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Kurihara S, Ichita C, Goto T, Hatayama K, Fushimi K, Shimizu S. Association Between Intraoperative Periarticular Injection of Triamcinolone and Early Postoperative Infection in Total Knee Arthroplasty: An Analysis of a Japanese Nationwide Database. J Arthroplasty 2025:S0883-5403(25)00378-X. [PMID: 40280208 DOI: 10.1016/j.arth.2025.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2024] [Revised: 04/14/2025] [Accepted: 04/15/2025] [Indexed: 04/29/2025] Open
Abstract
BACKGROUND The safety of intraoperative periarticular triamcinolone injection in total knee arthroplasty (TKA) remains unclear. This study aimed to assess the association between periarticular injection of triamcinolone during primary TKA and complications, including early postoperative infection. METHODS A Japanese nationwide database was used to identify adults who underwent primary TKA between April 2016 and March 2022. Patients were divided into triamcinolone and control groups. The primary outcome was reoperation for infection within 90 days from primary TKA. Secondary outcomes included diagnosis of postoperative infection, wound complications, deep vein thrombosis (DVT), pulmonary embolism (PE), in-hospital death, and readmission within 90 days. Propensity score matching was performed to adjust baseline differences. During the study period, 242,571 cases underwent primary knee arthroplasty. Among 212,427 eligible TKA patients, 15,229 (7.2%) were in the triamcinolone group and 197,198 (92.8%) were in the control group. RESULTS Overall, there were 551 reoperations for infection within 90 days (0.26%), including 61 (0.40%) patients in the triamcinolone group and 490 (0.25%) in the control group. Propensity score matching yielded 14,683 pairs. The triamcinolone group had a higher incidence of reoperation for infection, with a risk ratio (RR) of 1.67 (95% confidence interval [CI]: 1.10 to 2.53) and risk difference of 0.16% (95% CI: 0.03 to 0.29). Diagnoses of infection (RR: 1.25 [95% CI: 1.09 to 1.44]) and wound complications (RR: 1.18 [95% CI: 0.99 to 1.39]) were more frequent in the triamcinolone group, while DVT incidence was significantly lower (RR: 0.69 [95% CI: 0.65 to 0.73]). No significant differences were observed in PE or in-hospital death, although 90-day readmission was more frequent in the triamcinolone group (RR: 1.22 [95% CI: 1.06 to 1.40]). CONCLUSIONS Although the difference was subtle, periarticular injection of triamcinolone during TKA was associated with an increased risk of early postoperative infection requiring reoperation.
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Affiliation(s)
- Shingo Kurihara
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, Kanagawa 236-0027, Japan.
| | - Chikamasa Ichita
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, Kanagawa 236-0027, Japan; Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanagawa 247-8533, Japan.
| | - Tadahiro Goto
- TXP Medical Co., Ltd., 41-1 Higashimatsushita, Kanda, Chiyoda, Tokyo 101-0042, Japan; Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, Kanagawa 236-0027, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-0033, Japan.
| | - Kazuhisa Hatayama
- Department of Orthopaedic Surgery, Japan Community Health Care Organization Gunma Central Hospital, 1-7-13 Koun, Maebashi, Gunma 371-0025, Japan.
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo 113-8519, Japan.
| | - Sayuri Shimizu
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Kanazawa, Yokohama, Kanagawa 236-0027, Japan.
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Singh AK, Wani AH, Thorat B, Krishna V, Das A. Steroid Versus Non-steroid Intraoperative Multimodal Periarticular Injection in Simultaneous Bilateral Total Knee Arthroplasty Using Real Intelligence CORI: Comparative Observational Study on Postoperative Pain and Early Functional Recovery. Cureus 2025; 17:e80014. [PMID: 40182357 PMCID: PMC11966590 DOI: 10.7759/cureus.80014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2025] [Indexed: 04/05/2025] Open
Abstract
AIMS AND OBJECTIVES This study aimed to compare the postoperative pain, early knee range of flexion, and straight leg raise (SLR) outcomes between the right and left knees in patients undergoing simultaneous bilateral primary total knee arthroplasty (TKA). The primary objective of this study was to investigate the comparative effects of a multimodal periarticular cocktail injection injected intraoperatively to both knees, with a specific focus on the impact of adding methylprednisolone to the injection administered to the right knee. MATERIALS AND METHODS This prospective observational comparative study enrolled 30 patients (60 knees) who underwent simultaneous bilateral primary TKA. Following strict inclusion and exclusion criteria, all patients were carefully selected for participation. Intraoperatively, a multimodal periarticular cocktail mixture was injected into both knees prior to final implantation. Notably, the right-sided mixture contained methylprednisolone (80 mg). Postoperative follow-up assessments focused on evaluating Visual Analog Scale (VAS) pain scores, degree of range of flexion, and degree of SLR. RESULTS The study sample consisted of patients with a mean age of 61.07 years, exhibiting a female-to-male ratio of 16.6:1. Our study demonstrated a significant reduction in VAS scores for the right knee compared to the left knee at all post-operative time points (12, 24, 48, and 72 hours), with p-value < 0.001. Early functional recovery, assessed by knee flexion and SLR, showed improved outcomes in the right knee. At 24, 48, and 72 hours post-operation, the right knee demonstrated a significantly greater range of motion (ROM) compared to the left knee (p < 0.05). The right knee exhibited significantly higher active SLR values than the left knee at 24, 48, and 72 hours post-operation, with statistically significant differences (p < 0.05). CONCLUSION This study demonstrated that the adjunctive use of methylprednisolone in a periarticular intraoperative multimodal cocktail injection significantly improved the postoperative pain and functional outcomes following TKA. Specifically, the addition of methylprednisolone resulted in reduced postoperative pain scores with increased ROM (degrees) and greater active SLR (degrees) compared to the conventional multimodal periarticular cocktail injection.
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Affiliation(s)
| | - Arshid H Wani
- Orthopaedic Surgery, Amandeep Hospital, Amritsar, IND
| | - Babaji Thorat
- Orthopedic Surgery, Amandeep Hospital, Amritsar, IND
| | | | - Abhijit Das
- Orthopaedics, Amandeep Hospital, Amritsar, IND
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Light JJ, John MP, Bonner KF, Styron JF. The Mechanisms and Safety of Corticosteroid Injections in Orthopaedic Surgery. JBJS Rev 2025; 13:01874474-202502000-00004. [PMID: 39937923 DOI: 10.2106/jbjs.rvw.24.00177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2025]
Abstract
» Corticosteroid injections (CSIs), including intra-articular, perineural, and those involving tendon sheaths or bursae, offer potential relief from osteoarthritic and inflammatory musculoskeletal pain, including gout attacks, as well as tarsal tunnel syndrome, plantar fasciitis, and interdigital neuromas.» CSI for musculoskeletal pain is commonly used as a nonoperative management option for both diagnostic and therapeutic purposes, offering pain relief, typically lasting from days to months.» CSIs are often performed prior to surgery as part of the nonoperative management of many conditions, with multiple CSIs within the year of surgery increasing postoperative infection risk in some major joints.» Despite the potential benefits of CSI, there are risks, including a potential increase in the risk of surgical site infection secondary to bacterial contamination and the immunomodulating effect of corticosteroids when given in the perioperative period.» To date, a multitude of studies across orthopaedic subspecialties has reported on perioperative infection risk associated with CSIs. However, heterogeneity in study design and patient populations has made standardized recommendations challenging. It is, therefore, difficult to elucidate, with a high level of evidence, the most appropriate perioperative timeline for CSI administration for which infection risk is nonsignificant.
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Affiliation(s)
- Jonathan J Light
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York
| | - Mitchell P John
- Hand Surgery, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kevin F Bonner
- Jordan-Young Institute Orthopedic Surgery, Virginia Beach, Virginia
| | - Joseph F Styron
- Hand Surgery, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Choudhury AK, Gupta K, Regmi A, Niraula BB, Sharma D, Gupta T, Kalia RB. Effect of periarticular cocktail of analgesia on immediate post-operative clinical outcomes after bilateral simultaneous total knee arthroplasty: a randomized placebo controlled, split-body superiority trial. J Clin Orthop Trauma 2024; 58:102794. [PMID: 39554282 PMCID: PMC11567932 DOI: 10.1016/j.jcot.2024.102794] [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: 06/15/2024] [Revised: 09/19/2024] [Accepted: 10/28/2024] [Indexed: 11/19/2024] Open
Abstract
Introduction Total knee arthroplasty is the commonest procedure being done for Osteoarthritis of knee in current practice. In spite of its success many patients suffer from post-operative pain especially in the early post-operative period. The study aimed to evaluate the pain relief and functional benefit of periarticular cocktail infiltration. Methodology Sixty-four patients undergoing simultaneous bilateral total knee were randomised to receive peri-articular cocktail injection in one knee and a similar amount of normal saline in contralateral knee. Cocktail consisted of ketorolac, ropivacaine and epinephrine. Patients' visual analog pain score (VAS), knee range of motion, quadriceps strength, single step test (SST) were recorded post-operatively. Results The cocktail infiltrated knee had significantly lesser pain scores during the first 48 h. Intervened knee achieved better knee range of motion at 72 h and 14 days post-surgery. Quadriceps power and SST had better results in cocktail injected knees at 72 h, but no significant difference was detected at 14-day follow-up. Conclusion Use of peri-articular cocktail injection is an effective modality to achieve better pain relief in early post-operative period. Though the benefits are not long lived, but its superior effects can be utilised for early functional recovery after TKA and improved patient rehabilitation. Level of evidence I, Randomized Controlled Trial.
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Affiliation(s)
- Arghya Kundu Choudhury
- Centre of Robotics and Joint Replacement Surgery, Sarvodaya Hospital and Research Centre, Faridabad, India
| | - Kshitij Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Anil Regmi
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Bishwa Bandhu Niraula
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Divyansh Sharma
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Tushar Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Roop Bhushan Kalia
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
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Wainwright JD, Gugala Z, Krueger CA, Wenke JC. Adding corticosteroids to intra-operative periarticular injections in total knee arthroplasty: A systematic review. Knee 2024; 49:87-96. [PMID: 38876084 DOI: 10.1016/j.knee.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 05/20/2024] [Accepted: 05/24/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Adding corticosteroids to intraoperative periarticular injections (PAIs) have become a current trend in total knee arthroplasty (TKA). Periarticular corticosteroid injections (PACSIs) intend to improve postoperative pain and function. However, preoperative corticosteroid injections for symptomatic arthritis increase the rates of prosthetic joint infection (PJI) when given months prior to TKA. The aim of this systematic review was to determine whether the addition of corticosteroids to PAIs during TKA improves patient outcomes and whether such practice increases the risk of PJI? METHODS A systematic review of the current literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines screened 1025 abstracts. Thirteen studies meeting specific eligibility criteria were included for further analysis. RESULTS Among the studies comparing the PACSIs versus nonsteroidal PAIs, 36% showed a significant reduction in postoperative pain scores, 20% showed significant improvement in range of motion (ROM), and 16% showed a significant reduction in total morphine equivalence (TME). While 100% of the studies comparing PACSI to saline or no injections showed significant improvement in pain, ROM and TME. In total, there were 3 infections in 576 TKA cases receiving PACSIs and 2 infections in 534 cases not receiving a PACSI. However, studies were not powered specifically to assess for infection. CONCLUSIONS The addition of corticosteroids to intraoperative PAIs do not demonstrate a significant benefit in the majority of studies, and tend to not have an effect on PJI risk; however, studies were not specifically powered to assess PJI risk.
