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Laconi G, Coppens S, Roofthooft E, Van De Velde M. High dose glucocorticoids for treatment of postoperative pain: A systematic review of the literature and meta-analysis. J Clin Anesth 2024; 93:111352. [PMID: 38091865 DOI: 10.1016/j.jclinane.2023.111352] [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: 04/27/2023] [Revised: 10/30/2023] [Accepted: 11/22/2023] [Indexed: 01/14/2024]
Abstract
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.
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Affiliation(s)
- Giulia Laconi
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy.
| | - Steve Coppens
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium
| | - Eva Roofthooft
- Department of Anesthesia, GZA Hospitals, Antwerp, Belgium and Department of Cardiovascular sciences, KULeuven, Leuven, Belgium
| | - Marc Van De Velde
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium
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Churchill L, John Bade M, Koonce RC, Stevens-Lapsley JE, Bandholm T. The past and future of peri-operative interventions to reduce arthrogenic quadriceps muscle inhibition after total knee arthroplasty: A narrative review. OSTEOARTHRITIS AND CARTILAGE OPEN 2024; 6:100429. [PMID: 38304413 PMCID: PMC10832271 DOI: 10.1016/j.ocarto.2023.100429] [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: 02/10/2023] [Accepted: 12/16/2023] [Indexed: 02/03/2024] Open
Abstract
Total knee arthroplasty (TKA) improves patient-reported function by alleviating joint pain, however the surgical trauma exacerbates already impaired muscle function, which leads to further muscle weakness and disability after surgery. This early postoperative strength loss indicates a massive neural inhibition and is primarily driven by a deficit in quadriceps muscle activation, a process known as arthrogenic muscle inhibition (AMI). To enhance acute recovery of quadriceps muscle function and long-term rehabilitation of individuals after TKA, AMI must be significantly reduced in the early post-operative period. The aim of this narrative review is to review and discuss previous efforts to mitigate AMI after TKA and to suggest new approaches and interventions for future efficacy evaluation. Several strategies have been explored to reduce the degree of post-operative quadriceps AMI and improve strength recovery after TKA by targeting post-operative swelling and inflammation or changing neural discharge. A challenge of this work is the ability to directly measure AMI and relevant contributing factors. For this review we focused on interventions that aimed to reduce post-operative swelling or improve knee extension strength or quadriceps muscle activation measured by twitch interpolation. For individuals undergoing TKA, the use of anti-inflammatory medications, tranexamic acid, cryotherapy, intra-articular drains, torniquets, and minimally invasive surgical techniques for TKA have limited benefit in attenuating quadriceps AMI early after surgery. However, interventions such as inelastic compression garments, voluntary muscle contractions, and neuro-muscular electrical stimulation show promise in mitigating or circumventing AMI and should continue to be refined and explored.
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Affiliation(s)
- Laura Churchill
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Michael John Bade
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Eastern Colorado VA Geriatric Research Education and Clinical Center (GRECC), Aurora, CO, USA
| | - Ryan C. Koonce
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Highlands Ranch, CO, USA
| | - Jennifer E. Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Eastern Colorado VA Geriatric Research Education and Clinical Center (GRECC), Aurora, CO, USA
| | - Thomas Bandholm
- Physical Medicine & Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
- Department of Clinical Research, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
- Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Hvidovre, Denmark
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Systemic glucocorticoids as an adjunct to treatment of postoperative pain after total hip and knee arthroplasty: A systematic review with meta-analysis and trial sequential analysis. Ugeskr Laeger 2023; 40:155-170. [PMID: 36325886 DOI: 10.1097/eja.0000000000001768] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Postoperative analgesic effects of systemic glucocorticoids given as an adjunct to treatment are largely undetermined in alloplastic procedures. OBJECTIVES To investigate the beneficial and harmful effects of peri-operative systemic glucocorticoid treatment for pain after total hip arthroplasty (THA) or total knee arthroplasty (TKA). DESIGN A systematic review of randomised clinical trials (RCTs) with meta-analyses, trial sequential analyses and GRADE. Primary outcome was 24 h intravenous (i.v.) morphine (or equivalent) consumption with a predefined minimal important difference (MID) of 5 mg. Secondary outcomes included pain at rest and during mobilisation (MID, VAS 10 mm), adverse and serious adverse events (SAEs). DATA SOURCES We searched EMBASE, Cochrane CENTRAL, PubMed and Google Scholar up to October 2021. ELIGIBILITY CRITERIA RCTs investigating peri-operative systemic glucocorticoid versus placebo or no intervention, for analgesic pain management of patients at least 18 years undergoing planned THA or TKA, irrespective of publication date and language. RESULTS We included 32 RCTs with 3521 patients. Nine trials were at a low risk of bias. Meta-analyses showed evidence of a reduction in 24 h cumulative morphine consumption with glucocorticoids by 5.0 mg (95% CI 2.2 to 7.7; P = 0.0004). Pain at rest was reduced at 6 h by 7.8 mm (95% CI 5.5 to 10.2; P < 0.00001), and at 24 h by 6.3 mm (95% CI 3.8 to 8.8; P < 0.00001). Pain during mobilisation was reduced at 6 h by 9.8 mm (95% CI 6.9 to 12.8; P < 0.00001), and at 24 h by 9.0 mm (95% CI 5.5 to 12.4, P < 0.00001). Incidence of adverse events was generally lower in the glucocorticoid treatment group. SAEs were rarely reported. The GRADE rated quality of evidence was low to very low. CONCLUSION Peri-operative systemic glucocorticoid treatment reduced postoperative morphine consumption to an individually relevant level following hip and knee arthroplasty. Pain levels were reduced but were below the predefined MID. The quality of evidence was generally low. REGISTRATION PROSPERO ID: CRD42019135034.
