Peri-articular steroid injection improves the outcome after unicondylar knee replacement

Association Between Intraoperative Periarticular Injection of Triamcinolone and Early Postoperative Infection in Total Knee Arthroplasty: An Analysis of a Japanese Nationwide Database

BACKGROUND

The safety of intraoperative periarticular triamcinolone injection in total knee arthroplasty (TKA) remains unclear. This study aimed to assess the association between periarticular injection of triamcinolone during primary TKA and complications, including early postoperative infection.

METHODS

A Japanese nationwide database was used to identify adults who underwent primary TKA between April 2016 and March 2022. Patients were divided into triamcinolone and control groups. The primary outcome was reoperation for infection within 90 days from primary TKA. Secondary outcomes included diagnosis of postoperative infection, wound complications, deep vein thrombosis (DVT), pulmonary embolism (PE), in-hospital death, and readmission within 90 days. Propensity score matching was performed to adjust baseline differences. During the study period, 242,571 cases underwent primary knee arthroplasty. Among 212,427 eligible TKA patients, 15,229 (7.2%) were in the triamcinolone group and 197,198 (92.8%) were in the control group.

RESULTS

Overall, there were 551 reoperations for infection within 90 days (0.26%), including 61 (0.40%) patients in the triamcinolone group and 490 (0.25%) in the control group. Propensity score matching yielded 14,683 pairs. The triamcinolone group had a higher incidence of reoperation for infection, with a risk ratio (RR) of 1.67 (95% confidence interval [CI]: 1.10 to 2.53) and risk difference of 0.16% (95% CI: 0.03 to 0.29). Diagnoses of infection (RR: 1.25 [95% CI: 1.09 to 1.44]) and wound complications (RR: 1.18 [95% CI: 0.99 to 1.39]) were more frequent in the triamcinolone group, while DVT incidence was significantly lower (RR: 0.69 [95% CI: 0.65 to 0.73]). No significant differences were observed in PE or in-hospital death, although 90-day readmission was more frequent in the triamcinolone group (RR: 1.22 [95% CI: 1.06 to 1.40]).

CONCLUSIONS

Although the difference was subtle, periarticular injection of triamcinolone during TKA was associated with an increased risk of early postoperative infection requiring reoperation.

The Mechanisms and Safety of Corticosteroid Injections in Orthopaedic Surgery

» Corticosteroid injections (CSIs), including intra-articular, perineural, and those involving tendon sheaths or bursae, offer potential relief from osteoarthritic and inflammatory musculoskeletal pain, including gout attacks, as well as tarsal tunnel syndrome, plantar fasciitis, and interdigital neuromas.» CSI for musculoskeletal pain is commonly used as a nonoperative management option for both diagnostic and therapeutic purposes, offering pain relief, typically lasting from days to months.» CSIs are often performed prior to surgery as part of the nonoperative management of many conditions, with multiple CSIs within the year of surgery increasing postoperative infection risk in some major joints.» Despite the potential benefits of CSI, there are risks, including a potential increase in the risk of surgical site infection secondary to bacterial contamination and the immunomodulating effect of corticosteroids when given in the perioperative period.» To date, a multitude of studies across orthopaedic subspecialties has reported on perioperative infection risk associated with CSIs. However, heterogeneity in study design and patient populations has made standardized recommendations challenging. It is, therefore, difficult to elucidate, with a high level of evidence, the most appropriate perioperative timeline for CSI administration for which infection risk is nonsignificant.

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.

Is particulate or non-particulate steroid the determinant of periarticular injection efficacy for controlling postoperative TKR pain? Network meta-analysis

Purpose

Combining steroids for a periarticular injection (PAI) regiment has resulted in better pain control for postoperative TKR pain. Despite the available evidence, the most effective type of steroid for PAI still needs to be established. Network meta-analysis is conducted to analyze whether there is any difference in the effect of particulate compared to non-particulate periarticular steroid injection on post-TKR patients for pain control based on published literature.

Method

This study is conducted following the PRISMA guideline. In general, studies assessing the efficacy of periarticular injection analgesia added with either particulate (Triamcinolone, methylprednisolone, or prednisolone) or non-particulate (dexamethasone or betamethasone) steroid compared to the same regiment were analyzed.

Results

Ten studies were finally included from the 108 identified papers through database searching. VAS reduction on POD1 is found to be similar in particulate (0,91; CI95%: 0,45-1,37) compared to non-particulate (0,81; CI95%: 0,34-1,28) (Fig. 2). The difference becomes wider and favors non-particulate POD3. Subgroup analysis based on each steroid type was conducted. A stark difference can be observed for each pair of steroids (particulate and non-particulate), resulting in a similar cumulative effect of particulate and non-particulate steroids and inconsistent result on POD1 compared to POD3.

Conclusion

From the available evidence, we concluded that particulate or non-particulate steroid does not significantly affect post-TKR pain management. Instead, the specific type of steroid contributes more to postoperative VAS reduction.

Levels of evidence

Level III.