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Affiliation(s)
- Jared D Wainwright
- University of Texas Medical Branch Department of Orthopaedic Surgery and Rehabilitation, 301 University Blvd., Galveston, TX 77555, United States; Shriners Children's Hospital Texas, 815 Market St., Galveston, TX 77550, United States.
| | - Zbigniew Gugala
- University of Texas Medical Branch Department of Orthopaedic Surgery and Rehabilitation, 301 University Blvd., Galveston, TX 77555, United States
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St., Philadelphia, PA 19107, United States
| | - Joseph C Wenke
- University of Texas Medical Branch Department of Orthopaedic Surgery and Rehabilitation, 301 University Blvd., Galveston, TX 77555, United States; Shriners Children's Hospital Texas, 815 Market St., Galveston, TX 77550, United States
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Wang Y, Li Z, Gao X, Lin J. The efficacy and safety of intra-articular injection of corticosteroids in multimodal analgesic cocktails in total knee arthroplasty-a historically controlled study. Front Surg 2024; 11:1279462. [PMID: 38919978 PMCID: PMC11196593 DOI: 10.3389/fsurg.2024.1279462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 05/22/2024] [Indexed: 06/27/2024] Open
Abstract
Background Total knee arthroplasty (TKA) is a common and effective procedure. Optimizing pain control and reducing postoperative discomfort are essential for patient satisfaction. No studies have examined the safety and efficacy of intra-articular corticosteroid injections following TKA. This study aims to examine the safety and efficacy of corticosteroids in intra-articular multimodal analgesic injections. Materials and methods This was a historically controlled study conducted at a single academic institution. Before May 2019, patients received an intra-articular cocktail injection without corticosteroids during surgery, referred to as the non-corticosteroid (NC) group. After June 2019, intraoperatively, patients received an intra-articular cocktail injection containing corticosteroids, referred to as the corticosteroid (C) group. Finally, 738 patients were evaluated, 370 in the C cohort and 368 in the NC cohort. The mean follow-up duration was 30.4 months for the C group and 48.4 months for the NC group. Results The mean VAS scores at rest on postoperative day (POD) 1 (2.35) and POD3 (3.88) were significantly lower in the C group than those in the NC group, which were 2.86 (POD1) and 5.26 (POD3) (p < 0.05). Walking pain in the C group (4.42) was also significantly lower than that (5.96) in the NC group on POD3 (p < 0.05). Patients in the C group had a significantly higher mean range of motion (ROM) (92.55) on POD3 than that (86.38) in the NC group. The mean time to straight leg raise for group C (2.77) was significantly shorter than that (3.61) for the NC group (p < 0.05). The C group also had significantly fewer rescue morphine (1.9) and metoclopramide (0.21) uses per patient than the NC group, which were 3.1 and 0.24, respectively. No significant differences in fever or vomiting rates between groups were found. Patients in neither group developed periprosthetic joint infections or skin necrosis. One patient in the C group suffered from wound dehiscence, and the wound healed well after debridement. No patient died or had a re-operation in either group. Conclusions This pilot trial found that intra-articular injection of multimodal analgesia (including corticosteroids) reduced initial postoperative pain, increased ROM in the early postoperative days (up to POD3), and did not increase wound complications or infection rates in approximately 30 months of follow-up.
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Affiliation(s)
- Yixiong Wang
- Department of Orthopedic Diseases, Jincheng General Hospital, Jincheng, China
| | - Zhichang Li
- Arthritis Clinic & Research Center, Peking University People’s Hospital, Beijing, China
| | - Xuan Gao
- Department of Orthopedic Disease, Luanzhou People’s Hospital, Tangshan, Hebei, China
| | - Jianhao Lin
- Arthritis Clinic & Research Center, Peking University People’s Hospital, Beijing, China
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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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Wainwright JD, Alaraj S, Wenke JC. Systematic review of intraoperative corticosteroid injections and the risk of infection in arthroscopic surgery. J Clin Orthop Trauma 2024; 48:102332. [PMID: 38282804 PMCID: PMC10808960 DOI: 10.1016/j.jcot.2024.102332] [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: 09/25/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024] Open
Abstract
Background Despite the fact that preoperative corticosteroid injections within three to six months of surgery increase the risk of postoperative infection, there is a growing trend of using corticosteroid injections intraoperatively as an effort to decrease postoperative pain and opiate use. Our aim with this review was to answer the question "Do intraoperative corticosteroid injections increase the risk of infections in arthroscopic surgery?" Methods A systematic search of MEDLINE, Cochrane, and PMC databases was conducted adhering to PRISMA 2020 guidelines after registration with PROSPERO (ID: CRD42023459138). We included studies comparing infection rates in patients who received intraoperative corticosteroid injections (IOCSI) to those who received no injection. The MINORS risk of bias tool was used to assess the quality of included studies. Results 305 individual records were screened and a total of 8 studies met the criteria for inclusion in the study, containing data from over 700,000 patient records. All 7 retrospective studies showed an increase in infection rates and the single small randomized controlled trial had no infections in either the control or intervention group. The combined weighted odds ratio of infection rates in comparable studies was 2.23 95% CI (1.66-3.11). Conclusions Current data shows that IOCSIs more than double the risk of postoperative infection during arthroscopic surgery. Surgeons should consider and weigh the impact of infection to the minor clinical benefit corticosteroid injections add over other multimodal injections. We expect similar increases in infection rates in other surgeries where IOCSIs are used due to the inherent immunosuppressive mechanisms of corticosteroids.
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Affiliation(s)
- Jared D. Wainwright
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77550, USA
- Shriners Children's Texas, 815 Market Street, Galveston, TX, 77550, USA
| | - Sami Alaraj
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77550, USA
| | - Joseph C. Wenke
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77550, USA
- Shriners Children's Texas, 815 Market Street, Galveston, TX, 77550, USA
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King GA, Le A, Nickol M, Sarkis B, van der Merwe JM. Periarticular infiltration used in total joint replacements: an update and review article. J Orthop Surg Res 2023; 18:859. [PMID: 37957753 PMCID: PMC10641975 DOI: 10.1186/s13018-023-04333-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.
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Affiliation(s)
- Gavin Anthony King
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Alexander Le
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Michaela Nickol
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Bianca Sarkis
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
- Faculty of Medicine - Division of Orthopaedic Surgery, University of Montreal, Montreal, Canada
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Wang D, Chen W, Zhang L, Wang Z, Qian Y, Li T, Sun J. Dexamethasone as additive of local infiltration analgesia reduces opioids consumption after simultaneous bilateral total hip or knee arthroplasty: a randomized controlled double-blind trial. J Orthop Surg Res 2023; 18:715. [PMID: 37736729 PMCID: PMC10514997 DOI: 10.1186/s13018-023-04164-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023] Open
Abstract
PURPOSE A randomized controlled double-blind trial was conducted to evaluate the effects of adding dexamethasone to the local infiltration analgesia (LIA) mixture on frequency of patient controlled analgesia (PCA) and opioids consumption after simultaneous bilateral total hip or knee arthroplasty (THA or TKA). METHODS 108 patients who received simultaneous bilateral THA or TKA were randomly divided into dexamethasone group and normal saline (NS) group. The main difference between two groups was whether or not dexamethasone was added to the LIA mixture. The main outcome was the cumulative consumption of opioids within 24 h. The secondary outcome were the total cumulative consumption of opioids during postoperative hospitalization, consumption of opioids drug for rescue analgesia, frequency of PCA, postoperative Visual Analogue Scale (VAS), and complications. RESULTS Cumulative consumption of opioids in the 24 h was similar between two groups (P = 0.17). Total cumulative consumption of opioids in the dexamethasone group during postoperative hospitalization was significantly lower (P = 0.03). No significant difference in the consumption of opioids drug for rescue analgesia between two groups within 24 h, while the frequency of PCA was significantly different (P = 0.04). VAS of dexamethasone group and NS group were similar during postoperative hospitalization, while the incidence of postoperative nausea and vomiting (PONV) in dexamethasone group was lower than that in NS group. CONCLUSIONS Adding dexamethasone to LIA in the simultaneous bilateral THA or TKA can effectively reduce the total cumulative consumption of opioids and the frequency of PCA, as well as reduce the incidence of PONV. Trial Registration The trial has been registered in the Chinese Clinical Trial Registry (Registration Number: ChiCTR2100042551, Date: 23/01/2021).
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Affiliation(s)
- Dasai Wang
- Orthopedic Center, Nanjing Jiangbei Hospital, Nanjing, 210043, Jiangsu, People's Republic of China
- Department of Orthopedics Surgery, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241000, Anhui, People's Republic of China
| | - Wang Chen
- Department of Orthopedics Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, Heilongjiang, People's Republic of China
| | - Leshu Zhang
- Department of Orthopedics Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150000, Heilongjiang, People's Republic of China
| | - Zhigang Wang
- Orthopedic Center, Nanjing Jiangbei Hospital, Nanjing, 210043, Jiangsu, People's Republic of China
| | - Yu Qian
- Department of Orthopedics Surgery, Nanjing Drum Tower Hospital Group Suqian Hospital, Suqian, 223800, Jiangsu, People's Republic of China
| | - Tao Li
- Orthopedic Center, Nanjing Jiangbei Hospital, Nanjing, 210043, Jiangsu, People's Republic of China.
| | - Jianning Sun
- Department of Orthopedics Surgery, Nanjing Drum Tower Hospital Group Suqian Hospital, Suqian, 223800, Jiangsu, People's Republic of China.
- Department of Orthopedics Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, People's Republic of China.
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Kulkarni R, Pawar H, Panchal S, Prabhu R, Keny SA, Kamble PR, Rathod TN, Mohanty SS. Efficacy of Periarticular Local Infiltrative Analgesic Injection on Postoperative Pain Control and Functional Outcome in Sequential Bilateral Total Knee Replacement: A Prospective Controlled Trial in 120 Consecutive Patients. Indian J Orthop 2023; 57:689-695. [PMID: 37128569 PMCID: PMC10147849 DOI: 10.1007/s43465-023-00850-5] [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: 11/16/2022] [Accepted: 02/13/2023] [Indexed: 05/03/2023]
Abstract
Background One of the drawbacks of total knee replacements (TKR) is the early postoperative pain, which affects patient satisfaction and increases the duration of rehabilitation. The present study analyzes the potency of local infiltrative analgesia and its effect on rehabilitation in bilateral sequential TKRs. Materials and Methods The present prospective observational study was conducted on 120 patients undergoing bilateral sequential TKR performed by a single surgeon using an anterior midline incision with a standard medial parapatellar approach. At the end of the surgery, a periarticular cocktail injection was administered to one knee, whereas the other knee served as the control. Postoperatively, patients were assessed for the pain level in each knee based on the visual analog scale (VAS) score and improvement in the range of motion (ROM). Intergroup and intragroup analyses were performed using the unpaired t test and analysis of variance, respectively. A p value of < 0.05 was considered significant. Results Of the 120 patients, 58% were women and 42% were men with a mean age of 62.14 ± 8.58 years. The postoperative mean VAS score was significantly lower in the test knee group than in the control knee group (p < 0.05). The postoperative mean ROM was more in the test group as compared to the control group on days 3 and 7 (p < 0.05), whereas it was comparable on day 14 (p > 0.05). Conclusion Periarticular injection of a drug combination in patients managed with bilateral TKRs that are done simultaneously reduces the early postoperative pain and improves rehabilitation during the first week after surgery.