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Hannon CP, Fillingham YA, Mason JB, Sterling RS, Casambre FD, Verity TJ, Woznica A, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Corticosteroids in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty 2022; 37:1898-1905.e7. [PMID: 36162922 DOI: 10.1016/j.arth.2022.03.084] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/09/2022] [Accepted: 03/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Corticosteroids are commonly used intraoperatively to treat pain and reduce opioid consumption and nausea associated with primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of corticosteroids 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 the American Society of Regional Anesthesia and Pain Management. METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published before February 2020 on corticosteroids 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 corticosteroids. RESULTS Critical appraisal of 1,581 publications revealed 23 studies regarded as the best available evidence for analysis. Intraoperative dexamethasone reduces postoperative pain, opioid consumption, and nausea and vomiting. Multiple doses lead to further reduction in pain, opioid consumption, nausea and vomiting. There is insufficient evidence on the risk of adverse events with perioperative dexamethasone in TJA. CONCLUSION Strong evidence supports the use of a single dose or multiple doses of intravenous dexamethasone to reduce postoperative pain, opioid consumption, nausea and vomiting after primary TJA. There is insufficient evidence on perioperative dexamethasone in primary TJA to determine the optimal dose, number of doses, or risk of postoperative adverse events.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Yale A Fillingham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Robert S Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Anne Woznica
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
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Hannon CP, Fillingham YA, Mason JB, Sterling RS, Hamilton WG, Della Valle CJ. Corticosteroids 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; 37:1684-1687. [PMID: 35970568 DOI: 10.1016/j.arth.2022.03.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/23/2022] [Accepted: 03/07/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | | | | | - Robert S Sterling
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Steiness J, Hägi-Pedersen D, Lunn TH, Lindberg-Larsen M, Graungaard BK, Lundstrom LH, Lindholm P, Brorson S, Bieder MJ, Beck T, Skettrup M, von Cappeln AG, Thybo KH, Gasbjerg KS, Overgaard S, Jakobsen JC, Mathiesen O. Paracetamol, ibuprofen and dexamethasone for pain treatment after total hip arthroplasty: protocol for the randomised, placebo-controlled, parallel 4-group, blinded, multicentre RECIPE trial. BMJ Open 2022; 12:e058965. [PMID: 36190737 PMCID: PMC9438203 DOI: 10.1136/bmjopen-2021-058965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Multimodal analgesia with paracetamol, non-steroidal anti-inflammatory drug and glucocorticoid is recommended for hip arthroplasty, but with uncertain effects of the different combinations. We aim to investigate benefit and harm of different combinations of paracetamol, ibuprofen and dexamethasone following total hip arthroplasty. METHODS AND ANALYSIS RECIPE is a randomised, placebo-controlled, parallel 4-group, blinded trial with 90-day and 1-year follow-up performed at nine Danish hospitals. Interventions are initiated preoperatively and continued for 24 hours postoperatively. Eligible participants undergoing total hip arthroplasty are randomised to:group A: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous placebo; group B: oral paracetamol 1000 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group C: oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group D: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg.Primary outcome is cumulative opioid consumption at 0-24 hours. Secondary outcomes are pain at rest, during mobilisation and during a 5 m walk and adverse events. Follow-up includes serious adverse events and patient reported outcome measures at 90 days and 1 year. A total of 1060 participants are needed to demonstrate a difference of 8 mg in 24-hour morphine consumption assuming an SD of 24.5 mg, a risk of type I errors of 0.0083 and a risk of type 2 errors of 0.2. Primary analysis will be a modified intention-to-treat analysis.With this trial we aim to verify recommendations for pain treatment after total hip arthroplasty, and investigate the role of dexamethasone as an analgesic adjuvant to paracetamol and ibuprofen. ETHICS AND DISSEMINATION This trial is approved by the Region Zealand Committee on Health Research Ethics (SJ-799). Plans for dissemination include publication in peer-reviewed journals and presentation at scientific meetings. TRIAL REGISTRATION NUMBER NCT04123873.
