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Wainwright JD, Gugala Z, Krueger CA, Wenke JC. Adding corticosteroids to intra-operative periarticular injections in total knee arthroplasty: A systematic review. Knee 2024; 49:87-96. [PMID: 38876084 DOI: 10.1016/j.knee.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 05/20/2024] [Accepted: 05/24/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Adding corticosteroids to intraoperative periarticular injections (PAIs) have become a current trend in total knee arthroplasty (TKA). Periarticular corticosteroid injections (PACSIs) intend to improve postoperative pain and function. However, preoperative corticosteroid injections for symptomatic arthritis increase the rates of prosthetic joint infection (PJI) when given months prior to TKA. The aim of this systematic review was to determine whether the addition of corticosteroids to PAIs during TKA improves patient outcomes and whether such practice increases the risk of PJI? METHODS A systematic review of the current literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines screened 1025 abstracts. Thirteen studies meeting specific eligibility criteria were included for further analysis. RESULTS Among the studies comparing the PACSIs versus nonsteroidal PAIs, 36% showed a significant reduction in postoperative pain scores, 20% showed significant improvement in range of motion (ROM), and 16% showed a significant reduction in total morphine equivalence (TME). While 100% of the studies comparing PACSI to saline or no injections showed significant improvement in pain, ROM and TME. In total, there were 3 infections in 576 TKA cases receiving PACSIs and 2 infections in 534 cases not receiving a PACSI. However, studies were not powered specifically to assess for infection. CONCLUSIONS The addition of corticosteroids to intraoperative PAIs do not demonstrate a significant benefit in the majority of studies, and tend to not have an effect on PJI risk; however, studies were not specifically powered to assess PJI risk.
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Affiliation(s)
- Jared D Wainwright
- University of Texas Medical Branch Department of Orthopaedic Surgery and Rehabilitation, 301 University Blvd., Galveston, TX 77555, United States; Shriners Children's Hospital Texas, 815 Market St., Galveston, TX 77550, United States.
| | - Zbigniew Gugala
- University of Texas Medical Branch Department of Orthopaedic Surgery and Rehabilitation, 301 University Blvd., Galveston, TX 77555, United States
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St., Philadelphia, PA 19107, United States
| | - Joseph C Wenke
- University of Texas Medical Branch Department of Orthopaedic Surgery and Rehabilitation, 301 University Blvd., Galveston, TX 77555, United States; Shriners Children's Hospital Texas, 815 Market St., Galveston, TX 77550, United States
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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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Deng S, Chen L, Song X, Guo L, Zhao F, Liu J, Dong L. Analgesic Effect of Intraoperative Intravenous S(+)-Ketamine During Total Knee Arthroplasty Surgery: Study Protocol for a Randomized Controlled Clinical Trial. JMIR Res Protoc 2023; 12:e53063. [PMID: 38064260 PMCID: PMC10746976 DOI: 10.2196/53063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is currently the main treatment for end-stage knee disease. The number of cases of TKA in China increased from 53,880 in 2011 to 374,833 in 2019, representing a 5.9-fold increase. Moderate to severe pain often occurs after TKA, which seriously affects postoperative rehabilitation, patient satisfaction, and overall outcome. Multimodal analgesia is considered the ideal solution. Adequate postoperative analgesia can not only reduce pain, opioid consumption, and, consequently, opioid-related adverse events, but can also reduce the length of hospital stay and costs and improve rehabilitation and patient satisfaction. OBJECTIVE Effective multimodal pain management in the early postoperative period is essential for anesthesiologists. Additional studies have demonstrated that a low-dose intravenous infusion of ketamine can be administered as an adjuvant drug to alleviate acute postoperative pain. Therefore, we aim to appraise the efficacy and safety of intraoperative intravenous injection of S(+)-ketamine to relieve acute pain after TKA in older patients. METHODS This is a protocol for a randomized, placebo-controlled trial. A total of 144 participants aged 65 years and older undergoing TKA will be randomly allocated into the S(+)-ketamine and placebo groups in a 1:1 ratio. S(+)-ketamine or the placebo will be intravenously administered at 0.3 mg/kg/h during the operation by anesthesiologists. Blinded evaluation by trained investigators will be completed at 2 hours, 24 hours, and 48 hours after surgery. The primary outcome measure will be the numeric rating scale score at rest and movement at 24 hours after surgery. The secondary outcomes will include the numeric rating scale scores at rest and movement at 2 hours and 48 hours after surgery, the number of patients who require additional analgesics during the first 48 hours after operation, the total consumption of opioids or nonsteroid anti-inflammatory drugs during the first 48 hours after operation, and adverse events at 2, 24, and 48 hours after operation. RESULTS The protocol was registered at Clinical Trials.gov on February 26, 2022. It was performed in accordance with the approved guidelines and regulations of the participating institutions. Recruitment began in April 2022. Data collection is expected to conclude in September 2024. Study completion is expected in December 2024. CONCLUSIONS A randomized, controlled, clinical study was designed to observe the analgesic effect of intraoperative intravenous administration of a lower dose of S(+)-ketamine (0.3 mg/kg/h) in older patients after TKA surgery. The protocol will appraise the efficacy and safety of intraoperative intravenous injection of S(+)-ketamine to relieve acute pain after TKA in older patients who may benefit from the administration of S(+)-ketamine. TRIAL REGISTRATION ClinicalTrials.gov NCT05289050; https://clinicaltrials.gov/ct2/show/NCT05289050. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/53063.
