The Efficacy and Safety of Corticosteroids in Total Joint Arthroplasty: A Direct Meta-Analysis

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The James A. Rand Young Investigator's Award: What Is the Safest and Most Effective Dose of Intravenous Dexamethasone in Total Knee Arthroplasty? A Multicenter Randomized Controlled Trial

BACKGROUND

The purpose of this multicenter, double-blinded, prospective, randomized controlled trial was to determine the safest and most effective dose of intravenous (IV) dexamethasone administered during primary total knee arthroplasty (TKA).

METHODS

There were 404 patients undergoing inpatient primary TKA randomized across 11 centers to receive four (n = 138), eight (n = 137), or 16 mg (n = 129) of IV dexamethasone intraoperatively. All sites utilized the same perioperative multimodal protocol. Opioid consumption measured in morphine milligram equivalents (MME), pain scores, nausea scores, vomiting episodes, and sleep duration was collected for 7 days postoperatively. Glucose levels were measured on postoperative day 1 (POD1). The mean age was 68 years, the mean body mass index was 33, and 62% were women. Independent sample t-tests were used for continuous data, and Chi-square and Fisher's exact tests were used for discrete data. Demographic characteristics were comparable between groups, suggesting successful randomization.

RESULTS

Patients who received 16 mg IV dexamethasone consumed less MME on POD1 (38 versus 37 versus 27 MME; P = 0.047) and had fewer vomiting episodes (P = 0.02). Patients who received 16 mg also had lower pain scores at rest at 24 hours, 48 hours, and one week. There were no differences in cumulative opioid consumption within the first 48 hours (P = 0.24), one week (P = 0.43), or pain with activity at any time point. The POD1 glucose was highest in patients who received 16 mg (P < 0.001). There were no differences in length of stay, hours slept, or 90-day complication rates between groups.

CONCLUSIONS

High-dose (16 mg) IV dexamethasone in TKA reduces opioid consumption, pain, and vomiting on the first day after surgery. Outcomes, including opioid consumption, sleep, and nausea, are comparable beyond 24 hours for all doses.

LEVEL OF EVIDENCE

I. Prospective randomized controlled trial.

Efficacy of Vitamin C as Glucocorticoid Substitute for Reducing Pain and Inflammation After Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Vitamin C shows strong anti-inflammatory and analgesic effects, so we explored whether it can replace glucocorticoids in reducing pain and inflammation after total hip arthroplasty (THA).

METHODS

In this prospective trial, a consecutive series of 107 patients (43.0% men, 56.8 ± 10.1 years of age, 100% Han Chinese) who underwent THA due to end-stage hip disease at our medical center between January 2023 and January 2024 were randomized to receive vitamin C, dexamethasone, or neither dexamethasone nor vitamin C after surgery. The 3 groups were compared in terms of the primary outcomes of pain reported on a visual analogue scale (VAS), perioperative morphine use, and blood indices of inflammation and fibrinolysis as well as in terms of secondary outcomes of efficacy and safety.

RESULTS

Compared with patients in the control group, those who received vitamin C or dexamethasone reported a significantly lower VAS pain score on postoperative day 1, had significantly lower perioperative morphine consumption, and demonstrated significantly lower blood levels of C-reactive protein on days 1 and 2. The 2 groups also showed a significantly lower rate of rescue analgesia on postoperative day 1 and significantly higher Harris hip scores of joint function at 2 and 12 weeks after surgery, as well as significantly smaller thigh circumference and a lower rate of swelling on the first 2 days after surgery. Either treatment was associated with a significantly lower rate of postoperative nausea and vomiting. Dexamethasone was associated with greater blood glucose levels after surgery.

CONCLUSIONS

Vitamin C may be an effective substitute for glucocorticoids for reducing morphine use and the risk of nausea or vomiting and for improving joint function after THA without side effects causing blood glucose fluctuations.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Administration of a Methylprednisolone Taper and Complication Rates Following Total Knee Arthroplasty: A Multicenter Retrospective Study

Background

Most patients undergoing total knee arthroplasty (TKA) report moderate to severe pain in the acute postoperative period. Recent preliminary data have suggested that a short course of oral corticosteroid may improve early postoperative pain after various orthopedic operations, but the safety of this practice has not been rigorously evaluated in larger patient populations. The purpose of this study was to evaluate complication rates in patients receiving a methylprednisolone taper (MT) vs controls after primary TKA.

