Preoperative dexamethasone for pain relief after total knee arthroplasty: A randomised controlled trial

A systematic review and meta-analysis on the effects of intravenous dexamethasone on postoperative outcomes in patients undergoing total knee arthroplasty

PURPOSE

Dexamethasone has shown promising efficacy in alleviating pain and enhancing outcomes undergoing TKA. However, an optimal route of administration, dosage, and treatment duration have not yet been established. This study is to assess the effects of intravenous dexamethasone administration on postoperative pain management and prognosis in patients undergoing TKA.

METHODS

Data were retrieved from PubMed, Embase, the Cochrane Library, and Web of Science to compare the effects of intravenous dexamethasone administration versus non-administration on outcomes following TKA. Primary endpoints included pain scores and morphine consumption. Secondary endpoints comprised walking distance, ROM, patients requiring rescue analgesics and antiemetics, LOS, levels of CRP and IL-6, QoR, and the incidence of adverse events.

RESULTS

This meta-analysis included 15 RCTs involving 2,584 patients. The study indicated that intravenous dexamethasone can decrease VAS scores at rest (24 h, 95% CI: -0.71 [-0.86, -0.55], I²=66%, P < 0.00001; 48 h, 95% CI: -0.30 [-0.43, -0.18], I²=46%, P < 0.00001) and movement (24 h, 95% CI: -0.89 [-1.23, -0.55], I²=91%,P < 0.00001; 48 h, 95% CI: -0.42 [-0.62, -0.23], I²=84%, P < 0.0001). Moreover, it can reduce morphine consumption (24 h, 95% CI: -3.06 [-4.82, -1.30], I²=46%, P = 0.0006; 48 h, 95% CI: -5.23 [-8.28, -2.18], I²=76%, P = 0.0008) and increase walking distances on postoperative days 1 to 3, and improve the ROM on postoperative day 1 to 2. Furthermore, intravenous dexamethasone reduced the need for requiring rescue analgesics and antiemetics, shortened LOS, lowered CRP and IL-6 levels, and improved the quality of life after TKA. The incidence of infection, gastrointestinal hemorrhage, wound healing, or deep vein thrombosis/pulmonary embolism did not differ significantly. Subgroup analyses revealed no significant differences between single-administration and repeat-administration groups, except in the context of rescue antiemetic requirements.

CONCLUSION

Our study revealed that a single intravenous dose of dexamethasone, ranging from 8 to 16 mg administered before or after the induction of anesthesia or one hour prior to surgery, is efficacious in diminishing postoperative pain and cumulative morphine consumption, reducing the necessity for rescue analgesics and antiemetics, and shorten LOS for TKA. Additionally, it contributed to an increase in postoperative walking distance, ROM, and overall quality of postoperative recovery.

TRIAL REGISTRATION

We conducted literature selection, eligibility criteria evaluation, data extraction and analysis on the research program registered in Prospero (CRD42024521224) in January 2025.

Complete Blood Cell Count-Based Ratios Identify Total Joint Arthroplasty Patients Likely to Benefit from Perioperative Dexamethasone

BACKGROUND

Complete blood cell count-based ratios (CBRs), including the neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR), are inflammatory markers associated with postoperative morbidity. Given the link between the surgical stress response and complications after total joint arthroplasty (TJA), this study aimed to evaluate whether higher preoperative CBR values predict greater postoperative benefits associated with dexamethasone utilization.

METHODS

The Premier Healthcare Database was queried for adult patients who underwent primary, elective total hip or knee arthroplasty (THA or TKA). Multivariable logistic regression models using dexamethasone exposure and CBRs as independent variables assessed primary end points of 90-day postoperative complications and length of stay (LOS) of ≥3 days. The probability difference between the dexamethasone and non-dexamethasone groups for each primary end point was determined across all values of each CBR. Probability differences were compared across CBR quartiles.

RESULTS

A total of 32,849 primary, elective TJAs (12,788 THAs [38.93%], 20,061 TKAs [61.07%]) performed between 2016 and 2021 were identified, and 22,282 (67.83%) of the patients received perioperative dexamethasone. Among patients with an NLR value of >1.00, those receiving dexamethasone had a lower probability of postoperative complications (all p < 0.05). Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients in the highest NLR quartile (≥4.67) compared with the lowest quartile (NLR <1.84) (p = 0.002). Among patients with an MLR value of ≥0.36, those receiving dexamethasone had significantly lower odds of postoperative complications. Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients with an MLR of ≥0.33 (the 2 highest quartiles) compared with an MLR of <0.24 (the lowest quartile) (p = 0.039).

