neurology, Memorial University, Newfoundland, Canada (Dr. Sokol-Randell); Rorabeck Bourne Joint Replacement Clinic, London Health Sciences Centre, Western University, London, ON, Canada (Dr. Lanting)
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Tan TK, Gopal Subramaniam A, Hau R. Effects of combined dexamethasone and tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomized clinical trials. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3327-3335. [PMID: 37329454 DOI: 10.1007/s00590-023-03612-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/01/2023] [Indexed: 06/19/2023]
Abstract
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.
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MESH Headings
- Humans
- Tranexamic Acid/therapeutic use
- Antifibrinolytic Agents/therapeutic use
- Postoperative Nausea and Vomiting/etiology
- Postoperative Nausea and Vomiting/prevention & control
- Metoclopramide/therapeutic use
- Oxycodone
- Blood Loss, Surgical/prevention & control
- Randomized Controlled Trials as Topic
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Dexamethasone
- Administration, Intravenous
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Affiliation(s)
- Tze Khiang Tan
- Department of Orthopaedic Surgery, Monash Health Dandenong Hospital, Dandenong, VIC, Australia.
| | | | - Raphael Hau
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
- Department of Surgery, University of Melbourne, Carlton, VIC, Australia
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Abdallah Z, Staibano P, Zhou K, Khalife S, Nguyen TBV, Sommer DD. Tranexamic acid in endoscopic sinus and skull base surgery: A systematic review and meta-analysis. Int Forum Allergy Rhinol 2023; 13:2187-2204. [PMID: 37259887 DOI: 10.1002/alr.23203] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/24/2023] [Accepted: 05/26/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Endoscopic sinus surgery (ESS) and endoscopic skull base surgery (ESBS) approaches have revolutionized the management of sinonasal and intracranial pathology. Maintaining surgical hemostasis is essential as bleeding can obscure the visibility of the surgical field, thus increasing surgical duration, risk of complications, and procedural failure. Tranexamic acid (TXA) acts to reduce bleeding by inhibiting fibrin degradation. This review aims to assess whether TXA improves surgical field quality and reduces intraoperative blood loss compared with control. METHODS We searched PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library from inception until September 1, 2022. Two reviewers independently screened citations, extracted data, and assessed methodological quality using the Cochrane risk-of-bias tool for randomized trials. Data were pooled using a random-effect model, with continuous data presented as mean differences and dichotomous data presented as odds ratios. RESULTS Seventeen ESS randomized controlled trials (n = 1377) and one ESBS randomized controlled trial (n = 50) were reviewed. Significant improvement in surgical field quality was achieved with both systemic TXA (six studies, p < 0.00001) and topical TXA (six studies, p = 0.01) compared with the control. Systemic TXA (eight studies) and topical TXA (three studies) both achieved a significant reduction in intraoperative blood loss compared with the control (p < 0.00001). There were significant differences in operative times (p < 0.001) but no significant difference in perioperative outcomes (p = 0.30). CONCLUSION This meta-analysis demonstrated that the administration of TXA in ESS can improve surgical field quality and reduce intraoperative blood loss. TXA use did not result in increased perioperative complications including thrombotic events.