Adductor Canal Block Does not Confer Better Immediate Postoperative Pain Relief after Total Knee Arthroplasty

The adductor canal block (ACB) is a useful adjunct to control postoperative pain in total knee arthroplasty (TKA). The aim of our study was to compare postoperative day 1 (POD1) pain scores, ambulation distance, range of motion, active straight leg raise (SLR), and length of stay (LOS) in TKA patients receiving no ACB (NACB), ACB by surgeon (ACBS), or ACB by anesthetist (ACBA). After obtaining institutional ethics approval, a retrospective review of 135 patients who underwent TKA between September 2020 and March 2021 was performed. All patients underwent TKA by the same surgeon and received the same standardized postoperative rehabilitation. Operating theater time was shortest in the NACB group with 129.3 ± 23.1 minutes compared with 152.4 ± 31.6 minutes in ACBA and 139.2 ± 29.4 minutes in ABCS (p = 0.001). For the POD1 pain score after therapy, the NACB group scored 4.9 ± 3.1 compared with 3.5 ± 2.2 and 3.9 ± 1.8 scored by the ACBA and ACBS groups, respectively (p = 0.302). The mean POD1 ambulation distance was 21.1 ± 15.2 m in the NACB group compared with 15.4 ± 1.3 and 17.8 ± 13.2 m in the ACBA and ACBS groups (all p > 0.05), respectively. There were no significant differences in the median LOS between three groups or ability to perform active SLR (all p > 0.05). Our study found no significant differences when comparing ACBS and ACBA by POD1 pain score, ambulation distance, range of motion, and LOS. We recommend against the use of ACB and instead recommend surgeons to perform an adequate periarticular cocktail injection.

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.

An Injectable Containing Morphine, Ropivacaine, Epinephrine, and Ketorolac Is Not Cytotoxic to Articular Cartilage Explants From Degenerative Knees

PURPOSE

The purpose of this study was to determine the effects of a multidrug injectate containing morphine, ropivacaine, epinephrine, and ketorolac, commonly referred to as the "Orthococktail," on cartilage tissue viability and metabolic responses using an established in vitro model.

METHODS

With institutional review board approval and informed patient consent, tissues normally discarded after total knee arthroplasty (TKA) were recovered. Full-thickness cartilage explants (n = 72, Outerbridge grade 1 to 3) were created and bisected. Paired explant halves were treated with either 1 mL Orthococktail or 1 mL of saline and cultured for 8 hours at 37°C, with 0.5 mL of the treatment being removed and replaced with tissue culture media every hour. Explants were cultured for 6 days, and media were changed and collected on days 3 and 6. After day 6, tissues were processed for cell viability, weighed, and processed for histologic grading. Outcome measures were compared for significant differences between treated and untreated samples.

RESULTS

There were no significant differences in cartilage viability between control and Orthococktail-treated samples across a spectrum of cartilage pathologies. Orthococktail treatment consistently resulted in a significant decrease in the release of PGE2, MCP-1, MMP-7, and MMP-8 on day 3 of culture and PGE2, MMP-3, MMP-7, and MMP-8 on day 6 of culture, compared with saline controls.

CONCLUSION

The results of the present study indicate that an Orthococktail injection composed of morphine, ropivacaine, epinephrine, and ketorolac is associated with a transient decrease in degradative and inflammatory mediators produced by more severely affected articular cartilage and may mitigate perioperative joint pain such that postoperative narcotic drug use could be reduced.

CLINICAL RELEVANCE

The Orthococktail solution used in this study may be a safe intraoperative, intra-articular injection option for patients undergoing joint arthroplasty and other joint preservation surgical procedures.

The comparison of dexamethasone and triamcinolone periarticular administration in total knee arthroplasty: retrospective cohort study

Background

Intraoperative periarticular injection of corticosteroid effectively reduces perioperative pain in total knee arthroplasty (TKA). However, which corticosteroid is most effective for intraoperative periarticular injection remains controversial. We compared the effects of corticosteroids between dexamethasone and triamcinolone acetonide periarticular administration for reducing pain and postoperative nausea and increasing fasting blood glucose concentrations during the perioperative period following TKA.

Methods

One hundred and two patients who underwent TKA from August 2018 to September 2020 were divided into two groups: one received 10 mg dexamethasone for intraoperative periarticular injection and another receiving 40 mg triamcinolone acetonide. Postoperative pain scores at rest and during walking and nausea scores were recorded using a 0-to-10 Numerical Rating Scale. C-reactive protein (CRP) and fasting blood glucose levels were measured pre- and postoperatively.

Results

Pain scores in the triamcinolone group were significantly lower than in the dexamethasone group at rest 7 days postoperatively (1.5 vs. 2.0; p = 0.046) and while walking at both 72 h (3.9 vs. 4.8; p = 0.008) and 7 days postoperatively (3.2 vs. 4.0; p = 0.03). The CRP levels in the triamcinolone group were significantly lower than in the dexamethasone group at 7 days postoperatively (1.6 mg/dl vs. 3.0 mg/dl: p < 0.001). The fasting blood glucose levels at 1 day postoperatively were increased in both groups but not significantly different between the groups. No significant differences in the nausea score were noted between the groups.

Conclusions

Triamcinolone acetonide periarticular administration provided greater pain relief by reducing inflammation to a greater degree than dexamethasone.

