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Liu F, Duan M, Fu H, Wang T. The efficacy and safety of perioperative glucocorticoid for total knee arthroplasty: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:144. [PMID: 38622510 PMCID: PMC11017604 DOI: 10.1186/s12871-024-02530-9] [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: 07/30/2023] [Accepted: 04/08/2024] [Indexed: 04/17/2024] Open
Abstract
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.
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Affiliation(s)
- Fangyan Liu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Mei Duan
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Huiqun Fu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.
- National Clinical Research Center for Geriatric Diseases, Beijing, China.
- Beijing Institute for Brain Disorders, Beijing, China.
- Center for Sleep and Consciousness Disorders, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.
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Kishimoto K, Asai S, Takahashi N, Terabe K, Sobue Y, Nishiume T, Suzuki M, Ishiguro N, Kojima T. Changes in perioperative C-reactive protein levels in patients with rheumatoid arthritis undergoing total knee arthroplasty in the biologic era. NAGOYA JOURNAL OF MEDICAL SCIENCE 2022; 84:286-300. [PMID: 35967944 PMCID: PMC9350574 DOI: 10.18999/nagjms.84.2.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/05/2021] [Indexed: 11/24/2022]
Abstract
This study aimed to investigate changes in and factors associated with perioperative serum C-reactive protein (CRP) levels in rheumatoid arthritis (RA) patients undergoing total knee arthroplasty (TKA) in the biologic era. A total of 173 patients (228 knees) with RA underwent elective primary TKA at our institute between January 1, 2006 and December 31, 2018. Of these, 214 cases among 161 patients were examined in this retrospective study after excluding 3cases among 3 patients who developed postoperative complications and 11 cases among 9 patients who were treated with tocilizumab. Factors associated with changes in CRP levels between baseline (preoperative) and day 7 after TKA [ΔCRP (0-7days)] were assessed by multiple regression analysis. Median (interquartile range) CRP levels were 0.69 (0.21, 1.82) mg/dl preoperatively, 5.66 (4.21, 7.61) mg/dl on postoperative day 1, 12.75 (9.79, 16.74) mg/dl on postoperative days 3-4, 3.26 (2.21, 4.85) mg/dl on postoperative day 7, and 0.87 (0.45, 1.81) mg/dl on postoperative day 14. Multivariate regression analysis revealed that body mass index ≥25 [partial regression coefficient (B)=1.03, P=0.012] and use of glucocorticoids (B=-0.86, P=0.017) were independently associated with ΔCRP (0-7days), whereas use of methotrexate and targeted drug modifying antirheumatic drugs and preoperative CRP levels (an objective biomarker of RA activity) were not. In conclusion, serum CRP levels increased rapidly after TKA and peaked on postoperative days 3-4, followed by a return to preoperative levels by postoperative day 14 in patients with RA. Obesity and the use of glucocorticoids were independently associated with changes in CRP levels.