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Affiliation(s)
- Zahra Abdallah
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Phillip Staibano
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kelvin Zhou
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Khalife
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Thomas B V Nguyen
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Doron D Sommer
- Department of Surgery, Division of Otolaryngology, Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
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Wu C, Luo D, Zhu Y, Zhao Q, Wang J, Dai Y. Efficacy of combining intravenous and topical dexamethasone against postoperative pain and function recovery after total knee arthroplasty: A prospective, double-blind, randomized controlled trial. J Orthop Surg (Hong Kong) 2023; 31:10225536231189782. [PMID: 37437069 DOI: 10.1177/10225536231189782] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Dexamethasone is a corticosteroid with powerful anti-inflammatory effects. This study aimed to explore whether combining intravenous and topical dexamethasone could improve postoperative pain, swelling, and function recovery after total knee arthroplasty (TKA). METHODS In this prospective, double-blind, randomized controlled study, 90 patients undergoing primary unilateral TKA were randomized into a dexamethasone group, which received dexamethasone (10 mg) by periarticular infiltration during surgery, as well as intravenous dexamethasone (10 mg) before tourniquet release and at 12 h postoperatively; or a control group, which received equal volumes of isotonic saline instead of dexamethasone. The primary outcome was postoperative pain, as assessed on the visual analogue scale (VAS). Secondary outcomes were postoperative consumption of morphine hydrochloride for rescue analgesia, postoperative swelling ratio of the thigh, knee, and tibia; functional recovery in terms of total range of motion (ROM) of knee and daily ambulation distance; postoperative inflammation biomarkers levels of C-reactive protein and interleukin-6; and postoperative complications. RESULTS Resting VAS scores at postoperative 6, 12, and 24 h, and VAS scores during motion at postoperative 2, 6, 12, and 24 h were significantly lower in the dexamethasone group. The dexamethasone group also showed significantly less morphine consumption during the first 24 h after surgery and cumulatively during hospitalization, milder limb swelling at 24 and 48 h postoperatively, greater flexion and total ROM on postoperative day 1, and longer ambulation distance on postoperative days 1 and 2, and lower levels of inflammatory biomarkers on postoperative days 1 and 2. The dexamethasone group had significantly lower incidence of postoperative nausea and vomiting. CONCLUSION Compared with placebo, the combination of intravenous and topical dexamethasone can reduce pain, swelling, and inflammation after TKA, it also can improve functional recovery and reduce the incidence of postoperative nausea and vomiting.
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Affiliation(s)
- Changjun Wu
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
| | - Defa Luo
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
| | - Yu Zhu
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
| | - Qingyuan Zhao
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
| | - Jian Wang
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
| | - Yunlei Dai
- Department of Orthopaedics Surgery, Dafang County People's Hospital, Bijie, China
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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. Ugeskr Laeger 2023; 40:155-170. [PMID: 36325886 DOI: 10.1097/eja.0000000000001768] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Hannon CP, Fillingham YA, Mason JB, Sterling RS, Casambre FD, Verity TJ, Woznica A, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Corticosteroids in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty 2022; 37:1898-1905.e7. [PMID: 36162922 DOI: 10.1016/j.arth.2022.03.084] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/09/2022] [Accepted: 03/31/2022] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Yale A Fillingham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Robert S Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Anne Woznica
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
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Hannon CP, Fillingham YA, Mason JB, Sterling RS, Hamilton WG, Della Valle CJ. Corticosteroids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2022; 37:1684-1687. [PMID: 35970568 DOI: 10.1016/j.arth.2022.03.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/23/2022] [Accepted: 03/07/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | | | | | - Robert S Sterling
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Konarski W, Poboży T, Hordowicz M. Tranexamic acid in total knee replacement and total hip replacement - a single-center retrospective, observational study. Orthop Rev (Pavia) 2022; 14:33875. [PMID: 35775036 PMCID: PMC9239398 DOI: 10.52965/001c.33875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 08/12/2023] Open
Abstract
Background Numerous strategies are used to decrease the risk of the need for [allogeneic blood transfusion (ABT)], including [tranexamic acid (TXA)]. Objective In a single-center retrospective observational study, we have assessed the impact of TXA on the need and average volume of blood used during transfusion. Methods We have reviewed medical records of a total of 491 patients undergoing arthroplasty in our hospital from Dec 2016 to Dec 2019. Results 226 patients were administered TXA IV, and 265 did not receive an additional intervention. In the TXA group, 7/226 patients required ABT vs. 41/265 in the non-TXA group (p<0,001). The Non-TXA group required a significantly higher blood transfusion volume than the TXA group (mean 82,42 mL vs. 12,74 mL; p<0,001). Conclusion We conclude that two doses of 1g TXA administered [intravenously (IV)] before incision and during skin suturing reduce the need for blood transfusion in patients undergoing JRS.