Should corticosteroids be administered for local infiltration analgesia in knee arthroplasty? A meta-analysis and systematic review

WHAT IS KNOWN AND OBJECTIVE

The benefits of local infiltration analgesia (LIA) in knee arthroplasty (KA) have been well-documented. However, it is unknown whether adding a corticosteroid to the composition of the LIA is beneficial. This study aimed to investigate the efficacy and safety of administering periarticular steroids intraoperatively in patients who underwent KA through a systematic review and meta-analysis.

METHODS

A systematic search was conducted to identify relevant randomized controlled trials in the PubMed, Embase, Web of Science and Cochrane databases up to January 19th, 2021 to perform a meta-analysis. Outcome variables included pain scores, total opioid consumption, knee range of motion (ROM) and postoperative complications.

RESULTS

Corticosteroid injections did not reduce pain scores at 6, 12, 24 or 72 h postoperatively, although a minimal degree of transient pain relief was achieved at 48 h postoperatively compared with those in the placebo group, nor was there a significant difference in total opioid consumption. However, patients receiving corticosteroids did exhibit a transient ROM increase on postoperative days 1, 2 and 3. Since the minimal clinically important difference (MCID) for ROM is unclear, it is unknown if the improvement in ROM is clinically significant.

WHAT IS NEW AND CONCLUSION

Our specific end-point analysis demonstrated that corticosteroid administration did not provide pain relief or reduce opioid consumption compared with placebo. However, corticosteroids might provide a statistically significant, though transient and minimal improvement in knee ROM after KA, although no firm conclusions about the benefits of administering corticosteroids in KA can be made based on the available evidence.

Adding corticosteroids to periarticular infiltration analgesia improves the short-term analgesic effects after total knee arthroplasty: a prospective, double-blind, randomized controlled trial

PURPOSE

Periarticular infiltration analgesia (PIA) is widely used to control postoperative pain in patients who underwent total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding corticosteroids to the PIA cocktail for pain management in patients who underwent TKA.

METHODS

The patients were randomized to the corticosteroid or control group (double-blind). The patients in the corticosteroid group received a periarticular infiltration of an analgesic cocktail of ropivacaine, epinephrine, and dexamethasone. Dexamethasone was omitted from the cocktail in the control group. The primary outcomes were postoperative pain [assessed using a visual analog scale (VAS)], time until the administration of first rescue analgesia, morphine consumption, and postoperative inflammatory biomarkers [C-reactive protein (CRP) and interleukin-6 (IL-6)]. The secondary outcomes were functional recovery, assessed by the range of knee motion, quadriceps strength, and daily ambulation distance. The tertiary outcomes included postoperative adverse effects.

RESULTS

The patients in the corticosteroid group had significantly lower resting VAS scores at 6 and 12 h after surgery, lower VAS scores during motion up to 24 h after surgery, and lower levels of inflammatory biomarkers. All the differences in the VAS scores between the two groups did not reach the point to be considered clinically significant. The additional use of corticosteroid significantly prolonged analgesic effects and led to lower rescue morphine consumption. The patients in the corticosteroid group had significantly better functional recovery on the first day after surgery. The two groups had a similar occurrence of adverse effects.

CONCLUSIONS

Adding corticosteroids to an analgesic cocktail for PIA could lightly improve early pain relief and accelerate recovery in the first 24 h after TKA.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

Comparison of different local analgesia protocols in postoperative pain management after total knee arthroplasty

Objectives

This study was to compare the effects of different local analgesia protocols on osteoarthritis patients undergoing total knee arthroplasty (TKA).

Methods

Medical records of 148 osteoarthritis patients who underwent unilateral TKA between October 2016 and October 2017 in our hospital were retrospectively analyzed. All these patients were divided into three groups according to the pain management protocol (morphine, morphine + cocktail [100 mg ropivacaine, 10 mg morphine, and 30 mL 0.9% sodium chloride solution containing 2 mL betamethasone (4 mg)], or cocktail). The postoperative visual analog scale (VAS) score, muscle strength, and complications were compared between the groups.

Results

At 6 and 12 hours post-operation, the VAS score in group C was significantly higher than that in group A or group B. In addition, the muscle (quadriceps femoris) strength score of group C (3.7 ± 2.8) was significantly higher than that in groups A and B at 6 and 12 hours post-operation. The VAS score and muscle strength score showed no significant differences among the three groups at 24 and 36 hours post-operation. The time of postoperative first void of group C was significantly shorter than that of groups A and B. Groups A or B had a significantly higher incidence of nausea and emesis compared with group C. The incidence of pruritus was higher in groups A or B than that in group C.

Conclusion

Epidural anesthesia combined with local analgesic cocktail injection is a preferable effective multimodal analgesia for TKA.

Comparison of Intravenous and Periarticular Administration of Corticosteroids in Total Knee Arthroplasty: A Prospective, Randomized Controlled Study

BACKGROUND

Corticosteroids are widely used in total knee arthroplasty (TKA) to relieve postoperative pain and prevent postoperative nausea. The aim of this prospective, randomized controlled study was to compare the effects of intravenous and periarticular administration of corticosteroids on pain control, prevention of postoperative nausea, and inflammation and thromboembolism markers following TKA.

