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Liu XY, Mou P, Cao J, Wang HY, Zeng WN, Zhou ZK. Effects of Dexamethasone on Postoperative Glycemic Control in Patients After Primary Total Joint Arthroplasty: A Randomized Double-Blind Controlled Trial. J Arthroplasty 2024; 39:2213-2220. [PMID: 38614358 DOI: 10.1016/j.arth.2024.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND In patients undergoing total joint arthroplasty, the use of dexamethasone (DEX) may cause perioperative blood glucose (BG) disorders, leading to complications even in patients who do not have diabetes. We aimed to evaluate the effects of different DEX doses on perioperative BG levels. METHODS A total of 135 patients who do not have diabetes were randomized into three groups: preoperative intravenous (IV) injection of normal saline (Group A, the placebo group), preoperative IV injection of 10 mg DEX (Group B), and preoperative IV injection of 20 mg DEX (Group C). Postoperative fasting BG (FBG) levels were designated as the primary outcome, while postoperative postprandial BG (PBG) levels were assigned as the secondary outcome. The incidence of complications was recorded. We also investigated the risk factors for FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL. RESULTS The FBG levels were higher in Groups B and C than in Group A on postoperative days (PODs) 0 and 1. The PBG levels were lower for Groups A and B compared to Group C on POD 1. No differences in FBG or PBG were detected beyond POD 1. Elevated preoperative glycosylated hemoglobin A1c levels increased the risk of FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL, respectively. However, preoperative IV injection of DEX was not associated with FBG ≥ 140 mg/dL or PBG ≥ 180 mg/dL. No differences were found in postoperative complications among the three groups. CONCLUSIONS The preoperative IV administration of 10 or 20 mg DEX in patients who do not have diabetes showed transient effects on postoperative BG after total joint arthroplasty. The preoperative glycosylated hemoglobin A1c level threshold (regardless of the administration or dosage of DEX) that increased the risk for the occurrence of FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL was 5.75 and 5.85%, respectively.
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Affiliation(s)
- Xiao-Yang Liu
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Ping Mou
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China; Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jian Cao
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Hao-Yang Wang
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Wei-Nan Zeng
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zong-Ke Zhou
- Department of Orthopedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Burch MA, Keshishian A, Wittmann C, Nehrbass D, Thompson K, Arens D, Richards RG, Mdingi V, Chitto M, Morgenstern M, Moriarty TF, Eijer H. Impact of Perioperative Dexamethasone Administration on Infection and Implant Osseointegration in a Preclinical Model of Orthopedic Device-Related Infection. Microorganisms 2024; 12:1134. [PMID: 38930516 PMCID: PMC11205448 DOI: 10.3390/microorganisms12061134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
Glucocorticoids may be given prior to major orthopedic surgery to decrease postoperative nausea, vomiting, and pain. Additionally, many orthopedic patients may be on chronic glucocorticoid therapy. The aim of our study was to investigate whether glucocorticoid administration influences Orthopedic-Device-Related Infection (ODRI) in a rat model. Screws colonized with Staphylococcus epidermidis were implanted in the tibia of skeletally mature female Wistar rats. The treated groups received either a single shot of dexamethasone in a short-term risk study, or a daily dose of dexamethasone in a longer-term interference study. In both phases, bone changes in the vicinity of the implant were monitored with microCT. There were no statistically significant differences in bacteriological outcome with or without dexamethasone. In the interference study, new bone formation was statistically higher in the dexamethasone-treated group (p = 0.0005) as revealed by CT and histopathological analysis, although with relatively low direct osseointegration of the implant. In conclusion, dexamethasone does not increase the risk of developing periprosthetic osteolysis or infection in a pre-clinical model of ODRI. Long-term administration of dexamethasone seemed to offer a benefit in terms of new bone formation around the implant, but with low osseointegration.
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Affiliation(s)
- Marc-Antoine Burch
- AO Research Institute Davos, 7270 Davos, Switzerland; (M.-A.B.)
- Klinik für Orthopädie und Traumatologie, Universitätsspital Basel, 4031 Basel, Switzerland
| | - Aron Keshishian
- AO Research Institute Davos, 7270 Davos, Switzerland; (M.-A.B.)
- Spital Emmental, 3400 Burgdorf, Switzerland
| | | | - Dirk Nehrbass
- AO Research Institute Davos, 7270 Davos, Switzerland; (M.-A.B.)
| | - Keith Thompson
- AO Research Institute Davos, 7270 Davos, Switzerland; (M.-A.B.)
| | - Daniel Arens
- AO Research Institute Davos, 7270 Davos, Switzerland; (M.-A.B.)
| | | | - Vuysa Mdingi
- AO Research Institute Davos, 7270 Davos, Switzerland; (M.-A.B.)
- Department of Orthopaedic Surgery, Dr Pixley Ka Isaka Seme Memorial Hospital, School of Clinical Medicine, University of KwaZulu Natal, Durban 4041, South Africa
| | - Marco Chitto
- AO Research Institute Davos, 7270 Davos, Switzerland; (M.-A.B.)
| | - Mario Morgenstern
- Klinik für Orthopädie und Traumatologie, Universitätsspital Basel, 4031 Basel, Switzerland
- Center for Muskuloskeletal Infections (ZMSI), University Hospital Basel, 4031 Basel, Switzerland
| | - T. Fintan Moriarty
- AO Research Institute Davos, 7270 Davos, Switzerland; (M.-A.B.)
- Center for Muskuloskeletal Infections (ZMSI), University Hospital Basel, 4031 Basel, Switzerland
| | - Henk Eijer
- Spital Emmental, 3400 Burgdorf, Switzerland
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Gettleman BS, Liu KC, Yoshida B, Vega AN, Kusnezov N, Lieberman JR, Heckmann ND. Perioperative Dexamethasone is Associated with a Decreased Risk of Pulmonary Embolism and Deep Vein Thrombosis Following Total Joint Arthroplasty: An Analysis of 70,000 High-Risk Patients. J Arthroplasty 2024:S0883-5403(24)00453-4. [PMID: 38735549 DOI: 10.1016/j.arth.2024.05.020] [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: 09/23/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Dexamethasone (DEX) has demonstrated promise with respect to decreasing postoperative thromboembolic complications following total joint arthroplasty (TJA). Therefore, the aim of this study was to investigate the effects of perioperative intravenous DEX on rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) after primary TJA in patients who have a history of venous thromboembolism (VTE). METHODS Patients who have a history of VTE who underwent primary, elective TJA from 2015 to 2021 were identified using a commercial healthcare database. Patients were divided based on receipt of perioperative intravenous DEX [DEX(+) versus DEX(-)] on the day of index TJA. Patient demographics and hospital factors were collected. The 90-day risk of postoperative complications, readmission, and in-hospital mortality were compared. RESULTS Overall, 70,147 patients who had a history of VTE underwent TJA, of which 40,607 (57.89%) received DEX and 29,540 (42.11%) did not. The DEX(+) patients were younger (67 ± 9.8 versus 68 ± 9.9 years, P < 0.001) and had a significantly shorter length of stay compared to the DEX(-) patients (1.8 ± 1.6 versus 2.2 ± 1.8 days, P < 0.001). The DEX(+) patients demonstrated lower rates of PE (1.37 versus 1.75%, P < 0.001) and DVT (2.37 versus 3.01%, P < 0.001) compared to DEX(-) patients. The DEX(+) patients experienced a lower risk of PE (adjusted odds ratio [aOR] 0.78, 95% confidence interval [95%-CI]: 0.66 to 0.93, P = 0.006) and DVT (aOR: 0.84, 95%-CI: 0.74 to 0.95, P = 0.006) compared to DEX(-) patients. The DEX(+) patients demonstrated no differences in the odds of surgical site infection, periprosthetic joint infection, or sepsis compared to the DEX(-) patients (P > 0.05). CONCLUSION The administration of DEX was associated with a decreased risk of PE and DVT in patients who have a history of VTE who underwent TJA. These data warrant further study investigating the postoperative benefits of perioperative DEX administration for high-risk patients undergoing TJA.
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Affiliation(s)
- Brandon S Gettleman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kevin C Liu
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon Yoshida
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Andrew N Vega
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nicholas Kusnezov
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California.
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Li Q, Fang G, Liao W, Chen B, Yang Y, Liao J, Fu G, Ma Y, Zheng Q. Intraoperative intravenous versus periarticular injection of glucocorticoids in improving clinical outcomes after total knee arthroplasty: A prospective, randomized and controlled study. J Orthop Surg (Hong Kong) 2024; 32:10225536241256554. [PMID: 38753310 DOI: 10.1177/10225536241256554] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Glucocorticoids have been widely used in perioperative period for postoperative pain relief after total knee arthroplasty (TKA). However, the optimal administration protocols of glucocorticoids remain controversial. This study aims to compare the efficacy of glucocorticoids between intravenous and periarticular injection on clinical outcomes. METHODS A total of 114 patients were randomly assigned to intravenous (IV) group (n = 57) and periarticular injection (PI) group (n = 57). The IV group received 10 mg dexamethasone intravenously and the PI group received periarticular injection of 10 mg dexamethasone during the procedure. The clinical outcomes were assessed using visual analogue scale (VAS), knee society score (KSS), range of motion (ROM), knee swelling, inflammation markers and complications after TKA. RESULTS The VAS score during walking at 2nd day postoperatively was lower in the PI group compared with the IV group (2.08 ± 1.45 vs 2.73 ± 1.69, p = .039), and there was no significant difference at the other time points of VAS score in two groups. The inflammation markers, knee swelling, knee ROM and KSS score were not statistically different. Vomiting and other complications occurrence were not significantly different between the two groups. CONCLUSIONS Intraoperative periarticular injection of glucocorticoids has similar analgesic effect compared to intravenous in the postoperative period following TKA and may be even more effective on the second postoperative day. In addition, periarticular injection of glucocorticoids does not impose an excess risk or complication on patients.
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Affiliation(s)
- Qingtian Li
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Guibin Fang
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Weihong Liao
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Binlong Chen
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Yuhui Yang
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Junxing Liao
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Guangtao Fu
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Yuanchen Ma
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Qiujian Zheng
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
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Wagner ER, Hussain ZB, Karzon AL, Cooke HL, Toston RJ, Hurt JT, Dawes AM, Gottschalk MB. Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner. J Shoulder Elbow Surg 2024; 33:985-993. [PMID: 38316236 DOI: 10.1016/j.jse.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/05/2023] [Accepted: 12/17/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Perioperative corticosteroids have shown potential as nonopioid analgesic adjuncts for various orthopedic pathologies, but there is a lack of research on their use in the postoperative setting after total shoulder arthroplasty (TSA). The purpose of this study was to assess the effect of a methylprednisolone taper on a multimodal pain regimen after TSA. METHODS This study was a randomized controlled trial (clinicaltrials.gov NCT03661645) of opioid-naive patients undergoing TSA. Patients were randomly assigned to receive intraoperative dexamethasone only (control group) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group). All patients received the same standardized perioperative pain management protocol. Standardized pain journal entries were used to record visual analog pain scores (VAS-pain), VAS-nausea scores, and quantity of opioid tablet consumption during the first 7 postoperative days (POD). Patients were followed for at least one year postoperatively for clinical evaluation, collection of patient-reported outcomes, and observation of complications. RESULTS A total of 67 patients were enrolled in the study; 32 in the control group and 35 in the treatment group. The groups had similar demographics and comorbidities. The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 POD. Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively. There were no differences in Europe Quality of Life, shoulder subjective value (SSV), at any time point between groups, although American Shoulder and Elbow Surgeons questionnaire scores showed a slight improvement at 6-weeks in the treatment group. At mean follow-up, (control group: 23.4 months; treatment group:19.4 months), there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. No other complications were reported. CONCLUSIONS A methylprednisolone taper course shows promise in reducing acute pain and opioid consumption as part of a multimodal regimen following TSA. As a result of this study, we have included this 6-day methylprednisolone taper course in our multimodal regimen for all primary shoulder arthroplasties. We hope this trial serves as a foundation for future studies on the use of low-dose oral corticosteroids and other nonnarcotic modalities to control pain after shoulder surgeries.