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Affiliation(s)
| | - Tomasz Poboży
- Department of Orthopaedic Surgery, Ciechanów Hospital, Ciechanów
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Gasbjerg KS, Hägi-Pedersen D, Lunn TH, Laursen CC, Holmqvist M, Vinstrup LØ, Ammitzboell M, Jakobsen K, Jensen MS, Pallesen MJ, Bagger J, Lindholm P, Pedersen NA, Schrøder HM, Lindberg-Larsen M, Nørskov AK, Thybo KH, Brorson S, Overgaard S, Jakobsen JC, Mathiesen O. Effect of dexamethasone as an analgesic adjuvant to multimodal pain treatment after total knee arthroplasty: randomised clinical trial. BMJ 2022; 376:e067325. [PMID: 34983775 PMCID: PMC8724786 DOI: 10.1136/bmj-2021-067325] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Kasper Smidt Gasbjerg
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Daniel Hägi-Pedersen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Cleveland Laursen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Centre for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Majken Holmqvist
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Louise Ørts Vinstrup
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Centre for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mette Ammitzboell
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Karina Jakobsen
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Mette Skov Jensen
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Marie Jøhnk Pallesen
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jens Bagger
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Lindholm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | | | - Martin Lindberg-Larsen
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anders Kehlet Nørskov
- Department of Anaesthesiology, Nordsjællands University Hospital, Hillerød, Denmark Anders
- Copenhagen Trial Unit Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Kasper Højgaard Thybo
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | - Søren Overgaard
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
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Xu H, Xie J, Yang J, Huang Z, Wang D, Pei F. Synergistic Effect of a Prolonged Combination Course of Tranexamic Acid and Dexamethasone Involving High Initial Doses in Total Knee Arthroplasty: A Randomized Controlled Trial. J Knee Surg 2021; 36:515-523. [PMID: 34794198 DOI: 10.1055/s-0041-1739197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The optimal regimes of tranexamic acid (TXA) and dexamethasone (DXM) in total knee arthroplasty (TKA) are still uncertain. The aim of this study was to assess the efficacy and safety of a prolonged course of intravenous TXA and DXM involving a high initial dose in TKA. Patients who underwent primary TKA at our center were randomized to receive one of four regimes: control (group A), prolonged course of TXA (B), prolonged course of DXM (C), or the combination of a prolonged course of TXA and DXM (D). The four groups were compared in primary outcomes (fibrinolytic and inflammatory markers, knee function, postoperative pain levels, and consumption of opioids) and secondary outcomes (blood loss, maximal drop in hemoglobin, coagulation, fasting blood glucose, and complications). A total of 162 patients were enrolled. On postoperative days 2 and 3, fibrinolytic markers were lower in groups B and D than in groups A and C; inflammatory markers were lower in groups C and D than in groups A and B. Inflammatory markers were lower in group B than in group A on postoperative day 3. Postoperative pain levels and oxycodone consumption were lower, and knee function was better in groups C and D. The four groups did not differ in any of the secondary outcomes. A prolonged course of intravenous TXA and DXM involving high initial doses can effectively inhibit postoperative fibrinolytic and inflammatory responses, reduce pain, and improve knee function after TKA.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Sichuan, China
| | - Jinwei Xie
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Sichuan, China
| | - Jingli Yang
- College of Earth and Environmental Sciences and School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Duan Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Sichuan, China