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Affiliation(s)
- Rajiv Kulkarni
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra 400012 India
| | - Harshad Pawar
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra 400012 India
| | - Sameer Panchal
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra 400012 India
| | - Rudra Prabhu
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra 400012 India
| | - Swapnil A. Keny
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra 400012 India
| | - Prashant R. Kamble
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra 400012 India
| | - Tushar N. Rathod
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra 400012 India
| | - Shubhranshu S. Mohanty
- Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra 400012 India
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Saini MK, Reddy NR, Reddy PJ, Thakur AS, Reddy CD. The application of low-dose dexamethasone in total knee arthroplasty: finding out the best route and dosage schedule. Arch Orthop Trauma Surg 2023; 143:1005-1012. [PMID: 35075551 DOI: 10.1007/s00402-022-04356-x] [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: 09/17/2021] [Accepted: 01/10/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND The use of dexamethasone as additive to multimodal analgesic regimen in total knee arthroplasty has been well established, but the most suitable route, effectiveness, safety and dose schedule of low-dose dexamethasone is not known. METHODS We conducted a prospective, randomized, double-blinded trial to investigate and compare the analgesic and antiemetic effects and safety of low-dose (8 mg) dexamethasone introduced as periarticular injection or intravenous (as a single dose or in two divided doses of 4 mg separated by 24 h) in unilateral total knee arthroplasty patients. RESULTS The single dose intravenous administration as well as the periarticular administration of dexamethasone had similar mean visual analogue scores which were significantly lower than divided dose group at 24 and 48 h postoperatively. The rate of postoperative nausea and vomiting was lowest among single intravenous dose group and highest among interval dose group at 24 h, while no difference was noted at 48 h. No significant differences were noted in terms of knee flexion angle at 48 h and modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 6 weeks. CONCLUSION Single low-dose intravenous dexamethasone is the most appropriate dose which can safely be given to TKA patients and is only moderately associated with rise in blood sugar not causing any significant complication. Alternatively, periarticular infiltration of low-dose dexamethasone can produce equivalent analgesic effect as SDIV in first 24 h without causing significant blood sugar rise and wound complications, but its antiemetic effect remains subtle. Therefore, it is recommended to further study the combination of intraoperative periarticular and postoperative intravenous dexamethasone for their possible additive effect.
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Affiliation(s)
- Mukesh Kumar Saini
- FNB (Arthroplasty) Trainee, Arthroplasty division, Star Hospitals, Hyderabad, India.
| | - Neelam Ramana Reddy
- Consultant, Department of Orthopaedics, Arthroplasty Division, Star Hospitals, B Block Road no 10 Banjara Hills, Hyderabad, India
| | - Pera Jayavardhan Reddy
- Senior resident, Department of Orthopaedics, Star Hospitals, B Block Road no 10 Banjara Hills, Hyderabad, India
| | - Ajay Singh Thakur
- Consultant, Department of Orthopaedics, Arthroplasty Division, Star Hospitals, B Block Road no 10 Banjara Hills, Hyderabad, India
| | - Challa Dinesh Reddy
- FNB (Arthroplasty) Trainee, Arthroplasty division, Star Hospitals, Hyderabad, India
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13
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Ebihara T, Hamada T, Nakamura K, Inokuchi A, Izumi T, Imamura R, Inoue T, Inoue H, Kuroki Y, Arizono T. Efficacy of Corticosteroid Addition to a Periarticular Cocktail Injection to Counteract Nausea and Vomiting After Total Knee Arthroplasty. Cureus 2023; 15:e33874. [PMID: 36819319 PMCID: PMC9934463 DOI: 10.7759/cureus.33874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Intraoperative periarticular injection of a "cocktail" of drugs is undertaken commonly in total knee arthroplasty (TKA). The addition of a corticosteroid to the periarticular injection is believed to offer greater pain relief because of its local anti-inflammatory effects, but the prevalence of postoperative nausea and vomiting (PONV) is not known. This retrospective observational study aimed to elucidate the relationship between corticosteroid addition to a periarticular cocktail injection (PCI) and PONV. MATERIALS AND METHODS Fifty-nine patients who underwent unilateral TKA for primary osteoarthritis were divided into two groups: corticosteroid and non-corticosteroid. The former had triamcinolone acetonide (40 mg) added to the same PCI. The primary outcome was the prevalence of nausea and vomiting within 48 hours following TKA. RESULTS There was no significant difference between the two groups in terms of patient demographics. The overall prevalence of PONV was 16.9%. Fewer patients in the corticosteroid group complained of PONV than in the non-corticosteroid group (6.4% vs. 58.3%; p = 0.012). CONCLUSIONS The addition of a corticosteroid to a PCI suppressed PONV. Our results suggested that cocktail injections may have local and systemic effects.
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Affiliation(s)
- Toshihiro Ebihara
- Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Takahiro Hamada
- Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Kimitaka Nakamura
- Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Akihiko Inokuchi
- Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Teiyu Izumi
- Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Ryuta Imamura
- Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Takahiro Inoue
- Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Hayato Inoue
- Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Yosuke Kuroki
- Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
| | - Takeshi Arizono
- Department of Orthopaedic Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, JPN
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14
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Han C, Hashimoto Y, Nakagawa S, Takahashi S, Nishida Y, Yamasaki S, Takigami J, Nakamura H. The effect and safety of periarticular multimodal drug injection without morphine and epinephrine in anterior cruciate ligament reconstruction. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2022. [DOI: 10.1177/22104917221136285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Periarticular multimodal drug injection (PMDI) is a safe and effective pain management technique after anterior cruciate ligament reconstruction (ACLR); however, adding morphine and epinephrine sometimes causes adverse effects. Therefore, we evaluated the efficacy of PMDI without morphine and epinephrine after ACLR. Methods This retrospective matched case-control study included patients who had undergone primary double-bundle ACLR with PMDI and were then matched one-to-one with a control group without PMDI based on sex, age, and body mass index using propensity-matched analysis. The following clinical outcomes were compared between the groups: visual analog scale (VAS) score, C-reactive protein (CRP) concentration, number of times the patients used additional analgesics, complication rate, and postoperative time to achieve straight leg raise (SLR). Results Twenty-nine patients with PMDI and 29 controls were enrolled. The VAS score at 1 day postoperatively was lower in the PMDI than the control group (1.93 ± 1.44 vs. 3.41 ± 1.75, respectively; P < 0.001). The CRP concentration at 1 and 3 days was lower in the PMDI than the control group (0.46 ± 0.47 vs. 1.00 ± 0.69 mg/dL, P < 0.001; and 1.93 ± 1.71 vs. 4.01 ± 2.55 mg/dL, P < 0.001, respectively). The average number of additional analgesics used was significantly lower in the PMDI than the control group. There were no significant differences in the frequency of occurrence of postoperative complications between the two groups. The number of patients who could achieve SLR within 1 day was 27/29 (93%) in PMDI group, which was significantly higher than the control group (12/29, 41%) ( P < 0.001). Conclusion PMDI without morphine and epinephrine after ACLR reduced patients’ subjective pain level, objective inflammatory response without complications and enabled patients to achieve early functional recovery.
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Affiliation(s)
- Changhun Han
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Yusuke Hashimoto
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Sunao Nakagawa
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Shinji Takahashi
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Yohei Nishida
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Shinya Yamasaki
- Department of Orthopaedic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Junsei Takigami
- Department of Orthopaedic Surgery, Shimada Hospital, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
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15
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Hannon CP, Fillingham YA, Spangehl MJ, Karas V, Kamath AF, Casambre FD, Verity TJ, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty 2022; 37:1928-1938.e9. [PMID: 36162925 DOI: 10.1016/j.arth.2022.03.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine. METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI. RESULTS Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine. CONCLUSION Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | | | | | - Vasili Karas
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Atul F Kamath
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | | | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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16
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Jou E, Zhou AK, Ho JSY, Thahir A. Perioperative use of intra-articular steroids during the COVID-19 pandemic. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022; 32:1225-1235. [PMID: 34468841 PMCID: PMC8408365 DOI: 10.1007/s00590-021-03105-x] [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] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/23/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE There are growing concerns with the widely used glucocorticoids during the Coronavirus disease-19 (COVID-19) pandemic due to the associated immunosuppressive effects, which may increase the risk of COVID-19 infection and worsen COVID-19 patient outcome. Heavily affecting orthopaedics, the pandemic led to delay and cancellation of almost all surgical cases, and procedures including perioperative intra-articular corticosteroid injections (ICIs) saw similar decreases. However, the benefits of ICI treatments during the pandemic may outweigh these potential risks, and their continued use may be warranted. METHODS A literature search was conducted, and all relevant articles including original articles and reviews were identified and considered in full for inclusion, and analysed with expert opinion. Epidemiological statistics and medical guidelines were consulted from relevant authorities. RESULTS ICIs allow a targeted approach on the affected joint and are effective in reducing pain while improving functional outcome and patient quality-of-life. ICIs delay the requirement for surgery, accommodating for the increased healthcare burden during the pandemic, while reducing postoperative hospital stay, bringing significant financial benefits. However, ICIs can exert systemic effects and suppress the immune system. ICIs may increase the risk of COVID-19 infection and reduce the efficacy of COVID-19 vaccinations, leading to important public health implications. CONCLUSION Perioperative ICI treatments may bring significant, multifaceted benefits during the pandemic. However, ICIs increase the risk of infection, and perioperative COVID-19 is associated with mortality. The use of ICIs during the COVID-19 pandemic should therefore be considered carefully on an individual patient basis, weighing the associated risks and benefits.
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Affiliation(s)
- Eric Jou
- School of Clinical Medicine, University of Cambridge, Cambridge, UK.
- MRC Laboratory of Molecular Biology, Cambridge Biomedical Campus, Cambridge, UK.
| | | | | | - Azeem Thahir
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Department of Trauma and Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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17
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Periarticular Injection in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2022; 37:1701-1707. [PMID: 35970572 DOI: 10.1016/j.arth.2022.03.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 02/06/2023] Open
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18
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Dong W, Wang X, Wang H, You J, Zheng R, Xu Y, Zhang X, Guo J, Ruan J, Fan F. Comparison of Multimodal Cocktail to Ropivacaine Intercostal Nerve Block for Chest Pain After Costal Cartilage Harvest: A Randomized Controlled Trial. Facial Plast Surg Aesthet Med 2022; 24:102-108. [PMID: 35230140 DOI: 10.1089/fpsam.2021.0264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: To compare the effectiveness of an intercostal nerve block after costal cartilage harvest when a multimodal cocktail or ropivacaine plus patient-controlled analgesia is used, as measured by visual analog scale (VAS) scores, rescue analgesic consumption, and related complications. Materials and Methods: Eligible patients who underwent costal cartilage harvest were equally randomized to receive a multimodal cocktail (multimodal group) or ropivacaine plus patient-controlled analgesia (ropivacaine group). Results: Of 112 patients assessed, 12 (10.7%) patients were excluded and 100 (89.3%) patients were enrolled and assigned to multimodal group (n = 50) and ropivacaine group (n = 50). The VAS scores in the multimodal group were significantly lower than those in the ropivacaine group both at rest (0.924 ± 0.073 vs. 1.920 ± 0.073, p < 0.001) and during coughing (2.340 ± 0.083 vs. 3.944 ± 0.083, p < 0.001) in mixed-effects model analysis. Rescue analgesic consumption and rate of complications were significantly lower in the multimodal group compared with the ropivacaine group (all p < 0.05). Conclusions: Multimodal cocktail improved chest pain after costal cartilage harvest with less rescue analgesic consumption and complications compared with ropivacaine plus patient-controlled analgesia. Clinical Trial Registration: ChiCTR2100042445.
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Affiliation(s)
- Wenfang Dong
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Xin Wang
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Huan Wang
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Jianjun You
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Ruobing Zheng
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Yihao Xu
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Xulong Zhang
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Junsheng Guo
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Jingjing Ruan
- Department of Ear Reconstruction, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Fei Fan
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
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19
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Oshima A, Hatayama K, Terauchi M, Kakiage H, Hashimoto S, Chikuda H. The comparison of dexamethasone and triamcinolone periarticular administration in total knee arthroplasty: retrospective cohort study. BMC Musculoskelet Disord 2022; 23:120. [PMID: 35123474 PMCID: PMC8818232 DOI: 10.1186/s12891-022-05048-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background Intraoperative periarticular injection of corticosteroid effectively reduces perioperative pain in total knee arthroplasty (TKA). However, which corticosteroid is most effective for intraoperative periarticular injection remains controversial. We compared the effects of corticosteroids between dexamethasone and triamcinolone acetonide periarticular administration for reducing pain and postoperative nausea and increasing fasting blood glucose concentrations during the perioperative period following TKA. Methods One hundred and two patients who underwent TKA from August 2018 to September 2020 were divided into two groups: one received 10 mg dexamethasone for intraoperative periarticular injection and another receiving 40 mg triamcinolone acetonide. Postoperative pain scores at rest and during walking and nausea scores were recorded using a 0-to-10 Numerical Rating Scale. C-reactive protein (CRP) and fasting blood glucose levels were measured pre- and postoperatively. Results Pain scores in the triamcinolone group were significantly lower than in the dexamethasone group at rest 7 days postoperatively (1.5 vs. 2.0; p = 0.046) and while walking at both 72 h (3.9 vs. 4.8; p = 0.008) and 7 days postoperatively (3.2 vs. 4.0; p = 0.03). The CRP levels in the triamcinolone group were significantly lower than in the dexamethasone group at 7 days postoperatively (1.6 mg/dl vs. 3.0 mg/dl: p < 0.001). The fasting blood glucose levels at 1 day postoperatively were increased in both groups but not significantly different between the groups. No significant differences in the nausea score were noted between the groups. Conclusions Triamcinolone acetonide periarticular administration provided greater pain relief by reducing inflammation to a greater degree than dexamethasone.
