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

Safety of perioperative intravenous different doses of dexamethasone in primary total joint arthroplasty: a retrospective large-scale cohort study

PURPOSE

Perioperative intravenous different doses of dexamethasone (DEX) can realize effective clinical outcomes in total joint arthroplasty (TJA). However, the effect of different DEX doses on readmission rates and postoperative complications remains unclear.

METHODS

We retrospectively analyzed patients who underwent primary TJA between December 2012 and October 2020. Patients were categorized into three groups based on the total perioperative dose of DEX: control group (DEX = 0 mg), low-dose group (DEX < 15 mg), and high-dose group (DEX ≥ 15 mg). Primary outcomes included 30-day and 90-day readmission rates. Secondary outcomes included the rates of periprosthetic joint infection (PJI) and wound complications, with treatment outcomes for these complications were also evaluated. Multivariable analysis was used to identify risk factors for readmission.

RESULTS

A total of 14,557 procedures were included, with 6,686 in the control group, 4,325 in the low-dose group, and 3,546 in the high-dose group. No significant differences were observed among the groups for 30-day (p = 0.645) or 90-day readmission rates (p = 0.539). Additionally, there were no significant differences in rates of PJI (p = 0.401) or wound complications (p = 0.079). Treatment for PJI and wound complications was successful across all groups. Risk factors for 30-day readmission included age > 80 years (OR: 2.585, 95% CI: 1.123-5.954, p = 0.026) and undergoing total hip arthroplasty (THA) (OR: 1.692, 95% CI: 1.137-2.518, p = 0.009). For 90-day readmission, age 71-80 years (OR: 2.199, 95% CI: 1.349-3.583, p = 0.002), age > 80 years (OR: 3.897, 95% CI: 1.966-7.727, p < 0.001), and THA (OR: 1.622, 95% CI: 1.179-2.230, p = 0.003) were significant risk factors. However, neither low-dose nor high-dose DEX was associated with increased 30-day or 90-day readmission rates.

CONCLUSIONS

Perioperative intravenous DEX may be not associated with the readmission, PJI, and wound complications in patients undergoing primary TJA.

Perioperative Dexamethasone Split Between Two Doses Further Reduced Early Postoperative Nausea and Vomiting Than Single-Dose Dexamethasone: A Randomized Blinded Placebo-Controlled Trial

BACKGROUND

We investigated whether two doses of dexamethasone are more effective than a single dose in reducing early postoperative nausea and vomiting (PONV) during total knee arthroplasty (TKA).

METHODS

A total of 150 patients between June 2021 and June 2022 were randomized into 3 groups: two doses of normal saline (group A), a single dose of 10 mg dexamethasone before surgery and normal saline after surgery (group B), and two doses of 5 mg dexamethasone during the perioperative period (group C). Primary outcomes were incidences and severity of PONV within 24 hours after surgery, the number and consumption of patients requiring morphine and metoclopramine, and visual analog scale scores for nausea and vomiting at 2, 4, 6, and 24 hours after surgery. Blood glucose levels on days 1, 2, and 3 after operation and incidences of surgical site infection (SSI) as well as gastrointestinal bleeding (GIB) within 45 days after operation were compared.

RESULTS

Within 24 hours after operation, the number and consumption of patients requiring morphine and metoclopramide in groups B and C were significantly lower than those in group A. Incidences and severity of PONV in groups B and C were significantly lower than those in group A. And these differences between groups B and C were significant. At 2, 4, 6, and 24 hours after operation, there were significant differences in visual analog scale scores of PONV between groups A and B, A and C, as well as B and C. On postoperative days 1, 2, and 3, there were no significant differences in blood glucose levels among the groups, and there were no incidences of SSI or GIB in any group within 45 days after operation.

CONCLUSION

Dexamethasone significantly reduces PONV within 24 hours after TKA, does not result in significant changes in postoperative blood glucose levels, and does not increase the risk of SSI or GIB, particularly on group C.

REGISTRATION NUMBER

ChiCTR2400088512.

REGISTRATION CENTER

Chinese Clinical Trial Registry (ChiCTR). WEBSITE: www.chictr.org.cn.

Non-Opioid Analgesia Protocols After Total Hip Arthroplasty and Total Knee Arthroplasty: An Updated Scoping Review and Meta-Analysis

BACKGROUND

Despite their effectiveness in postoperative analgesia regimens for total knee arthroplasty (TKA) and total hip arthroplasty (THA), opioid medications are accompanied by well-known side effects and a risk of long-term dependence. These drawbacks have prompted the exploration of opioid-free analgesia protocols. The purpose of this study was to summarize the nature and extent of evidence available on opioid-free analgesia protocols in THA and TKA management.