Methods

Records were reviewed for patients undergoing primary TKA from 2018 to 2023 by 2 surgeons at different institutions who began routinely prescribing a 6-day MT to patients without a contraindication or poorly controlled diabetes. The primary outcome of periprosthetic joint infection at 90 days and final follow-up was assessed as were secondary outcomes of surgical site infection and wound complications. A total of 930 patients were included in the study, with 641 patients in the control cohort and 289 patients in the methylprednisolone cohort.

Results

There were no significant differences between the methylprednisolone and control cohorts in 90-day periprosthetic joint infection (0.7% vs 0%, P = .1, respectively), surgical site infection (1.0% vs 1.4%, P = .4, respectively), or wound complication (1.0% vs 2.0%, P = .4, respectively). There were no significant differences in any complication at final follow-up.

Conclusions

MT following TKA did not significantly increase rates of wound complications or infections in this multi-institutional retrospective cohort study. This study provides preliminary evidence regarding the safety profile of a short duration of postoperative oral corticosteroids following TKA.

Additional Dose of Intravenous Dexamethasone Can Replace Patient-Controlled Analgesia in Pain Control after Total Knee Arthroplasty while Reducing Opioid Complications

The purpose of this study was to evaluate whether intravenous (IV) dexamethasone, within the current multimodal pain management protocol, (1) could maintain postoperative pain at a comparable level without IV patient-controlled analgesia (PCA), (2) could reduce opioids-related side effects, and (3) whether an additional dose of dexamethasone on postoperative day (POD) 2 would offer further pain-relieving effect without increasing the risk of complications. A total of 178 patients (182 knees) who underwent total knee arthroplasty for osteoarthritis were included in the study. The patients were divided into Dexa 2 & PCA and Dexa 3 & NoPCA groups. From operative day to POD 5, pain visual analogue score (VAS), rescue opioids consumption, episodes of postoperative nausea and vomiting (PONV), antiemetics usage, and side effects of opioids such as postoperative urinary retention (POUR) and constipation were checked. For safety, wound complication and infection were checked. There was no difference in pain VAS between the two groups during all six perioperative days. Rescue opioids consumption was lower in Dexa 2 & PCA group. Total dosage of used opioids for six perioperative days was lower in Dexa 3 & NoPCA group. Dexa 3 & NoPCA group had less PONV and POUR. There was a marked increase in pain VAS and the use of rescue opioids from POD 1 to POD 2 in the Dexa 2 & PCA. There were no wound problems or infections in either group. Under the current multimodal pain management protocol, comparable level of postoperative pain could be achieved by dexamethasone without the need of IV PCA. By not using IV PCA, overall opioid usage was reduced, which could lead to a lower frequency of PONV and POUR. While there is still room for further research on the duration and frequency of administering dexamethasone, additional administration on POD 2 is believed to provide additional pain management benefits compared with administering only until POD 1.

Multimodal Analgesia and Small Opioid Prescriptions are the New Standard in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership

BACKGROUND

The purpose of this survey study was to assess the current analgesia and anesthesia practices used by total joint arthroplasty surgeon members of the American Association of Hip and Knee Surgeons (AAHKS) as well as identify changes in practice made by AAHKS members over time.

METHODS

A survey of 37 questions was created and approved by the AAHKS Research Committee. The survey was distributed to all 3,243 practicing adult reconstruction surgeon members of AAHKS in May 2023. Results were compared to a nearly identical survey sent out to all board-certified adult reconstruction surgeon members of AAHKS 5 years previously in November 2018.