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A Comprehensive Single-Center Analysis of Postoperative Nausea and Vomiting Following Orthognathic Surgery. J Craniofac Surg 2021; 33:584-587. [PMID: 34510064 DOI: 10.1097/scs.0000000000008052] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) remains a major clinical end-point for directing enhanced recovery after surgery (ERAS) protocols in facial plastic surgery. This study aimed to identify risk factors for PONV and evaluate strategies for PONV reduction in orthognathic surgery patients. METHODS A retrospective cohort study was performed among patients receiving orthognathic surgery at our institution from 2011 to 2018. Patient demographics, surgical operative and anesthesia notes, medications, and nausea/vomiting were assessed for each patient. The amount of opioid analgesia given both perioperatively and postoperatively was recorded and converted into morphine equivalents (MEQ). Stepwise regression analysis was used to identify significant risk factors for PONV. Post hoc analyses were employed to compare PONV among patients based on MEQ dosage and antiemetic prophylaxis regimes. RESULTS A total of 492 patients were included; mean age was 23.0 years (range: 13-60); 54.4% were female. The majority of patients received concurrent Le Fort I osteotomy, BSSO, and genioplasty (70.1%). During hospitalization, 59.4% of patients experienced nausea requiring antiemetic medications and 28.4% experienced emesis. Stepwise regression yielded Apfel scores (P = 0.003) and postoperative opioids (P = 0.013) as the strongest predictors of PONV. Post hoc analyses showed that undertreatment with prophylactic antiemetics (based on Apfel) predicted increased PONV (+12.9%, P = 0.020), and that lower postoperative MEQs (<28.0) predicted decreased PONV (-11.8%, P = 0.01). CONCLUSIONS The study findings confirm the high incidence of PONV among orthognathic surgical patients and stratify previously reported PONV risk factors. More aggressive utilization of antiemetic medications and decreased dependence on opioid analgesia may decrease nausea/vomiting following orthognathic surgery.
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13
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Feeley AA, Feeley TB, Feeley IH, Sheehan E. Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies. J Arthroplasty 2021; 36:3042-3053. [PMID: 33902983 DOI: 10.1016/j.arth.2021.03.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Perioperative corticosteroid administration is associated with reduced postoperative nausea, pain, and enhanced recovery after surgery. However, potential complications including wound and periprosthetic joint infections remain a concern for surgeons after total joint arthroplasty (TJA). METHODS A systematic review of the search databases PubMed, Google Scholar, and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk after perioperative corticosteroid administration in TJA. PRISMA guidelines were used for this review. Meta-analysis was used to assess infection risk in accordance with joint and corticosteroid dosing regimen used. RESULTS 201 studies were returned after initial search strategy, with 29 included for review after application of inclusion and exclusion criteria. Studies were categorized as using low- or high-dose corticosteroid with single or repeat dosing regimens. Single low-dose corticosteroid administration was not associated with an increased risk of infection (P = .4; CI = 0.00-0.00). Single high-dose corticosteroid was not associated with an increased infection risk (P = .3; CI = 0.00-0.01) nor did repeat low-dose regimens result in increased risk of infection (P = .8; CI = -0.02-0.02). Studies assessing repeat high-dosing regimens reported no increased infection, with small numbers of participants included. No significant risk difference in infection risk was noted in hip (P = .59; CI = -0.03-0.02) or knee (P = .2; CI = 0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted. CONCLUSION Use of perioperative corticosteroid in TJA does not appear to be associated with increased risk of postoperative infection in patients with limited comorbidities. Further research is warranted to evaluate postoperative complications after TJA in these at-risk patient populations.