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Affiliation(s)
- Kenji Kishimoto
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shuji Asai
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobunori Takahashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenya Terabe
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasumori Sobue
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
,Department of Orthopedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Tsuyoshi Nishiume
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
,Department of Orthopedic Surgery, Okazaki City Hospital, Okazaki, Japan
| | - Mochihito Suzuki
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
,Aichi Developmental Disability Center, Kasugai, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Pre-emptive analgesia with methylprednisolone and gabapentin in total knee arthroplasty in the elderly. Sci Rep 2022; 12:2320. [PMID: 35149701 PMCID: PMC8837623 DOI: 10.1038/s41598-022-05423-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/10/2022] [Indexed: 11/10/2022] Open
Abstract
The aim of this study is to assess whether administration of gabapentin and methylprednisolone as “pre-emptive analgesia” in a group of patients above 65 years of age would be effective in complex pain management therapy following total knee arthroplasty (TKA). One hundred seventy patients above 65 years were qualified for the study, with exclusion of 10 patients due to clinical circumstances. One hundred sixty patients were randomly double-blinded into two groups: the study group (80 patients) and the control group (80 patients). The study group received as “pre-emptive” analgesia a single dose of 300 mg oral (PO) gabapentin and 125 mg intravenous (IV) methylprednisolone, while the control received a placebo. All patients received opioid and non-opioid analgesic agents perioperatively calculated for 1 kg of total body weight. We measured (1) pain intensity level at rest (numerical rating scale, NRS), (2) life parameters, (3) levels of inflammatory markers (leukocytosis, C reactive protein CRP), and (4) all complications. Following administration of gabapentin and methylprednisolone as “pre-emptive” analgesia, the NRS score at rest was calculated at 6, 12 (p < 0.000001), 18 (p < 0.00004) and 24 (p = 0.005569) h postoperatively. Methylprednisolone with gabapentin significantly decreased the dose of parenteral opioid preparations (p = 0.000006). The duration time of analgesia was significantly longer in study group (p < 0.000001), with CRP values lower on all postoperative days (1, 2 days—p < 0.00001, 3 days—p = 0.00538), and leukocytosis on day 2 (p < 0.0086) and 3 (p < 0.00042). No infectious complications were observed in the first postoperative days; in the control group, one patient manifested transient ischemic attack (TIA). The use of gabapentin and methylprednisolone as a single dose decreased the level of postoperative pain on the day of surgery, the dose of opioid analgesic preparations, and the level of inflammatory parameters without infectious processes.
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Hansen CB, Sandholdt H, Møller MEE, Pérez-Alós L, Pedersen L, Bastrup Israelsen S, Garred P, Benfield T. Prediction of Respiratory Failure and Mortality in COVID-19 Patients Using Long Pentraxin PTX3. J Innate Immun 2022; 14:493-501. [PMID: 35066500 PMCID: PMC9059012 DOI: 10.1159/000521612] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/16/2021] [Indexed: 01/08/2023] Open
Abstract
The course of COVID-19 is unpredictable, ranging from asymptomatic to respiratory failure and death. Prognostic biomarkers are urgently needed. We hypothesized that long pentraxin PTX3 could be a valuable plasma biomarker due to its essential role in inflammatory processes. In a prospective hospitalized COVID-19 derivation cohort (n = 126) during the spring of 2020, we measured PTX3 within 4 days of admission. The predictive value of mechanical ventilation (MV) and 30-day mortality compared with clinical parameters and other markers of inflammation were assessed by logistic regression analysis and expressed as odds ratio (OR) with 95% confidence interval (CI). Analyses were repeated in a prospective validation cohort (n = 112) of hospitalized patients with COVID-19 treated with remdesivir and dexamethasone. Thirty-day mortality in the derivation cohort was 26.2%. In patients who died, the median PTX3 concentration upon admission was 19.5 ng/mL (IQR: 12.5–33.3) versus 6.6 ng/mL (IQR 2.9–12.3) (p < 0.0001) for survivors. After adjustment for covariates, the odds of 30-day mortality increased two-fold for each doubling of PTX3 (OR 2.03 [95% CI: 1.23–3.34], p = 0.006), which was also observed in the validation cohort (OR 1.70 [95% CI: 1.09–2.67], p = 0.02). Similarly, PTX3 levels were associated with MV. After adjustment for covariates, OR of MV was 2.34 (95% CI: 1.33–4.12, p = 0.003) in the derivation cohort and 1.64 (95% CI: 1.03–2.62, p = 0.04) in the validation cohort. PTX3 appears to be a useful clinical biomarker to predict 30-day respiratory failure and mortality risk in COVID-19 patients treated with and without remdesivir and dexamethasone.