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Affiliation(s)
- Joakim Steiness
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
- Department of Anaesthesiology, Nastved Hospital, Naestved, Denmark
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Bispebjerg Hospital, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | | | | | - Peter Lindholm
- Department of Anaesthesiology, Odense University Hospital, Odense, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital Koge, Koege, Denmark
| | | | - Torben Beck
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Michael Skettrup
- Department of Orthopaedic Surgery, Gentofte Hospital, Hellerup, Denmark
| | | | - Kasper Højgaard Thybo
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
| | | | - Søren Overgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Salamanna F, Contartese D, Brogini S, Visani A, Martikos K, Griffoni C, Ricci A, Gasbarrini A, Fini M. Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review. J Clin Med 2022; 11:4222. [PMID: 35887986 PMCID: PMC9322698 DOI: 10.3390/jcm11144222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.
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Affiliation(s)
- Francesca Salamanna
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Deyanira Contartese
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Silvia Brogini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Andrea Visani
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Konstantinos Martikos
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Cristiana Griffoni
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Alessandro Ricci
- Anesthesia-Resuscitation and Intensive Care, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Alessandro Gasbarrini
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Milena Fini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
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Paravlic AH, Meulenberg CJ, Drole K. The Time Course of Quadriceps Strength Recovery After Total Knee Arthroplasty Is Influenced by Body Mass Index, Sex, and Age of Patients: Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:865412. [PMID: 35692543 PMCID: PMC9174520 DOI: 10.3389/fmed.2022.865412] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/14/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction For patients with osteoarthritis who have undergone total knee arthroplasty (TKA), quadriceps strength is a major determinant of general physical function regardless of the parameters adopted for functional assessment. Understanding the time course of quadriceps strength recovery and effectiveness of different rehabilitation protocols is a must. Therefore, the aim of this study was to: (i) determine the magnitude of maximal voluntary strength (MVS) loss and the time course of recovery of the quadriceps muscle following TKA, (ii) identify potential moderators of strength outcomes, and (iii) investigate whether different rehabilitation practices can moderate the strength outcomes following TKA, respectively. Design General scientific databases and relevant journals in the field of orthopedics were searched, identifying prospective studies that investigated quadriceps’ MVS pre-to post-surgery. Results Seventeen studies with a total of 832 patients (39% males) were included. Results showed that in the early post-operative days, the involved quadriceps’ MVS markedly declined, after which it slowly recovered over time in a linear fashion. Thus, the greatest decline of the MVS was observed 3 days after TKA. When compared to pre-operative values, the MVS was still significantly lower 3 months after TKA and did not fully recover up to 6 months following TKA. Furthermore, a meta-regression analysis identified that the variables, time point of evaluation, patient age, sex, and BMI, significantly moderate the MVS of the quadriceps muscle. Conclusion The analyzed literature data showed that the decrease in strength of the involved quadriceps muscles following TKA is considerable and lasts for several months post-surgery. Therefore, we recommend to specifically target the strengthening of knee extensor muscles, preserve motor control, and apply appropriate nutrition to ensure a holistic quadriceps muscle recovery. Since age, sex, and BMI were found to be moderating factors in patients’ recovery, further research should include specific analyses considering these moderators.