METHODS

One hundred patients undergoing TKA were randomly allocated to either the intravenous administration or periarticular injection group. The intravenous administration group received 10 mg dexamethasone 1 hour before and 24 hours after the surgical procedure, as well as a periarticular injection placebo during the procedure. The periarticular injection group received a 40-mg injection of triamcinolone acetonide during the surgical procedure, as well as an intravenous administration placebo 1 hour before and 24 hours after the procedure. Postoperative pain scores at rest and during walking and nausea scores were recorded according to the 0-to-10 Numerical Rating Scale. Interleukin-6 (IL-6), C-reactive protein (CRP), and prothrombin fragment 1.2 (PF1.2) were measured preoperatively and postoperatively.

RESULTS

Pain scores at rest and during walking 24 hours postoperatively were significantly lower in the periarticular injection group than in the intravenous administration group. Nausea scores showed no significant difference between groups. IL-6 at 24 and 48 hours postoperatively also showed no significant difference between groups. CRP at 24 and 48 hours postoperatively was significantly lower in the intravenous administration group than in the periarticular injection group. In contrast, CRP at 1 week postoperatively was significantly higher in the intravenous administration group than in the periarticular injection group. The mean PF1.2 was significantly lower in the intravenous administration group than in the periarticular injection group at 4 hours postoperatively. Two cases of deep venous thrombosis in each group were detected with use of ultrasonographic examination.

CONCLUSIONS

Periarticular injection of corticosteroids showed a better pain-control effect at 24 hours postoperatively than did intravenous administration, whereas the antiemetic effect was similar between treatments. Although intravenous administration had a better anti-thromboembolic effect than periarticular injection, the incidence of deep venous thrombosis was low in both groups.

LEVEL OF EVIDENCE

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

Efficacy of additional corticosteroids to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis of randomized controlled trials

BACKGROUND

As the ultimate method for the treatment of osteoarthritis, total knee arthroplasty (TKA) has been widely used in the clinic. Local injection of multimodal cocktails, including corticosteroids, is commonly used for pain management after TKA. This meta-analysis aims to systematically evaluate the effect of periarticular injection of corticosteroids on postoperative pain relief and knee functional recovery in patients undergoing TKA.

METHODS

PubMed, Cochrane Library, EMBASE, and Web of Science databases were comprehensively searched for all randomized controlled trials (RCTs) published before July 1, 2020, that investigated the efficacy of corticosteroids for TKA.

RESULTS

Ten RCTs involving a total of 829 patients were assessed in the meta-analysis. Compared with the control group, the visual analogue scale (VAS) score at rest of the corticosteroid group decreased significantly at postoperative day 1 (POD1), POD2, and POD3 (p < 0.05). Besides, the range of flexion motion of the knee joint in the corticosteroid group at POD1 and POD2 was significantly increased (p < 0.05); at the same time, the range of extension motion at POD2 and POD3 showed the opposite trend between the two groups (p < 0.05). The morphine equivalent of postoperative analgesia was significantly reduced (p < 0.05), and the time required for straight leg raising (SLR) was significantly shortened (p < 0.05). There was no significant difference between the two groups in terms of postoperative drainage, length of hospital stay, and complications such as infection, nausea, and vomiting (p > 0.05).

CONCLUSION

The additional corticosteroids to multimodal cocktail periarticular injection can relieve the early pain intensity at rest after TKA, increase the early range of motion (ROM) of the knee joint, reduce the dosage of postoperative analgesics, and shorten the duration of time required for SLR. However, it has no effect on reducing postoperative complications and shortening the length of hospital stay.

Addition of dexamethasone to local infiltration analgesia in elective total knee arthroplasty: double-blind, randomized control trial

BACKGROUND AND OBJECTIVES

Total knee arthroplasty is associated with significant pain, and effective analgesia is beneficial to patient satisfaction and functional outcomes. Studies have demonstrated that dexamethasone may have a facilitatory role on the action of local anesthesia, but this effect, when added to a local infiltration analgesia (LIA) mixture for patients having knee arthroplasty, is underexplored. Our hypothesis was that the addition of dexamethasone to local anesthetic infiltration would improve analgesic outcomes following total knee arthroplasty.

METHODS

We performed a double-blind, randomized controlled trial of 140 patients undergoing elective, unilateral, total knee arthroplasty. Patients were randomly allocated to receive either 2 mL of saline 0.9% or 2 mL of dexamethasone 4 mg/mL added to a LIA mixture. Our primary outcome was 24 hours of oral morphine equivalent consumption. Our secondary outcomes included short-term and long-term analgesic and functional outcomes and adverse events.

RESULTS

A total of 72 patients were included in the saline group and 68 were included in the dexamethasone group. We found comparable 24 hours of morphine consumption between saline and dexamethasone groups, with a median of 60 (IQR 40-105 (range 16-230)) mg and 56 (IQR 41-75 (range 0-300)) mg, respectively (p=0.096). Dexamethasone was associated with a statistically significant reduction in total inpatient opioid consumption, incidence of requiring rescue patient-controlled analgesia, length of hospital stay, and postoperative nausea, compared with saline. Patients in the dexamethasone group had a greater range of joint movement and distance walked on postoperative day 1 than the saline group. There were no differences in rest or active pain scores, timed up and go or 3-month outcomes.