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20
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Chan VWK, Chan PK, Yan CH, Henry CH, Chan CW, Chiu KY. Effect of Steroid in Local Infiltration Analgesia in One-Stage Bilateral Total Knee Arthroplasty: A Paired-Randomized Controlled Study. J Knee Surg 2022; 35:317-322. [PMID: 32688398 DOI: 10.1055/s-0040-1713811] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although local infiltration analgesia (LIA) is effective in relieving pain after total knee arthroplasty (TKA), its effect is short lasting and the optimal combination of drugs is unknown. Steroids being a potent and long-acting anti-inflammatory drug might extend LIA's effect. This study aims to evaluate the role of steroids in LIA. This is a paired-randomized controlled study involving one-stage bilateral TKA patients. LIA containing ropivacaine, ketorolac, and adrenaline with or without triamcinolone was given. One knee was randomized to receive LIA with steroids, while the other received LIA without steroids. The primary outcome was knee pain in terms of the visual analog scale (VAS). Secondary outcomes were rehabilitation progress, functional scores, and complications. Outcomes were compared between the knees of the same patient and documented up to 1 year. A total of 45 patients (90 TKAs) were included. LIA with steroid knees showed lower VAS score at rest and during activity from postoperation day 1 to 5 and at 6 weeks (p < 0.05). Passive and active range of movement was also greater in LIA with steroid group from day 1 to 7 and day 2 to 5, respectively (p < 0.05). Steroid-treated knees also achieved active straight leg raise earlier (1.2 vs. 2.0 days, p < 0.05). No differences in Knee Society Score and complication rates between both groups. Steroids in LIA offer additional and extended benefit in pain control and rehabilitation after TKA, while no adverse effects were found up to 1-year follow-up.
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Affiliation(s)
- Vincent Wai Kwan Chan
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, SAR, People's Republic of China
| | - Ping Keung Chan
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, SAR, People's Republic of China
| | - Chun Hoi Yan
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, SAR, People's Republic of China
| | - Chun Him Henry
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, SAR, People's Republic of China
| | - Chi Wing Chan
- Department of Anaesthesiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, SAR, People's Republic of China
| | - Kwong Yuen Chiu
- Division of Joint Replacement Surgery, Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, SAR, People's Republic of China
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21
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McLawhorn AS, Poultsides LA, Sakellariou VI, Kunze KN, Fields KG, Jules-Elysée K, Sculco TP. Low-Dose Perioperative Corticosteroids Can Be Administered Without Additional Morbidity in Patients Undergoing Bilateral Total Knee Replacement: A Retrospective Follow-up Study of a Randomized Controlled Trial. HSS J 2022; 18:48-56. [PMID: 35087332 PMCID: PMC8753552 DOI: 10.1177/15563316211006098] [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: 11/13/2020] [Accepted: 11/20/2020] [Indexed: 02/03/2023]
Abstract
Background: Short-term benefits of perioperative corticosteroid injections (CSIs) for bilateral total knee replacement (BTKR) include suppressed inflammation, improved knee motion, and reduced pain. Very little is known about the long-term benefits, complications, and safety of corticosteroids administered in the perioperative period. Purpose: We sought to compare 3-year follow-up outcomes of BTKR patients who received perioperative CSI with those who received placebo. We hypothesized that there would be no statistically significant differences in functional outcomes or adverse events based on whether or not CSIs were administered in the perioperative period. Methods: We conducted a retrospective review of chart and registry data of BTKR patients from a prior randomized controlled trial to compare outcomes in patients who received hydrocortisone vs placebo injections after BTKR (ClinicalTrials.gov: NCT01399268 and NCT01815918). Outcomes were compared at 6 and 12 weeks and at 1, 2, and 3 years. The Knee Injury and Osteoarthritis Outcome Scores (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used to evaluate clinical outcomes. Cochran-Mantel-Haenszel tests were used to compare the risk of complications between treatments after adjustment for trial. When possible, summary relative risk estimates were calculated using the Mantel-Haenszel method. Results: No BTKR patients in the treatment group developed an infection. The risk of complications did not increase in patients who received CSI compared with those who received placebo. Patients in the CSI group experienced greater reductions in pain and stiffness, though these results were not statistically significant. There were no statistically significant differences in the KOOS-Symptoms, KOOS-Activities of Daily Living, KOOS-Sports, KOOS-Quality of Life, or WOMAC Function scores. Conclusions: Low-dose corticosteroids can be administered in selected patients who undergo BTKR without increasing the risk of adverse events. At 3-year follow-up, administration of low-dose corticosteroids did not result in superior clinical outcomes scores when compared with placebo.
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Affiliation(s)
- Alexander S. McLawhorn
- Department of Orthopaedic Surgery, Adult Reconstruction & Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA,Alexander S. McLawhorn, MD, MBA, Department of Orthopaedic Surgery, Adult Reconstruction & Joint Replacement Service, Hospital for Special Surgery, New York, NY 10021, USA.
| | - Lazaros A. Poultsides
- Department of Orthopaedic Surgery, Adult Reconstruction & Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Vasileios I. Sakellariou
- Department of Orthopaedic Surgery, Adult Reconstruction & Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Kyle N. Kunze
- Department of Orthopaedic Surgery, Adult Reconstruction & Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Kara G. Fields
- Research Institute, Hospital for Special Surgery, New York, NY, USA
| | - Kethy Jules-Elysée
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Thomas P. Sculco
- Department of Orthopaedic Surgery, Adult Reconstruction & Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
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22
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Dong W, Wang X, Wang H, You J, Zheng R, Xu Y, Zhang X, Guo J, Fan F. A Prospective Study of Multimodal Cocktail Intercostal Injection for Chest Pain Relief after Costal Cartilage Harvest for Rhinoplasty. Br J Oral Maxillofac Surg 2021; 60:841-846. [DOI: 10.1016/j.bjoms.2021.12.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/15/2021] [Accepted: 12/23/2021] [Indexed: 11/28/2022]
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23
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Zhong C, He R, Lu X, Zhong L, Lin DK, Liu J, Guo D. Would high-dose corticosteroid addition to multimodal cocktail periarticular injection contribute to prolonged pain control and better recovery following total knee arthroplasty?: study protocol for a randomized controlled trial. Trials 2021; 22:703. [PMID: 34654469 PMCID: PMC8518286 DOI: 10.1186/s13063-021-05655-1] [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] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/24/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Enhanced recovery following total knee arthroplasty (TKA) has been advocated to enhance postoperative recovery. Multimodal cocktail periarticular injection (MCPI) use for pain control in TKA has gained wide acceptance. MCPI-containing corticosteroids are believed to be an effective solution owing to their local anti-inflammatory effects and ability to reduce the local stress response postoperatively. However, there is conflicting evidence regarding its benefits. This trial aims to compare MCPI with a high dose of corticosteroid, normal dose of corticosteroid, and non-corticosteroid during TKA, to assess the effectiveness of MCPI containing corticosteroids in postoperative pain relief, functional improvement, rescue analgesia, and side effects and provide evidence that high-dose corticosteroids result in prolonged pain control and better recovery following TKA. METHODS This is a double-blinded, randomized, placebo-controlled study. A total of 234 patients scheduled for TKA will be recruited. During surgery, before wound closure, 80 ml of the cocktail analgesic will be injected into the muscle and joint capsule for local infiltration analgesia; the participants will be randomly assigned to three groups to receive a high dose of betamethasone MCPI (group H), normal dose of betamethasone MCPI (group N), and non-betamethasone MCPI (group C). The following indices will be recorded and analyzed: the strongest knee pain experienced during 90° flexion at 6 h, 24 h, 48 h, 72 h, 5 days, 14 days, and 30 days after surgery; 1 min walking ability; and circumference around the patella at 2, 5, 14, and 30 days after surgery; Knee Society knee score at 14 days and 30 days after surgery; C-reactive protein and blood sedimentation; blood sugar 2, 5, 14, and 30 days following surgery; rescue analgesic consumption; and adverse events. If any participant withdraws from the trial, an intention-to-treat analysis will be performed. DISCUSSION The results of this study will provide clinical evidence on the effectiveness of MCPI-containing corticosteroids in postoperative pain relief, functional improvement, rescue analgesia, and adverse events, as well as provide evidence on the efficacy of high-dose corticosteroids in prolonged pain control and better recovery following TKA. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2000038671 . Registered on September 27, 2020.
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Affiliation(s)
- Chengfan Zhong
- Department of Orthopedic Surgery, People's Hospital of Gaozhou, No. 89, Xiguan Road, Gaozhou City, 525200, Guangdong, China
| | - Rong He
- Department of Orthopedic Surgery, Maoming People's Hospital, No.101, Weimin Road, Maoming City, 525000, Guangdong, China
| | - Xiaomin Lu
- Clinical Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong, China
| | - Lilun Zhong
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China
| | - Ding-Kun Lin
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China
| | - Jun Liu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China
| | - Da Guo
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 111 Dade Road, Guangzhou, 510120, Guangdong, China.
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Comparison of Efficacy of Adductor Canal Block, Local Infiltration Analgesia and Both Combined in Postoperative Pain Management After Total Knee Arthroplasty: A Randomized Controlled Trial. Indian J Orthop 2021; 55:1111-1117. [PMID: 34824710 PMCID: PMC8586381 DOI: 10.1007/s43465-021-00482-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 08/07/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of our study is to compare the efficacy of adductor canal block (ACB), periarticular local infiltration (PLI) and both combined (ACB + PLI) in multimodal pain management after TKA. METHODS This is a prospective, randomized controlled double-blinded study undergoing primary unilateral TKA. They were randomized into three groups with fifty patients in each group: ACB alone (30 ml of 0.2% ropivacaine), PLI alone (30 ml 0.5% ropivacaine in 20 ml of normal saline), and both combined (ACB + PLI). The primary outcome studied was pain using visual analog score (VAS) in postoperative days (POD) 1 and 2. The secondary outcomes estimated were the ambulation capacity, the knee range of motion, need for rescue analgesia and length of hospital stay. RESULTS The mean VAS score was significantly lower at rest and after mobilization in the combined group (3.51 at POD 1, 2.04 at POD 2), compared with either alone group (ACB = 4.70, 2.86 versus PLI = 4.39, 3.41 at POD 1 and 2 respectively after mobilization, p < 0.001). The ambulation capacity (combined = 103.3 steps versus ACB = 98.1 and PLI = 95.2 steps, p = 0.04) and the knee range of motion (arc of motion 106.7 degrees versus ACB = 104.9 and PLI = 102.2 degrees, p = 0.004) were significantly higher in the combined group compared to the other groups. There was no significant difference in the length of stay between the groups (p = 0.12). CONCLUSION Adductor canal block combined with periarticular local infiltration provides better pain relief, good range of motion, quicker rehabilitation, and reduced opioid consumption.