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Affiliation(s)
- Armin H. Paravlic
- Institute for Kinesiology Research, Scientific Research Center Koper, Koper, Slovenia
- Faculty of Sport, Institute of Kinesiology, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Sport Studies, Masaryk University, Brno, Czechia
- *Correspondence: Armin H. Paravlic,
| | - Cécil J. Meulenberg
- Institute for Kinesiology Research, Scientific Research Center Koper, Koper, Slovenia
| | - Kristina Drole
- Faculty of Sport, Institute of Kinesiology, University of Ljubljana, Ljubljana, Slovenia
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Kanstrup K, Foss NB. AHA STEROID trial, dexamethasone in acute high-risk abdominal surgery, the protocol for a randomized controlled trial. Acta Anaesthesiol Scand 2022; 66:640-650. [PMID: 35124808 DOI: 10.1111/aas.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/10/2022] [Accepted: 02/02/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Existing multimodal pathways for patients undergoing acute high-risk abdominal surgery for intestinal obstruction (IO) and perforated viscus (PV) have focused on rescue in the immediate perioperative period. However, there is little focus on the peri-operative pathophysiology of recovery in this patient group, as done to develop enhanced recovery pathways in elective care. Acute inflammation is the main driver of the perioperative pathophysiology leading to adverse outcomes. Pre-operative high-dose of glucocorticoids provides a reduction in the inflammatory response after surgery, effective pain relief in several major surgical procedures, as well as reduce fatigue and improving endothelial dysfunction. AIM To evaluate the effect of high-dose glucocorticoid on the inflammatory response, fluid distribution and recovery after acute high-risk abdominal surgery in patients with IO and PV. METHODS AHA STEROID trial is a sponsor-initiated single-center, randomized, double-blind placebo-controlled trial, assessing preoperative high-dose dexamethasone (1 mg/kg) versus placebo (normal saline) in patients undergoing emergency high-risk abdominal surgery. We plan to enroll 120 patients. Primary outcome is the reduction in C-reactive protein on postoperative day 1 as a marker of successful attenuation of the acute stress response. Secondary outcomes include perioperative changes in endothelial and other inflammatory markers, fluid distribution, pulmonary function, pain, fatigue, and mobilization. The statistical plan is outlined in the protocol. DISCUSSION The AHA STEROID trial will provide important evidence to guide the potential use of high-dose glucocorticoids in emergency high-risk abdominal surgery, with respect to different pathophysiologies.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology Rigshospitalet Denmark
| | | | - Jakob Højlund
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
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Pre-emptive analgesia with methylprednisolone and gabapentin in total knee arthroplasty in the elderly. Sci Rep 2022; 12:2320. [PMID: 35149701 PMCID: PMC8837623 DOI: 10.1038/s41598-022-05423-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/10/2022] [Indexed: 11/10/2022] Open
Abstract
The aim of this study is to assess whether administration of gabapentin and methylprednisolone as “pre-emptive analgesia” in a group of patients above 65 years of age would be effective in complex pain management therapy following total knee arthroplasty (TKA). One hundred seventy patients above 65 years were qualified for the study, with exclusion of 10 patients due to clinical circumstances. One hundred sixty patients were randomly double-blinded into two groups: the study group (80 patients) and the control group (80 patients). The study group received as “pre-emptive” analgesia a single dose of 300 mg oral (PO) gabapentin and 125 mg intravenous (IV) methylprednisolone, while the control received a placebo. All patients received opioid and non-opioid analgesic agents perioperatively calculated for 1 kg of total body weight. We measured (1) pain intensity level at rest (numerical rating scale, NRS), (2) life parameters, (3) levels of inflammatory markers (leukocytosis, C reactive protein CRP), and (4) all complications. Following administration of gabapentin and methylprednisolone as “pre-emptive” analgesia, the NRS score at rest was calculated at 6, 12 (p < 0.000001), 18 (p < 0.00004) and 24 (p = 0.005569) h postoperatively. Methylprednisolone with gabapentin significantly decreased the dose of parenteral opioid preparations (p = 0.000006). The duration time of analgesia was significantly longer in study group (p < 0.000001), with CRP values lower on all postoperative days (1, 2 days—p < 0.00001, 3 days—p = 0.00538), and leukocytosis on day 2 (p < 0.0086) and 3 (p < 0.00042). No infectious complications were observed in the first postoperative days; in the control group, one patient manifested transient ischemic attack (TIA). The use of gabapentin and methylprednisolone as a single dose decreased the level of postoperative pain on the day of surgery, the dose of opioid analgesic preparations, and the level of inflammatory parameters without infectious processes.