CONCLUSIONS

Dexamethasone 8 mg was associated with no improvements in 24 hours of morphine consumption but was associated with modest improvements in short-term analgesia, short-term function, length of stay and postoperative nausea. There were no long-term benefits in the use of dexamethasone in LIA for patients undergoing total knee arthroplasty.

TRIAL REGISTRATION NUMBER

NCT02760043.

Addition of corticosteroid to periarticular injections reduces postoperative pain following total hip arthroplasty under general anaesthesia: a double-blind randomized controlled trial

Aims

Although periarticular injection plays an important role in multimodal pain management following total hip arthroplasty (THA), there is no consensus on the optimal composition of the injection. In particular, it is not clear whether the addition of a corticosteroid improves the pain relief achieved nor whether it is associated with more complications than are observed without corticosteroid. The aim of this study was to quantify the safety and effectiveness of cortocosteroid use in periarticular injection during THA.

Methods

We conducted a prospective, two-arm, parallel-group, randomized controlled trial involving patients scheduled for unilateral THA. A total of 187 patients were randomly assigned to receive periarticular injection containing either a corticosteroid (CS group) or without corticosteroid (no-CS group). Other perioperative interventions were identical for all patients. The primary outcome was postoperative pain at rest during the initial 24 hours after surgery. Pain score was recorded every three hours until 24 hours using a 100 mm visual analogue scale (VAS). The primary outcome was assessed based on the area under the curve (AUC).

Results

The CS group had a significantly lower AUC postoperatively at 0 to 24 hours compared to the no-CS group (AUC of VAS score at rest 550 ± 362 vs 392 ± 320, respectively; mean difference 158 mm; 95% confidence interval (CI) 58 to 257; p = 0.0021). In point-by-point evaluation, the CS group had significantly lower VAS scores at 12, 15, 18, 21, 24, and 48 hours. There were no significant differences in complication rates, including surgical site infection, between the two groups.

Conclusion

The addition of corticosteroid to periarticular injections reduces postoperative pain without increasing complication rate following THA.

Cite this article: Bone Joint J 2020;102-B(10):1297–1302.

What is the optimal regimen for intravenous dexamethasone administration in primary total hip arthroplasty?: A protocol of randomized controlled trial

BACKGROUND

A number of recent studies have investigated the optimal dosage and timing of dexamethasone in total hip arthroplasty (THA) but have inconsistent findings. Therefore, we designed the randomized controlled research to look for the optimal intravenous dexamethasone dose for the treatment of early postoperative pain after the THA.

METHODS

The Declaration of Helsinki principles was followed and the Consolidated Standards of Reporting Trials guidelines for randomized controlled trials was adhered in this study. The First Medical Center in People's Liberation Army General Hospital approved the study (2020-089). After written informed consent was obtained, patients aged between 18 and 80 years with Physical Status I to III of American Society of Anesthesiologists, scheduled for primary unilateral THA, were included in this present work. Randomization is the use of a computer-formed list via a secretary, at a ratio of 1:1:1. The major end points were pain scores at 24 hours, 48 hours, and 72 hours after surgery, with visual analog scale (VAS) utilized at rest, and at 45 degrees passive hip flexion. The secondary outcomes involved the total consumption of morphine, opioid-related side effects, hip range of motion, inflammation markers, and the length of hospital stay.

RESULTS

We assumed that the patients who received 3 doses of dexamethasone intravenously possessed the best postoperative results compared to those who received 1 or 2 doses of the dexamethasone.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5864).

Does adding corticosteroids to periarticular injection affect the postoperative acute phase response after total knee arthroplasty?

BACKGROUND

Periarticular injection (PAI) can reduce pain and improve early outcomes following total knee arthroplasty (TKA). Although corticosteroid PAI has been reported to be safe and effective, investigations on the postoperative acute phase response (APR) are scarce.

METHODS

This retrospective cohort study with propensity score matching investigated two groups of patients after TKA: the steroid group (n = 50) received an intraoperative corticosteroid PAI (methylprednisolone 40 mg); the non-steroid group (n = 50) did not receive the corticosteroid. To evaluate the APR, C-reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR) were determined preoperatively and on postoperative day (POD) 2, 4, 6, 14, and 28. A visual analogue scale (VAS) was used to measure pain on the night of surgery and on POD 1, 2, 4, and 6. Maximal flexion at discharge (POD 7), morphine equivalent dose (MED), and complications were also evaluated.

RESULTS

The steroid group showed significantly lower CRP levels on POD 2 (P < .05) and POD 4 (P < .05) but a higher CRP level on POD 6 (P < .05). However, ESR levels did not differ between the two groups in all measurements. Peak values in CRP and ESR in the steroid group (POD 4 and 6) appeared two days later compared with the non-steroid group (POD 2 and 4). The VAS pain score was significantly lower in the steroid group on POD 2 (P < .05). Maximal flexion on discharge, MED and complication rate were similar in the two groups.