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Affiliation(s)
- Eric R Wagner
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA.
| | - Zaamin B Hussain
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
| | - Anthony L Karzon
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
| | - Hayden L Cooke
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
| | - Roy J Toston
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
| | - John T Hurt
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
| | - Alexander M Dawes
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
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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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Steiness J, Hägi-Pedersen D, Lunn TH, Overgaard S, Brorson S, Graungaard BK, Lindberg-Larsen M, Varnum C, Lundstrøm LH, Beck T, Skettrup M, Pedersen NA, Bieder MJ, von Cappeln AG, Pleckaitiene L, Lindholm P, Bukhari SSH, Derby CB, Nielsen MG, Exsteen OW, Vinstrup LØ, Thybo KH, Gasbjerg KS, Nørskov AK, Jakobsen JC, Mathiesen O. Non-opioid analgesic combinations following total hip arthroplasty (RECIPE): a randomised, placebo-controlled, blinded, multicentre trial. THE LANCET. RHEUMATOLOGY 2024; 6:e205-e215. [PMID: 38458208 DOI: 10.1016/s2665-9913(24)00020-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Multimodal postoperative analgesia following total hip arthroplasty is recommended, but the optimal combination of drugs remains uncertain. The aim of the RECIPE trial was to investigate the relative benefit and harm of the different combinations of paracetamol, ibuprofen, and the analgesic adjuvant dexamethasone for treatment of postoperative pain following total hip arthroplasty. METHODS The RECIPE trial was a randomised, blinded, placebo-controlled trial conducted at nine Danish hospitals. Adults scheduled for total hip arthroplasty were randomly assigned (1:1:1:1) using a computer-generated list with stratification by site to receive combinations of oral paracetamol 1000 mg every 6 h, oral ibuprofen 400 mg every 6 h, or a single-dose of intravenous dexamethasone 24 mg in the following groups: paracetamol plus ibuprofen, ibuprofen plus dexamethasone, paracetamol plus dexamethasone, and paracetamol plus ibuprofen plus dexamethasone. The primary outcome was 24 h intravenous morphine consumption, analysed in a modified intention-to-treat population, defined as all randomly assigned participants who underwent total hip arthroplasty. The predefined minimal important difference was 8 mg. Safety outcomes included serious and non-serious adverse events within 90 days and 24 h. The trial was registered with ClinicalTrials.gov, NCT04123873. FINDINGS Between March 5, 2020, and Nov 15, 2022, we randomly assigned 1060 participants, of whom 1043 (589 [56%] women and 454 [44%] men) were included in the modified intention-to-treat population. 261 were assigned to paracetamol plus ibuprofen, 262 to ibuprofen plus dexamethasone, 262 to paracetamol plus dexamethasone, and 258 to paracetamol plus ibuprofen plus dexamethasone. Median 24 h morphine consumption was 24 mg (IQR 12-38) in the paracetamol plus ibuprofen group, 20 mg (12-32) in the paracetamol plus dexamethasone group, 16 mg (10-30) in the ibuprofen plus dexamethasone group, and 15 mg (8-26) in the paracetamol plus ibuprofen plus dexamethasone group. The paracetamol plus ibuprofen plus dexamethasone group had a significantly reduced 24 h morphine consumption compared with paracetamol plus ibuprofen (Hodges-Lehmann median difference -6 mg [99% CI -10 to -3]; p<0·0001) and paracetamol plus dexamethasone (-4 mg [-8 to -1]; p=0·0013), however, none of the comparisons showed differences reaching the minimal important threshold of 8 mg. 91 (35%) of 258 participants in the paracetamol plus ibuprofen plus dexamethasone group had one or more adverse events, compared with 99 (38%) of 262 in the ibuprofen plus dexamethasone group, 103 (39%) of 262 in the paracetamol plus dexamethasone group, and 165 (63%) of 261 in the paracetamol plus ibuprofen group. INTERPRETATION In adults undergoing total hip arthroplasty, a combination of paracetamol, ibuprofen, and dexamethasone had the lowest morphine consumption within 24 h following surgery and the most favourable adverse event profile, with a lower incidence of serious and non-serious adverse events (primarily driven by differences in nausea, vomiting, and dizziness) compared with paracetamol plus ibuprofen. FUNDING The Novo Nordisk Foundation and Næstved-Slagelse-Ringsted Hospitals' Research Fund.
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Affiliation(s)
- Joakim Steiness
- Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark.
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Næstved, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stig Brorson
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ben Kristian Graungaard
- Department of Anaesthesiology, Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark; Department of Orthopaedic Surgery, Odense University Hospital, Svendborg, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebælt Hospital, Vejle, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Torben Beck
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Michael Skettrup
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark
| | | | - Manuel Josef Bieder
- Department of Orthopaedic Surgery, Næstved-Slagelse-Ringsted Hospitals, Næstved, Denmark
| | | | | | - Peter Lindholm
- Department of Anaesthesiology, Odense University Hospital, Odense, Denmark
| | | | | | - Maria Gantzel Nielsen
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Oskar Wilborg Exsteen
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Louise Ørts Vinstrup
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Kasper Højgaard Thybo
- Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Næstved, Denmark
| | - Kasper Smidt Gasbjerg
- Department of Anaesthesiology, Copenhagen University Hospital, Herlev Hospital, Copenhagen, Denmark
| | - Anders Kehlet Nørskov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kaiser D, Hoch A, Dimitriou D, Groeber T, Bomberg H, Aguirre JA, Eichenberger U, Zingg PO. Perioperative Intravenous Dexamethasone Significantly Reduces Postoperative Opioid Requirement and Nausea After Unilateral Elective Hip Arthroscopy: A Randomized Double-blinded Placebo-controlled Trial. Am J Sports Med 2024; 52:1165-1172. [PMID: 38456291 PMCID: PMC10986151 DOI: 10.1177/03635465241232157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/20/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Previous studies have shown that dexamethasone has a positive effect on postoperative pain control, opioid consumption, nausea, and vomiting and length of hospital stay after arthroplasty surgery. PURPOSE/HYPOTHESIS The purpose of this study was to assess whether adding perioperative dexamethasone to our current pain regimen after hip arthroscopy is more effective than a placebo. It was hypothesized that dexamethasone would reduce postoperative pain, reduce opioid consumption, improve subjective pain and nausea scores, and reduce the number of vomiting events. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 50 patients requiring unilateral elective hip arthroscopy were randomized to receive intravenous dexamethasone immediately before induction of anesthesia and at 8 am on the first postoperative day (2 ×12 mg) or a placebo (sodium chloride 0.9%). The patient, the surgeons, the treating anesthesiologist, and the involved nursing and physical therapy personnel were blinded to group assignment. The primary outcome was postoperative pain, and secondary outcomes were opioid consumption and nausea scores-assessed using a translated revised version of the American Pain Society Patient Outcome Questionnaire 6 hours postoperatively and on days 1 and 2-and vomiting events. A clinical follow-up was performed 12 weeks postoperatively to assess adverse events. RESULTS The mean age at inclusion was 29 years in both groups. Postoperative pain levels did not differ significantly in most instances. Opioid requirements during the hospitalization in the dexamethasone group were significantly lower than those in the placebo group (31.96 ± 20.56 mg vs 51.43 ± 38 mg; P = .014). Significantly fewer vomiting events were noted in the dexamethasone group (0.15 ± 0.59 vs 0.65 ± 0.91; P = .034). Descriptive data and surgical parameters did not differ significantly. CONCLUSION Perioperative intravenous dexamethasone significantly reduced postoperative opioid consumption by 40% without compromising pain level and safety, as no corticosteroid-related side effects were observed. Dexamethasone may be a valuable adjuvant to a multimodal systemic pain regimen after hip arthroscopy. REGISTRATION NCT04610398 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Dominik Kaiser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armando Hoch
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dimitris Dimitriou
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Tanja Groeber
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Hagen Bomberg
- Department of Anaesthesiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - José A. Aguirre
- Department of Anaesthesiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Urs Eichenberger
- Department of Anaesthesiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick O. Zingg
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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9
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Mou P, Zhao XD, Cai XY, Liu ZH, He CQ. The effect of preoperative different dexamethasone regimens on postoperative glycemic control in patients with type 2 diabetes mellitus undergoing total joint arthroplasty: a retrospective cohort study. J Orthop Surg Res 2024; 19:14. [PMID: 38167107 PMCID: PMC10763206 DOI: 10.1186/s13018-023-04485-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Concerns have been raised regarding the impact of preoperative intravenous dexamethasone on postoperative glycemic control in diabetic patients undergoing total joint arthroplasty (TJA). This study aimed to determine relationships between preoperative different dexamethasone regimens and postoperative fasting blood glucose (FBG), as well as to identify risk factors for postoperative FBG ≥ 200 mg/dl in diabetic patients undergoing TJA. METHODS This retrospective study included 1216 diabetic patients undergoing TJA and categorized into group A (dexamethasone = 0 mg), group B (dexamethasone = 5 mg), and group C (dexamethasone = 10 mg). All dexamethasone was administered before skin incision. FBG levels were monitored until postoperative day (POD) 3. Analyses were conducted for periprosthetic joint infection (PJI) and wound complications during 90 days postoperatively. And the risk factors for postoperative FBG ≥ 200 mg/dl were identified. RESULTS Preoperative dexamethasone administration resulted in a transiently higher FBG on POD 0 and POD 1 (all P < 0.001). However, no differences were observed on POD 2 (P = 0.583) and POD 3 (P = 0.131) among three groups. While preoperative dexamethasone led to an increase in postoperative mean FBG and postoperative maximum FBG (all P < 0.001), no differences were found in wound complications (P = 0.548) and PJI (P = 1.000). Increased HbA1c and preoperative high FBG, but not preoperative dexamethasone, were identified as risk factors for postoperative FBG ≥ 200 mg/dl. Preoperative HbA1c level of ≥ 7.15% was associated with an elevated risk of postoperative FBG ≥ 200 mg/dl. CONCLUSIONS Although preoperative intravenous administration of 5 mg or 10 mg dexamethasone in diabetic patients showed transient effects on postoperative FBG after TJA, no differences were found in the rates of PJI and wound complications during 90 days postoperatively. Notably, patients with a preoperative HbA1c level of ≥ 7.15% and elevated preoperative FBG may encountered postoperative FBG ≥ 200 mg/dl.
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Affiliation(s)
- Ping Mou
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Xiao-Dan Zhao
- Department of Orthopaedic Surgery, Trauma Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xin-Yu Cai
- Rehabilitation Medicine Department, Medical Technology Institute, West China Clinical Medical College, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Zun-Han Liu
- Department of Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital of the Army Military Medical University, Chongqing, 400038, People's Republic of China
| | - Cheng-Qi He
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China.
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China.
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10
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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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11
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Abdel-Wahab AH, Abd Alla ES, Abd El-Azeem T. Effect of intravenous dexamethasone on the duration of hyperbaric bupivacaine spinal anesthesia in lower abdominal surgery, Randomized controlled trial. BMC Anesthesiol 2023; 23:323. [PMID: 37736711 PMCID: PMC10515039 DOI: 10.1186/s12871-023-02282-y] [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: 07/15/2023] [Accepted: 09/14/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate the effect of intravenous (IV) dexamethasone on the duration of hyperbaric bupivacaine spinal anesthesia. METHODS Two hundred patients between the ages of 18 and 60, of both sexes with ASA I- II classification scheduled for lower abdominal surgery under spinal anesthesia using hyperbaric bupivacaine 0.5% were randomly divided into two groups: the dexamethasone group (Dexa group) and the control group, with 100 patients in each group. Before the administration of spinal anesthesia, the Dexa group received an intravenous infusion of 8 mg dexamethasone in 500 mL normal saline, while the control group received 500 mL normal saline only. The primary outcome of this study was to assess the effect of IV dexamethasone on the regression of hyperbaric bupivacaine spinal anesthesia. Secondary outcome measures included the total duration of sensory and motor blocks, VAS score, time of first analgesic request, total analgesic consumption within the first 24 h, and the occurrence of any side effects. RESULTS The Dexa group had significantly delayed onset of 2 dermatomes regression (P < 0.001) compared to the control group. Additionally, the Dexa group had significantly longer duration of both sensory block (P = 0.01) and motor block (P < 0.001). The Dexa group had significantly longer duration until the first postoperative analgesic request (P < 0.001) and a lower incidence of side effects compared to the control group. CONCLUSION Although the intravenous administration of dexamethasone had a limited effect on the duration of hyperbaric bupivacaine spinal anesthesia, it improved postoperative VAS scores compared to the control group and decreased overall postoperative analgesic consumption. Therefore, it can be considered a valuable addition to postoperative multimodal analgesia strategies, aiming to minimize total analgesic consumption. CLINICAL TRIAL REGISTRATION ID: NCT04778189 (2/3/2021).