RESULTS

There were 527 responses (16%) to the survey. Since 2018, the mean number of opioid pills prescribed after total joint arthroplasty has declined significantly from 49 to 32 pills after total knee arthroplasty (TKA) and from 44 to 18 pills after total hip arthroplasty (THA). The use of multimodal analgesics in addition to opioids has also increased over the past 5 years from 74 to 93%. The most common medications utilized include nonsteroidal anti-inflammatories (98%), acetaminophen (80%), and gabapentinoids (32%). A majority of surgeons (78%) still use a spinal for TKA and THA. However, there has been an increase in the number of surgeons using peripheral nerve blocks for TKA from 69% in 2018 to 84% in 2023. The routine use of periarticular injection or local infiltration anesthesia in THA and TKA has also increased over the past 5 years from 80 to 86%.

CONCLUSIONS

Since 2018, there has been increased adoption of multimodal analgesia and anesthesia, and improved consensus regarding the optimal regimen among surveyed arthroplasty surgeon members of AAHKS. The number of opioid pills prescribed after THA and TKA has declined significantly over the past 5 years.

Nonopioid Drugs for Postoperative Pain: A Selection Governed by Choices of the Authors of Academic Articles

The opioid crisis has profoundly changed the interest in using nonopioid analgesics. This review identified nonopioid drugs receiving the most interest in the treatment of postoperative pain. Publication-based interest, which reflects the authors' choices of subjects for academic articles, was used to show the shifts in their interest. The authors' choices of a particular drug for an article's subject were regarded as reflective of the collective opinion of experts most knowledgeable on the subject. The frequency with which a drug was the topic of an article was measured with the use of specific bibliometric indices. They were employed to select nonopioid drugs for this review. These included acetaminophen, dexmedetomidine, dexamethasone, ketamine, gabapentin, ibuprofen, ketorolac, diclofenac, magnesium sulfate, clonidine, intravenous lidocaine, and meloxicam (in order of most to least bibliometric interest). Individual reviews on these agents described how the bibliometric indices characterized a drug. They also addressed the question of whether a nonopioid analgesic produced a marked opioid-sparing effect. Information relative to this question was presented via the results of meta-analyses with emphasis on the possible reduction of opioid-related side effects. Overall, nonopioid drugs demonstrating the largest popularity among authors and continuous interest growth in 2018-2022 include acetaminophen, dexmedetomidine, dexamethasone, and ibuprofen. The relevant meta-analyses show that nonopioids, administered as components of multimodal analgesia, provided the opioid-sparing effect; they also show that the most common change in the opioid-related side effects was a lower incidence of postoperative nausea and vomiting.

Perioperative intravenous dexamethasone use is not associated with periprosthetic joint infection or wound healing complications following shoulder arthroplasty

BACKGROUND

Perioperative intravenous (IV) dexamethasone is commonly used in lower extremity total joint arthroplasty to manage postoperative pain and nausea/vomiting, and recent studies have demonstrated that its use may lower rates of acute postoperative medical complications. However, there is limited information regarding the safety and efficacy of IV dexamethasone in patients undergoing total shoulder arthroplasty (TSA). Additionally, there is concern surrounding corticosteroid use prior to surgery as preoperative corticosteroid injections have been associated with adverse outcomes after TSA, including periprosthetic joint infection (PJI) and revision surgery. Thus, the purpose of this study was to evaluate the effect of perioperative IV dexamethasone on 90-day rates of PJI, wound complications, and medical complications after TSA.

METHODS

The Premiere national hospital database was used to identify adult patients undergoing elective TSA between 2016 and 2020; patients were excluded if they were under 18 years old, were undergoing revision TSA, or had a prior proximal humerus open reduction internal fixation procedure. Patients who did and did not receive perioperative IV dexamethasone were then compared in both univariate and multivariate analyses. A Bonferroni correction was utilized to adjust for multiple comparisons. The primary end point was risk of acute infectious complications within 90 days of surgery, including PJI and wound infection/dehiscence. Secondary end points included acute pulmonary, renal, and thromboembolic complications.

RESULTS

A total of 135,333 patients underwent TSA during the study period; 61.2% underwent reverse total shoulder arthroplasty, 33.8% underwent anatomic total shoulder arthroplasty, and 5.0% underwent hemiarthroplasty. From 2016 to 2020, perioperative IV dexamethasone use increased by 135%. Multivariate analysis revealed that patients who received perioperative IV dexamethasone did not have increased odds of PJI, superficial wound infection, or wound dehiscence (P = .15-.47) but did have decreased odds of sepsis (odds ratio [OR] 0.67, 95% confidence interval [CI] 0.55-0.81) and other medical complications such as urinary tract infection and acute kidney injury. Additionally, there was a trend towards decreased 90-day hospital readmission (OR 0.88, 95% CI 0.81-0.96, P = .003).