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25
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The Efficacy and Safety of Glucocorticoid on Periarticular Infiltration Analgesia in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Arthroplasty 2021; 36:3340-3350. [PMID: 33926778 DOI: 10.1016/j.arth.2021.03.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/17/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The objective of this systematic review and meta-analysis was to examine the effect and safety of multimodal cocktail protocols implemented with or without glucocorticoids on periarticular infiltration analgesia (PIA) in patients undergoing total knee arthroplasty (TKA). METHODS We comprehensively searched the PubMed, Medline, Embase, and Cochrane Library databases up to November 2020 for randomized controlled trials on glucocorticoids as a component of the cocktail protocol used in PIA for patients with TKA. RESULTS Our meta-analysis included 11 randomized controlled trial studies with 1051 primary TKAs (930 patients). Visual analog scale scores at postoperative day (POD) 1 and POD 2 in the glucocorticoid groups were significantly lower than those in the control group (95% CI [-1.01--0.10], P = .02; 95% CI [-0.51--0.13], P = .001). Furthermore, the glucocorticoid group was associated with a statistically significant improvement in the range of motion at POD 1 (95% CI [3.20-8.05] P < .00001), reduction in total morphine consumption at 24 hours, and lower levels of C-reactive protein on POD 2/3 compared with the control group. However, neither the length of hospital stays nor the long-term Knee Society Knee Score showed any differences between the two groups. In addition, the results of subgroup analyses favored triamcinolone acetonide over betamethasone, methylprednisolone, and dexamethasone regarding the postoperative visual analog scale scores and range of motion. CONCLUSION Glucocorticoid supplementation in PIA is effective and does not increase complications or side effects for patients with either unilateral or bilateral TKA. Moreover, triamcinolone acetonide could be recommended in multimodal cocktail protocols for glucocorticoid supplementation.
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26
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Do We Need to Wait 3 Months After Corticosteroid Injections to Reduce the Risk of Infection After Total Knee Arthroplasty? J Am Acad Orthop Surg 2021; 29:e714-e721. [PMID: 33229905 DOI: 10.5435/jaaos-d-20-00850] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/23/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Corticosteroid injections administered within 3 months before total knee arthroplasty (TKA) have been linked to increased risk of postoperative infection. However, it would be beneficial to further delineate the timing of injections to determine whether a narrower window exists for safe administration of corticosteroid injections. The purposes of our study were to (1) determine whether there were a different time frame between corticosteroid injection and primary TKA that increased infection risk and (2) determine risk factors associated with infection after TKA. METHODS TKA patients were identified from a national database from 2007 to 2017 and stratified based on their history of corticosteroid injections within the 6-month preoperative period. Patients who received injections were stratified into biweekly cohorts by the timing of their most recent injection. The 1-year rate of postoperative infection treated by surgical débridement was compared between injection and noninjection cohorts. Univariate logistic regressions of risk factors and a multivariate analysis for patient comorbidities and injection cohorts associated with increased infection risk were conducted. RESULTS In the 76,090 TKA patients identified, corticosteroid injection within 2 weeks before TKA increased the risk of postoperative infection (P = 0.02) and injections within 2 to 4 weeks trended toward increased infection in univariate regression. No significant differences were observed in any other injection time frames. In the multivariate analysis, injections within 2 weeks before TKA were identified as an independent risk factor (odds ratio: 2.89; P = 0.04) for postoperative infection. Additional risk factors included chronic obstructive pulmonary disease, coronary artery disease, diabetes, ischemic heart disease, obesity, rheumatoid arthritis, and tobacco, whereas female sex and patient aged older than 65 were protective. DISCUSSION Our results suggest that TKA performed within four weeks of a corticosteroid injection may be associated with a higher risk of postoperative infection; however, delaying surgery more than four weeks may not provide additional infection risk reduction. Further prospective randomized studies are needed to determine the optimal timing of TKA after corticosteroid injections. LEVEL OF EVIDENCE Level III.
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27
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Huang LY, Hu HH, Zhong ZL, Teng C, He B, Yan SG. Should corticosteroids be administered for local infiltration analgesia in knee arthroplasty? A meta-analysis and systematic review. J Clin Pharm Ther 2021; 46:1441-1458. [PMID: 34254696 DOI: 10.1111/jcpt.13443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/23/2021] [Accepted: 05/11/2021] [Indexed: 12/22/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The benefits of local infiltration analgesia (LIA) in knee arthroplasty (KA) have been well-documented. However, it is unknown whether adding a corticosteroid to the composition of the LIA is beneficial. This study aimed to investigate the efficacy and safety of administering periarticular steroids intraoperatively in patients who underwent KA through a systematic review and meta-analysis. METHODS A systematic search was conducted to identify relevant randomized controlled trials in the PubMed, Embase, Web of Science and Cochrane databases up to January 19th, 2021 to perform a meta-analysis. Outcome variables included pain scores, total opioid consumption, knee range of motion (ROM) and postoperative complications. RESULTS Corticosteroid injections did not reduce pain scores at 6, 12, 24 or 72 h postoperatively, although a minimal degree of transient pain relief was achieved at 48 h postoperatively compared with those in the placebo group, nor was there a significant difference in total opioid consumption. However, patients receiving corticosteroids did exhibit a transient ROM increase on postoperative days 1, 2 and 3. Since the minimal clinically important difference (MCID) for ROM is unclear, it is unknown if the improvement in ROM is clinically significant. WHAT IS NEW AND CONCLUSION Our specific end-point analysis demonstrated that corticosteroid administration did not provide pain relief or reduce opioid consumption compared with placebo. However, corticosteroids might provide a statistically significant, though transient and minimal improvement in knee ROM after KA, although no firm conclusions about the benefits of administering corticosteroids in KA can be made based on the available evidence.
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Affiliation(s)
- Le-Yi Huang
- Zhejiang University School of Medicine, Hangzhou, China.,Department of Orthopaedic Surgery, The Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, China
| | - Hong-Hua Hu
- Zhejiang University School of Medicine, Hangzhou, China.,Department of Dermatology, The Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, China
| | - Zhuo-Lin Zhong
- Zhejiang University School of Medicine, Hangzhou, China.,Department of Orthopaedic Surgery, The Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, China
| | - Chong Teng
- Zhejiang University School of Medicine, Hangzhou, China.,Department of Orthopaedic Surgery, The Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, China
| | - Bin He
- Zhejiang University School of Medicine, Hangzhou, China.,Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Shi-Gui Yan
- Zhejiang University School of Medicine, Hangzhou, China.,Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
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28
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Bigalke S, Maeßen TV, Schnabel K, Kaiser U, Segelcke D, Meyer-Frießem CH, Liedgens H, Macháček PA, Zahn PK, Pogatzki-Zahn EM. Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty. Pain 2021; 162:1914-1934. [PMID: 33492036 DOI: 10.1097/j.pain.0000000000002209] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/21/2020] [Indexed: 01/04/2023]
Abstract
ABSTRACT The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.
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Affiliation(s)
- Stephan Bigalke
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | - Timo V Maeßen
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Kathrin Schnabel
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Ulrike Kaiser
- University Pain Centre, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Daniel Segelcke
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Christine H Meyer-Frießem
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | | | - Philipp A Macháček
- Faculty of Electrical Engineering and Information Technology, Ruhr-University Bochum, Bochum, Germany
| | - Peter K Zahn
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | - Esther M Pogatzki-Zahn
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
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Local Efficacy of Corticosteroids as an Adjuvant for Periarticular Cocktail Injection in Simultaneous Bilateral Total Knee Arthroplasty: A Prospective Randomized Double-Blind Controlled Trial. Pain Res Manag 2021; 2021:5595095. [PMID: 34113408 PMCID: PMC8154299 DOI: 10.1155/2021/5595095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/08/2021] [Indexed: 11/17/2022]
Abstract
Multimodal cocktail periarticular injections comprising corticosteroids are the most suggested therapy for postoperative discomfort and swelling following total knee arthroplasty (TKA). Nevertheless, previous findings cannot be applied to instances of unilateral total knee arthroplasty on bilateral knees. This randomized, prospective, double-blind, controlled clinical study examines the efficacy as well as safety of periarticular multimodal cocktail injection along or sans corticosteroids in certain situations. The 60 patients (120 knees) that experienced concurrent bilateral total knee arthroplasty were provided periarticular injections along additional betamethasone (7 mg) in the randomized knee, as well as the other knee, where corticosteroid was not administered. Key results were “pain scores at rest as well as in action” on a visual analogue scale of 11 pt. Other results included motion range, swelling of the thigh, Hospital for Special Surgery score (HSS score), and adverse effects were measured between the two sides. No statistically promising variations were found in the visual analogue scale ranking, motion range, girth of the thigh, and HSS score, as well as complications between the two sides. The impact on treatment outcomes was maintained between the knees on postoperative day 3 or at 3 months of follow-up. Multimodal periarticular injection without corticosteroid will alleviate postoperative swelling and pain. More studies are needed for the use of betamethasone as a corticosteroid in periarticular multimodal cocktail injections. This Chinese Clinical Trial Registry is registered with ChiCTR-OPC-17013503, dated 2017-11-23, available from http://www.chictr.org.cn/showproj.aspxproj=23146.
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30
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Tiwari V, Dwidmuthe S. Letter to the Editor on "Does Topical Administration Provide Better Pain Relief on First Post-Operative Day Than Intravenous Dexamethasone After TKA?". J Arthroplasty 2021; 36:e50. [PMID: 33931161 DOI: 10.1016/j.arth.2020.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/08/2020] [Indexed: 02/02/2023] Open
Affiliation(s)
- Vivek Tiwari
- Department of Orthopaedics, All India Institute of Medical Sciences, Nagpur, India
| | - Samir Dwidmuthe
- Department of Orthopaedics, All India Institute of Medical Sciences, Nagpur, India
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31
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Wang Q, Tan G, Mohammed A, Zhang Y, Li D, Chen L, Kang P. Adding corticosteroids to periarticular infiltration analgesia improves the short-term analgesic effects after total knee arthroplasty: a prospective, double-blind, randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2021; 29:867-875. [PMID: 32361928 DOI: 10.1007/s00167-020-06039-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/27/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE Periarticular infiltration analgesia (PIA) is widely used to control postoperative pain in patients who underwent total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding corticosteroids to the PIA cocktail for pain management in patients who underwent TKA. METHODS The patients were randomized to the corticosteroid or control group (double-blind). The patients in the corticosteroid group received a periarticular infiltration of an analgesic cocktail of ropivacaine, epinephrine, and dexamethasone. Dexamethasone was omitted from the cocktail in the control group. The primary outcomes were postoperative pain [assessed using a visual analog scale (VAS)], time until the administration of first rescue analgesia, morphine consumption, and postoperative inflammatory biomarkers [C-reactive protein (CRP) and interleukin-6 (IL-6)]. The secondary outcomes were functional recovery, assessed by the range of knee motion, quadriceps strength, and daily ambulation distance. The tertiary outcomes included postoperative adverse effects. RESULTS The patients in the corticosteroid group had significantly lower resting VAS scores at 6 and 12 h after surgery, lower VAS scores during motion up to 24 h after surgery, and lower levels of inflammatory biomarkers. All the differences in the VAS scores between the two groups did not reach the point to be considered clinically significant. The additional use of corticosteroid significantly prolonged analgesic effects and led to lower rescue morphine consumption. The patients in the corticosteroid group had significantly better functional recovery on the first day after surgery. The two groups had a similar occurrence of adverse effects. CONCLUSIONS Adding corticosteroids to an analgesic cocktail for PIA could lightly improve early pain relief and accelerate recovery in the first 24 h after TKA. LEVEL OF EVIDENCE Randomized controlled trial, Level I.
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Affiliation(s)
- Qiuru Wang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Gang Tan
- Department of Orthopaedics Surgery, West China Fourth Hospital, Sichuan University, 18# Section 3, Renmin South Road, Chengdu, 610041, People's Republic of China
| | - Alqwbani Mohammed
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yueyang Zhang
- School of Public Health, Shandong University, 44# Wenhua West Road, Jinan, 250012, People's Republic of China
| | - Donghai Li
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Liyile Chen
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China.