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Affiliation(s)
- Amani H Abdel-Wahab
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Essam S Abd Alla
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Taghreed Abd El-Azeem
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
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12
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Kwan SA, Tulipan JE, Hameed D, Matzon JL. Effect of Perioperative Corticosteroid Administration on Early Postoperative Range of Motion and Functional Outcomes Following Dupuytren's Fasciectomy. Hand (N Y) 2023; 18:925-930. [PMID: 35321575 PMCID: PMC10470228 DOI: 10.1177/15589447221084013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of the study was to evaluate whether perioperative corticosteroid (CS) administration improves early postoperative range of motion (ROM) and function in patients undergoing Dupuytren's fasciectomy. METHODS We retrospectively identified 58 patients who underwent Dupuytren's fasciectomy by a single fellowship-trained orthopedic hand surgeon from 2016 to 2020. During this time period, 51 digits in 34 patients received a single intraoperative dose of 10 mg of intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course (CS group), and 37 digits in 24 patients did not (control group). Postoperatively, all patients started hand therapy within 1 week of surgery. At 2 and 6 weeks, patients had ROM data and Disabilities of the Arm, Shoulder, and Hand (DASH) scores collected by a blinded hand therapist. Paired t tests were used to compare the change in ROM and DASH scores at weeks 2 and 6. RESULTS The 2 cohorts had similar preoperative ROM. At 2 weeks postoperatively, the CS group had greater metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) flexion. There was no difference in MP, PIP, or DIP extension. At 6 weeks postoperatively, the CS group had greater PIP flexion. There was no difference between the groups in MP extension, MP flexion, PIP extension, DIP extension, or DIP flexion. Mean DASH scores were significantly lower in the CS group at weeks 2 and 6. There were no postoperative deep infections or complications requiring surgery in either group. CONCLUSION Perioperative CS administration appears to be safe and to improve early ROM and DASH scores following Dupuytren's fasciectomy.
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Affiliation(s)
| | - Jacob E. Tulipan
- Thomas Jefferson University and Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Daniel Hameed
- Thomas Jefferson University and Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Jonas L. Matzon
- Thomas Jefferson University and Rothman Orthopaedic Institute, Philadelphia, PA, USA
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13
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Stormholt ER, Steiness J, Derby CB, Larsen ME, Maagaard M, Mathiesen O. Glucocorticoids added to paracetamol and NSAIDs for post-operative pain: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2023; 67:688-702. [PMID: 36919281 DOI: 10.1111/aas.14237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the basic pain treatment regimen for most surgeries. Glucocorticoids have well-known anti-inflammatory and anti-emetic properties and may also demonstrate analgesic effects. We assessed benefit and harm of adding glucocorticoids to a combination of paracetamol and NSAIDs for post-operative pain management. METHODS We searched Embase, Medline and CENTRAL for randomised clinical trials investigating the addition of glucocorticoids versus placebo/no intervention to paracetamol and an NSAID in adults undergoing any type of surgery. We assessed three primary outcomes: cumulative opioid consumption at 24 h postoperatively, serious adverse events and pain at rest at 24 h postoperatively. We performed meta-analysis and trial sequential analysis (TSA), assessed risk of bias using the Risk of Bias 2 tool and used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the certainty of the evidence. RESULTS We identified 12 relevant trials of which nine trials randomising 804 participants were included in quantitative analysis. When added to paracetamol and NSAIDs, we found no evidence of a difference of glucocorticoids versus placebo/no intervention in cumulative opioid consumption at 24 h postoperatively (mean difference [MD] -0.28, TSA-adjusted 95% confidence interval [CI] -1.90 to 1.33, p = .68, moderate certainty of evidence), serious adverse events (risk ratio (RR) 0.99, TSA-adjusted 95% CI 0.27-3.63, p = .93, very low certainty of evidence) or pain on the Numeric Rating Scale at 24 h postoperatively (MD -0.39, TSA-adjusted 95% CI -0.84 to 0.17, p = .10, moderate certainty of evidence). All outcomes were assessed to be at high risk of bias and TSA showed that we had insufficient information for most outcomes. CONCLUSION Glucocorticoids added to a baseline therapy of paracetamol and an NSAID likely result in little to no difference in cumulative opioid consumption and pain at rest at 24 h postoperatively. In addition, the evidence is very uncertain about the effect on serious adverse events. For most outcomes we did not have sufficient information to draw firm conclusions and the certainty of the evidence varied from moderate to very low. EDITORIAL COMMENT Multimodal approaches for post-operative analgesia are favoured, including paracetamol and nonsteroidal anti-inflammatory drugs. In this meta-analysis, pooled results from clinical trials are assessed to describe possible benefit of addition of glucocorticoid treatment for analgesia. The findings did not identify additional benefit, though the certainty of the evidence was not high.
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Affiliation(s)
- Emma Ritsmer Stormholt
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Joakim Steiness
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Anaesthesiology, Naestved Hospital, Naestved, Denmark
| | - Cecilie Bauer Derby
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Mia Esta Larsen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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14
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Steiness J, Hägi-Pedersen D, Lunn TH, Lindberg-Larsen M, Graungaard BK, Lundstrom LH, Lindholm P, Brorson S, Bieder MJ, Beck T, Skettrup M, von Cappeln AG, Thybo KH, Gasbjerg KS, Overgaard S, Jakobsen JC, Mathiesen O. Paracetamol, ibuprofen and dexamethasone for pain treatment after total hip arthroplasty: protocol for the randomised, placebo-controlled, parallel 4-group, blinded, multicentre RECIPE trial. BMJ Open 2022; 12:e058965. [PMID: 36190737 PMCID: PMC9438203 DOI: 10.1136/bmjopen-2021-058965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Multimodal analgesia with paracetamol, non-steroidal anti-inflammatory drug and glucocorticoid is recommended for hip arthroplasty, but with uncertain effects of the different combinations. We aim to investigate benefit and harm of different combinations of paracetamol, ibuprofen and dexamethasone following total hip arthroplasty. METHODS AND ANALYSIS RECIPE is a randomised, placebo-controlled, parallel 4-group, blinded trial with 90-day and 1-year follow-up performed at nine Danish hospitals. Interventions are initiated preoperatively and continued for 24 hours postoperatively. Eligible participants undergoing total hip arthroplasty are randomised to:group A: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous placebo; group B: oral paracetamol 1000 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group C: oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group D: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg.Primary outcome is cumulative opioid consumption at 0-24 hours. Secondary outcomes are pain at rest, during mobilisation and during a 5 m walk and adverse events. Follow-up includes serious adverse events and patient reported outcome measures at 90 days and 1 year. A total of 1060 participants are needed to demonstrate a difference of 8 mg in 24-hour morphine consumption assuming an SD of 24.5 mg, a risk of type I errors of 0.0083 and a risk of type 2 errors of 0.2. Primary analysis will be a modified intention-to-treat analysis.With this trial we aim to verify recommendations for pain treatment after total hip arthroplasty, and investigate the role of dexamethasone as an analgesic adjuvant to paracetamol and ibuprofen. ETHICS AND DISSEMINATION This trial is approved by the Region Zealand Committee on Health Research Ethics (SJ-799). Plans for dissemination include publication in peer-reviewed journals and presentation at scientific meetings. TRIAL REGISTRATION NUMBER NCT04123873.
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Affiliation(s)
- Joakim Steiness
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
- Department of Anaesthesiology, Nastved Hospital, Naestved, Denmark
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Bispebjerg Hospital, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | | | | | - Peter Lindholm
- Department of Anaesthesiology, Odense University Hospital, Odense, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital Koge, Koege, Denmark
| | | | - Torben Beck
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Michael Skettrup
- Department of Orthopaedic Surgery, Gentofte Hospital, Hellerup, Denmark
| | | | - Kasper Højgaard Thybo
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
| | | | - Søren Overgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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15
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Gantzel M, Gasbjerg KS, Hägi-Pedersen D, Meyhoff CS, Olsen MH, Mathiesen O, Jakobsen JC, Lunn TH. Effect of dexamethasone on intraoperative remifentanil dose in total knee arthroplasty surgery under general anaesthesia. Acta Anaesthesiol Scand 2022; 66:1070-1076. [PMID: 35908167 PMCID: PMC9543467 DOI: 10.1111/aas.14118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/01/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022]
Abstract
Background The effects of glucocorticoids may include both genomic and rapid nongenomic effects. The potential rapid analgesic effect during surgery has not previously been investigated. We aimed to explore the effect of dexamethasone on intraoperative infusion rate of remifentanil in patients undergoing total knee arthroplasty (TKA) surgery under general anaesthesia. Methods In this post hoc subgroup analysis, we included patients randomised in the DEX‐2‐TKA trial, who were operated under total intravenous anaesthesia with remifentanil and propofol. Trial medication, intravenous dexamethasone 24 mg or placebo, was administered immediately after anaesthesia onset. The primary outcome was the median weight‐corrected infusion rate of remifentanil during surgery. Secondary outcomes included median weight‐corrected infusion rate of propofol, median intraoperative bispectral index and time spent in the post‐anaesthesia care unit. Results Eighty‐seven patients were included in the analysis of the primary outcome. A significantly higher remifentanil infusion rate was observed in the dexamethasone group compared with the placebo group, p = .02. None of the secondary outcomes resulted in statistically significant differences between groups. Conclusion This explorative post hoc analysis of the randomised DEX‐2‐TKA trail showed that patients undergoing TKA surgery under general anaesthesia and who received dexamethasone seemed to have a higher remifentanil infusion rate compared with patients who received placebo. The clinical implications of the potentially increased remifentanil infusion rate need to be validated and explored further. Clinical trial registration ClinicalTrials.gov Identifier: NCT05002361 (12 August 2021).
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Affiliation(s)
- Maria Gantzel
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Kasper Smidt Gasbjerg
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Naestved-Slagelse- Ringsted Hospitals, Denmark
| | - Daniel Hägi-Pedersen
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Naestved-Slagelse- Ringsted Hospitals, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Christian Sylvest Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark.,Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark.,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Ritsmer Stormholt E, Steiness J, Bauer Derby C, Esta Larsen M, Maagaard M, Mathiesen O. Paracetamol, non-steroidal anti-inflammatory drugs and glucocorticoids for postoperative pain: A protocol for a systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2021; 65:1505-1513. [PMID: 34138463 DOI: 10.1111/aas.13943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/13/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Multimodal analgesia is the leading principle for managing postoperative pain. Recent guidelines recommend combinations of paracetamol and a non-steroidal anti-inflammatory drug (NSAID) for most surgeries. Glucocorticoids have been used for decades due to their potent anti-inflammatory and antipyretic properties. Subsequently, glucocorticoids may improve postoperative analgesia. We will perform a systematic review to assess benefits and harms of adding glucocorticoids to paracetamol and NSAIDs. We expect to uncover pros and cons of the addition of glucocorticoid to the basic standard regimen of paracetamol and NSAIDs for postoperative analgesia. METHOD This protocol for a systematic review was written according to the The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will search for trials in the following electronic databases: Medline, CENTRAL, CDSR and Embase. Two authors will independently screen trials for inclusion using Covidence, extract data and assess risk of bias using Cochrane's ROB 2 tool. We will analyse data using Review Manager and Trial Sequential Analysis. Meta-analysis will be performed according to the Cochrane guidelines and results will be validated according to the eight-step procedure suggested by Jakobsen et al We will present our primary findings in a 'summary of findings' table. We will evaluate the overall certainty of evidence using the GRADE approach. DISCUSSION This review will aim to explore the combination of glucocorticoids together with paracetamol and NSAIDs for postoperative pain. We will attempt to provide reliable evidence regarding the role of glucocorticoids as part of a multimodal analgesic regimen in combination with paracetamol and NSAID.