CONCLUSIONS

Adding a corticosteroid to the PAI following TKA attenuated the APR, and also provided significant pain relief.

Addition of dexamethasone to local infiltration analgesia in elective total hip arthroplasty: a double-blind, randomized control trial

BACKGROUND AND OBJECTIVES

Pain following total hip arthroplasty is significant, and effective analgesia is associated with an improvement in functional outcomes. Dexamethasone may facilitate the action of local anesthesia, but its role as an additive to a local infiltration analgesia (LIA) mixture in hip arthroplasty settings has not been investigated. We hypothesized that the addition of dexamethasone to local anesthetic infiltration improves analgesic outcomes following total hip arthroplasty.

METHODS

We performed a double-blind, randomized control trial of 170 patients undergoing total hip arthroplasty. Patients were randomized to receive LIA mixed with either 2 mL of saline 0.9% or 2 mL of dexamethasone 4 mg/mL. The primary outcome was 24 hours oral morphine consumption. Secondary outcomes included short-term and long-term analgesic and functional outcomes and adverse events.

RESULTS

85 patients were included in each arm. 24 hours morphine consumption was similar between saline and dexamethasone groups, with a median (IQR (range)) of 75 (45-105 (0-240)) and 62.5 (37.5-102.5 (0-210)) mg, respectively (p=0.145). However, patients receiving dexamethasone had significantly reduced opioid consumption for their total in-hospital stay, but not at any other time points examined. Functional outcomes were similar between groups. The incidence of postoperative nausea and vomiting was reduced in patients receiving dexamethasone.

CONCLUSIONS

The addition of 8 mg dexamethasone to LIA did not reduce 24 hours morphine consumption but was associated with limited improvement in short-term analgesic outcomes and a reduction in postoperative nausea and vomiting. Dexamethasone had no effect on functional outcomes or long-term analgesia.

TRIAL REGISTRATION NUMBER

NCT02760043.

Perioperative combined administration of tranexamic acid and dexamethasone in total knee arthroplasty-benefit versus harm?

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.

The efficiency and safety of steroid addition to multimodal cocktail periarticular injection in knee joint arthroplasty: a meta-analysis of randomized controlled trials

Steroids are frequently used for postoperative pain relief without definite evidence. This study was conducted to assess the pain management effect of the addition of steroids to a multimodal cocktail periarticular injection (MCPI) in patients undergoing knee arthroplasty and evaluate their safety. Pubmed, Embase, and Cochrane Library were searched through April, 2018. A total of 918 patients from ten randomized controlled trials (RCTs) were ultimately included. Compared with placebo groups, steroids application could effectively relieve pain on postoperative day (POD)1; decrease C-Reactive protein (CRP) level on POD3; improve range of motion (ROM) in postoperative 5 days; reduce morphine consumption, achieve earlier straight leg raising (SLR), and shorten the length of stay (LOS) in hospital. With regards to adverse effects, it did not increase the risk of postoperative infection, postoperative nausea and vomiting (PONV), or other complications. However, no significant difference in pain relief, ROM, or increased Knee Society Knee Function Scores were found during long-term follow up. Overall, this meta-analysis ensured the efficiency and safety of steroids with MCPI in knee arthroplasty patients during the early postoperative period.

Effect of local infiltration analgesia, peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in unicompartmental knee arthroplasty

Background

The aim of the study was to analyze the effect of local infiltration analgesia (LIA), peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in primary unicompartmental knee arthroplasty (UKA).

Methods

Between January 2016 until August 2016, 134 patients underwent primary UKA and were subdivided into four groups according to their concomitant pain and anesthetic procedure with catheter-based techniques of femoral and sciatic nerve block (group GA&FNB, n = 38) or epidural catheter (group SP&EPI, n = 20) in combination with general anesthesia or spinal anesthesia, respectively, and LIA combined with general anesthesia (group GA&LIA, n = 46) or spinal anesthesia (group SP&LIA, n = 30). Outcome parameters focused on the evaluation of pain (NRS scores), mobilization, muscle strength and range of motion up to 7 days postoperatively. The cumulative consumption of (rescue) pain medication was analyzed.

Results

The LIA groups revealed significantly lower (about 50%) mean NRS scores (at rest) compared to the catheter-based groups at the day of surgery. In the early postoperative period, the dose of hydromorphone as rescue pain medication was significantly lower (up to 68%) in patients with SP&EPI compared to all other groups. No significant differences could be detected with regard to grade of mobilization, muscle strength and range of motion. However, there seemed to be a trend towards improved mobilization and muscle strength with general anesthesia and LIA, whereof general anesthesia generally tended to ameliorate mobilization.

Conclusions

Except for a significant lower NRS score at rest in the LIA groups at day of surgery, pain relief was comparable in all groups without clinically relevant differences, while the use of opioids was significantly lower in patients with SP&EPI. A clear clinically relevant benefit for LIA in UKA cannot be stated. However, LIA offers a safe and effective treatment option comparable to the well-established conventional procedures.