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Feeley AA, Feeley TB, Feeley IH, Sheehan E. Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies. J Arthroplasty 2021; 36:3042-3053. [PMID: 33902983 DOI: 10.1016/j.arth.2021.03.057] [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: 02/15/2021] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Perioperative corticosteroid administration is associated with reduced postoperative nausea, pain, and enhanced recovery after surgery. However, potential complications including wound and periprosthetic joint infections remain a concern for surgeons after total joint arthroplasty (TJA). METHODS A systematic review of the search databases PubMed, Google Scholar, and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk after perioperative corticosteroid administration in TJA. PRISMA guidelines were used for this review. Meta-analysis was used to assess infection risk in accordance with joint and corticosteroid dosing regimen used. RESULTS 201 studies were returned after initial search strategy, with 29 included for review after application of inclusion and exclusion criteria. Studies were categorized as using low- or high-dose corticosteroid with single or repeat dosing regimens. Single low-dose corticosteroid administration was not associated with an increased risk of infection (P = .4; CI = 0.00-0.00). Single high-dose corticosteroid was not associated with an increased infection risk (P = .3; CI = 0.00-0.01) nor did repeat low-dose regimens result in increased risk of infection (P = .8; CI = -0.02-0.02). Studies assessing repeat high-dosing regimens reported no increased infection, with small numbers of participants included. No significant risk difference in infection risk was noted in hip (P = .59; CI = -0.03-0.02) or knee (P = .2; CI = 0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted. CONCLUSION Use of perioperative corticosteroid in TJA does not appear to be associated with increased risk of postoperative infection in patients with limited comorbidities. Further research is warranted to evaluate postoperative complications after TJA in these at-risk patient populations.
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Affiliation(s)
- Aoife A Feeley
- Department of Orthopaedics, Midland Regional Hospital Tullamore, Puttaghan, Tullamore, Ireland
| | - Tara B Feeley
- Department of Anaesthetics, Starship Children's Hospital, Auckland, New Zealand
| | - Iain H Feeley
- Department of Orthopaedics, National Orthopaedic Hospital Cappagh, Cappoge, Dublin, Ireland
| | - Eoin Sheehan
- Department of Orthopaedics, Midland Regional Hospital Tullamore, Puttaghan, Tullamore, Ireland
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12
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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: 4] [Impact Index Per Article: 1.3] [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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13
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Zheng T, Hu B, Zheng CY, Huang FY, Gao F, Zheng XC. Improvement of analgesic efficacy for total hip arthroplasty by a modified ultrasound-guided supra-inguinal fascia iliaca compartment block. BMC Anesthesiol 2021; 21:75. [PMID: 33691623 PMCID: PMC7944595 DOI: 10.1186/s12871-021-01296-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 03/03/2021] [Indexed: 12/03/2022] Open
Abstract
Background Fascia iliaca compartment block (FICB) is an anterior approach to the lumbar plexus block and provides the effective adjunctive analgesia for total hip arthroplasty (THA). Methods As a case series study, 28 patients (≥ 65 years old) with THA were received a modified in-plane ultrasound-guided supra-inguinal (S-FICB) as an analgesic adjunct to evaluate the analgesic effectiveness and the local anesthetic diffusion with magnetic resonance imaging (MRI). A combination of propofol and sufentanil was administered to conduct target-controlled infusion. Results The pain scores were 1 (0–4), 2 (1–5), 3 (1–6) and 3 (1–6) at 4, 8, 12, and 24 h. The cumulative opioids were 8 (8–12), 18 (16–32), 28 (24–54) and 66 (48–104) mg of i.v. morphine equivalents at 4, 8, 12, and 24 h. The patient-controlled analgesia (PCA) times were 0 (0–1), 1 (0–2), 2 (0–5) and 5 (3–8) at 4, 8, 12, and 24 h. In lateral, anterior and medial part of thigh, the sensory blockade in 28 patients was 23 (82 %), 21 (75 %) and 19 (68 %) at 5 min; 28 (100 %) at 10 and 20 min. Motor blockade of femoral nerve (FN) and obturator nerve (ON) was present in 13 (46 %) and 3 (11 %) patients at 5 min, 24 (86 %) and 9 (32 %) at 10 min, 26 (93 %) and 11 (39 %) at 20 min. Injectate permeated to the FN and extended superiorly over the surface of iliac muscle (IM) and pectineus muscle (PM) in all patients. Conclusions The modified S-FICB has provided an effective postoperative analgesic adjunct after THA with the satisfactory blockade of femoral (FN), obturator (ON) and sciatic (SN) nerves, especially for ON, when compared with the existing techniques.