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Affiliation(s)
- Emma Ritsmer Stormholt
- Centre for Anaesthesiological Research Department of Anaesthesiology Zealand University Hospital Køge Denmark
| | - Joakim Steiness
- Centre for Anaesthesiological Research Department of Anaesthesiology Zealand University Hospital Køge Denmark
- Department of Anaesthesiology Næstved Hospital Næstved Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Cecilie Bauer Derby
- Centre for Anaesthesiological Research Department of Anaesthesiology Zealand University Hospital Køge Denmark
| | - Mia Esta Larsen
- Centre for Anaesthesiological Research Department of Anaesthesiology Zealand University Hospital Køge Denmark
- Department of Anaesthesiology Herlev and Gentofte Hospital Herlev Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research Department of Anaesthesiology Zealand University Hospital Køge Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research Department of Anaesthesiology Zealand University Hospital Køge Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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17
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Leipe J, Holle JU, Weseloh C, Pfeil A, Krüger K. German Society of Rheumatology recommendations for management of glucocorticoid-induced osteoporosis. Z Rheumatol 2021; 80:49-63. [PMID: 34705070 DOI: 10.1007/s00393-021-01025-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Glucocorticoids are of substantial therapeutic importance in the treatment of inflammatory diseases, but are also associated with bone mineral density loss, osteoporosis, and fractures, especially with long-term use. OBJECTIVE To develop recommendations for the management of glucocorticoid-induced osteoporosis (GIOP) in adult patients on long-term glucocorticoid (GC) treatment. METHODS A systematic literature search (SLR) was conducted to synthesize the evidence for GIOP prevention and treatment options. Recommendations were developed based on SLR/level of evidence and by previously defined questions and in a structured group consensus process. RESULTS Recommendations include supplementation with calcium and vitamin D under long-term GC therapy in adults. If specific osteologic treatment is indicated, we recommend bisphosphonates or denosumab as first-line treatment. If fracture risk is high, we recommend teriparatide as primary specific osteologic treatment. Denosumab should be used in cases of severe renal insufficiency, and specific osteologic treatment should not be given in pregnancy. For patients who have not reached the treatment goal, a switch to another class of specific osteologic drugs should be performed. We recommend re-evaluation after a treatment duration of 3-5 years or after termination of long-term GC treatment. CONCLUSION This work aims to provide evidence-based and consensus-based recommendations for the best possible management of GIOP in Germany and to support treatment decisions.
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Affiliation(s)
- Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany. .,Division of Rheumatology and Clinical Immunology, Medizinische Klinik and Poliklinik IV, University of Munich, Munich, Germany.
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Christiane Weseloh
- German Society of Rheumatology (Deutsche Gesellschaft für Rheumatologie, DGRh), Berlin, Germany
| | - Alexander Pfeil
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Klaus Krüger
- Rheumatologisches Praxiszentrum München, Munich, Germany
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Hazrati E, Afsahi M, Namazi M, Kheradmand B, Rafiei M. Effect on analgesia duration and pain intensity of adding dexamethasone to lidocaine in digital nerve block in patients with finger trauma. HAND SURGERY & REHABILITATION 2021; 40:794-798. [PMID: 34438110 DOI: 10.1016/j.hansur.2021.08.007] [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: 05/20/2021] [Revised: 07/20/2021] [Accepted: 08/06/2021] [Indexed: 11/19/2022]
Abstract
Digital nerve block is one of the multimodal analgesia methods used in finger trauma cases. According to some studies, dexamethasone needs further investigation before being used routinely. We therefore investigated dexamethasone's effect on the parameters of digital nerve block. In this double-blind clinical study, 60 patients were allocated to two groups: lidocaine alone and lidocaine + dexamethasone. Groups were compared for pain intensity, analgesia duration and demographic characteristics. Patients in the intervention group received 3 cc 2% lidocaine + 1 cc (equivalent to 4 mg) dexamethasone and patients in the control group received 3 cc lidocaine 2% + 1 cc normal saline. The two groups were comparable for age and gender. In the lidocaine + dexamethasone group, postoperative pain severity was significantly lower and the pain-free period was longer (P < 0.05). Dexamethasone as an adjuvant in digital nerve block after trauma reduced the severity of postoperative pain and increased the pain-free period.
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Affiliation(s)
- E Hazrati
- Department of Anesthesiology, School of Medicine, Surgical and Trauma Research Center, Third Floor of Emam Reza Hospital, AJA University of Medical Sciences, West Fatemi St. - Etemadzadeh St., 8158177365 Isfahan, Isfahan Province, Dolatabad, Iran
| | - M Afsahi
- Department of Anesthesiology, School of Medicine, Surgical and Trauma Research Center, Third Floor of Emam Reza Hospital, AJA University of Medical Sciences, West Fatemi St. - Etemadzadeh St., 8158177365 Isfahan, Isfahan Province, Dolatabad, Iran
| | - M Namazi
- Department of Anesthesiology, School of Medicine, Surgical and Trauma Research Center, Third Floor of Emam Reza Hospital, AJA University of Medical Sciences, West Fatemi St. - Etemadzadeh St., 8158177365 Isfahan, Isfahan Province, Dolatabad, Iran
| | - B Kheradmand
- Department of Anesthesiology, School of Medicine, Surgical and Trauma Research Center, Third Floor of Emam Reza Hospital, AJA University of Medical Sciences, West Fatemi St. - Etemadzadeh St., 8158177365 Isfahan, Isfahan Province, Dolatabad, Iran
| | - M Rafiei
- Department of Anesthesiology, School of Medicine, Surgical and Trauma Research Center, Third Floor of Emam Reza Hospital, AJA University of Medical Sciences, West Fatemi St. - Etemadzadeh St., 8158177365 Isfahan, Isfahan Province, Dolatabad, Iran.
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19
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Leipe J, Holle JU, Weseloh C, Pfeil A, Krüger K. [German Society of Rheumatology Recommendations for the management of glucocorticoid-induced Osteoporosis. German version]. Z Rheumatol 2021; 80:670-687. [PMID: 34357436 DOI: 10.1007/s00393-021-01028-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Glucocorticoids are of substantial therapeutic importance in the treatment of inflammatory diseases, but are also associated with bone mineral density loss, osteoporosis, and fractures, especially with long-term use. OBJECTIVE To develop recommendations for the management of glucocorticoid-induced osteoporosis (GIOP) in adult patients on long-term glucocorticoid (GC) treatment. METHODS A systematic literature search (SLR) was conducted to synthesize the evidence for GIOP prevention and treatment options. Recommendations were developed based on SLR/level of evidence and by previously defined questions and in a structured group consensus process. RESULTS Recommendations include supplementation with calcium and vitamin D under long-term GC therapy in adults. If specific osteologic treatment is indicated, we recommend bisphosphonates or denosumab as first-line treatment. If fracture risk is high, we recommend teriparatide as primary specific osteologic treatment. Denosumab should be used in cases of severe renal insufficiency, and specific osteologic treatment should not be given in pregnancy. For patients who have not reached the treatment goal, a switch to another class of specific osteologic drugs should be performed. We recommend re-evaluation after a treatment duration of 3-5 years or after termination of long-term GC treatment. CONCLUSION This work aims to provide evidence-based and consensus-based recommendations for the best possible management of GIOP in Germany and to support treatment decisions.
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Affiliation(s)
- Jan Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätskrankenhaus Mannheim, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland. .,Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik IV, Ludwig-Maximilians-Universität München, München, Deutschland.
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | | | - Alexander Pfeil
- Klinik für Innere Medizin III, Funktionsbereich Rheumatologie, Universitätsklinikum Jena, Jena, Deutschland
| | - Klaus Krüger
- Rheumatologisches Praxiszentrum München, München, Deutschland
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Comparison of the Effect of Different Local Analgesia Administration Techniques in Total Hip Arthroplasty: A Retrospective Comparative Cohort Study. Pain Res Manag 2021; 2021:9914590. [PMID: 34349850 PMCID: PMC8328737 DOI: 10.1155/2021/9914590] [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: 03/18/2021] [Revised: 06/22/2021] [Accepted: 07/14/2021] [Indexed: 11/22/2022]
Abstract
Objective To improve postoperative pain management, several authors have described the use of periarticular injection (PAI) or intra-articular injection (IAI) following total hip arthroplasty (THA). However, no comparative studies examining the results between PAI and IAI following THA have been published. This study aimed to evaluate the analgesic and anti-inflammatory effects of PAI and IAI following THA. Methods This single-center, retrospective cohort study enrolled patients who underwent unilateral primary THA. A total of 278 patients (281 hips) were included in the final analyses, with 112 patients (113 hips) in the control group, 85 patients (87 hips) in the PAI group, and 81 patients (81 hips) in the IAI group. Numeric rating scale (NRS) scores and laboratory data were assessed preoperatively and on postoperative days (POD) 1 and 7. Results NRS scores, creatine phosphokinase, and C-reactive protein levels in the PAI and IAI groups were significantly lower than those in the control group on POD 1 and 7. D-dimer levels were significantly lower in the PAI and IAI groups than in the control group on POD 7. The white blood cell count was significantly higher in the PAI and IAI groups than in the control group on POD 1 and 7. Aspartate transaminase, alanine aminotransferase, blood urea nitrogen, and creatinine levels were within the reference ranges in all three groups at all time points. NRS scores and laboratory data showed no significant differences between the PAI and IAI groups at all time points. Conclusion PAI and IAI have equivalent analgesic and anti-inflammatory effects. Considering the technical challenges of PAI, IAI may be preferable because of its simplicity in the case of using a closed suction drain.
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Hashimoto A, Sonohata M, Hirata H, Kawano S, Eto S, Ueno M, Mawatari M. Periarticular analgesic injection containing a corticosteroid after total hip arthroplasty may prevent deep venous thrombosis: a retrospective comparative cohort study. BMC Musculoskelet Disord 2021; 22:19. [PMID: 33407331 PMCID: PMC7786517 DOI: 10.1186/s12891-020-03879-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/14/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Of late, periarticular analgesic injection (PAI) has become a common alternative treatment for pain following total hip arthroplasty (THA). However, the systemic effects of PAI containing corticosteroids in patients subjected to THA have not been investigated. This study evaluated the analgesic efficacy and systemic effects of PAI containing a corticosteroid in patients subjected to THA. METHODS This single-center, retrospective cohort study enrolled patients undergoing unilateral, primary THA. A total of 197 patients (200 hips) were included in the final analyses, with 87 hips in the PAI group and 113 hips in the control group. Numeric Rating Scale (NRS) and laboratory data were assessed preoperatively and on postoperative days (POD) 1 and 7. Pearson's correlation coefficients were obtained to assess the correlations between the D-dimer level on POD 7 and each outcome measure on POD 1. RESULTS The postoperative white blood cell count (WBC) was significantly higher in the PAI group than in the control group. Postoperative NRS, creatine phosphokinase (CK), and C-reactive protein (CRP) levels were significantly lower in the PAI group. D-dimer levels were significantly lower in the PAI group on POD 7. Postoperative aspartate transaminase (AST), alanine aminotransferase, blood urea nitrogen, and creatinine levels were within reference ranges. D-dimer levels on POD 7 showed a significant negative correlation with WBC on POD 1 (r=-0.4652) and a significant positive correlation with the NRS score and AST, CK, CRP, and D-dimer levels on POD 1 (r = 0.1558, 0.2353, 0.2718, 0.3545, and 0.3359, respectively). CONCLUSIONS PAI containing a corticosteroid may be an effective treatment for pain and inflammation after THA, and it does not seem to cause drug-induced liver or kidney injury. Moreover, corticosteroid PAI can may accelerate early ambulation, which prevents the elevation of postoperative D-dimer levels, and may reduce the risk of deep venous thrombosis.