CONCLUSIONS

Higher NLR and MLR values were associated with greater marginal benefit from perioperative dexamethasone treatment, establishing a modifiable link between adverse outcomes and perioperative inflammation in TJA.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Dexamethasone in Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized, Placebo-Controlled Trials

BACKGROUND

The perioperative use of dexamethasone in diabetic patients remains controversial due to concerns related to infection and adverse events. This study aimed to determine whether clinical evidence supports withholding dexamethasone in diabetic patients due to concern for infection risk. We hypothesized that there is no difference in infectious outcomes between dexamethasone-treated patients and controls.

METHODS

A literature search was performed on November 22, 2022 to identify randomized, placebo-controlled trials investigating short-course (<72 hours), perioperative dexamethasone that explicitly included diabetic patients and measured at least 1 clinical outcome. Pertinent studies were independently searched in PubMed, Embase, and Cochrane. Authors for all identified studies were contacted with the aim of performing quantitative subgroup analyses of diabetic patients. The primary end point was surgical site infection and the secondary end point was a composite of adverse events. Qualitative remarks were reported based on the total available data and a quality assessment tool. Meta-analyses were performed using inverse variance with random effects. Heterogeneity was assessed via standard χ2 and I2 tests.

RESULTS

Sixteen unique studies were included, 5 of which were analyzed quantitatively. Of the 2592 diabetic patients, 2344 (1184 randomized to dexamethasone and 1160 to placebo) were analyzed in at least 1 quantitative outcome. Quantitative analysis showed that the use of perioperative dexamethasone had no effect on the risk of surgical site infections (log odds ratio [LOR], -0.10, 95%; 95% confidence interval [CI], -0.64 to 0.44) while significantly reducing the risk of composite adverse events (LOR, -0.33; 95% CI, -0.62 to -0.05). Qualitative analysis reinforced these findings, demonstrating noninferior to superior results across all clinical outcomes. There was high heterogeneity between the included studies.

CONCLUSIONS

Current evidence suggests perioperative dexamethasone may be given to diabetic patients without increasing the risk of infectious complications. Prospective investigations aimed at optimizing dose, frequency, and timing are needed, as well as studies aimed explicitly at exploring the use of dexamethasone in patients with poorly controlled diabetes.

Perioperative systemic corticosteroids in primary unilateral total knee arthroplasty: a systematic review

Main reasons for prolonged hospital stay after total knee arthroplasty (TKA) are postoperative nausea and vomiting (PONV) and pain. Having a positive effect on both PONV and pain, perioperative administration of corticosteroids might improve rehabilitation and reduce length of hospital stay (LOS) after TKA. Aim of this review is to determine the effect of different corticosteroid dosages on PONV, pain, and LOS in TKA. A systematic search for articles comparing dosage effects of corticosteroids regarding PONV, pain, and LOS after primary unilateral TKA was conducted using EMBASE, PubMed publisher, MEDLINE, Cochrane, Google scholar, and Web-of-Science for articles published from inception to March 17, 2022. 16 studies were included involving 2352 TKA procedures. Most studies showed reduced pain scores in corticosteroid groups and some described better pain reduction in high-dose groups. All studies showed reduced PONV in the corticosteroid groups. LOS was similar in most studies comparing placebo and perioperative corticosteroids. Only one study reported increased infection rates and intramuscular venous thrombosis in the corticosteroid group. Concluding, current literature on corticosteroids use in TKA is highly variable in type, dosage, and timing of administering medication. Overall, corticosteroids mostly reduce pain and PONV with limited effects on LOS after TKA. Only minimal statistically significant and clinically relevant benefits were found in perioperative high-dose corticosteroids compared to low-dose. Given the short follow-up in most studies, it is not possible to evaluate safety of high-dose corticosteroids.

Intraoperative intravenous versus periarticular injection of glucocorticoids in improving clinical outcomes after total knee arthroplasty: A prospective, randomized and controlled study

BACKGROUND

Glucocorticoids have been widely used in perioperative period for postoperative pain relief after total knee arthroplasty (TKA). However, the optimal administration protocols of glucocorticoids remain controversial. This study aims to compare the efficacy of glucocorticoids between intravenous and periarticular injection on clinical outcomes.