Perioperative adjuvant corticosteroids for postoperative analgesia in knee arthroplasty

Background and purpose - Immediate postoperative pain management offered in knee arthroplasty is suboptimal in up to one-third of patients resulting in high opiate consumption and delayed discharge. In this meta-analysis we investigate the analgesic effect and safety of perioperative adjuvant corticosteroids in knee arthroplasty. Methods - Databases Medline, Embase, and Central were searched for randomized studies comparing the analgesic effect of adjuvant perioperative corticosteroids in knee arthroplasty. Our primary outcome was pain score at 24 hours postoperatively. Secondary outcomes included pain at 12, 48, and 72 hours, opiate consumption, postoperative nausea and vomiting, infection, and discharge time. Systemic (intravenous) and local (intra-articular) corticosteroids were analyzed separately. Results - 14 randomized controlled trials (1,396 knees) were included. Mean corticosteroid dosages were predominantly 50-75mg oral prednisolone equivalents for both systemic and local routes. Systemic corticosteroids demonstrated statistically significant and clinically modest reductions in pain at 12 hours by -1.1 points (95%CI -2.2 to 0.02), 24 hours by -1.3 points (CI -2.3 to -0.26) and 48 hours by -0.4 points (CI -0.67 to -0.04). Local corticosteroids did not reduce pain. Opiate consumption, postoperative nausea and vomiting, infection, or time till discharge were similar between groups. Interpretation - Corticosteroids modestly reduce pain postoperatively at 12 and 24 hours when used systemically without any increase in associated risks for dosages between 50 and 75 mg oral prednisolone equivalents.

Formulation of a Peribulbar Block for Prolonged Postoperative Pain Management in Vitreoretinal Surgery: A Randomized Clinical Trial

PURPOSE

To evaluate postoperative pain level using a supplemental peribulbar injection at the conclusion of retinal surgery.

DESIGN

Prospective, parallel-assigned, single-masked, randomized clinical trial.

PARTICIPANTS

Fifty-eight patients undergoing scleral buckle, vitrectomy, or combined surgery.

METHODS

In a single academic institutional practice, 58 patients undergoing scleral buckle, vitrectomy, or combined surgery were enrolled. Exclusion criteria included those with a risk for glaucoma, a pre-existing chronic pain disorder, among others. Patients were assigned randomly to receive a postoperative peribulbar formulation of either bupivacaine, triamcinolone acetonide, and cefazolin (group A) or bupivacaine, balanced salt solution, and cefazolin (group B). The postoperative pain score and ocular motility were assessed by a masked observer on the first postoperative day.

MAIN OUTCOME MEASURES

The primary outcome measure was the postoperative pain score. Secondary outcome measures included oral analgesic use, ocular motility, and intraocular pressure (IOP).

RESULTS

The mean pain scores were 2.8±2.9 for group A and 3.8±2.6 for group B (P = 0.095). Pain was absent in 28% of group A patients versus 14% of group B patients (P = 0.11). Group A required less narcotic pain medication (hydroxycodone: group A, 0.7±3 mg vs. group B, 3±6 mg; P = 0.05; oxycodone: group A, 7±7 mg vs. 9±13 mg; P = 0.2) than group B. Motility was full in group B and limited in group A (P ≤ 0.001), with no differences in mean IOP measurements at any point after surgery.

CONCLUSIONS

We did not demonstrate a statistically significant reduction in mean postoperative pain scores. However, patients in group A required less hydroxycodone use and had greater akinesia, suggesting prolonged neural blockade.

Periarticular Injections in Knee and Hip Arthroplasty: Where and What to Inject

BACKGROUND

Periarticular injections have become a valuable adjunct to multimodal pain control regimens after knee and hip arthroplasties. Injection techniques vary greatly among surgeons with little standardization of practice.

METHODS

We performed an extensive literature search to determine where nociceptive pain fibers are located in the hip and the knee and also to explore the pharmacology of periarticular cocktail ingredients.

RESULTS

Large concentrations of nociceptors are present throughout the various tissues of the knee joint with elevated concentrations in the infrapatellar fat pad, fibrous capsule, ligament insertions, periosteum, subchondral bone, and lateral retinaculum. Less empiric evidence is available on nociceptor locations in the hip joint, but they are known to be located diffusely throughout the hip capsule with elevated concentrations at the labral base and central ligamentum teres. Local anesthetics are the base ingredient in most injection cocktails and function by blocking voltage-gated sodium channels. Liposomal anesthetics may offer longer duration of action over traditional anesthetics. Nonsteroidal anti-inflammatory agents and corticosteroids block peripheral production of inflammatory mediators and may desensitize nociceptors. Opioid receptors are present in lower densities peripherally as compared with the central nervous system, but their inclusion in injections can lead to pain relief. Sympathetic drugs can provide adjunct effects to periarticular cocktails to increase duration of action and effectiveness of medications.

CONCLUSION

Targeting specific sites of nociceptors may help to further decrease pain after knee and hip arthroplasties. Altering periarticular cocktail ingredients may aid in multimodal pain control with injections.