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Affiliation(s)
- Akira Hashimoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, 849-8501, Saga, Japan
| | - Motoki Sonohata
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, 849-8501, Saga, Japan.
| | - Hirohito Hirata
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, 849-8501, Saga, Japan
| | - Shunsuke Kawano
- Research Center of Arthroplasty, Faculty of Medicine, Saga University, Nabeshima 5-1-1, 849-8501, Saga, Japan
| | - Shuichi Eto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, 849-8501, Saga, Japan
| | - Masaya Ueno
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, 849-8501, Saga, Japan
| | - Masaaki Mawatari
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, 849-8501, Saga, Japan
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Wang Y, Zhou A. A new improvement: subperiosteal cocktail application to effectively reduce pain and blood loss after total knee arthroplasty. J Orthop Surg Res 2020; 15:33. [PMID: 32000816 PMCID: PMC6993367 DOI: 10.1186/s13018-020-1563-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 01/16/2020] [Indexed: 12/20/2022] Open
Abstract
Background Pain and blood loss after total knee arthroplasty (TKA) are unsolved clinical problems. Some studies reported that periarticular cocktail injection can effectively reduce pain and blood loss. However, there was no gold standard about the cocktail ingredient and injection location. More osteotomy and less soft tissue release in TKA with mild deformity; besides, plenty of nerves and blood vessels are contained in the periosteums and bone marrow. In this study, we aimed to detect the clinical results of subperiosteal cocktail application in TKA. Methods Two groups were included according to the different injection location in our study. In group 1, cocktails were injected into the muscles, tendons, suprapatellar bursa, and subpatellar bursa surrounding knee joint. In group 2, cocktail injection was performed under the periosteum of the distal femur and proximal tibia. Our primary outcomes were visual analogue scale (VAS) and hemoglobin (Hb), and the secondary outcomes were wound healing, infection, deep vein thrombosis (DVT), operation time, and hospitalization. Results At the first operative day, the mean (standard deviation) VAS score in a state of static was lower in group 2 compared with group 1 (0.98 ± 0.27 in group 1 and 0.86 ± 0.60 in group 2, p < 0.05). In the state of flexion and extension, the mean (standard deviation) VAS was 1.61 ± 0.66 in group 1 and 1.10 ± 0.57 in group 2 (p < 0.05). The mean (standard deviation) blood loss was higher in group 1 than in group 2 at the first postoperative day (440.19 (167.68) ml in group 1 and 333.67 (205.99) ml in group 2, p < 0.05). At the third day after surgery, the mean (standard deviation) blood loss was 686.44 (140.29) ml in group 1 and 609.19 (260.30) ml in group 2, and there was significant difference between these two groups (p < 0.05). Conclusions We concluded that subperiosteal cocktail injection can significantly reduce pain and blood loss compared with periarticular cocktail injection after TKA.
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Affiliation(s)
- Yanxin Wang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Aiguo Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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Anastasio AT, Farley KX, Boden SD, Bradbury TL, Premkumar A, Gottschalk MB. Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use. J Arthroplasty 2020; 35:82-88. [PMID: 31500913 PMCID: PMC7194191 DOI: 10.1016/j.arth.2019.07.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/29/2019] [Accepted: 07/31/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We sought to identify independent modifiable risk factors for delayed discharge after total knee arthroplasty (TKA) that have been previously underrepresented in the literature, particularly postoperative opioid use, postoperative laboratory abnormalities, and the frequency of hypotensive events. METHODS Data from 1033 patients undergoing TKA for primary osteoarthritis of the knee between June 2012 and August 2014 at an academic orthopedic specialty hospital were reviewed. Patient demographics, comorbidities, inpatient opioid medication, postoperative hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1, were collected. Multivariate logistic regression analysis was performed to identify independent risk factors for a prolonged length of stay (LOS) >3 days. RESULTS The average age of patients undergoing primary TKA in our cohort was 65.9 (standard deviation, 9.1) years, and 61.7% were women. The mean LOS for all patients was 2.64 days (standard deviation, 1.14; range, 1-9). And 15.3% of patients had a LOS >3 days. On multivariate logistic regression analysis, nonmodifiable risk factors associated with a prolonged LOS included nonwhite race (odds ratio [OR], 2.01), single marital status (OR, 1.53), and increasing age (OR, 1.47). Modifiable risk factors included every 5 postoperative hypotensive events (OR, 1.31), 10-mg increases in oral morphine equivalent consumption (OR, 1.04), and postoperative laboratory abnormalities (hypocalcemia: OR, 2.15; low hemoglobin: OR, 2.63). CONCLUSION This study identifies potentially modifiable factors that are associated with increased LOS after TKA. Doubling down on efforts to control the narcotic use and to use opioid alternatives when possible will likely have efficacy in reducing LOS. Attempts should be made to correct laboratory abnormalities and to be cognizant of patient opioid use, age, and race when considering potential avenues to reduce LOS.
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Affiliation(s)
- Albert T. Anastasio
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Kevin X. Farley
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Scott D. Boden
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Thomas L. Bradbury
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Michael B. Gottschalk
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA,Reprint requests: Michael B. Gottschalk, MD, Department of Orthopaedic Surgery, Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA 30307
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Effect of Methylprednisolone in Periarticular Infiltration for Primary Total Knee Arthroplasty on Pain and Rehabilitation. J Arthroplasty 2019; 34:1646-1649. [PMID: 31155459 DOI: 10.1016/j.arth.2019.04.060] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/08/2019] [Accepted: 04/26/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Optimal pain management after total knee arthroplasty (TKA) is important to ensure timely rehabilitation and patient satisfaction. This study examines the efficacy of adding corticosteroid in periarticular infiltration cocktail with relation to postoperative pain management and rehabilitation in patients undergoing simultaneous bilateral TKA. METHODS Fifty patients with symptomatic end-stage bilateral knee osteoarthritis undergoing bilateral TKA under the same anesthetic were recruited. More painful knee was operated first, and the study solution containing ropivacaine, clonidine, epinephrine, and ketorolac with methylprednisolone was infiltrated in one knee and an identical mixture but without methylprednisolone was infiltrated in the second knee. Outcome measures included comparison of visual analogue scale on movement of each knee and range of motion achieved during the first three days after surgery. RESULTS Differences in visual analogue scale score and range of motion at day one and three between the two groups of knees were significant (P < .05). Postoperative inflammation and the ability to straight leg raise showed better trends in the knees receiving prednisolone although this did not reach statistical significance. CONCLUSION Addition of methylprednisolone to periarticular infiltration cocktail for patients undergoing TKA has significant influence on reduction of pain in the early postoperative period and patients are able to regain knee flexion more quickly.
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25
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Kimna C, Lieleg O. Engineering an orchestrated release avalanche from hydrogels using DNA-nanotechnology. J Control Release 2019; 304:19-28. [DOI: 10.1016/j.jconrel.2019.04.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 01/08/2023]
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Perioperative Dietary Restriction of Carbohydrates in the Management of Blood Glucose Levels in Patients Undergoing Total Knee Replacement. J Arthroplasty 2019; 34:1105-1109. [PMID: 30797646 DOI: 10.1016/j.arth.2019.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/12/2018] [Accepted: 01/22/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Approximately 75% of the US population over 65 years has prediabetes or diabetes. Despite current evidence for the efficacy of carbohydrate restriction in managing blood glucose, this practice has not been implemented as part of routine perioperative blood sugar management. We hypothesize that a carbohydrate reduced hospital diet (CRD) of 135 g/d may improve blood sugar levels following total knee arthroplasty (TKA) compared to a non-carbohydrate reduced hospital diet (NCRD). METHODS We randomized non-insulin-dependent prediabetic and diabetic patients undergoing TKA to either an NCRD or a CRD. Sixty-four patients were enrolled in the study and 2 were excluded, leading to 62 patients in the final analysis. The NCRD group included 14 females (47%) and 16 males (53%), with mean age of 68.5 years (±6.3 years). The CRD group included 16 females (50%) and 16 males (50%), with mean age of 68.0 years (±8.0 years). For hemoglobin A1C, the NCRD group had mean 5.8% (±0.6%) and the CRD group had mean 5.7% (±0.8%). For body mass index, the NCRD group had mean 29.3 kg/m2 (±6.3 kg/m2) and the CRD group 32.7 kg/m2 (±5.0 kg/m2). The primary outcome measure was mean blood glucose. RESULTS Mean blood sugar values during hospital stay were significantly lower in the CRD group with 121.5 mg/dL (±17.1 mg/dL) compared to the NCRD group 141.2 mg/dL (±31.3 mg/dL, P = .0031). CONCLUSION Blood sugar levels after surgery can be significantly reduced with a CRD. Further research is necessary to study the effect of reduced blood sugar levels on complications and infection rates following TKA surgery. LEVEL OF EVIDENCE I.
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Abdelmonem A, Rizk SN. Comparative study between intravenous and local dexamethasone as adjuvant to bupivacaine in perianal block. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2011.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Amr Abdelmonem
- Department of Anaesthesiology, Faculty of Medicine , Cairo University , Egypt
| | - Sherry Nabil Rizk
- Department of Anaesthesiology, Faculty of Medicine , Cairo University , Egypt
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28
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Godshaw BM, Mehl AE, Shaffer JG, Meyer MS, Thomas LC, Chimento GF. The Effects of Peri-Operative Dexamethasone on Patients Undergoing Total Hip or Knee Arthroplasty: Is It Safe for Diabetics? J Arthroplasty 2019; 34:645-649. [PMID: 30612830 DOI: 10.1016/j.arth.2018.12.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 11/24/2018] [Accepted: 12/11/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Peri-operative dexamethasone has been shown to effectively reduce post-operative nausea and vomiting and aide in analgesia after total joint arthroplasty (TJA); however, systemic glucocorticoid therapy has many adverse effects. The purpose of this study is to determine the effects of dexamethasone on prosthetic joint infection (PJI) and blood glucose levels in patients undergoing TJA. METHODS A retrospective chart review of all patients receiving primary TJA from 2011 to 2015 (n = 2317) was conducted. Patients were divided into 2 cohorts: dexamethasone (n = 1426) and no dexamethasone (n = 891); these groups were subdivided into diabetic and non-diabetic patients. The primary outcome was PJI; secondary measures included glucose levels and pre-operative hemoglobin A1c (A1c) values. Statistics were carried out using logistic and regression models. RESULTS Of the 2317 joints, 1.12% developed PJI; this was not affected by dexamethasone (P = .166). Diabetics were found to have higher rate of infection (P < .001); however, diabetics who received dexamethasone were not found to have a significantly higher infection rate that non-diabetics (P = .646). Blood glucose levels were found to increase post-operatively, and dexamethasone did not increase this change (P = .537). Diabetes (P < .001) and increasing hemoglobin A1c (P < .001) were also associated with increased serum glucose levels; however, this was not influenced by dexamethasone (P = .595). CONCLUSION Although diabetic patients were found to have a higher infection rate overall, this was not affected by administration of intravenous dexamethasone, nor was the post-operative elevation in serum glucose levels. In this study population, peri-operative intravenous dexamethasone did not increase the rate of PJI and was safe to administer in patients undergoing TJA.