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Affiliation(s)
- Ting Zheng
- The Provincial Clinical Medical College, Fujian Medical University, 134 Dong Street, Fujian, 350004, Fuzhou, China.,Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Bin Hu
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Chun-Ying Zheng
- The Provincial Clinical Medical College, Fujian Medical University, 134 Dong Street, Fujian, 350004, Fuzhou, China.,Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Feng-Yi Huang
- The Provincial Clinical Medical College, Fujian Medical University, 134 Dong Street, Fujian, 350004, Fuzhou, China.,Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Fei Gao
- The Provincial Clinical Medical College, Fujian Medical University, 134 Dong Street, Fujian, 350004, Fuzhou, China.,Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Xiao-Chun Zheng
- The Provincial Clinical Medical College, Fujian Medical University, 134 Dong Street, Fujian, 350004, Fuzhou, China. .,Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian, China. .,Fujian Provincial Emergency Center, Fuzhou, Fujian, China.
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14
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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: 0.7] [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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15
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Preoperative dexamethasone for pain relief after total knee arthroplasty: A randomised controlled trial. Eur J Anaesthesiol 2020; 37:1157-1167. [PMID: 33105245 DOI: 10.1097/eja.0000000000001372] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Corticosteroids can reduce pain but the optimal dose and safety profiles are still uncertain. OBJECTIVE This study aimed to evaluate two different doses of dexamethasone for pain management and their side effects after total knee arthroplasty. DESIGN A prospective randomised, controlled trial. SETTING A tertiary teaching hospital in Hong Kong. PATIENTS One hundred and forty-six patients were randomly allocated to one of three study groups. INTERVENTIONS Before operation, patients in group D8, D16 and P received dexamethasone 8 mg, dexamethasone 16 mg and placebo (0.9% saline), respectively. MAIN OUTCOME MEASURES The primary outcome was postoperative pain score. Secondary outcomes were opioid consumption, physical parameters of the knees and side effects of dexamethasone. RESULTS Compared with placebo, group D16 patients had significantly less pain during maximal active flexion on postoperative day 3 [-1.3 (95% CI, -2.2 to -0.31), P = 0.005]. There was also a significant dose-dependent trend between pain scores and dexamethasone dose (P = 0.002). Compared with placebo, patients in group D16 consumed significantly less opioid [-6.4 mg (95% CI, -11.6 to -1.2), P = 0.025] and had stronger quadriceps power on the first three postoperative days (all P < 0.05). They also had significantly longer walking distance on postoperative day 1 [7.8 m ([95% CI, 0.85 to 14.7), P = 0.023] with less assistance during walking on the first two postoperative days (all P < 0.029) and significantly better quality-of-recovery scores on postoperative day 1 (P = 0.018). There were significant dose-dependent trends between all the above parameters and dexamethasone dose (all P < 0.05). No significant differences were found in the incidence of chronic pain or knee function 3, 6 and 12 months postoperatively. CONCLUSION Dexamethasone 16 mg given before total knee arthroplasty led to a reduction in postoperative pain, less opioid consumption, stronger quadriceps muscle power, better mobilisation and better overall quality-of-recovery after operation. No long-term improvement in reduction in pain and function of the knee was found. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02767882.