METHODS

A scoping review of all Medline, Embase, and CENTRAL-indexed studies published between March 2019 and May 2023 was conducted, focusing on opioid-free analgesia regimens following THA and TKA. All included studies were assessed for potential risk of bias. Meta-analyses of pooled opioid-free percentages and pain scores were conducted using odds ratio and standardized mean difference, respectively, in a random-effects model.

RESULTS

A total of 23 studies (15 TKAs and eight THAs) were included. Among both TKA and THA, rescue opioids were the most commonly reported postoperative intervention. The most commonly investigated nonopioid analgesic modality was local anesthetics/nerve blocks with 52.2% (12 of 23) of the studies, followed by multimodal combinations (21.7%) and intravenous corticosteroids (13.0%). Only two of the 10 included TKA randomized controlled studies demonstrated statistically significant increases in the postoperative opioid-free rates. Of the six included THA randomized controlled trials, four demonstrated statistically significant increases in patients completing the postoperative period opioid-free. Our meta-analysis demonstrated a statistically significant impact of nerve blocks following TKA on the opioid-free rate and postoperative pain scores. Among the included THA studies, all studies in which patients received postoperative intravenous corticosteroids demonstrated significant increases in opioid-free percentage.

CONCLUSIONS

Despite some nonopioid analgesics demonstrating promise, rescue opioids remained the most frequently employed postoperative pain medication. The optimized opioid-free analgesic regimen likely requires a multimodal approach, especially using both local anesthetics/nerve blocks and intravenous corticosteroids. Further investigation and reporting of opioid-free episodes of care are needed.

The effect of a split-dose intravenous dexamethasone and a single high-dose on postoperative blood glucose after total joint arthroplasty: a randomized double-blind placebo-controlled trial

BACKGROUND

In patients undergoing total joint arthroplasty (TJA), the administration of dexamethasone may contribute to perioperative blood glucose (BG) disturbances, potentially resulting in complications, even in patients without diabetes. This study aimed to demonstrate the impact of different administration regimens of dexamethasone in postoperative BG levels.

METHODS

In this randomized, controlled, double-blind trial, 136 patients without diabetes scheduled for TJA were randomly assigned to three groups: two perioperative saline injections (Group A, placebo); a single preoperative injection of 20 mg dexamethasone and a postoperative saline injection (Group B), and two perioperative injections of 10 mg dexamethasone (Group C). Primary outcomes were the postoperative fasting blood glucose (FBG) levels. Secondary outcome parameters were the postoperative postprandial blood glucose (PBG) levels. Postoperative complications within 90 days were also recorded. Risk factors for FBG ≥ 140 mg/dl and PBG ≥ 180 mg/dl were investigated.

RESULTS

Compared to Group A, there were transient increases in FBG and PBG on postoperative days (PODs) 0 and 1 in Groups B and C. Statistical differences in FBG and PBG among the three groups were nearly absent from POD 1 onward. Both dexamethasone regimens did not increase the risk for postoperative FBG ≥ 140 mg/dl or PBG ≥ 180 mg/dl. Elevated preoperative HbA1c levels may increase the risk of postoperative FBG ≥ 140 mg/dl or PBG ≥ 180 mg/dl, respectively.

CONCLUSION

Perioperative intravenous high-dose dexamethasone to patients without diabetes has transient effects on increasing BG levels after TJA. However, no differences were found between the split-dose and single high-dose regimens. The elevated preoperative HbA1c, but not the dexamethasone regimens were the risk factor for FBG ≥ 140 mg/dl and PBG ≥ 180 mg/dl.

TRIAL REGISTRATION

Chinese Clinical Trail Registry, ChiCTR2300069473. Registered 17 March 2023, https://www.chictr.org.cn/showproj.html?proj=186760 .

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

STUDY OBJECTIVE

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

DESIGN

Systematic review of RCTs with meta-analysis.

SETTING

Acute postoperative pain treatment in non-obese adult population.

INTERVENTIONS

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

MEASUREMENTS

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

MAIN RESULTS

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

CONCLUSION

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

PROTOCOL REGISTRATION

CRD42020137119.

The impact of preoperative single low-dose dexamethasone on in-hospital prognosis in geriatric intertrochanteric fracture patients: Analysis of secondary outcomes in a randomized controlled trial

BACKGROUND

Intertrochanteric fracture in the geriatric population is associated with poor prognosis, which may be attributed to consistent stress and the systemic inflammatory response. Dexamethasone is an exogenous glucocorticoid commonly used in clinical practice for broad anti-inflammatory action. The purpose is to investigate whether a single preoperative low-dose dexamethasone can improve the in-hospital prognosis in geriatric intertrochanteric fracture patients undergoing internal fixation surgery.