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Affiliation(s)
- Brian M Godshaw
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA
| | - Ashley E Mehl
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA
| | - Jeffrey G Shaffer
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Mark S Meyer
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA
| | - Leslie C Thomas
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA
| | - George F Chimento
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA
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29
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Bustos FP, Coobs BR, Moskal JT. A retrospective analysis of the use of intravenous dexamethasone for postoperative nausea and vomiting in total joint replacement. Arthroplast Today 2019; 5:211-215. [PMID: 31286046 PMCID: PMC6588720 DOI: 10.1016/j.artd.2019.01.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/23/2019] [Accepted: 01/31/2019] [Indexed: 12/21/2022] Open
Abstract
Background Multimodal perioperative pain-management protocols have contributed to the success of elective total joint replacement in orthopedic surgery. General or neuraxial anesthesia for arthroplasty is accompanied by complications such as pruritis, nausea, and vomiting. Dexamethasone has been demonstrated to be a safe perioperative antiemetic. This study evaluates the benefit of low-dose intravenous dexamethasone used in the perioperative period to prevent postoperative nausea and vomiting. Methods Two scheduled doses of 8 mg of dexamethasone 12 hours apart after total hip arthroplasty or total knee arthroplasty were given to a dexamethasone group (n = 492) and were retrospectively compared with a no-dexamethasone group (n = 364) based on the use of antiemetics in the postoperative period. Frequency of antiemetic use in both groups was compared using a zero-inflated fixed-model Poisson distribution. Additional analysis included need for opioid analgesic, administration of diphenhydramine, and postoperative infection rates at 30 and 90 days. Results The dexamethasone group was found to have a significant reduction in need for the rescue antiemetic ondansetron (P = .00194). There was an associated reduction in length of stay for the treatment group (mean 1.83 days) relative to the control group (mean 2.17 days) (P < .001). There was no significant difference in postoperative infection rates at 30 or 90 days after arthroplasty. Conclusions Dexamethasone is a safe adjunct to perioperative protocol that may reduce nausea, thus improving patient satisfaction. There is an associated reduction in length of stay that may reduce cost of hospitalization.
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Affiliation(s)
- Francis P Bustos
- Virginia Tech Carilion School of Medicine, University of Virginia, Charlottesville, VA, USA
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Effectiveness of Perioperative Auricular Therapy on Postoperative Pain after Total Hip Arthroplasty: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:2979780. [PMID: 30941191 PMCID: PMC6420993 DOI: 10.1155/2019/2979780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 01/25/2019] [Accepted: 02/14/2019] [Indexed: 11/25/2022]
Abstract
Auricular therapy (AT) is a conventional therapy in traditional Chinese medicine. However, the effectiveness of perioperative AT in pain treatment after total hip arthroplasty (THA) is still controversial. Nine randomised controlled trials (RCTs) involving 605 patients who have undergone THA with or without AT from inception to March 2018 were collected and included in this study by searching more than 12 databases (e.g., PubMed, Excerpta Medica Database, and Cochrane Library). A random-effects model that pooled seven articles showed that the visual analogue scale (VAS) in the AT group was lower than that of the control group at each postoperative time point in patients after THA, except at the time points of 6 and 36 h. The intraoperative body mass-adjusted fentanyl amount in the AT group was also lower than that of the control group in two trials. The other outcomes (time to first analgesic request and incidence of postoperative nausea and vomiting, perioperative bradycardia, and transitory hypotension) showed insignificant difference. Then, subgroup analysis showed similar results to those of the total articles with the term “VAS”. Regression analysis found that the prolonged time after the operation decreased the difference in VAS between the two groups. Although all the outcomes were assessed as very low to low in the GRADE system, evidence on the effectiveness of perioperative AT in pain treatment after total hip replacement was positive.
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Kew ME, Cancienne JM, Christensen JE, Werner BC. The Timing of Corticosteroid Injections After Arthroscopic Shoulder Procedures Affects Postoperative Infection Risk. Am J Sports Med 2019; 47:915-921. [PMID: 30758977 DOI: 10.1177/0363546518825348] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Corticosteroid injections are sometimes used in the postoperative period after shoulder arthroscopy; however, a well-defined safety profile has not been established. PURPOSE To examine the association between the timing of postoperative corticosteroid injections and rates of infection after shoulder arthroscopy. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Private payer and Medicare national insurance databases were queried for patients who underwent arthroscopic rotator cuff repair, debridement, or subacromial decompression. Patients who underwent corticosteroid injections within 1, 2, 3, or 4 months postoperatively were identified and compared with a matched control group that underwent the same procedures without a postoperative steroid injection. International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes were used to identify rates of postoperative infection within 90 days after injection for the study groups and controls. Multivariate binomial logistic regression analysis was used to compare groups, and adjusted odds ratios (ORs) and 95% CIs were calculated, with P < .05 considered significant. RESULTS A total of 3946 patients were identified, including 264 patients who received an injection within 1 month after surgery, 471 within 2 months, 1037 within 3 months, 1874 within 4 months, and 2640 matched controls. When compared with controls, patients who underwent a corticosteroid injection within 1 month postoperatively had a significantly higher rate of infection (private payer: OR, 2.63; P = .014; Medicare: OR, 11.2; P < .0001). There were no differences in infection rates at all other time points ( P = .264-.835). CONCLUSION This study adds to the evidence suggesting caution when administering injections in the immediate postoperative period after shoulder arthroscopy. Although causality cannot be determined on the basis of this database review, the authors found a significant association between intra-articular corticosteroid injections administered 1 month postoperatively and an increased rate of postoperative infection in Medicare and private payer patient cohorts as compared with a control group.
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Affiliation(s)
- Michelle E Kew
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - James E Christensen
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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Formica FA, Barreto G, Zenobi-Wong M. Cartilage-targeting dexamethasone prodrugs increase the efficacy of dexamethasone. J Control Release 2018; 295:118-129. [PMID: 30572035 DOI: 10.1016/j.jconrel.2018.12.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 12/09/2018] [Accepted: 12/15/2018] [Indexed: 12/21/2022]
Abstract
Intra-articular administration of glucocorticoids such as dexamethasone is a common treatment for osteoarthritic inflammation and pain. Despite its potent anti-inflammatory properties, multiple barriers hinder the drug's effectiveness in the articular space. In particular, the high turnover rate of the synovial fluid and the dense cartilage extracellular matrix (ECM) lead to poor drug penetration into cartilage. In order to increase the infiltration and retention time, two dexamethasone prodrugs were developed. Firstly, dexamethasone was conjugated to polycationic chitosan, which led to deep and sustained infiltration of the drug into full thickness cartilage, due to its strong electrostatic interactions with the high negative fixed charges of the cartilage ECM. Secondly, dexamethasone was conjugated to a collagen type II-binding peptide, WYRGRL, and this prodrug was shown to be retained in the deep zones of cartilage through specific interactions with cartilage-specific collagen type II bundles. In both cases, active dexamethasone was released from the carrier by ester linkage hydrolysis. Complexing dexamethasone with either chitosan or collagen type II-affinity carriers increased its binding and therapeutic efficacy inside cartilage, compared to the free drug. Both dexamethasone conjugates significantly reduced levels of inflammatory markers and slowed the loss of glycosaminoglycans in an ex vivo model. A single dose of a cartilage-targeting dexamethasone prodrug represents a promising alternative to the repetitive glucocorticoid injections needed to compensate for its rapid clearance from the joint cavity.
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Affiliation(s)
- Florian A Formica
- Tissue Engineering & Biofabrication, Department of Health Sciences and Technology, Swiss Federal Institute of Technology Zürich (ETH Zürich), Otto-Stern-Weg 7, 8093 Zürich, Switzerland
| | - Goncalo Barreto
- Tissue Engineering & Biofabrication, Department of Health Sciences and Technology, Swiss Federal Institute of Technology Zürich (ETH Zürich), Otto-Stern-Weg 7, 8093 Zürich, Switzerland
| | - Marcy Zenobi-Wong
- Tissue Engineering & Biofabrication, Department of Health Sciences and Technology, Swiss Federal Institute of Technology Zürich (ETH Zürich), Otto-Stern-Weg 7, 8093 Zürich, Switzerland.
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Park SY, Gong HS, Kim KM, Kim D, Kim HY, Jeon CH, Ju JH, Lee SS, Park DA, Sung YK, Kim SW. Korean Guideline for the Prevention and Treatment of Glucocorticoid-induced Osteoporosis. J Bone Metab 2018; 25:195-211. [PMID: 30574464 PMCID: PMC6288607 DOI: 10.11005/jbm.2018.25.4.195] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/06/2018] [Accepted: 08/10/2018] [Indexed: 12/15/2022] Open
Abstract
Background To develop guidelines and recommendations to prevent and treat glucocorticoid (GC)-induced osteoporosis (GIOP) in Korea. Methods The Korean Society for Bone and Mineral Research and the Korean College of Rheumatology have developed this guideline based on Guidance for the Development of Clinical Practice Guidelines ver. 1.0 established by the National Evidence-Based Healthcare Collaborating Agency. This guideline was developed by adapting previously published guidelines, and a systematic review and quality assessment were performed. Results This guideline applies to adults aged ≥19 years who are using or plan to use GCs. It does not include children and adolescents. An initial assessment of fracture risk should be performed within 6 months of initial GC use. Fracture risk should be estimated using the fracture-risk assessment tool (FRAX) after adjustments for GC dose, history of osteoporotic fractures, and bone mineral density (BMD) results. All patients administered with prednisolone or an equivalent medication at a dose ≥2.5 mg/day for ≥3 months are recommended to use adequate calcium and vitamin D during treatment. Patients showing a moderate-to-high fracture risk should be treated with additional medication for osteoporosis. All patients continuing GC therapy should undergo annual BMD testing, vertebral X-ray, and fracture risk assessment using FRAX. When treatment failure is suspected, switching to another drug should be considered. Conclusions This guideline is intended to guide clinicians in the prevention and treatment of GIOP.
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Affiliation(s)
- So Young Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyoung Min Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dam Kim
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Kim
- Division of Endocrinology, Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea
| | - Chan Hong Jeon
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Ji Hyeon Ju
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Shin-Seok Lee
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Dong-Ah Park
- Division of Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Sang Wan Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Boramae Medical Center, Seoul, Korea
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Xu H, Zhang S, Xie J, Lei Y, Cao G, Pei F. Multiple Doses of Perioperative Dexamethasone Further Improve Clinical Outcomes After Total Knee Arthroplasty: A Prospective, Randomized, Controlled Study. J Arthroplasty 2018; 33:3448-3454. [PMID: 30033064 DOI: 10.1016/j.arth.2018.06.031] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/23/2018] [Accepted: 06/25/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study aimed to evaluate the effect and safety of multiple doses of preoperative dexamethasone on pain and recovery after total knee arthroplasty (TKA). METHODS Altogether, 182 patients undergoing TKA received 3 intravenous injections of normal saline (group A), 1 injection of high-dose dexamethasone (20 mg) and 2 injections of normal saline (group B), or 1 injection of high-dose dexamethasone and 2 injections of low-dose (10 mg) dexamethasone (group C). RESULTS Visual analog scale was lower in group C than in group A or B and was different between groups A and B on postoperative days 1, 2, and 3 (all P < .05). Fewer group C patients required analgesic rescue and had lower total analgesic than those in group A or B, with the same difference between groups A and B (all P < .05). C-reactive protein and interleukin-6 levels were lower in groups B and C than in group A at 24, 48, and 72 hours postoperatively. C-reactive protein at 72 hours and interleukin-6 at 48 and 72 hours were lower in group C than in group B (all P < .05). Incidences of postoperative nausea and vomiting, number of patients requiring antiemetic rescue, and overall consumption of metoclopramide were lower in groups B and C than in group A (all P < .05). No surgical-site infections or gastrointestinal hemorrhages were detected in any group. CONCLUSION Multiple dexamethasone doses further reduced postoperative pain, decreased consumption of analgesic drugs, and provided more powered inflammation control. These findings call for further studies to further evaluate its safety.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang, Mianyang, People's Republic of China
| | - Jinwei Xie
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yiting Lei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Guorui Cao
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Dissanayake R, Du HN, Robertson IK, Ogden K, Wiltshire K, Mulford JS. Does Dexamethasone Reduce Hospital Readiness for Discharge, Pain, Nausea, and Early Patient Satisfaction in Hip and Knee Arthroplasty? A Randomized, Controlled Trial. J Arthroplasty 2018; 33:3429-3436. [PMID: 30078660 DOI: 10.1016/j.arth.2018.07.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/02/2018] [Accepted: 07/12/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Reduction in postoperative pain, nausea, and vomiting in patients undergoing total joint arthroplasty may facilitate earlier discharge from hospital and reduce healthcare costs. This study was performed to primarily assess whether perioperative dexamethasone reduced hospital length of stay and to assess the effect on pain, nausea and vomiting, and patient satisfaction. METHODS One hundred sixty-four patients undergoing total hip arthroplasty or total knee arthroplasty were randomized to receive either 8 mg intravenous dexamethasone (n = 86) or placebo (n = 78) at induction and at 24 hours postsurgery. The primary outcome was length of stay and secondary outcomes were pain and nausea visual analog scale scores, analgesic and antiemetic usage, blood glucose level, and patient satisfaction. RESULTS Participants in the study group achieved earlier readiness for discharge. There was a 20% reduction in pain scores and morphine usage was 27% lower in the study group. Nausea scores were similar in the 2 groups but there was lower antiemetic usage in the study group. Satisfaction scores at 6 weeks postsurgery in the dexamethasone group were significantly higher than the placebo group. There was no difference in complication rates between the 2 groups. CONCLUSION The administration of intravenous dexamethasone could lead to earlier readiness for discharge especially in patients undergoing elective total hip arthroplasty, primarily by a reduction in postoperative pain scores and/or morphine requirements.