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16
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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: 5] [Impact Index Per Article: 1.3] [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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17
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Ganio EA, Stanley N, Lindberg-Larsen V, Einhaus J, Tsai AS, Verdonk F, Culos A, Ghaemi S, Rumer KK, Stelzer IA, Gaudilliere D, Tsai E, Fallahzadeh R, Choisy B, Kehlet H, Aghaeepour N, Angst MS, Gaudilliere B. Preferential inhibition of adaptive immune system dynamics by glucocorticoids in patients after acute surgical trauma. Nat Commun 2020; 11:3737. [PMID: 32719355 PMCID: PMC7385146 DOI: 10.1038/s41467-020-17565-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 07/03/2020] [Indexed: 02/08/2023] Open
Abstract
Glucocorticoids (GC) are a controversial yet commonly used intervention in the clinical management of acute inflammatory conditions, including sepsis or traumatic injury. In the context of major trauma such as surgery, concerns have been raised regarding adverse effects from GC, thereby necessitating a better understanding of how GCs modulate the immune response. Here we report the results of a randomized controlled trial (NCT02542592) in which we employ a high-dimensional mass cytometry approach to characterize innate and adaptive cell signaling dynamics after a major surgery (primary outcome) in patients treated with placebo or methylprednisolone (MP). A robust, unsupervised bootstrap clustering of immune cell subsets coupled with random forest analysis shows profound (AUC = 0.92, p-value = 3.16E-8) MP-induced alterations of immune cell signaling trajectories, particularly in the adaptive compartments. By contrast, key innate signaling responses previously associated with pain and functional recovery after surgery, including STAT3 and CREB phosphorylation, are not affected by MP. These results imply cell-specific and pathway-specific effects of GCs, and also prompt future studies to examine GCs' effects on clinical outcomes likely dependent on functional adaptive immune responses.
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Affiliation(s)
- Edward A Ganio
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Natalie Stanley
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | | | - Jakob Einhaus
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Amy S Tsai
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Franck Verdonk
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Anthony Culos
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Sajjad Ghaemi
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
- Digital Technologies Research Centre, National Research Council Canada, Toronto, ON, Canada
| | - Kristen K Rumer
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Ina A Stelzer
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Dyani Gaudilliere
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Eileen Tsai
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Ramin Fallahzadeh
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Benjamin Choisy
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Henrik Kehlet
- Section of Surgical Pathophysiology 7621, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Nima Aghaeepour
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Martin S Angst
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Brice Gaudilliere
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA.
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18
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Summers S, Mohile N, McNamara C, Osman B, Gebhard R, Hernandez VH. Analgesia in Total Knee Arthroplasty: Current Pain Control Modalities and Outcomes. J Bone Joint Surg Am 2020; 102:719-727. [PMID: 31985507 DOI: 10.2106/jbjs.19.01035] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Spencer Summers
- Departments of Orthopaedics and Rehabilitation (S.S., N.M., C.M., and V.H.H.), and Anesthesiology, Perioperative Medicine, and Pain Management (B.O. and R.G.), University of Miami, Miami, Florida
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19
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Paravlic AH, Kovač S, Pisot R, Marusic U. Neurostructural correlates of strength decrease following total knee arthroplasty: A systematic review of the literature with meta-analysis. Bosn J Basic Med Sci 2020; 20:1-12. [PMID: 30640590 PMCID: PMC7029198 DOI: 10.17305/bjbms.2019.3814] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/25/2018] [Indexed: 11/16/2022] Open
Abstract
Recent literature suggests that alterations in both neural and structural components of the neuromuscular system are major determinants of knee extensor muscle weakness after total knee arthroplasty (TKA). Therefore, the goal of this study was to investigate the maximal voluntary strength (MVS), voluntary muscle activation (VMA), and the cross-sectional area (CSA) of the muscle, up to 33 months after the TKA. We searched relevant scientific databases and literature for outcomes of interest, including quadriceps MVS, VMA, and CSA. Ten studies met the inclusion criteria and involved a total of 289 patients. The quality of the studies was evaluated by Methodological Index for Non-Randomized Studies (MINORS). Results showed that quadriceps MVS markedly declines in the early postoperative period, after which it slowly and linearly recovers over time. However, the same phenomenon was not observed for VMA and CSA, which were not significantly altered after the TKA. Furthermore, a meta-regression analysis revealed that the change in VMA accounted for 39% of the relative change in quadriceps strength (R2=0.39; p=0.015) in the early postoperative period. Patients treated with TKA had considerable weakness of the quadriceps muscle, which was detectable up to 3 months after surgery. Although the change in VMA largely explains quadriceps weakness, this change and CSA differences were not significant, suggesting that other neural correlates, such as hamstrings coactivation, might alter quadriceps muscle function. Thus, more attention should be paid to address VMA failure and coactivation of antagonist muscles. More comprehensive rehabilitation approaches may be required to target the whole neural circuit controlling the motor action.