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Li Q, Mu G, Liu X, Chen M. Efficacy of additional corticosteroids to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2021; 16:77. [PMID: 33482865 PMCID: PMC7821531 DOI: 10.1186/s13018-020-02144-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/01/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND As the ultimate method for the treatment of osteoarthritis, total knee arthroplasty (TKA) has been widely used in the clinic. Local injection of multimodal cocktails, including corticosteroids, is commonly used for pain management after TKA. This meta-analysis aims to systematically evaluate the effect of periarticular injection of corticosteroids on postoperative pain relief and knee functional recovery in patients undergoing TKA. METHODS PubMed, Cochrane Library, EMBASE, and Web of Science databases were comprehensively searched for all randomized controlled trials (RCTs) published before July 1, 2020, that investigated the efficacy of corticosteroids for TKA. RESULTS Ten RCTs involving a total of 829 patients were assessed in the meta-analysis. Compared with the control group, the visual analogue scale (VAS) score at rest of the corticosteroid group decreased significantly at postoperative day 1 (POD1), POD2, and POD3 (p < 0.05). Besides, the range of flexion motion of the knee joint in the corticosteroid group at POD1 and POD2 was significantly increased (p < 0.05); at the same time, the range of extension motion at POD2 and POD3 showed the opposite trend between the two groups (p < 0.05). The morphine equivalent of postoperative analgesia was significantly reduced (p < 0.05), and the time required for straight leg raising (SLR) was significantly shortened (p < 0.05). There was no significant difference between the two groups in terms of postoperative drainage, length of hospital stay, and complications such as infection, nausea, and vomiting (p > 0.05). CONCLUSION The additional corticosteroids to multimodal cocktail periarticular injection can relieve the early pain intensity at rest after TKA, increase the early range of motion (ROM) of the knee joint, reduce the dosage of postoperative analgesics, and shorten the duration of time required for SLR. However, it has no effect on reducing postoperative complications and shortening the length of hospital stay.
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Affiliation(s)
- Qi Li
- Department of Anesthesiology, Shehong People's Hospital, NO.19, Guanghan road, Shehong, 629200, Sichuan Province, People's Republic of China
| | - Guo Mu
- Southwest Medical University, NO.319, Section 3, Zhongshan road, Jiangyang District, Luzhou, 646000, Sichuan Province, People's Republic of China
| | - Xiangbo Liu
- Department of Anesthesiology, Zigong Fourth People's Hospital, NO.19, Tanmulin Street, Ziliujing District, Zigong, 643000, Sichuan Province, People's Republic of China
| | - Milian Chen
- Department of Anesthesiology, Shehong People's Hospital, NO.19, Guanghan road, Shehong, 629200, Sichuan Province, People's Republic of China.
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Previtali D, Di Laura Frattura G, Filardo G, Delcogliano M, Deabate L, Candrian C. Peri-operative steroids reduce pain, inflammatory response and hospitalisation length following knee arthroplasty without increased risk of acute complications: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2021; 29:59-81. [PMID: 31494685 DOI: 10.1007/s00167-019-05700-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/28/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE There is no consensus regarding the risks and benefits of peri-operative steroid supplementation in total knee arthroplasty (TKA). The aim of this meta-analysis is to compare TKA protocols implemented with or without steroids in terms of pain, inflammatory response, hospitalisation length, and complications. METHODS A systematic literature search was performed on July 2019 in PubMed, Medline, Embase, Web of Science, Cochrane library, and the grey literature for a meta-analysis of RCTs comparing peri-operative analgesia protocols implemented with or without steroids. Sub-analyses considering the administration route, steroid type, and dosage were performed. The inverse variance method and the Mantel-Haenszel test were used for pooling continuous variables and for dichotomous variables, respectively. Risk of bias and quality of evidence were defined according to the Cochrane guidelines. RESULTS Twenty articles were included. Steroid supplementation provides significantly lower post-operative pain from day 1 to day 4 (p < 0.05), with less opioid consumption (p = 0.05), less nausea and vomiting (p < 0.05), and greater knee range of motion (p < 0.001), thus resulting in a shorter hospitalisation length (p = 0.01). Moreover, lower C-reactive protein (p < 0.05), and IL-6 (p < 0.05) levels, but a higher blood glucose level at day 1 (p = 0.004), were documented. No significant differences were documented in all the outcomes after 4 days of follow-up. These results were achieved without an increased incidence of complications. According to the results of the sub-analyses, the intravenous administration of 200 steroid equivalents of a long-acting steroid was associated with better results. CONCLUSION Steroid supplementation of peri-operative drug protocols is effective in decreasing post-operative pain, opioid consumption, nausea and vomiting, range of motion limitation, and inflammatory markers without increasing short- and mid-term complications. Although these benefits last only the peri-operative period, steroid supplementation can reduce the length of hospitalisation after TKA. LEVEL OF EVIDENCE Systematic review and meta-analysis, level II.
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Affiliation(s)
- Davide Previtali
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Giorgio Di Laura Frattura
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland.
| | - Giuseppe Filardo
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
- ATRC, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Delcogliano
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Luca Deabate
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
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Bernthal NM, Hart CM, Sheth KR, Bergese SD, Ho HS, Apfel CC, Stoicea N, Rojhani A, Jahr JS. Local and Intra-articular Administration of Nonsteroidal Anti-inflammatory Drugs for Pain Management in Orthopedic Surgery. Am J Ther 2020; 29:e219-e228. [PMID: 33315593 DOI: 10.1097/mjt.0000000000001309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although growing evidence demonstrates the benefits of locally administered nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery. AREAS OF UNCERTAINTY Current data largely support a local site of NSAID action and suggest that effective pain control can be achieved with delivery of NSAIDs intra-articularly (IA) and/or locally at the site of injury, where they can block peripheral production of inflammatory mediators and may desensitize nociceptors. Improvements in postoperative pain control with locally administered NSAIDs have been widely reported in the total joint arthroplasty literature and may offer benefits in patient's undergoing arthroscopic procedures and those with osteoarthritis as well. The purpose of this review is to examine the available evidence in the literature regarding the efficacy and safety profile of the use of local and IA NSAIDs in orthopedic surgery. DATA SOURCES Narrative literature review using keywords, expert opinion, either during or from live conference. THERAPEUTIC ADVANCES Local and IA administration of NSAIDs for pain management in orthopedic surgery. CONCLUSION There is convincing evidence that NSAIDs administered locally in and around the joint reduce postoperative pain scores and opioid consumption in patients undergoing total joint arthroplasty, yet further research is required regarding the risks of potential chondrotoxicity and the inhibition of bone and soft-tissue healing with locally administered NSAIDs.
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Affiliation(s)
- Nicholas M Bernthal
- Department of Orthopaedic Surgery, University of California Los Angeles David Geffen School of Medicine, UCLA Medical Center, Santa Monica, CA
| | - Christopher M Hart
- Department of Orthopaedic Surgery, University of California Los Angeles David Geffen School of Medicine, UCLA Medical Center, Santa Monica, CA
| | - Ketan R Sheth
- Department of General Surgery, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA
| | - Sergio D Bergese
- Department of Anesthesiology, School of Medicine, Stony Brook University, Health Sciences Center, Stony Brook, NY
| | - Hung S Ho
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Christian C Apfel
- Department of Epidemiology and Biostatistics, University of California San Francisco, CA
| | - Nicoleta Stoicea
- Department of Biological Chemistry and Pharmacology, Ohio State University, Columbus, OH
| | - Allen Rojhani
- Drexel University College of Medicine, Philadelphia, PA
| | - Jonathan S Jahr
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA
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El-Boghdadly K, Short AJ, Gandhi R, Chan V. Addition of dexamethasone to local infiltration analgesia in elective total knee arthroplasty: double-blind, randomized control trial. Reg Anesth Pain Med 2020; 46:130-136. [PMID: 33199379 DOI: 10.1136/rapm-2020-102079] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Total knee arthroplasty is associated with significant pain, and effective analgesia is beneficial to patient satisfaction and functional outcomes. Studies have demonstrated that dexamethasone may have a facilitatory role on the action of local anesthesia, but this effect, when added to a local infiltration analgesia (LIA) mixture for patients having knee arthroplasty, is underexplored. Our hypothesis was that the addition of dexamethasone to local anesthetic infiltration would improve analgesic outcomes following total knee arthroplasty. METHODS We performed a double-blind, randomized controlled trial of 140 patients undergoing elective, unilateral, total knee arthroplasty. Patients were randomly allocated to receive either 2 mL of saline 0.9% or 2 mL of dexamethasone 4 mg/mL added to a LIA mixture. Our primary outcome was 24 hours of oral morphine equivalent consumption. Our secondary outcomes included short-term and long-term analgesic and functional outcomes and adverse events. RESULTS A total of 72 patients were included in the saline group and 68 were included in the dexamethasone group. We found comparable 24 hours of morphine consumption between saline and dexamethasone groups, with a median of 60 (IQR 40-105 (range 16-230)) mg and 56 (IQR 41-75 (range 0-300)) mg, respectively (p=0.096). Dexamethasone was associated with a statistically significant reduction in total inpatient opioid consumption, incidence of requiring rescue patient-controlled analgesia, length of hospital stay, and postoperative nausea, compared with saline. Patients in the dexamethasone group had a greater range of joint movement and distance walked on postoperative day 1 than the saline group. There were no differences in rest or active pain scores, timed up and go or 3-month outcomes. CONCLUSIONS Dexamethasone 8 mg was associated with no improvements in 24 hours of morphine consumption but was associated with modest improvements in short-term analgesia, short-term function, length of stay and postoperative nausea. There were no long-term benefits in the use of dexamethasone in LIA for patients undergoing total knee arthroplasty. TRIAL REGISTRATION NUMBER NCT02760043.
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Affiliation(s)
- Kariem El-Boghdadly
- Department of Theatres, Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK .,King's College London, London, London, UK
| | - Anthony James Short
- Department of Anaesthetics, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Rajiv Gandhi
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Vincent Chan
- Department of Anesthesia and Pain Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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Keohane D, Sheridan G, Harty J. Perioperative steroid administration improves knee function and reduces opioid consumption in bilateral total knee arthroplasty. J Orthop 2020; 22:449-453. [PMID: 33093753 PMCID: PMC7557967 DOI: 10.1016/j.jor.2020.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/04/2020] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The benefits of steroid usage have been well described for unilateral total knee arthroplasty (TKA), however it's benefits in bilateral TKA has not been well published in the literature. We describe the impact of perioperative steroid administration in a cohort of bilateral TKAs (74 knees) with regard to immediate postoperative knee function, postoperative knee strength and opioid consumption. MATERIALS AND METHODS We report on a single-surgeon consecutive case series of simultaneously-performed bilateral TKAs. Eighteen patients received 2 doses of 8 mg IV dexamethasone in the perioperative setting. There were 19 patients in the control group. Primary outcome measures were day 1 postoperative knee flexion (degrees), knee strength and postoperative analgesic requirements (mg/mcg). Morphine dose equivalents (MDE) were calculated to compare all opioid-based analgesics. Secondary outcomes included post-operative pain according to the VAS (at 24, 48 and 72 h), anti-emetic requirements (mg) and length of stay (days). RESULTS The mean knee flexion achieved day 1 in the steroid group was 70.1°(σ = 17.64, 95% CI 64.1-76.0) compared to 55.8° in the non-steroid group (σ = 19.8, 95% CI 49.2-62.3) (p = 0.0008). Regarding the straight leg raise, 88.9% of the steroid group were able to achieve this compared to only 55.2% of the non-steroid group (p = 0.002). There was a reduction in the MDE requirement per patient across all medications for the 'steroid' group. Both Targin® (p = 0.03) (Prolonged-Release Oxycodone) and Fentanyl (p = 0.01) requirements were significantly reduced in the 'steroid' group. CONCLUSION We recommend the use of perioperative steroids in bilateral TKA to allow accelerated rehabilitation, improved immediate knee function and an overall reduction in the consumption of potentially problematic opioid-based analgesics.