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Affiliation(s)
- Aoife A Feeley
- Department of Orthopaedics, Midland Regional Hospital Tullamore, Puttaghan, Tullamore, Ireland
| | - Tara B Feeley
- Department of Anaesthetics, Starship Children's Hospital, Auckland, New Zealand
| | - Iain H Feeley
- Department of Orthopaedics, National Orthopaedic Hospital Cappagh, Cappoge, Dublin, Ireland
| | - Eoin Sheehan
- Department of Orthopaedics, Midland Regional Hospital Tullamore, Puttaghan, Tullamore, Ireland
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Wang F, Ma W, Huang Z. Analgesia effects of IPACK block added to multimodal analgesia regiments after total knee replacement: A systematic review of the literature and meta-analysis of 5 randomized controlled trials. Medicine (Baltimore) 2021; 100:e25884. [PMID: 34087830 PMCID: PMC8183733 DOI: 10.1097/md.0000000000025884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/21/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Currently, no meta-analysis exists elucidate the analgesic effect of adding IPACK block to our current multimodal analgesia regimen after total knee replacement (TKR). The purpose of this study is to systematically review the level I evidence in the literature to ascertain whether IPACK block can bring additional analgesic benefits to existing multimodal analgesia regimens. METHODS The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Only level I randomized controlled trials (RCTs) were included in our study. The primary outcome was the pain scores with rest and activity. Secondary outcomes included cumulative opioid consumption, cumulative distance ambulated, and length of stay (LOS). RESULTS Five RCTs with a total of 467 patients were included. The most important finding in our study was that although IPACK block supplementation improved pain scores at 12 hours with rest or activity after surgery, no such benefit was observed at subsequent time points during the postoperative period. Interestingly, IPACK supplementation did not reduce opioid consumption, especially in the first 24 hours after surgery. Furthermore, other postoperative outcomes, including cumulative distance ambulated and LOS, were also not improved by the addition of an IPACK. CONCLUSIONS The addition of an IPACK block to multimodal analgesia regiments does not reduce the postoperative opioid consumption nor improve functional performance. However, it may be an appropriate method to improve immediate analgesic effects after TKR.
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Lex JR, Edwards TC, Packer TW, Jones GG, Ravi B. Perioperative Systemic Dexamethasone Reduces Length of Stay in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Arthroplasty 2021; 36:1168-1186. [PMID: 33190999 DOI: 10.1016/j.arth.2020.10.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The objective of this review is to examine the effect of perioperative systemic corticosteroids at varying doses and timings on early postoperative recovery outcomes following unilateral total knee and total hip arthroplasty. The primary outcome was length of stay (LOS). METHODS A systematic review and meta-analysis of randomized controlled trials was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched from inception to June 1, 2020. Studies comparing the outcome of adult patients receiving a systemic steroid to patients who did not receive steroids were included. RESULTS Seventeen studies were included, incorporating 1957 patients. Perioperative corticosteroids reduced hospital LOS (mean difference [MD] = -0.39 days, 95% confidence interval [CI] -0.61 to -0.18). A subsequent dose of corticosteroid at 24 hours further reduced LOS (MD = -0.33, 95% CI -0.55 to -0.11). Corticosteroids resulted in reduced levels of pain on postoperative day (POD) 0 (MD = -1.99, 95% CI -3.30 to -0.69), POD1 (MD = -1.47, 95% CI -2.15 to -0.79), and POD2. Higher doses were more effective in reducing pain with activity on POD0 (P = .006) and 1 (P = .023). Steroids reduced the incidence of PONV on POD1 (log odds ratio [OR] = -1.05, 95% CI -1.26 to -0.84) and POD2, with greater effect at higher doses (P = .046). Corticosteroids did not increase the incidence of infection (P = 1.000), venous thromboembolism (P = 1.000), or gastrointestinal hemorrhage (P = 1.000) but were associated with an increase in blood glucose (MD = 5.30 mg/dL, 95% CI 2.69-7.90). CONCLUSION Perioperative corticosteroids are safe, facilitate earlier discharge, and improve patient recovery following unilateral total knee arthroplasty and total hip arthroplasty. Higher doses (15-20 mg of dexamethasone) are associated with further reductions in dynamic pain and PONV, and repeat dosing may further reduce LOS.