CONCLUSIONS

Perioperative IV dexamethasone was not associated with increased risk of acute infectious and wound healing complications. Moreover, patients who received perioperative IV dexamethasone had decreased odds of medical complications and trended toward lower rates of 90-day hospital readmission. The results of this study support the safety of perioperative IV dexamethasone use in patients undergoing elective TSA.

Increased Risk of Postoperative Complications in Patients Who Have Obstructive Sleep Apnea Undergoing Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Obstructive sleep apnea (OSA) has been linked to multiple adverse health outcomes and postoperative complications. Despite the high prevalence of OSA in patients undergoing total joint arthroplasty (TJA), few studies have evaluated the postoperative course of OSA patients after joint arthroplasty surgery.

METHODS

PubMed (MEDLINE) and Scopus (EMBASE, MEDLINE, and COMPENDEX) were used to conduct a systematic review of articles from inception to July 2023. Primary studies comparing postoperative outcomes following TJA between patients who had and did not have OSA were included. Postoperative medical complications, utilization of critical care, hospital stay, and mortality data were extracted. Descriptive statistics and random-effects meta-analysis models were used to analyze the available data. Included studies were evaluated for methodological risks of bias using the risk of bias in non-randomized studies of interventions. This review was registered on the International Prospective Register of Systematic Reviews (ID: CRD42023447610).

RESULTS

There were 7 studies with a total of 20,977 patients (9,425 hip; 11,137 knee; 415 hip or knee) that were included. Pulmonary complications were most frequently studied, followed by thromboembolic events. Cardiac, gastrointestinal, hematologic, genitourinary, and delirium events were also reported across studies. Meta-analysis revealed that OSA patients had 4-fold increased odds of overall medical complications (OR [odds ratio], 4.23; 95% confidence interval (CI), 2.97 to 6.04; P < .001; I2 = 0%), 4-fold increased odds of pulmonary complications (OR, 4.31; 95% CI, 2.82 to 6.60; P < .001; I2 = 0%), 2-fold increased odds of thromboembolic complications (OR, 1.92; 95% CI, 1.22 to 3.03; P = .005; I2 = 9%), and 4-fold increased odds of delirium (OR, 3.94; 95% CI, 1.72 to 9.04; P = .001; I2 = 0%).

CONCLUSIONS

A significant association was found between OSA and overall medical, pulmonary, and thromboembolic complications. These patients also had a higher incidence of postoperative delirium. The present findings underscore the need for comprehensive perioperative strategies to mitigate these risks in OSA patients who elect to undergo TJA.

Effects of Dexamethasone on Postoperative Glycemic Control in Patients After Primary Total Joint Arthroplasty: A Randomized Double-Blind Controlled Trial

BACKGROUND

In patients undergoing total joint arthroplasty, the use of dexamethasone (DEX) may cause perioperative blood glucose (BG) disorders, leading to complications even in patients who do not have diabetes. We aimed to evaluate the effects of different DEX doses on perioperative BG levels.

METHODS

A total of 135 patients who do not have diabetes were randomized into three groups: preoperative intravenous (IV) injection of normal saline (Group A, the placebo group), preoperative IV injection of 10 mg DEX (Group B), and preoperative IV injection of 20 mg DEX (Group C). Postoperative fasting BG (FBG) levels were designated as the primary outcome, while postoperative postprandial BG (PBG) levels were assigned as the secondary outcome. The incidence of complications was recorded. We also investigated the risk factors for FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL.

RESULTS

The FBG levels were higher in Groups B and C than in Group A on postoperative days (PODs) 0 and 1. The PBG levels were lower for Groups A and B compared to Group C on POD 1. No differences in FBG or PBG were detected beyond POD 1. Elevated preoperative glycosylated hemoglobin A1c levels increased the risk of FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL, respectively. However, preoperative IV injection of DEX was not associated with FBG ≥ 140 mg/dL or PBG ≥ 180 mg/dL. No differences were found in postoperative complications among the three groups.