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Affiliation(s)
- Ravi Dissanayake
- Department of Orthopaedic Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Hao Nan Du
- Department of Orthopaedic Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Iain K Robertson
- College of Health and Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Kathryn Ogden
- College of Health and Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Kaitlyn Wiltshire
- Department of Medicine, Alfred Hospital, Prarhan, Victoria, Australia
| | - Jonathan S Mulford
- Department of Orthopaedic Surgery, Launceston General Hospital, Launceston, Tasmania, Australia
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Bugada D, Allegri M, Gemma M, Ambrosoli AL, Gazzerro G, Chiumiento F, Dongu D, Nobili F, Fanelli A, Ferrua P, Berruto M, Cappelleri G. Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study. Eur J Anaesthesiol 2018; 106:230-8. [PMID: 28767456 DOI: 10.1093/bja/aeq333] [Citation(s) in RCA: 196] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA). OBJECTIVES Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA. DESIGN A web-based prospective observational registry. SETTING Five Italian Private and University Hospitals from 2012 to 2015. PATIENTS Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery. INTERVENTION(S) Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability. MAIN OUTCOME MEASURES Experience of PPSP according to the type of peri-operative analgesia. RESULTS Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months. CONCLUSION Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02147730.
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Affiliation(s)
- Dario Bugada
- From the Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital of Parma (DB, MA), Department of Surgical Sciences, University of Parma, Parma (DB, MA), Department of Anaesthesiology, Intensive Care, IRCCS Ospedale San Raffaele, Milano (MG), Department of Anaesthesiology, Intensive Care and Pain Therapy, Ospedale di Circolo, Varese (ALA), Department of Anaesthesiology, Intensive Care, AORN dei Colli Monaldi Cotugno CTO, Napoli (GG, FC), Department of Anaesthesiology and Pain Therapy, Presidio Sanitario Ospedale Cottolengo, Torino (DD), Department of Anaesthesia, IRCCS Istituto Auxologico Italiano, Milano (FN), Department of Anaesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Policlinico S. Orsola-Malpighi, Bologna (AF), Department of Orthopaedic and Traumatology, ASST-Gaetano Pini-CTO (PF, MB); and Department of Anaesthesiology and Pain Therapy, ASST-Gaetano Pini-CTO, Milano, Italy (GC)
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Intraoperative Dexamethasone Reduces Readmission Rates Without Affecting Risk of Thromboembolic Events or Infection After Total Joint Arthroplasty. J Arthroplasty 2018; 33:3252-3256. [PMID: 29885970 DOI: 10.1016/j.arth.2018.05.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/10/2018] [Accepted: 05/11/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The use of perioperative dexamethasone has been proven to reduce pain and shorten recovery for patients undergoing total hip and knee arthroplasty. However, the effect of these medications on 90-day readmissions and the rates of clinically significant venous thromboembolic events (VTE) after total joint arthroplasty (TJA) remains unknown. METHODS Patients undergoing unilateral, primary total joint arthroplasty between 2009 and 2016 in a single institution were identified. There were 6617 patients who did not receive dexamethasone intraoperatively compared to 1293 patients who received a single, intraoperative, intravenous dose of dexamethasone (8-10 mg). The primary outcomes were the rate of clinically significant VTE and 90-day readmission. Secondary outcomes included wound complications, periprosthetic joint infection, and 90-day mortality. RESULTS While the overall rate of clinically symptomatic VTE was lower in the dexamethasone group, this did not reach significance in a univariate analysis (0.1% vs 0.2%, P = .353). Only body mass index (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.03-1.24; P = .006) and longer length of stay (OR, 1.16; 95% CI, 1.06-1.28; P = .001) were associated with VTE in the multivariate analysis (OR, 0.31; 95% CI, 0.04-2.36; P = .319). However, the use of intravenous dexamethasone was independently associated with a reduction in 90-day readmission rate (1.6% vs 2.5%; OR, 0.57; 95% CI, 0.36-0.90; P = .016). There was no difference in the rate of periprosthetic joint infection or mortality. CONCLUSION A single, intraoperative, low dose of dexamethasone is not associated with a reduction in clinically significant VTE but may be a safe and effective adjunct medication to lower 90-day readmission rates. LEVEL OF EVIDENCE Level III.
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Vuorinen MA, Palanne RA, Mäkinen TJ, Leskinen JT, Huhtala H, Huotari KA. Infection safety of dexamethasone in total hip and total knee arthroplasty: a study of eighteen thousand, eight hundred and seventy two operations. INTERNATIONAL ORTHOPAEDICS 2018; 43:1787-1792. [PMID: 30232525 DOI: 10.1007/s00264-018-4156-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 09/10/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE Dexamethasone has been shown to prevent post-operative nausea and vomiting (PONV) and seems to reduce post-operative pain. Both factors, which can extend the hospital stay, delay rehabilitation, and impact patient satisfaction. Because of the immunosuppressive and glucose-rising effects of dexamethasone, there has been concern of its safety in arthroplasty surgery. The purpose of our study was to examine infection safety of dexamethasone in arthroplasty surgery with enough large study material to reliably detect a possible, even small, difference in infection incidence. METHODS A total of 18,872 consecutive primary and revision hip and knee arthroplasties were analyzed with data gathered from clinical information databases and a surgical site infection surveillance database with prospective data collection. Also, emergency operations due to fractures were included except for hip hemiarthroplasties. RESULTS During the follow-up, 189 (1.0%) prosthetic joint infections (PJIs) occurred: 0.8% after primary arthroplasty and 1.9% after revision arthroplasty. Dexamethasone was used in 2922 (15.5%) operations. The PJI rate in the dexamethasone group was 1.1% (31/2922) and in the non-dexamethasone group 1.0% (161/15950), with no significant difference in the risk of PJI between the two groups (OR 1.052, 95% CI 0.715-1.548, P = 0.773). CONCLUSIONS In our study material, the use of a single 5-10 mg dose of dexamethasone did not increase the incidence of post-operative PJI. A low dose of dexamethasone may be safely used to prevent PONV and as part of multimodal analgesia on patients undergoing arthroplasty operation.
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Affiliation(s)
- Markku A Vuorinen
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Riku A Palanne
- Peijas Hospital, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Vantaa, Finland
| | - Tatu J Mäkinen
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jarkko T Leskinen
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Kaisa A Huotari
- Department of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Clemmesen CG, Lunn TH, Kristensen MT, Palm H, Foss NB. Effect of a single pre‐operative 125 mg dose of methylprednisolone on postoperative delirium in hip fracture patients; a randomised, double‐blind, placebo‐controlled trial. Anaesthesia 2018; 73:1353-1360. [DOI: 10.1111/anae.14406] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2018] [Indexed: 12/27/2022]
Affiliation(s)
- C. G. Clemmesen
- Department of Anaesthesiology Copenhagen University Hospital Hvidovre Denmark
| | - T. H. Lunn
- Department of Anaesthesiology Copenhagen University Hospital Hvidovre Denmark
| | - M. T. Kristensen
- Department of Orthopaedic Surgery Copenhagen University Hospital Hvidovre Denmark
| | - H. Palm
- Department of Orthopaedic Surgery Copenhagen University Hospital Hvidovre Denmark
| | - N. B. Foss
- Department of Anaesthesiology Copenhagen University Hospital Hvidovre Denmark
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Xie T, Ma B, Li Y, Zou J, Qiu X, Chen H, Wang C, Rui Y. [Research status of the enhanced recovery after surgery in the geriatric hip fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1038-1046. [PMID: 30238732 PMCID: PMC8429995 DOI: 10.7507/1002-1892.201712083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Indexed: 11/03/2022]
Abstract
Objective To summarize the latest developments in the enhanced recovery after surgery (ERAS) in the geriatric hip fractures and its perioperative therapy management. Methods The recent original literature on the ERAS in the geriatric hip fractures were extensively reviewed, illustrating the concepts and properties of the ERAS in the geriatric hip fractures. Results It has been considered to be associated with the decreased postoperative morbidity, reduced hospital length of stay, and cost savings to implement ERAS protocols, including multimodal analgesia, inflammation control, intravenous fluid therapy, early mobilization, psychological counseling, and so on, in the perioperative (emergency, preoperative, intraoperative, postoperative) management of the geriatric hip fractures. The application of ERAS in the geriatric hip fractures guarantees the health benefits of patients and saves medical expenses, which also provides basis and guidance for the further development and improvement of the entire process perioperative management in the geriatric hip fractures. Conclusion Significant progress has been made in the application of ERAS in the geriatric hip fractures. ERAS protocols should be a priority for perioperative therapy management in the geriatric hip fractures.
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Affiliation(s)
- Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Binbin Ma
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yingjuan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Jihong Zou
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xiaodong Qiu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Chen Wang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yunfeng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009,
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Bridging multimodal pain management provides 48-hour pain control in patients undergoing total shoulder replacement. J Shoulder Elbow Surg 2018; 27:S65-S69. [PMID: 29426743 DOI: 10.1016/j.jse.2017.12.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/13/2017] [Accepted: 12/26/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND We report our experience with a bridging multimodal pain management program that provides comprehensive 48-hour pain control in patients undergoing total shoulder replacement (TSR). METHODS The study included all patients undergoing unilateral TSR by 1 surgeon between May 2015 and April 2017. There were 62 patients (23 men, 39 women) with an average age of 68 years (range 38-92 years). Of these, 31 underwent standard nonconstrained TSR and 31 underwent reverse TSR. The bridging multimodal pain management protocol included scalene block regional anesthesia using 0.25% bupivacaine enhanced with 4 mg of dexamethasone, application of 20 mg of liposomal bupivacaine diluted with 40 mL of normal saline in the periarticular soft tissues at time of closure, scheduled 24 hours of intravenous acetaminophen and ketorolac, and immediate cryotherapy. Parameters measured included hospital length of stay, postoperative use of intravenous narcotics, and 30-day hospital readmission. RESULTS The median length of stay was 1 day (range, 1-6; average, 1.5 days). Overall, 41 patients (66%) were discharged on postoperative day 1. Intravenous narcotics were required postoperatively in 22 patients (35.5%). There were no 30-day readmissions. CONCLUSION This bridging multimodal pain management protocol resulted in a length of stay of 1 day for 66% of patients, even for higher-risk patients with American Society of Anesthesiologists Physical Status Classification III (63%). Of the 62 patients, 64% (n = 40) did not require postoperative intravenous narcotics. For properly selected patients, this program may be considered for performing TSR as an ambulatory procedure.