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Affiliation(s)
- Shiyuan Deng
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Lina Chen
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Xiao Song
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Liang Guo
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Fei Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Jing Liu
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Ling Dong
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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Oeyen AL, Kircher J, Vogl M, Ickert I, Osada N, Krauspe R, Bittersohl B, Herten M. Dexamethasone Does not Compensate for Local Anesthetic Cytotoxic Effects on Tenocytes: Morphine or Morphine Plus Dexamethasone May Be a Safe Alternative. Arthrosc Sports Med Rehabil 2022; 4:e459-e469. [PMID: 35494256 PMCID: PMC9042774 DOI: 10.1016/j.asmr.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/03/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose The purposes of this in vitro study were to investigate whether the addition of dexamethasone can compensate for any cytotoxic effects of the amide-type local anesthetics (LA) bupivacaine and ropivacaine and whether morphine and morphine-6-glucuronide (M6G) may be a safe alternative for peritendinous application. Methods Biopsies of human biceps tendons (n = 6) were dissected and cultivated. Cells were characterized by the expression for tenocyte markers, collagen I, biglycan, tenascin C, scleraxis, and RUNX via reverse transcriptase-polymerase chain reaction and immunohistochemistry. Tenocytes were incubated with bupivacaine, ropivacaine, morphine, M6G, or a saline control with and without addition of dexamethasone for 15, 60, or 240 min. Cell viability was determined by quantifying the presence of adenosine-triphosphate. Results Significant time-dependent cytotoxic effects were observed for LA after all exposure times. After 15, 60, and 240 minutes, cell viability decreased to 81.1%, 49.4% and 0% (P < .001) for bupivacaine and to 81.4%, 69.6%, and 9.3% (P < .001) for ropivacaine compared to saline control. Dexamethasone did not compensate for these cytotoxic effects. Cell viability was not affected after 15, 60-min exposures to morphine and M6G but decreased significantly (P < .001) after 240 minutes compared to saline control. However, in combination with dexamethasone, tenocyte viability was significantly increased at all times for morphine (P < .01) and at 15 and 60 minutes for M6G (P < .01). Conclusions The results showed that amide-type LA have a time-dependent cytotoxic effect on human tenocytes in vitro, which could not be compensated for by dexamethasone, whereas morphine and M6G had no cytotoxic effects on tenocytes after 15 and 60 minutes. The addition of dexamethasone to morphine and M6G had a positive effect on viability, which increased significantly compared to the opioids. Clinical Relevance It is known that amide-type local anesthetics used for local joint analgesia have chondrotoxic side-effects. The combined application of morphine and dexamethasone may be a safe alternative.
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Affiliation(s)
- Anne Lene Oeyen
- Department of Orthopedic and Trauma Surgery, Caritas-Klinik Maria Heimsuchung Berlin-Pankow, Berlin, Germany.,Department of Orthopedic Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Jörn Kircher
- Department of Shoulder and Elbow Surgery, ATOS Klinik Fleetinsel Hamburg, Hamburg, Germany.,Department of Orthopedic Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Melanie Vogl
- Department of Pediatrics, University Hospital Essen, Essen, Germany
| | - Irina Ickert
- Department of Medicine II, Rheinlandklinikum Neuss, Neuss, Germany
| | - Nani Osada
- Department of Medical Statistics and Biomathematics (formerly), University of Münster, Münster, Germany
| | - Rüdiger Krauspe
- Department of Orthopedic Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Bernd Bittersohl
- Department of Orthopedic Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.,Department of Orthopedic and Trauma Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Monika Herten
- Department of Orthopedic Surgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.,Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
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