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

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.

A Single Preoperative Low Dose of Dexamethasone Is Efficacious in Improving Early Postoperative Pain, Function, Nausea, and Vomiting After Primary Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

The primary objective was to evaluate a single preoperative low-dose (8 mg) dexamethasone (DXM) efficacy in relieving postoperative pain in patients undergoing total knee arthroplasty (TKA). The secondary objectives were to assess its effect on postoperative nausea and vomiting (PONV), C-reactive protein (CRP) levels, and early wound complications incidence.

METHODS

This was a single-center, double-blind, randomized controlled trial. We included 86 unilateral primary TKA divided equally into two groups (placebo [Group A] and DXM [Group B], as a single intravenous dose given after anesthesia). Postoperative pain was assessed as the primary outcome at rest and while walking using a visual analog scale (VAS). Secondary outcomes included PONV evaluated using VAS for postoperative nausea. The following variables were evaluated: the Time Up and Go test, serum CRP, quadriceps muscle power, and wound complications. All outcomes were reported in the first three days and at 14 days follow-up visit.

RESULTS

Both groups' baseline data were comparable. Group B reported significantly less pain at rest and walking throughout all time points (P < 0.001). Group B had fewer vomiting episodes on postoperative days one and two (P = 0.195 and 0.747, respectively) and no difference in PONV VAS score. Group B had significantly lower Time Up and Go test scores for postoperative days one and two (P = 0.029 and 0.016, respectively) and significantly better quadriceps muscle power on postoperative days two and three (P = 0.042 and 0.019, respectively). The Serum CRP levels were significantly less in Group B throughout all follow-up time points (P < 0.001) except on day three (P = 0.302). No wound complications were reported in any patient.

CONCLUSIONS

Preoperative single low dose (eight mg) DXM intravenous in patients undergoing unilateral TKA is safe (early postoperatively) and effective for reducing postoperative pain scores, improving early mobility, and reducing inflammatory markers. However, the effect on PONV was less evident.