CONCLUSIONS

The preoperative IV administration of 10 or 20 mg DEX in patients who do not have diabetes showed transient effects on postoperative BG after total joint arthroplasty. The preoperative glycosylated hemoglobin A1c level threshold (regardless of the administration or dosage of DEX) that increased the risk for the occurrence of FBG ≥ 140 mg/dL and PBG ≥ 180 mg/dL was 5.75 and 5.85%, respectively.

Perioperative Short-Term Glucocorticoids Do Not Increase Incidence of Complications after Total Joint Arthroplasty in Patients with Rheumatoid Arthritis

OBJECTIVES

The safety and analgesic efficacy of perioperative glucocorticoids have been established for patients without rheumatoid arthritis. Therefore, our study aims to investigate whether similar benefits can be observed in patients with rheumatoid arthritis undergoing total joint arthroplasty. Specifically, we aim to explore the impact of perioperative glucocorticoid use on postoperative complications, opioid consumption, incidence of hypotension, hyperglycemia, 30-day mortality, and 90-day re-admission in this patient population.

METHODS

Approval for the study protocol was obtained from the Medical Research Ethics Committee at Sichuan University, aligning with the principles outlined in the Declaration of Helsinki. We retrospectively analyzed a consecutive series of patients with rheumatoid arthritis who underwent total joint arthroplasty at our medical center between November 2009 and April 2021 and who were not on chronic glucocorticoid therapy before surgery. Those who received glucocorticoids at any time during hospitalization were compared to those who did not in terms of acute complications within 90 days after surgery as well as postoperative rescue opioid consumption, hypotension, and hyperglycemia during hospitalization. The two groups were also compared in terms of overall duration of hospitalization, all-cause mortality within 30 days, and readmission for any reason within 90 days. Continuous data were assessed for significance using the independent-samples t test. Categorical data were assessed using the Pearson chi-squared test.

RESULTS

Of the 849 patients included in the analysis, 598 administered perioperative glucocorticoids and 251 did not. Prior to surgery, the two groups did not differ significantly in any clinicodemographic variable that we examined. The incidence of acute postoperative complications (2.3% vs. 4.0%, p = 0.187) and acute postoperative infection (2.0% vs. 2.8%, p = 0.482) was comparable between those who received perioperative glucocorticoids and those who did not, but the former group exhibited a significantly lower incidence of rescue opioid use (17.9% vs. 44.6%, p < 0.001) as well as significantly lower total rescue opioid consumption (4.7 ± 2.1 mg vs. 8.9 ± 4.6 mg, p < 0.001). However, the two groups showed similar incidences of postoperative hypotension, hyperglycemia, 30-day mortality, and 90-day re-admission.

CONCLUSION

Perioperative glucocorticoids may reduce the need for rescue opioids after total joint arthroplasty of rheumatoid arthritis patients, without increasing the incidence of acute complications, hypotension or hyperglycemia.

The efficacy and safety of intra-articular injection of corticosteroids in multimodal analgesic cocktails in total knee arthroplasty-a historically controlled study

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.

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

STUDY OBJECTIVE

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

DESIGN

Systematic review of RCTs with meta-analysis.

SETTING

Acute postoperative pain treatment in non-obese adult population.

INTERVENTIONS

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

MEASUREMENTS

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

MAIN RESULTS

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

CONCLUSION

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

PROTOCOL REGISTRATION

CRD42020137119.

The efficacy and safety of perioperative glucocorticoid for total knee arthroplasty: a systematic review and meta-analysis

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.

Non-opioid analgesic combinations following total hip arthroplasty (RECIPE): a randomised, placebo-controlled, blinded, multicentre trial

BACKGROUND

Multimodal postoperative analgesia following total hip arthroplasty is recommended, but the optimal combination of drugs remains uncertain. The aim of the RECIPE trial was to investigate the relative benefit and harm of the different combinations of paracetamol, ibuprofen, and the analgesic adjuvant dexamethasone for treatment of postoperative pain following total hip arthroplasty.