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Affiliation(s)
| | | | - James Harty
- Cork University Hospital, Wilton, Cork, Ireland
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Smith CS, Mollon B, Vannabouathong C, Fu JM, Sales B, Bhandari M, Whelan DB. An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013. J Bone Joint Surg Am 2020; 102:e116. [PMID: 33086352 DOI: 10.2106/jbjs.18.00653] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials. METHODS A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted. RESULTS A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment. CONCLUSIONS The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.
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Affiliation(s)
| | - Brent Mollon
- Soldiers' Memorial Hospital, Orillia, Ontario, Canada
| | | | - Joyce M Fu
- Department of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | | | - Mohit Bhandari
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daniel B Whelan
- University of Toronto Orthopaedic Sports Medicine, St. Michael's and Women's College Hospitals, Toronto, Ontario, Canada
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Kurosaka K, Tsukada S, Ogawa H, Nishino M, Nakayama T, Yoshiya S, Hirasawa N. Addition of corticosteroid to periarticular injections reduces postoperative pain following total hip arthroplasty under general anaesthesia: a double-blind randomized controlled trial. Bone Joint J 2020; 102-B:1297-1302. [PMID: 32993338 PMCID: PMC7517720 DOI: 10.1302/0301-620x.102b10.bjj-2020-0428.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Aims Although periarticular injection plays an important role in multimodal pain management following total hip arthroplasty (THA), there is no consensus on the optimal composition of the injection. In particular, it is not clear whether the addition of a corticosteroid improves the pain relief achieved nor whether it is associated with more complications than are observed without corticosteroid. The aim of this study was to quantify the safety and effectiveness of cortocosteroid use in periarticular injection during THA. Methods We conducted a prospective, two-arm, parallel-group, randomized controlled trial involving patients scheduled for unilateral THA. A total of 187 patients were randomly assigned to receive periarticular injection containing either a corticosteroid (CS group) or without corticosteroid (no-CS group). Other perioperative interventions were identical for all patients. The primary outcome was postoperative pain at rest during the initial 24 hours after surgery. Pain score was recorded every three hours until 24 hours using a 100 mm visual analogue scale (VAS). The primary outcome was assessed based on the area under the curve (AUC). Results The CS group had a significantly lower AUC postoperatively at 0 to 24 hours compared to the no-CS group (AUC of VAS score at rest 550 ± 362 vs 392 ± 320, respectively; mean difference 158 mm; 95% confidence interval (CI) 58 to 257; p = 0.0021). In point-by-point evaluation, the CS group had significantly lower VAS scores at 12, 15, 18, 21, 24, and 48 hours. There were no significant differences in complication rates, including surgical site infection, between the two groups. Conclusion The addition of corticosteroid to periarticular injections reduces postoperative pain without increasing complication rate following THA. Cite this article: Bone Joint J 2020;102-B(10):1297–1302.
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Affiliation(s)
- Kenji Kurosaka
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Japan
| | - Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Japan
| | - Hiroyuki Ogawa
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Japan
| | - Masahiro Nishino
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Japan
| | - Tsutomu Nakayama
- Department of Rehabilitation, Hokusuikai Kinen Hospital, Mito, Japan
| | - Shinichi Yoshiya
- Department of Orthopaedic Surgery, Nishinomiya Kaisei Hospital, Hyogo, Japan
| | - Naoyuki Hirasawa
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Japan
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How periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair. Orthop Traumatol Surg Res 2020; 106:1159-1166. [PMID: 32826188 DOI: 10.1016/j.otsr.2020.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 04/18/2020] [Accepted: 05/05/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Multimodal analgesic (MMA) injections combined with corticosteroids have recently been shown to be effective for managing pain after arthroscopic rotator cuff repair. HYPOTHESIS The goal of this study was to analyze the effects of corticosteroid injections on the integrity of tendon repairs using magnetic resonance imaging (MRI). The hypothesis was that MMA injections combined with corticosteroids have no deleterious effects on functional outcomes and tendon healing 1 year after surgical rotator cuff repair. METHODS This was a prospective, double-blind study of 50 patients undergoing arthroscopic rotator cuff repair who were randomized into two groups. The study group (n=25) received a periarticular injection of a mixture of ropivacaine, morphine and methylprednisolone at the end of the procedure. The control group (n=25) received a placebo injection. The clinical outcomes were the pain level and complications, while the functional outcomes consisted of the Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons Shoulder (ASES) score and Simple Shoulder Test (SST). The structural integrity of the operated tendons was analyzed on MRI at a mean follow-up of 15.1±1.3 months for the study group and 15.2±1.1 for the control group (p=0.848). RESULTS Pain on a visual analog scale was significantly reduced in both groups after the surgery. Nevertheless, there was no significant difference between groups at the final follow-up visit (p=0.803). Compared to the preoperative values, the CMS, ASES and SST significantly improved in both groups after surgery but were not significantly different between groups at the final assessment (p=0.801, 0.869 and 0.769, respectively). MRI revealed supraspinatus tendon retears in 16% of patients in the study group and 36% in the control group (p=0.107). There were no infections in the study group as of the final assessment. Advanced age (p=0.049), diabetes (p<0.01) and posterior extension of the tear (p=0.039) negatively impact healing. Corticosteroid injection did not negatively impact healing (p=0.197). CONCLUSION This study shows that MMA injection combined with corticosteroids does not alter the tendon healing, clinical outcomes, or functional outcomes 1 year after arthroscopic rotator cuff repair. It remains a safe and effective analgesia method during rotator cuff repair surgery. LEVEL OF EVIDENCE II, low-powered placebo-controlled, randomized study.
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Wu L, Si H, Li M, Zeng Y, Wu Y, Liu Y, Shen B. The optimal dosage, route and timing of glucocorticoids administration for improving knee function, pain and inflammation in primary total knee arthroplasty: A systematic review and network meta-analysis of 34 randomized trials. Int J Surg 2020; 82:182-191. [PMID: 32877755 DOI: 10.1016/j.ijsu.2020.07.065] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/31/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Glucocorticoids are a mainstay to control postoperative pain, inflammation, nausea and vomiting (PONV) in total knee arthroplasty (TKA). Understanding the optimal dose and route of glucocorticoids administration in TKA is of great significance in speedy functional recovery. We aimed to summarize, evaluate and rank order the efficacy of glucocorticoids regimens in TKA. METHODS Electronic databases (PubMed et al.) were systematically searched from inception up to April 30, 2020. The primary outcomes were visual analogue scale (VAS), range of motion (ROM) and knee society score (KSS). C-reactive Protein (CRP) and PONV were also evaluated. Multivariable Bayesian random effects models were used to synthesize and rank the comparative efficacy of glucocorticoids regimens. RESULTS A total of 34 eligible randomized controlled trials with 11 different glucocorticoids regimens were assessed. Overall inconsistency and heterogeneity were acceptable. Multiple medium dose perioperative intravenous injection (IV) ranked first in the analgesia network and a single high doses of preoperative IV ranked first in the inflammation and PONV network. There was no statistically significant increase in ROM or KSS in all the glucocorticoid formulations and doses compared with controls on postoperative day 30. CONCLUSIONS Glucocorticoid multiple intravenous injection was preferable to a single intravenous injection (preoperative and postoperative), periarticular injection and intra-articular injection in analgesia. Based on the available evidence, a medium dose of hydrocortisone of 2-4 mg/kg is optimal.
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Affiliation(s)
- Limin Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Haibo Si
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Mingyang Li
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yi Zeng
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yuangang Wu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Yuan Liu
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
| | - Bin Shen
- Department of Orthopaedic Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, 610041, China.
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Efficacy of Periarticular Cocktail Injection in Rheumatoid Patients Undergoing Total Knee Replacement. Indian J Orthop 2020; 54:811-822. [PMID: 33133404 PMCID: PMC7572924 DOI: 10.1007/s43465-020-00230-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/08/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pain control after total knee replacement (TKR) is of primary importance to joint replacement surgeons to achieve good functional outcome post-surgery. This becomes even more challenging when these major procedures are done in immunocompromised patients like rheumatoid arthritis. Good peri-operative analgesia facilitates early rehabilitation, improves patient satisfaction, and reduces the hospital stay. The adverse effects caused by epidural analgesia or parenteral opioids can be avoided by replacing it with an analgesic cocktail locally. Our prospective study was to evaluate the benefits of a periarticular cocktail injection which was given in rheumatoid patients undergoing bilateral TKR in single sitting with respect to pain and knee motion recovery. METHODS Sixty-four rheumatoid arthritis patients undergoing simultaneous primary total knee replacement were included in the study. A total of 128 knees were randomized either to receive a periarticular intra-operative injection containing ropivacaine, fentanyl, clonidine, cefuroxime and epinephrine (Group A) on one knee and to receive plain ropivacaine (Group B) on the opposite knee. The perioperative and post-operative analgesic regimens were standardized. All patients received the same standard analgesia protocol. Visual analog scores for pain, knee range of motion and quadriceps function were recorded on the day of surgery, first post-operative day, second post-operative day, day of discharge, and 2 weeks and 6 weeks during follow-up. The need for rescue analgesic requirement and adverse effects to the cocktail injection were also noted during the study period. RESULTS The patients who received the periarticular cocktail fared better in terms of pain scores and functional recovery. Additional rescue agents used were significantly less at 6 h, at 12 h, and over the first 24 h after the surgery in group A when compared with group B. No cardiac or central nervous system toxicity was observed. CONCLUSIONS Periarticular cocktail injection significantly reduces the requirements for post-operative analgesia and also improves patient satisfaction, with no apparent risks, following total knee arthroplasty in rheumatoid arthritis.
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Abstract
BACKGROUND Postoperative nausea and vomiting (PONV) is a common complication after mastectomy. Although many researches have been studied the prophylactic effect of antiemetics, none of the results are effective. To overcome this problem, dexamethasone was used to relieve the occurrence of PONV. Since concerns about steroid-related morbidity still remain, We carried out a meta-analysis to evaluate the impact of prophylactic dexamethasone on PONV, post-operative pain undergoing mastectomy. METHODS Literature search was conducted through PubMed, Web of Science, EMBASE, MEDLINE, and Cochrane library database till June 2019 to identify eligible studies. Meanwhile, we also consulted some Chinese periodicals, such as China Academic Journals, Wanfang and Weipu. The research was reported according to the preferred reporting items for systematic reviews and meta-analysis guidelines. Randomized controlled trials were included in our meta-analysis. Meanwhile, 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. RESULTS Four studies with 490 patients were enrolled to this meta-analysis. Our study demonstrated that the dexamethasone group was significantly more effective than the placebo group in term of PONV (risk ratio [RR] = 0.46, 95% confidence intervals [CI]: 0.30-0.70, P = .0003), nausea (RR = 0.26, 95% CI: 0.10-0.68, P = .006) and vomiting (RR = 0.15, 95% CI: 0.04∼0.55, P = .004). The visual analog scale score was significantly diminished at 1 hour (weighted mean difference = -1.40, 95% CI: -1.53 to -1.26, P < .00001) in the dexamethasone group, while, no statistically significant difference was observed between the two groups in terms of visual analog scale at 24 hours (weighted mean difference = -0.56, 95% CI: -1.24 to 0.13, P = 0.11). CONCLUSION Not only does Dexamethasone reduce the incidence of PONV but also decreases postoperative pain. However, we still need larger samples and higher quality studies to determine the relationship between symptoms and administration time to reach the conclusion. TRIAL REGISTRATION NUMBER PROSPERO CRD 42018118575.