METHODS

A total of 114 patients were randomly assigned to intravenous (IV) group (n = 57) and periarticular injection (PI) group (n = 57). The IV group received 10 mg dexamethasone intravenously and the PI group received periarticular injection of 10 mg dexamethasone during the procedure. The clinical outcomes were assessed using visual analogue scale (VAS), knee society score (KSS), range of motion (ROM), knee swelling, inflammation markers and complications after TKA.

RESULTS

The VAS score during walking at 2nd day postoperatively was lower in the PI group compared with the IV group (2.08 ± 1.45 vs 2.73 ± 1.69, p = .039), and there was no significant difference at the other time points of VAS score in two groups. The inflammation markers, knee swelling, knee ROM and KSS score were not statistically different. Vomiting and other complications occurrence were not significantly different between the two groups.

CONCLUSIONS

Intraoperative periarticular injection of glucocorticoids has similar analgesic effect compared to intravenous in the postoperative period following TKA and may be even more effective on the second postoperative day. In addition, periarticular injection of glucocorticoids does not impose an excess risk or complication on patients.

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.

Chronic Pain and Functional Outcome 3 years After Total Knee Arthroplasty and Perioperative Dexamethasone: A Follow-Up of the Randomized, Clinical DEX-2-TKA Trial

BACKGROUND

Perioperative dexamethasone as an adjunct to multimodal analgesia, has an opioid-sparing and pain alleviating effect after total knee arthroplasty (TKA), however, the 3-year effects are unknown. We aimed to investigate the 3-year effect of 1 (DX1) or 2 (DX2) intravenous doses of 24 mg dexamethasone or placebo on pain, physical function, and health-related quality of life after TKA.

METHODS

Patients who participated in the Dexamethasone Twice for Pain Treatment after TKA (DEX-2-TKA) were invited to physical tests and questionnaires (self-reported characteristics, Oxford Knee Score, EuroQol-5Dimensions-5Levels (EQ5D5L), and PainDetect). The tests were 40-meter Fast Paced Walk (40FPW) test, Timed Up and Go (TUG), 30 Second Chair Stand test (30CST), Stair Climb Test (SCT), bilateral knee Range of Motion, and knee extension torque. For each test the peak pain intensity was registered on a 0 to 100 mm Visual Analogue Scale. Primary outcome was average peak pain intensity during the 40FPW, TUG, 30CST and SCT. Secondary outcomes were the tests and questionnaires. Out of 252 eligible patients, 133 (52.8%) underwent the tests and 160 (63.5%) answered the questionnaires. Mean follow-up time was 33 months (range, 23 to 40).

RESULTS

Median (interquartile range) peak pain intensity was 0 (0 to 65) for the DX2 group, 0 (0 to 51) for DX1 group and 0 (0 to 70) for the placebo group (P = .72). No differences in secondary outcomes were identified.

CONCLUSION

One or 2 intravenous doses of 24 mg dexamethasone did not impact chronic pain development or physical function 3 years after TKA.

Dexamethasone Plus Bupivacaine Versus Bupivacaine in Bilateral Transincisional Paravertebral Block in Lumbar Spine Surgeries: A Randomized Controlled Trial

OBJECTIVES

Few studies examined the analgesic effects of dexamethasone in lumbar paravertebral block, specifically the transincisional approach. This study aimed to compare dexamethasone with bupivacaine versus bupivacaine alone for bilateral transincisional paravertebral block (TiPVB) for postoperative analgesia in lumbar spine surgeries.

MATERIALS AND METHODS

Fifty patients who were aged 20 to 60 years and had American Society of Anesthesiologists Physical Status (ASA-PS) I or II of either sex were randomly allocated into 2 equal groups. Both groups received combined general anesthesia and bilateral lumbar TiPVB. However, in group 1 (dexamethasone group) (n=25), patients received 14 mL of bupivacaine 0.20% plus 1 mL containing 4 mg of dexamethasone on each side, while, in group 2 (control group) (n=25), patients received 14 mL of bupivacaine 0.20% plus 1 mL of saline on each side. Time to first analgesic need was the primary outcome, while total opioid consumption during the first 24 hours after surgery, the Visual Analog Scale for pain perception (0-10), and the incidence of side effects were secondary outcomes.