METHODS

The RECIPE trial was a randomised, blinded, placebo-controlled trial conducted at nine Danish hospitals. Adults scheduled for total hip arthroplasty were randomly assigned (1:1:1:1) using a computer-generated list with stratification by site to receive combinations of oral paracetamol 1000 mg every 6 h, oral ibuprofen 400 mg every 6 h, or a single-dose of intravenous dexamethasone 24 mg in the following groups: paracetamol plus ibuprofen, ibuprofen plus dexamethasone, paracetamol plus dexamethasone, and paracetamol plus ibuprofen plus dexamethasone. The primary outcome was 24 h intravenous morphine consumption, analysed in a modified intention-to-treat population, defined as all randomly assigned participants who underwent total hip arthroplasty. The predefined minimal important difference was 8 mg. Safety outcomes included serious and non-serious adverse events within 90 days and 24 h. The trial was registered with ClinicalTrials.gov, NCT04123873.

FINDINGS

Between March 5, 2020, and Nov 15, 2022, we randomly assigned 1060 participants, of whom 1043 (589 [56%] women and 454 [44%] men) were included in the modified intention-to-treat population. 261 were assigned to paracetamol plus ibuprofen, 262 to ibuprofen plus dexamethasone, 262 to paracetamol plus dexamethasone, and 258 to paracetamol plus ibuprofen plus dexamethasone. Median 24 h morphine consumption was 24 mg (IQR 12-38) in the paracetamol plus ibuprofen group, 20 mg (12-32) in the paracetamol plus dexamethasone group, 16 mg (10-30) in the ibuprofen plus dexamethasone group, and 15 mg (8-26) in the paracetamol plus ibuprofen plus dexamethasone group. The paracetamol plus ibuprofen plus dexamethasone group had a significantly reduced 24 h morphine consumption compared with paracetamol plus ibuprofen (Hodges-Lehmann median difference -6 mg [99% CI -10 to -3]; p<0·0001) and paracetamol plus dexamethasone (-4 mg [-8 to -1]; p=0·0013), however, none of the comparisons showed differences reaching the minimal important threshold of 8 mg. 91 (35%) of 258 participants in the paracetamol plus ibuprofen plus dexamethasone group had one or more adverse events, compared with 99 (38%) of 262 in the ibuprofen plus dexamethasone group, 103 (39%) of 262 in the paracetamol plus dexamethasone group, and 165 (63%) of 261 in the paracetamol plus ibuprofen group.

INTERPRETATION

In adults undergoing total hip arthroplasty, a combination of paracetamol, ibuprofen, and dexamethasone had the lowest morphine consumption within 24 h following surgery and the most favourable adverse event profile, with a lower incidence of serious and non-serious adverse events (primarily driven by differences in nausea, vomiting, and dizziness) compared with paracetamol plus ibuprofen.

FUNDING

The Novo Nordisk Foundation and Næstved-Slagelse-Ringsted Hospitals' Research Fund.

Safety of blood reinfusion drains after local infiltration analgesia in total joint replacement

BACKGROUND

Local infiltration analgesia (LIA) is frequently administered to patient undergoing joint replacement surgical procedures. The aim of the present research was to verify the safety of collected shed blood to be reinfused postoperatively, by measuring levobupivacaine levels in drainage blood in patients undergoing LIA during knee replacement surgery.

PATIENTS AND METHODS

24 patients who underwent total knee arthroplasty (TKA) and 12 scheduled for total hip arthroplasty (THA) who received intraoperative LIA were considered. Blood samples were collected from shed blood which was present in drainage 2 and 5 hours after surgery and serum was analysed by liquid chromatography-tandem mass spectrometry.

RESULTS

At 2 hours postoperatively, the median levobupivacaine serum concentration in the collected shed blood was 1.2 mg/L (SD: 4.2) for TKA and 17.13 mg/L (SD: 24.4) for THA. At 5 hours, levobupivacaine concentration was 1.84 mg/L (SD: 2.2) for TKA and 17.5 mg/L (SD: 25.2) for THA. Higher values of average serum levobupivacaine concentration were reported in drains collected from patients who had undergone THA compared to TKA (p<0.001). BMI significantly influenced levels of serum drug, that resulted to be higher in patients with BMI<25 (p= 0.01).