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Roecker Z, Quinlan ND, Browne JA, Werner BC. Risk of Periprosthetic Infection Following Intra-Articular Corticosteroid Injections After Total Knee Arthroplasty. J Arthroplasty 2020; 35:1090-1094. [PMID: 31813813 DOI: 10.1016/j.arth.2019.11.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/07/2019] [Accepted: 11/12/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Recent literature has advocated for the effectiveness of postoperative steroid injections following total knee arthroplasty (TKA) for improving pain and range of motion when other correctible causes of these symptoms have been eliminated. The safety of such injections has not been thoroughly evaluated. The aim of this study was to determine the risk of acute infection following intra-articular corticosteroid injection into a preexisting TKA. METHODS The Humana dataset was used to identify patients who underwent TKA from 2007 to 2017. Patients with ipsilateral knee corticosteroid injections in the postoperative period were then identified and compared to a 2:1 matched control cohort. A diagnosis of infection within 6 months and 1 year following the injection and an ipsilateral procedure for infection at any time postoperatively were then assessed and compared to controls using a multivariate binomial logistic regression analysis. RESULTS Of the 166,946 TKA performed during the study period, 5628 patients had a postoperative corticosteroid injection (3.4%). Patients with injections had a significantly higher rate of periprosthetic infection compared to noninjection matched controls at all studied time points. CONCLUSION In a large national database, about 3% of patients who undergo TKA have a postoperative steroid injection into their postoperative knee. While there is some existing literature demonstrating improvement in pain and stiffness symptoms after TKA with postoperative injections, the present study demonstrates a significant correlation between postoperative intra-articular corticosteroid injections in patients with preexisting TKA and periprosthetic joint infection compared to matched controls who did not receive an injection.
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Affiliation(s)
- Zoe Roecker
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Nicole D Quinlan
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
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Nassar I, Fahey J, Mitchell D. Rapid recovery following hip and knee arthroplasty using local infiltration analgesia: length of stay, rehabilitation protocol and cost savings. ANZ J Surg 2020; 90:355-359. [PMID: 31957218 PMCID: PMC7079075 DOI: 10.1111/ans.15663] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/03/2019] [Accepted: 12/16/2019] [Indexed: 12/27/2022]
Abstract
Background We implemented local infiltration analgesia (LIA) as a technique of providing post‐operative pain management and early mobilization after arthroplasty surgery and have progressively found patients able to go home earlier. This study compares the national data on hip and knee arthroplasty provided by the Royal Australasian College of Surgeons and Medibank Private with our outcomes using LIA and rapid recovery. Methods Prospective study of one surgeon including 200 knees, and 165 hips in the two years till June 2016. Variables included in comparison to the two groups were: length of stay, percentage of patients transferred to rehabilitation or intensive care unit (ICU), readmitted within 30 days and average separation cost. Results Hip replacement median length of stay in our series was two nights versus five nights, inpatient rehabilitation 7% versus 36%, ICU admission zero versus 4%, and readmissions 3.9% versus 6.0%, the average hospital separation cost in our series was $17 813 versus $26 734. Knee replacement median length of stay in our study was one night versus five nights, ICU 0.5% versus 3%, rehabilitation 4.5% versus 43%, and readmission 6% versus 7%, the average hospital separation cost in our group was $16 437 versus $27 505. Conclusion The comprehensive approach of LIA and rapid recovery enables patients to have shorter hospitalization, lower rehabilitation incidence and a resultant reduction in health expenditure.
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Affiliation(s)
- Islam Nassar
- Ballarat Health Services (Ballarat Base Hospital), St John of God Hospital, Ballarat, Victoria, Australia
| | | | - David Mitchell
- Ballarat Health Services (Ballarat Base Hospital), St John of God Hospital, Ballarat, Victoria, Australia
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45
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Kim JK, Ro DH, Lee HJ, Park JY, Han HS, Lee MC. Efficacy of Systemic Steroid Use Given One Day After Total Knee Arthroplasty for Pain and Nausea: A Randomized Controlled Study. J Arthroplasty 2020; 35:69-75. [PMID: 31563397 DOI: 10.1016/j.arth.2019.08.026] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/21/2019] [Accepted: 08/09/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Systemic steroid has been used to control pain and nausea in total knee arthroplasty (TKA), but most studies recommend a single dose administration prior to, or during, surgery. This study aimed to determine the efficacy of administration on 1 day postoperatively. METHODS Patients who were scheduled to undergo TKA were randomly assigned to the following groups: control group, receiving normal saline injection; group 1, receiving 10 mg dexamethasone intravenously (IV) 1 hour before surgery; group 2, receiving 0.1 mg/kg dexamethasone (IV) 24 hours after surgery; or group 3, receiving 0.2 mg/kg dexamethasone (IV) 24 hours after surgery (n = 44-46 per group). Primary outcomes were pain and nausea visual analogue scale (VAS). Secondary outcomes were analgesic administration, rescue antiemetic administration, C-reactive protein, range of motion, and complications. RESULTS Postoperative pain and nausea remained high for 48 hours post-TKA. Group 1 had lower pain and nausea VAS scores than did the control group (P < .01) for only 24 hours post-TKA. Groups 2 and 3 had lower pain and nausea VAS scores than did the control group and group 1 (P < .01) 48 hours post-TKA. Analgesic and antiemetic administration were significantly lower in groups 2 and 3 than in the control group during 48 hours after TKA. There were no differences in C-reactive protein level and range of motion, and complications were not detected. CONCLUSION The effect of preoperative and postoperative administration of dexamethasone for controlling pain and nausea was observed only for 24 hours. Considering that severe pain and nausea persisted for more than 48 hours after TKA, additional administration of dexamethasone at 1 day postoperatively is suggested. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Jong-Keun Kim
- Department of Orthopedic Surgery, Hanil General Hospital, Seoul, South Korea
| | - Du Hyun Ro
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Han-Jin Lee
- Department of Orthopedic Surgery, Hanil General Hospital, Seoul, South Korea
| | - Jae-Young Park
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyuk-Soo Han
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Myung Chul Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
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46
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Kehlet H, Joshi GP. The systematic review/meta‐analysis epidemic: a tale of glucocorticoid therapy in total knee arthroplasty. Anaesthesia 2019; 75:856-860. [DOI: 10.1111/anae.14946] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 11/29/2022]
Affiliation(s)
- H. Kehlet
- Section of Surgical Pathophysiology Rigshospitalet Copenhagen Denmark
| | - G. P. Joshi
- Department of Anesthesiology and Pain Management University of Texas Southwestern Medical Center Dallas TX USA
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Effect of Methylprednisolone on Pain Management in Total Knee or Hip Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin J Pain 2019; 34:967-974. [PMID: 29595528 DOI: 10.1097/ajp.0000000000000614] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Total joint arthroplasty (TJA) has been reported to be a successful strategy for patients with advanced osteoarthritis; however, early postoperative pain has become an unresolved issue. Perioperative methylprednisolone (MP) administration in TJA is an important and controversial topic. This study was conducted to assess the efficacy and safety of MP for pain management after total knee or hip arthroplasty (TKA/THA). MATERIALS AND METHODS PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials comparing MP versus placebo for patients undergoing TKA/THA. Related indicators that reflected the efficacy and safety for pain management were evaluated by meta-analysis. RESULTS Six randomized controlled trials involving a total of 350 patients met the inclusion criteria. The outcomes showed that intravenous MP significantly reduced pain scores at 6 and 24 hours during activity after TKA and THA but local use of MP had no clear benefit in reducing pain scores compared with the control group. There was no significant difference in VAS at 24 hours at rest and 48 hours during activity after TKA and THA. In addition, MP was associated with a reduction of morphine consumption at 24 hours after TKA. Furthermore, patients receiving MP had an obvious inflammatory control and improving postoperative nausea and vomiting and the use of MP was not associated with a significant increase in the risk of complications. There was no significant difference in the range of knee motion and length of hospital stay in both groups. CONCLUSIONS This study showed that intravenous MP significantly alleviated early postoperative pain and the incidence of postoperative nausea and vomiting after TKA and THA. For safety, intravenous MP as a promising strategy in rapid recovery to TJA.
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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: 4.2] [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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49
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Sreedharan Nair V, Ganeshan Radhamony N, Rajendra R, Mishra R. Effectiveness of intraoperative periarticular cocktail injection for pain control and knee motion recovery after total knee replacement. Arthroplast Today 2019; 5:320-324. [PMID: 31516975 PMCID: PMC6728801 DOI: 10.1016/j.artd.2019.05.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 05/28/2019] [Accepted: 05/28/2019] [Indexed: 12/03/2022] Open
Abstract
Background Pain control after total knee replacement (TKR) is pivotal in postoperative rehabilitation. Usage of epidural analgesia or parenteral opioids can cause undesirable side effects hampering early recovery and rehabilitation. These side effects can be avoided by infiltration of an analgesic cocktail locally. Our study was performed to evaluate the benefits of a particular cocktail combination in patients undergoing TKR with respect to pain and knee motion recovery. Methods One hundred consecutive patients who underwent simultaneous bilateral TKR were enrolled and received an intraoperative periarticular cocktail injection in the right knee (intervention) and normal saline in the left knee (control). Postoperative pain was recorded using the visual analog scale for each knee, and the time taken to achieve 90° of knee flexion was noted for each side. Results The cocktail injected knee had significantly less pain when compared with the control knee during the first 48 hours and significantly shorter period to achieve 90° of knee flexion. Conclusions The use of intraoperative periarticular cocktail injection significantly reduces early postoperative pain and provides better early knee motion.
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Affiliation(s)
- Vijayamohan Sreedharan Nair
- Aster Orthopaedics and Rheumatology, Aster Medcity Hospital, Kochi, Kerala, India
- Corresponding author. Kuttisahib Road, Cheranalloor, South Chittoor, Kochi, Kerala, India. Tel.: +91 944 776 0119.
| | | | - Riju Rajendra
- Aster Orthopaedics and Rheumatology, Aster Medcity Hospital, Kochi, Kerala, India
| | - Rahul Mishra
- Department of Orthopaedics, Siddharth Hospital, Nepal Gunj, Nepal
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50
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Deng Z, Li Y, Storm GR, Kotian RN, Sun X, Lei G, Gao S, Lu W. The efficiency and safety of steroid addition to multimodal cocktail periarticular injection in knee joint arthroplasty: a meta-analysis of randomized controlled trials. Sci Rep 2019; 9:7031. [PMID: 31065018 PMCID: PMC6505038 DOI: 10.1038/s41598-019-43540-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 04/26/2019] [Indexed: 02/08/2023] Open
Abstract
Steroids are frequently used for postoperative pain relief without definite evidence. This study was conducted to assess the pain management effect of the addition of steroids to a multimodal cocktail periarticular injection (MCPI) in patients undergoing knee arthroplasty and evaluate their safety. Pubmed, Embase, and Cochrane Library were searched through April, 2018. A total of 918 patients from ten randomized controlled trials (RCTs) were ultimately included. Compared with placebo groups, steroids application could effectively relieve pain on postoperative day (POD)1; decrease C-Reactive protein (CRP) level on POD3; improve range of motion (ROM) in postoperative 5 days; reduce morphine consumption, achieve earlier straight leg raising (SLR), and shorten the length of stay (LOS) in hospital. With regards to adverse effects, it did not increase the risk of postoperative infection, postoperative nausea and vomiting (PONV), or other complications. However, no significant difference in pain relief, ROM, or increased Knee Society Knee Function Scores were found during long-term follow up. Overall, this meta-analysis ensured the efficiency and safety of steroids with MCPI in knee arthroplasty patients during the early postoperative period.
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Affiliation(s)
- Zhenhan Deng
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China.,Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yusheng Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China. .,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China.
| | - Garrett R Storm
- Department of Cardiology, University of Colorado Denver, Aurora, Colorado, USA
| | - Ronak Naveenchandra Kotian
- Department of Orthopaedics, Victoria Hospital, Bangalore Medical College and Research Institute, Bangalore, India
| | - Xuying Sun
- Department of Orthopaedics, Biological Engineering and Regenerative Medicine Center, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Shanshan Gao
- Department of Cardiology, University of Colorado Denver, Aurora, Colorado, USA.
| | - Wei Lu
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China.
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