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An N, Liu K, Fan BY, Ma DH. WITHDRAWN: The efficacy and safety of intravenous glucocorticoids in total hip arthroplasty: A systematic review and meta-analysis. Int J Surg 2018:S1743-9191(18)30743-X. [PMID: 29730078 DOI: 10.1016/j.ijsu.2018.04.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/21/2018] [Indexed: 11/25/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
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Affiliation(s)
- Ning An
- Department of Orthopaedics, Zhongshan City People Hospital, Zhongshan City, Guangdong Province, China
| | - Kang Liu
- Department of Orthopaedics, Zhongshan City People Hospital, Zhongshan City, Guangdong Province, China
| | - Bao-Ying Fan
- Department of Orthopaedics, Zhongshan City People Hospital, Zhongshan City, Guangdong Province, China
| | - Dong-Hua Ma
- Department of Orthopaedics, Zhongshan City People Hospital, Zhongshan City, Guangdong Province, China
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Xu B, Ma J, Huang Q, Huang ZY, Zhang SY, Pei FX. Two doses of low-dose perioperative dexamethasone improve the clinical outcome after total knee arthroplasty: a randomized controlled study. Knee Surg Sports Traumatol Arthrosc 2018; 26:1549-1556. [PMID: 28474088 DOI: 10.1007/s00167-017-4506-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/01/2017] [Indexed: 11/30/2022]
Abstract
To study the clinical effect and safety of two doses of low-dose perioperative dexamethasone on pain and recovery after total knee arthroplasty. Methods A total of 108 patients were included in this randomized, double-blinded, placebo-controlled study. They received two doses of 10 mg IV dexamethasone (group Dexa) or IV isotonic saline (group Placebo). The CRP, IL-6 and pain levels, postoperative nausea and vomiting (PONV) incidence, nausea severity, postoperative fatigue, range of motion, length of stay, analgesic rescue and antiemetic rescue consumption, and complications were compared. Results The CRP and IL-6 levels in group Dexa were lower than in group Placebo at 24, 48, and 72 h postoperatively (P < 0.001, P < 0.001, and P < 0.001, respectively). In group Dexa, patients had less pain at 24 h postoperatively, at rest (P < 0.001) and during walking (P < 0.001); they also had a lower PONV incidence (P = 0.002) and a lower nausea VAS score (P = 0.008). Postoperative fatigue (P < 0.001) was relieved and the analgesic and antiemetic rescue consumption was reduced. Length of stay (n.s.) and range of motion (n.s.) were similar in both groups. No early surgical wound infection or gastrointestinal haemorrhage occurred in either group. Conclusions Administering two doses of low-dose perioperative dexamethasone for patients receiving total knee arthroplasty reduces postoperative CRP and IL-6 levels, provides additional analgesic effect, and reduces the PONV incidence and postoperative fatigue, without increasing the risk of early surgical wound infection and gastrointestinal haemorrhage. So two doses of low-dose perioperative dexamethasone are effective and safe for patients receiving TKA to decrease the inflammatory response, prevent PONV, relieve postoperative pain and fatigue, and enhance recovery. Level of evidence I.
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Affiliation(s)
- Bin Xu
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Jun Ma
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Qiang Huang
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Ze-Yu Huang
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Shao-Yun Zhang
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Fu-Xing Pei
- Department of Orthopaedics, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People's Republic of China.
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Etcheson JI, Gwam CU, George NE, Virani S, Mont MA, Delanois RE. Patients With Major Depressive Disorder Experience Increased Perception of Pain and Opioid Consumption Following Total Joint Arthroplasty. J Arthroplasty 2018; 33:997-1002. [PMID: 29129615 DOI: 10.1016/j.arth.2017.10.020] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/10/2017] [Accepted: 10/13/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Pain in the immediate postoperative period following total joint arthroplasty is influenced by various patient factors, including major depressive disorder (MDD). Therefore, this study aimed to compare the patient perception of pain and opioid consumption between patients with and without MDD who received either a total knee arthroplasty (TKA) or total hip arthroplasty (THA). Specifically, we compared (1) pain intensity, (2) lengths of stay, (3) opioid consumption, and (4) patient perception of pain control. METHODS We reviewed our institutional Press Ganey database to identify patients with a diagnosis of MDD who received a THA (n = 48) and TKA (n = 68) between 2012 and 2016. An independent samples t-test and chi-square analyses were conducted to assess continuous and categorical variables, respectively. Analysis of covariance assessed the effects of depression on postoperative pain intensity. Mixed-design analysis of variance assessed the difference in opioid consumption between groups. RESULTS Patients with MDD who received THA or TKA demonstrated a higher mean pain intensity score when compared to those without MDD; however, this was not statistically different (235.6 vs 207.7; P = .264 and 214.8 vs 185.1; P = .055, respectively). Patients with MDD who received THA or TKA consumed more opioids when compared to those without MDD (P = .048 and P = .038, respectively). CONCLUSION Patients with MDD undergoing total joint arthroplasty consume more opioids compared to their matched cohort during the immediate postoperative period. Identifying patient-specific factors, such as MDD, could help arthroplasty surgeons modulate patients' course of recovery. These findings warrant more cooperation between arthroplasty surgeons and primary care providers to optimize outcome.
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Affiliation(s)
- Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Chukwuweike U Gwam
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nicole E George
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sana Virani
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Fan ZR, Ma J, Ma XL, Wang Y, Sun L, Wang Y, Dong BC. The efficacy of dexamethasone on pain and recovery after total hip arthroplasty: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e0100. [PMID: 29595631 PMCID: PMC5895376 DOI: 10.1097/md.0000000000010100] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) perioperative dexamethasone treatment is still a controversial subject. We write this systematic review and meta-analysis to evaluate the efficacy of dexamethasone on pain and recovery after THA. METHODS Two researchers searched the relevant studies from Pubmed, Cochrane, and Embase. The research was reported according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Randomized controlled trials (RCTs) were included in our meta-analysis. At the same time, the assessment of the risk of bias was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions version. The pooled data are processed by software RevMan 5.3. RESULT In accordance with inclusion and exclusion, 3 studies with 207 patients were eligible and accepted into this meta-analysis. For RCTs, the risk of bias was evaluated by Cochrane Collaboration tool. Only one study did not have detection bias. Our study demonstrated that the dexamethasone group was more effective than the placebo group in term of visual analogue scale (VAS) score at 24 hours (P < .001), 48 hours (P = .04); opioid consumption (P < .001); length of stay (LOS, P < .001); and postoperative nausea (P = .001). CONCLUSION Dexamethasone not only reduces postoperative pain scores and postoperative opioids consumption within 48 hours, but also reduces postoperative vomiting and effectively reduces LOS. However, we still need large sample size and high quality studies to explore the relationship between complications and dose response to give the final conclusion.
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Affiliation(s)
- Zheng-rui Fan
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Jianxiong Ma
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
| | - Xin-long Ma
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
| | - Ying Wang
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
| | - Lei Sun
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
| | - Yan Wang
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
| | - Ben-chao Dong
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
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Park SY, Gong HS, Kim KM, Kim D, Kim H, Jeon CH, Ju JH, Lee SS, Park DA, Sung YK, Kim SW. Korean Guideline for the Prevention and Treatment of Glucocorticoid-induced Osteoporosis. JOURNAL OF RHEUMATIC DISEASES 2018. [DOI: 10.4078/jrd.2018.25.4.263] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- So Young Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyoung Min Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dam Kim
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hayoung Kim
- Division of Endocrinology, Department of Internal Medicine, Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea
| | - Chan Hong Jeon
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Ji Hyeon Ju
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Shin-Seok Lee
- Department of Rheumatology, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Dong Ah Park
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Sang Wan Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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Comparison of cortisol and inflammatory response between aged and middle-aged patients undergoing total hip arthroplasty: a prospective observational study. BMC Musculoskelet Disord 2017; 18:541. [PMID: 29258488 PMCID: PMC5738105 DOI: 10.1186/s12891-017-1900-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 12/08/2017] [Indexed: 02/08/2023] Open
Abstract
Background To investigate the differences in the perioperative serum cortisol, C-reactive protein (CRP) and interleukin-6 (IL-6) levels between aged and middle-aged patients undergoing total hip arthroplasty (THA). Methods Sixty patients (30 aged and 30 middle-aged) undergoing THA for osteoarthritis between August 2016 and January 2017 participated in this study. Blood samples were collected preoperatively and at 6 hours, 24 hours and 3 days after surgery to measure the cortisol, CRP and IL-6 concentrations. The clinical outcomes were assessed using the visual analogue scale (VAS) pain score and Harris hip score (HHS). Results No significant differences were found between the two groups before the operation in the cortisol, IL-6 and CRP levels; the VAS score; or the HHS. Cortisol was significantly lower at 6 hours after surgery in the aged group than in the middle-aged group (P < 0.05). IL-6 at 6 and 24 hours after surgery, CRP at 3 days after surgery and the VAS score at 6 and 24 hours after surgery in the aged group were significantly higher than those in the middle-aged group (P < 0.05). In the aged group, weak correlations were found between the cortisol concentration 6 hours after THA and the IL-6 level 24 hours after THA (r = −0.37, P = 0.04) and between the IL-6 level 6 hours after THA and the VAS score 24 hours after THA (r = 0.42, P = 0.02). Conclusion Aged patients showed lower cortisol levels at 6 hours after surgery and higher IL-6 levels at 6 and 24 hours after surgery than middle-aged patients undergoing THA.
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Komatsu R, You J, Rajan S, Kasuya Y, Sessler DI, Turan A. Steroid administration after anaesthetic induction with etomidate does not reduce in-hospital mortality or cardiovascular morbidity after non-cardiac surgery. Br J Anaesth 2017; 120:501-508. [PMID: 29452806 DOI: 10.1016/j.bja.2017.11.079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 09/06/2017] [Accepted: 09/11/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND We tested the primary hypothesis that corticosteroid administration after etomidate exposure reduces a composite of in-hospital mortality and cardiovascular morbidity after non-cardiac surgery. METHODS We evaluated ASA physical status III and IV patients who had non-cardiac surgery with general anaesthesia at the Cleveland Clinic. Amongst 4275 patients in whom anaesthesia was induced with etomidate, 804 were also given steroid intraoperatively, mostly dexamethasone at a median dose of 6 mg. We successfully matched 582 steroid patients with 1023 non-steroid patients. The matched groups were compared on composite of in-hospital mortality and cardiovascular morbidity using a generalized-estimating-equation model. Secondly, the matched groups were compared on length of hospital stay using a Cox proportional hazard model, and were descriptively compared on intraoperative blood pressures using a standardized difference. RESULTS There was no significant association between intraoperative steroid administration after anaesthetic induction with etomidate and the composite of in-hospital mortality or cardiovascular morbidity; the estimated common odds ratio across the two components of the composite was 0.86 [95% confidence interval (CI): 0.64, 1.16] for steroid vs non-steroid, P=0.33. The duration of postoperative hospitalisation was significantly shorter amongst steroid patients [median (Q1, Q3): 6 (3, 10) days] than non-steroid patients [7 (4, 11) days], with an estimated hazard ratio of 0.89 (0.80, 0.98) for steroid vs non-steroid, P=0.01. Intraoperative blood pressures were similar in steroid and non-steroid patients. CONCLUSIONS Steroid administration after induction of anaesthesia with etomidate did not reduce mortality or cardiovascular morbidity.
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Affiliation(s)
- R Komatsu
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305695, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
| | - J You
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH 44195, USA
| | - S Rajan
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Y Kasuya
- Department of Anesthesiology, Tokyo Women's Medical University, Shinjuku, Tokyo 162-8666, Japan
| | - D I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - A Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Li D, Wang C, Yang Z, Kang P. Effect of Intravenous Corticosteroids on Pain Management and Early Rehabilitation in Patients Undergoing Total Knee or Hip Arthroplasty: A Meta-Analysis of Randomized Controlled Trials. Pain Pract 2017; 18:487-499. [PMID: 28851016 DOI: 10.1111/papr.12637] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/20/2017] [Accepted: 08/09/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Donghai Li
- Department of Orthopaedics; West China Hospital; Sichuan University; Chengdu China
| | - Changde Wang
- Department of Orthopaedics; West China Hospital; Sichuan University; Chengdu China
| | - Zhouyuan Yang
- Department of Orthopaedics; West China Hospital; Sichuan University; Chengdu China
| | - Pengde Kang
- Department of Orthopaedics; West China Hospital; Sichuan University; Chengdu China
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McDonald C, Hennedige A, Henry A, Dawoud B, Kulkarni R, Gilbert K, Kyzas P, Morrison R, McCaul J. Management of cervicofacial infections: a survey of current practice in maxillofacial units in the UK. Br J Oral Maxillofac Surg 2017; 55:940-945. [DOI: 10.1016/j.bjoms.2017.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 09/07/2017] [Indexed: 11/28/2022]
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