RESULTS

The mean time to the first analgesic requirement was significantly prolonged among patients in the dexamethasone group than the control group (mean±SD: 18.4±0.8 vs. 8.7±1.2 h, respectively) ( P <0.001). Patients in the dexamethasone group had lower total opiates consumption than the control) P <0.001). Although nonsignificant, the incidence of postoperative nausea and vomiting was more frequent among the control group ( P =0.145).

DISCUSSION

Adding dexamethasone to bupivacaine in TiPVB resulted in a prolonged analgesia-free period and lower opioid consumption in lumbar spine surgeries with comparable incidence of adverse events.

Pain Relief After Total Knee Arthroplasty with Intravenous and Periarticular Corticosteroid: A Randomized Controlled Trial

BACKGROUND

Total knee arthroplasty (TKA) is a cost-effective procedure, but it is also associated with substantial postoperative pain. The present study aimed to compare pain relief and functional recovery after TKA among groups that received intravenous corticosteroids, periarticular corticosteroids, or a combination of both.

METHODS

This randomized, double-blinded clinical trial in a local institution in Hong Kong recruited 178 patients who underwent primary unilateral TKA. Six of these patients were excluded because of changes in surgical technique; 4, because of their hepatitis B status; 2, because of a history of peptic ulcer; and 2, because they declined to participate in the study. Patients were randomized 1:1:1:1 to receive placebo (P), intravenous corticosteroids (IVS), periarticular corticosteroids (PAS), or a combination of intravenous and periarticular corticosteroids (IVSPAS).

RESULTS

The pain scores at rest were significantly lower in the IVSPAS group than in the P group over the first 48 hours (p = 0.034) and 72 hours (p = 0.043) postoperatively. The pain scores during movement were also significantly lower in the IVS and IVSPAS groups than in the P group over the first 24, 48, and 72 hours (p ≤ 0.023 for all). The flexion range of the operatively treated knee was significantly better in the IVSPAS group than in the P group on postoperative day 3 (p = 0.027). Quadriceps power was also greater in the IVSPAS group than in the P group on postoperative days 2 (p = 0.005) and 3 (p = 0.007). Patients in the IVSPAS group were able to walk significantly further than patients in the P group in the first 3 postoperative days (p ≤ 0.003). Patients in the IVSPAS group also had a higher score on the Elderly Mobility Scale than those in the P group (p = 0.036).

CONCLUSIONS

IVS and IVSPAS yielded similar pain relief, but IVSPAS yielded a larger number of rehabilitation parameters that were significantly better than those in the P group. This study provides new insights into pain management and postoperative rehabilitation following TKA.

LEVEL OF EVIDENCE

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

Effects of Dexamethasone on Postoperative Glycemic Control in Diabetic Patients Following Primary Total Joint Arthroplasty: A Retrospective Cohort Study

INTRODUCTION

Concerns regarding the effects of dexamethasone on diabetics' glucose control have stymied its use following total joint arthroplasty (TJA). This study aimed to evaluate the effects of two intravenous (IV) perioperative doses of dexamethasone on glucose levels, pain scores, and inpatient opioid consumption following TJA in diabetic patients.

METHODS

A retrospective review of 523 diabetic patients who underwent primary elective THA and 953 diabetic patients who underwent primary elective TKA between May 6, 2020 and December 17, 2021. Patients who received one dose (1D) of perioperative dexamethasone 10 mg IV were compared to patients who received two doses (2D). Primary outcomes included postoperative glucose levels, opioid consumption as morphine milligram equivalences (MMEs), postoperative pain as Verbal Rating Scale (VRS) pain scores, and postoperative complications.

RESULTS

The 2D TKA cohort had significantly greater average and maximum blood glucose levels from 24 to 60 hours compared to the 1D TKA cohort. The 2D THA cohort had significantly greater average blood glucose levels at 24 to 36 hours compared to the 1D THA cohort. However, the 2D TKA group had significantly reduced opioid consumption from 24 to 72 hours and reduced total consumption compared to the 1D TKA group. VRS pain scores did not differ between cohorts for both TKA and THA at any interval.