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Affiliation(s)
- Johnathan R Lex
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Timothy W Packer
- St Mary's Hospital, Imperial Healthcare Trust, London, United Kingdom
| | - Gareth G Jones
- MSk Lab, Imperial College London, London, United Kingdom
| | - Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Division of Orthopaedic Surgery, Toronto, Ontario, Canada
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Jia Q, Chen X, Zhang J, Hu Y. Which is the better choice? A clinical cohort study protocol evaluating the differences between standard medial parapatellar and minimally invasive approaches in total knee replacement. Medicine (Baltimore) 2021; 100:e24209. [PMID: 33429813 PMCID: PMC7793439 DOI: 10.1097/md.0000000000024209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is still a lack of consensus on the best approach for total knee replacement (TKR). We carried out this present retrospective cohort study to assess the overall safety and effectiveness of a minimally invasive approach without the use of computer navigation in comparison with conventional TKR. METHODS A retrospective review of patients who receiving the primary TKR in the same institution from 2014 to 2016 was conducted. The inclusion criteria for the study indicated that the patient required a unilateral or bilateral TKR was between 18 and 80 years' old, provided informed consent, was followed up for at least 2 years, and was in stable health. There was no treatment for any condition or condition that might pose a risk of excessive surgery. The same TKR standard rehabilitation program was provided to all patients. Data were collected on patient demographics, anesthesia style, American Society of Anesthesiology scores, tourniquet duration, and surgical drainage loss. Our primary outcome measure was discharge time. Secondary outcomes included duration of surgery, incidence of postoperative complications, imaging location 6 weeks after surgery, Oxford Knee Score, Western Ontario and McMaster Universities Arthritis Index, and knee ROM. Complications were recorded and classified as surgical site, thromboembolic, systemic, or requiring reoperation. RESULTS It was assumed that there is a remarkable difference in postoperative outcomes between the 2 groups. CONCLUSION The limitations of our present research include the inherent limitations in any retrospective cohort research, including the observation bias and possibility of selection. TRIAL REGISTRATION This study protocol was registered in Research Registry (researchregistry6349).
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Affiliation(s)
- Qiong Jia
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangdong
| | - Xin Chen
- Department of Surgical Nursing, Hunan Traditional Chinese Medical College
| | - Jun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Hunan College of traditional Chinese Medicine, Hunan, China
| | - Yang Hu
- Department of Orthopedics, The First Affiliated Hospital of Hunan College of traditional Chinese Medicine, Hunan, China
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Chen J, Hu W, Li SM, Li XL, Yang ZM. The efficacy of ketamine in total knee arthroplasty: a randomized controlled trial protocol. Medicine (Baltimore) 2020; 99:e20645. [PMID: 32541504 PMCID: PMC7302669 DOI: 10.1097/md.0000000000020645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Appropriate pain management is essential to improve the postoperative recovery after total knee arthroplasty (TKA). There is a paucity of literature on ketamine for TKA procedures. The aim of this study was to evaluate the analgesic efficacy of ketamine in patients undergoing primary TKA. METHODS This study was designed as a prospective, double blind, single center, randomized controlled trial. The participants were randomly assigned to either the ketamine or placebo groups, using a set of random numbers for the allocation sequence. All patients underwent TKA without patella resurfacing under spinal anesthesia. Preoperative workup, surgical technique, and postoperative management were standardized for all the patients. The primary outcome of this noninferiority study is opioid consumption within the first 24 hours following surgery, pain scores, distance ambulated, patient satisfaction, length of hospital stay, and complications. RESULTS The results of this study were expected to provide useful information on the effectiveness and safety of ketamine for immediate postoperative analgesia after TKA surgery. TRIAL REGISTRATION This study protocol was registered in Research Registry (researchregistry5575).
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Affiliation(s)
- Jing Chen
- Department of Orthopedics, Aerospace Center Hospital, Beijing
| | - Wei Hu
- Department of Orthopedics, Ningxia Armed Police Corps Hospital, Ningxia Hui Autonomous Region
| | - Shu-Ming Li
- Department of Orthopedics, Aerospace Center Hospital, Beijing
| | - Xiao-Lin Li
- Department of Orthopedics, Ningxia Armed Police Corps Hospital, Ningxia Hui Autonomous Region
| | - Zhan-Min Yang
- Department of Anesthesiology, Aerospace Center Hospital, Beijing, China
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