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Affiliation(s)
- Cecilie Bo Hansen
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Section 7631, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Håkon Sandholdt
- Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | | | - Laura Pérez-Alós
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Section 7631, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Lise Pedersen
- Department of Clinical Biochemistry, Holbaek Hospital, Holbaek, Denmark
| | - Simone Bastrup Israelsen
- Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Peter Garred
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Section 7631, Rigshospitalet University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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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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The effect of pre-operative high doses of methylprednisolone on pain management and convalescence after total hip replacement in elderly: a double-blind randomized study. INTERNATIONAL ORTHOPAEDICS 2020; 45:857-863. [PMID: 32940751 PMCID: PMC8052240 DOI: 10.1007/s00264-020-04802-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022]
Abstract
Purpose The aim of the study was to assess whether administration of a single dose of methylprednisolone in the group patients above 65 years of age will be effective in complex analgesic management after total hip arthroplasty (THA). Methods Seventy-seven patients above 65 years old were double-blind randomized into two: the study and controls groups. Pre-operatively, the study group received as a single dose of 125 mg intravenous methylprednisolone, while the others saline solution as placebo. Peri-operatively, all the patients were administered opioid and nonopioid analgesic agents. We measured the levels of inflammatory markers (leukocytosis, C-reactive protein—CRP), pain intensity level (visual analog scale—VAS; numerical rating scale—NRS), the life parameters, and noted complications. Results Following administration of methylprednisolone were significantly lower levels of CRP on all the four post-operative days; leukocytosis on the second day; the VAS/NRS score at rest after six, 12, and 18 hours post-operatively, diminished the dose of parenteral opioid preparations (oxycodone hydrochloride), the duration of analgesia by peripheral nerve block was significantly higher as compared with the placebo group (p < 0.000001). No infectious complications were noted; there was one patient who developed post-operative delirium. Conclusion A single dose of methylprednisolone significantly reduces the level of post-operative pain at rest on the day of THA in the group patients above 65 years of age, decreases the dose of opioid analgesic agents, and significantly decreases the level of inflammatory markers, without infectious processes.
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Wu L, Si H, Li M, Zeng Y, Wu Y, Liu Y, Shen B. The optimal dosage, route and timing of glucocorticoids administration for improving knee function, pain and inflammation in primary total knee arthroplasty: A systematic review and network meta-analysis of 34 randomized trials. Int J Surg 2020; 82:182-191. [PMID: 32877755 DOI: 10.1016/j.ijsu.2020.07.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/31/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Glucocorticoids are a mainstay to control postoperative pain, inflammation, nausea and vomiting (PONV) in total knee arthroplasty (TKA). Understanding the optimal dose and route of glucocorticoids administration in TKA is of great significance in speedy functional recovery. We aimed to summarize, evaluate and rank order the efficacy of glucocorticoids regimens in TKA. METHODS Electronic databases (PubMed et al.) were systematically searched from inception up to April 30, 2020. The primary outcomes were visual analogue scale (VAS), range of motion (ROM) and knee society score (KSS). C-reactive Protein (CRP) and PONV were also evaluated. Multivariable Bayesian random effects models were used to synthesize and rank the comparative efficacy of glucocorticoids regimens. RESULTS A total of 34 eligible randomized controlled trials with 11 different glucocorticoids regimens were assessed. Overall inconsistency and heterogeneity were acceptable. Multiple medium dose perioperative intravenous injection (IV) ranked first in the analgesia network and a single high doses of preoperative IV ranked first in the inflammation and PONV network. There was no statistically significant increase in ROM or KSS in all the glucocorticoid formulations and doses compared with controls on postoperative day 30. CONCLUSIONS Glucocorticoid multiple intravenous injection was preferable to a single intravenous injection (preoperative and postoperative), periarticular injection and intra-articular injection in analgesia. Based on the available evidence, a medium dose of hydrocortisone of 2-4 mg/kg is optimal.
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Affiliation(s)
- Limin Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Haibo Si
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Mingyang Li
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yi Zeng
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yuan Liu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
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Kehlet H, Lindberg-Larsen V. High-dose glucocorticoid before hip and knee arthroplasty: To use or not to use-that's the question. Acta Orthop 2018; 89:477-479. [PMID: 29781366 PMCID: PMC6202732 DOI: 10.1080/17453674.2018.1475177] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University
- The Lundbeck Foundation Centre for Fast-track Hip and Knee replacement, Copenhagen, Denmark
| | - Viktoria Lindberg-Larsen
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University
- The Lundbeck Foundation Centre for Fast-track Hip and Knee replacement, Copenhagen, Denmark
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