CONCLUSION

Administration of a second perioperative dose of dexamethasone was associated with increased postoperative blood glucose levels. However, the observed effect on glucose control may not outweigh the clinical benefits of a second perioperative dose of glucocorticoids.

The Effect of Dexamethasone on Postoperative Pain Management in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

Objective The objective of this study was to evaluate the effectiveness of dexamethasone in treating postoperative pain in patients undergoing total knee arthroplasty (TKA). Methodology This randomized controlled trial (RCT) was completed over the course of two years (September 7, 2015, to September 6, 2017). In the course of their treatment for osteoarthritis of the knee, all of the patients who had primary unilateral total knee replacement (TKR) participated in the research. Under spinal anesthesia, each patient had medial para-patellar approach medial orthopedic surgery. Patients were assigned to group A or group B based on a random selection. Each of the groups consisted of 79 individuals. Group A was given dexamethasone through intravenous administration at a dose of 0.1 mg/kg before the operation. During the subsequent period of 24 hours, no more treatment was administered (control group). On a predesigned questionnaire, postoperative pain was measured using the visual analog scale (VAS) for pain. Functional results, duration of hospital stay, and complications were all recorded on the questionnaire (VAS). Analysis of data was carried out using the Statistical Package for the Social Sciences (SPSS) version 23 (IBM SPSS Statistics, Armonk, NY, USA). Results There were 158 patients in total in the study, out of which 98 were females and 60 were males in the group. The patients' average body mass index (BMI) was 26.94 ± 3.14 kg/m². Patients in group A had lower postoperative analgesic and antiemetic needs and higher VAS scores and spent less time in the hospital than patients in group B. There were no postoperative problems in either group. Conclusion In patients undergoing TKA, the use of dexamethasone during and after surgery decreases pain, the need for analgesics, and the duration of hospital stay.

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

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.

Methods and timing in the assessment of postoperative recovery: a scoping review

BACKGROUND

There is no consensus about the type of instrument with which to assess postoperative recovery or the time points when assessments are most appropriate. It is also unclear whether instruments measure the four dimensions of postoperative recovery, that is physical, psychological, social, and habitual recovery. This scoping review had three objectives: (1) to identify and describe instruments used in clinical trials to assess postoperative recovery; (2) to determine how, when, and the number of times postoperative recovery was measured; and (3) to explore whether the four dimensions of postoperative recovery are represented in the identified instruments.

METHODS

A literature search was conducted in CINAHL, MEDLINE, and Web of Science. The search terms were related to three search strands: postoperative recovery, instrument, and clinical trials. The limits were English language and publication January 2010 to November 2021. In total, 5015 studies were identified.

RESULTS

A total of 198 studies were included in the results. We identified 20 instruments measuring postoperative recovery. Different versions of Quality of Recovery represented 81.8% of the included instruments. Postoperative recovery was often assessed at one time point (47.2%) and most often on postoperative day 1 (81.5%). Thirteen instruments had items covering all four dimensions of postoperative recovery.

CONCLUSIONS

Assessing recovery is important to evaluate and improve perioperative care. We emphasise the importance of choosing the right instrument for the concept studied and, if postoperative recovery is of interest, of assessing more than once. Ideally, instruments should include all four dimensions to cover the whole recovery process.

A randomized, controlled trial on the effect of anesthesia on chronic pain after total knee arthroplasty

Aim: The study sought to evaluate the influence of anesthesia on chronic pain after total knee arthroplasty (TKA). Methods: This was a single-center, randomized controlled study, with patients receiving a spinal anesthetic (SP) alone or a general anesthetic (GA) with femoral block, with follow-up at 3 and at 6 months. The primary outcome was the WOMAC^® score at 6 months. Results: 199 patients were enrolled. Group SP had better function (WOMAC: GA: 16.9 vs SP: 14.4, p = 0.015) and less pain (WOMAC pain: GA: 3.04 vs SP: 2.69, p = 0.02) at 3 months, but not at 6 months. Overall, 11% of patients had chronic postsurgical pain (CPSP), with Group GA having a higher incidence of CPSP at 6 months. Neuropathic pain increased during the follow-up and was more common in patients with CPSP. Conclusion: An SP reduces pain and incidence of CPSP after TKA. Clinical Trial Registration: NCT04206046 (ClinicalTrials.gov).