METHODS

Between June 2020 and October 2022, 219 eligible patients with intertrochanteric fractures were in this study. After meeting the inclusion and exclusion criteria, 160 patients were randomly allocated to the dexamethasone or placebo groups (80 patients who are geriatric with an intertrochanteric fracture in each group). The patients in the dexamethasone group received 10 mg (2 mL) of dexamethasone intravenously, whereas the patients in the placebo group received 2 mL of saline intravenously within 30 minutes before being sent to the operating room. The efficacy-related outcomes (the first bed-chair transfer ability, in-hospital mortality, and length of stay) and safety-related outcomes (infection events and hyperglycemia) were collected for analysis.

RESULTS

There were no significant differences in the baseline characteristics between the 2 groups. The dexamethasone group had a significantly higher rate of the first bed-chair transfer than the placebo group (65.0% [52/80] vs 48.8% [39/80], relative risk = 1.46, 95% confidence interval = 1.02 to 2.11; P = .038). One patient in the dexamethasone group and 7 patients in the placebo group died during hospitalization (1.3% [1/80] vs 8.8% [7/80], relative risk = 0.92, 95% confidence interval = 0.86 to 0.99; P = .07). No differences were found in the length of stay, infections, and hyperglycemia between the 2 groups.

CONCLUSION

A single preoperative low-dose of dexamethasone can improve the in-hospital prognosis (increase the ability of the first bed-chair transfer and potentially decrease the in-hospital mortality) in geriatric intertrochanteric fracture patients after internal fixation surgery.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

RESULTS

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

CONCLUSION

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

REGISTRATION

PROSPERO ID: CRD42019135034.

The AAHKS Best Podium Presentation Research Award: A Second Dose of Dexamethasone Reduces Postoperative Opioid Consumption and Pain in Total Joint Arthroplasty

BACKGROUND

The optimal administration of dexamethasone for postoperative pain management and recovery following primary elective total joint arthroplasty (TJA) remains unclear. This study aimed to evaluate the effect of a second intravenous (IV) dose of dexamethasone on postoperative pain scores, inpatient opioid consumption, and functional recovery after total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

A retrospective review was conducted of 2,256 primary elective THAs and 1,951 primary elective TKAs between May 2020 and April 2021. Patients who received 2 perioperative doses (2D) of dexamethasone 10 mg IV were propensity-matched 1:1 to a control group who received 1 perioperative dose (1D). Primary outcomes were opiate consumption as morphine milligram equivalences (MMEs), postoperative pain as Verbal Rating Scale (VRS) pain scores, and functional status assessed by the Activity Measure for Post-Acute Care (AM-PAC) scores.

RESULTS

The 2D THA and 2D TKA cohorts consumed significantly less opiates at the 24 to 48-hour and 48 to 72-hour intervals. The 2D TKA cohort had significantly lower total opiate consumption compared to the 1D TKA cohort. Compared to the 1D cohorts, the 2D THA cohort and 2D TKA cohorts had significantly lower pain scores at the 48 to 60-hour interval; additionally, the 2D TKA cohort had significantly lower pain scores in the 36 to 48-hour interval. AM-PAC scores did not differ between cohorts for both TKA and THA at any interval.

CONCLUSION

The administration of a second perioperative dexamethasone dose significantly decreased opioid consumption in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining comparable functional recovery and superior pain control.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Patient satisfaction after total hip arthroplasty: Influencing factors

It is reported that the dissatisfaction rate after primary total hip arthroplasty (THA) is between 7% and 20%. Patient satisfaction has already become a public health problem that puzzles the world, and it is a problem to be solved that cannot be ignored in the development of global public health. The purpose of this paper is to conduct a narrative review of the literature to answer the following questions: what are the main factors leading to high patient satisfaction or dissatisfaction after THA? The literature on patient satisfaction after THA was reviewed. As far as we know, there is no such detailed and timely overview of THA satisfaction as this article, and the purpose articles we use search engines to search are all RCT (Randomized Controlled Trial) type works, excluding cross-sectional studies and other experiments with low evidence level. Hence, the quality of this article is high. The search engines used are MEDLINE (PubMed) and EMBASE. The keywords used are "THA" and "satisfaction." The main preoperative, perioperative, and postoperative factors that affect patient satisfaction are summarized in detail below.

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.

Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies

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.