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Affiliation(s)
- Armin H Paravlic
- Science and Research Centre Koper, Institute for Kinesiology Research, Koper, Slovenia
| | - Simon Kovač
- Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Rado Pisot
- Science and Research Centre Koper, Institute for Kinesiology Research, Koper, Slovenia
| | - Uros Marusic
- Science and Research Centre Koper, Institute for Kinesiology Research, Koper, and Department of Health Sciences, Alma Mater Europaea - ECM, Maribor, Slovenia.
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Yu Y, Lin H, Wu Z, Xu P, Lei Z. Perioperative combined administration of tranexamic acid and dexamethasone in total knee arthroplasty-benefit versus harm? Medicine (Baltimore) 2019; 98:e15852. [PMID: 31441836 PMCID: PMC6716714 DOI: 10.1097/md.0000000000015852] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate the benefits and harm of combined administration of tranexamic acid (TXA) and dexamethasone (Dexa) in total knee arthroplasty (TKA). METHODS A total of 88 consecutive patients undergoing TKA for knee osteoarthritis were stratified in 2 groups. All surgeries were performed under general anesthesia. Brief, patients in the TXA + Dexa group (n = 45) received 10 mg Dexa just after the anesthesia, and repeated at 24 hours after the surgery; and patients in the TXA group (n = 43) received 2 ml of normal saline solution at the same time. The measured outcomes were the C-reactive protein (CRP) and interleukin-6 (IL-6) from preoperatively to postoperatively, and postoperative nausea and vomiting (PONV), fatigue, range of motion (ROM), length of stay (LOS), and the analgesic and antiemetic rescue consumption RESULTS:: The level of CRP and IL-6 in the TXA + Dexa group were lower than that in the TXA group at 24 hours (P < .001, P < .001), 48 hours (P < .001, P < .001), and 72 hours (P < .001, P < .001) after the surgery. The pain scores in the TXA + Dexa group were lower during walking at 24 hours (P < .001), 48 hours (P < .001), and 72 hours (P < .001) and at rest at 24 hours (P = .022) after the surgery. Patients in the TXA + Dexa group had a lower nausea score, the incidence of PONV, fatigue, and the analgesic and antiemetic rescue consumption, and had a greater ROM than that in the TXA group. No significant differences were found in LOS and complications. CONCLUSION The combined administration of TXA + Dexa significantly reduced the level of postoperative CRP and IL-6, relieve postoperative pain, ameliorate the incidence of POVN, provide additional analgesic and antiemetic effects, reduce postoperative fatigue, and improve ROM, without increasing the risk of complications in primary TKA.
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21
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Kehlet H, Lindberg-Larsen V. High-dose glucocorticoid before hip and knee arthroplasty: To use or not to use-that's the question. Acta Orthop 2018; 89:477-479. [PMID: 29781366 PMCID: PMC6202732 DOI: 10.1080/17453674.2018.1475177] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University
- The Lundbeck Foundation Centre for Fast-track Hip and Knee replacement, Copenhagen, Denmark
| | - Viktoria Lindberg-Larsen
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University
- The Lundbeck Foundation Centre for Fast-track Hip and Knee replacement, Copenhagen, Denmark
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Abstract
As a result of the introduction of fast-track programs, the length of hospital stay after arthroplasty has decreased to a point where some patients meet the discharge criteria on the day of surgery. In several studies, well-established fast-track centers have demonstrated the feasibility of outpatient procedures in selected patients. However, in literature the term "outpatient" is sometimes also used for patients who spend one or more nights in hospital. We therefore propose to use "outpatient" solely for patients who are discharged to their own home on the day of surgery and do not have an overnight stay at either the hospital or another non-home facility. Also, several challenges need to be overcome before this becomes an established procedure. The combination of preoperative high-dose steroids and multimodal opioid-sparing analgesia has enhanced patient recovery after arthroplasty, but efforts to control undesirable pathophysiological responses will be a prerequisite to improve the success rate of an outpatient setting. Also, care must be taken to avoid extra activities or investments solely to enable discharge on the day of surgery. Further cost analyses will have to be performed to establish the true financial benefit of outpatient treatment.
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Affiliation(s)
- Stephan B W Vehmeijer
- Department of Orthopedic Surgery, Reinier de Graaf Groep, Delft, The Netherlands,Department of Orthopedic Surgery, Orthoparc, Bosch en Duin, The Netherlands,Correspondence:
| | - Henrik Husted
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark,Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
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