CONCLUSION

Levobupivacaine from collected shed blood that would have been returned to the patient, was below toxicity level at 2 and 5 hours after LIA during total joint replacement. The average serum levobupivacaine concentration was found to be higher in drains taken from THA patients than TKA patients. Patients with lower BMI demonstrated the highest levels of levobupivacaine in shed blood and a lower blood volume needed for central nervous system toxicity. Therefore, in patients with a lower BMI undergoing THA, anaesthetic dosage should be reduced or autotransfusion should be avoided to prevent potential risks of toxicity.

Dexamethasone with aggressive warming facilitates pain reduction, reduced blood loss, and quicker recovery after total hip arthroplasty

This study aimed to evaluate the optimal frequency of dexamethasone (DEX) administration and the efficacy of DEX with aggressive warming in total hip arthroplasty (THA), which remains unclear. A total of 150 patients were treated with DEX (10 mg) once before and once or twice after surgery with or without intraoperative aggressive warming. On postoperative day 3, the dynamic visual analogue scale scores and C-reactive protein (CRP) and interleukin-6 (IL-6) levels in participants administered with DEX twice after surgery were significantly lower than those who did not receive the second dose. The range of motion (ROM), postoperative fatigue based on Identity-Consequence-Fatigue Scale, average temperature at different stages, intraoperative blood loss, and postoperative drainage volume in patients who were subjected to warming were significantly higher than those who were not. The degree of satisfaction was also higher in the patients who received both second dose and warming than those who received neither. No differences in complications were observed based on the treatments. An additional dose of DEX at 48 h post-surgery has short-term advantages in terms of analgesia, anti-inflammatory effects, and accelerated rehabilitation after THA. DEX combined with aggressive warming further optimises short-term ROM and fatigue and improves the degree of satisfaction.Clinical trial was registered in the International Clinical Trial Registry, and the date of registration is 2/12/2020 (ChiCTR2000040560).

Modern Perioperative Pain Management Strategies to Minimize Opioids after Total Knee Arthroplasty

Total Knee Arthroplasty is associated with significant postoperative pain that can limit functional outcomes and patient satisfaction. In recent years, the standard of care for postoperative pain management has reduced reliance on opioids in favor of multimodal analgesia. These regimens consist of systemic medications such as COX-2 inhibitors, acetaminophen, corticosteroids, and gabapentinoids, as well as regional and local approaches such as peripheral nerve blocks and local infiltrative analgesics. Newer therapies, such as cryoneurolysis, are still being studied but have shown promising results. Additional studies are needed to determine the ideal pain regimen that will optimize pain control and eliminate the need for postoperative opioids.

Postoperative Pain Control Following Shoulder Arthroplasty: Rethinking the Need for Opioids

The use of opioid pain medication regimens to control perioperative pain has led to significant patient and societal consequences. There are several alternative, opioid-sparing and opioid-minimizing pain regimens that have been shown to provide equal, if not superior, pain relief with fewer secondary consequences. This article provides an in-depth review of the current evidence regarding efficacy, safety, and feasibility of a perioperative opioid-sparing clinical pathway for patients undergoing shoulder arthroplasty.

Epidural dexamethasone for acute postoperative pain management: a systematic review with meta-analysis

Aim: To study the effect of epidural dexamethasone in postoperative pain management. Methods: Random-effects meta-analysis was conducted in RevMan 5.4. Results: We included nine randomized-controlled trials (RCT) with 657 patients. Dexamethasone demonstrated longer analgesia duration (mean difference 266.18 minutes, 95% CI [3.21,529.14]; p 0.05), lower incidence of nausea and vomiting during the first postoperative day (risk ratio 0.36, 95% CI [0.18,0.71]; p 0.004), and lower antiemetic requirements (risk ratio 0.33, 95% CI [0.14,0.79]; p 0.01). No difference in pain reduction and the length of hospital stay was observed between the groups. Conclusion: Dexamethasone was associated with a longer analgesic effect, a lower number of patients requiring antiemetics, and lower incidences of nausea and vomiting.