Methylprednisolone reduces pain and decreases knee swelling in the first 24 h after fast-track unicompartmental knee arthroplasty

PURPOSE

Unicompartmental knee arthroplasty (UKA) results in less operative trauma and faster patient recovery than after a conventional total knee arthroplasty. Despite an increased focus on multimodal analgesic strategies, there is still a substantial level of patient-reported pain in the early postsurgical period after UKA. The purpose of the study was to evaluate the effect of a single preoperative dose of systemic methylprednisolone on postsurgical pain after fast-track UKA.

METHODS

Seventy-two patients in two consecutive series undergoing unilateral UKA were included in a prospective cohort study. The patients (n = 35) in the treatment group received a single preoperative dose of systemic methylprednisolone 125 mg, whereas the control group (n = 37) did not. Outcome measures were postsurgical pain at rest and during walking, consumption of opioids for pain rescue, knee swelling and knee range of motion, and complications.

RESULTS

In the first 24 h after surgery, the treatment group had less pain at rest (p < 0.001) and during walking (p < 0.001) and less consumption of opioids (p = 0.01) in comparison with the control group. Furthermore, the treatment group had 2.2 cm less knee swelling (p = 0.02) in the first post-operative day, and better knee extension (p = 0.004), whereas knee flexion was similar (n.s.) between groups. No serious complications were associated with the treatment.

CONCLUSION

Addition of a single preoperative dose of 125 mg systemic methylprednisolone to a multimodal analgesic regime significantly reduced postsurgical pain and opioid consumption and decreased knee swelling in the first 24 h after fast-track UKA.

LEVEL OF EVIDENCE

Therapeutic study, Level II.

Towards an understanding of the painful total knee: what is the role of patient biology?

Total knee arthroplasty (TKA) remains the treatment of choice for end-stage osteoarthritis of the knee. With an aging population, the demand for TKA continues to increase, placing a significant burden on a health care system that must function with limited resources. Although generally accepted as a successful procedure, 15-30 % of patients report persistent pain following TKA. Classically, pain generators have been divided into intra-articular and extra-articular causes. However, there remains a significant subset of patients for whom pain remains unexplained. Recent studies have questioned the role of biology (inflammation) in the persistence of pain following TKA. This article aims to serve as a review of previously identified causes of knee pain following TKA, as well as to explore the potential role of biology as a predictor of pain following knee replacement surgery.

Efficacy of multimodal analgesia injection combined with corticosteroids after arthroscopic rotator cuff repair

INTRODUCTION

Although arthroscopic rotator cuff repair is minimally invasive, there is still considerable postoperative pain, especially during the first 48 hours. The present study assessed the short-term efficacy and safety of multimodal analgesic (MMA) injection associated to corticosteroids in arthroscopic rotator cuff tear surgery.

MATERIAL AND METHOD

A single-center prospective randomized study included 50 patients undergoing arthroscopic rotator cuff tear surgery. The study group received subacromial injection of a mixture of morphine, ropivacaine and methylprednisolone associated to intra-articular injection of morphine plus methylprednisolone; the control group received only isotonic saline. All patients had had 24 hours self-administered morphine associated to standard analgesia. Postoperative data were recorded at 30 minutes and 1, 2, 4, 6, 12, 18 and 24 hours: pain intensity, morphine intake and side effects, and also time to first morphine bolus and additional analgesic intake. Constant, ASES and SST functional scores were recorded at 3 months.

RESULTS

Postoperative pain was significantly less intense in the MMA group than in controls at 30 min, H1, H4, H6, H12, H18 and H24 (P<0.05). A rebound at D10 occurred in both groups. During the first 24 hours, MMA significantly reduced cumulative resort to morphine (P<0.05 at H1/2, P<0.001 at H1-24). Mean time to first bolus was significantly longer in the MMA group (71.6 vs. 33 min; P<0.05). The rate of opioid-related side effects was similar between groups. At last follow-up, functional scores were similar between groups. There were no cases of infection or delayed skin healing.

CONCLUSION

MMA associated to corticosteroids after arthroscopic rotator cuff tear surgery provided immediate benefit in terms of analgesia and morphine sparing, without apparent risk of infection. The practice is presently little known in France and deserves longer-term assessment, especially as regards functional rehabilitation and tendon healing.

LEVEL OF EVIDENCE

2.

Single intra-articular dexamethasone injection immediately post-surgery in a rabbit model mitigates early inflammatory responses and post-traumatic osteoarthritis-like alterations

Despite surgical reconstruction of the anterior cruciate ligament, a significant number of patients will still develop post-traumatic osteoarthritis (PTOA). Our objective was to determine if mitigating aspects of the acute phase of inflammation following a defined knee surgery with a single administration of a glucocorticoid could prevent the development of PTOA-like changes within an established rabbit model of surgically induced PTOA. An early and late post-surgical time-point was investigated in this study (48 h and 9 weeks post-surgery) in which the following groups were repeated (each n=6, for a total of 24 rabbits per time-point, and 48 rabbits used in the study): control (age/sex matched), sham (arthrotomy), drill injury (arthrotomy+two drill holes to a non-cartilaginous area of the femoral notch), and drill injury+single intra-articular (IA) injection of dexamethasone (DEX). At 48 h post-surgery, DEX treatment significantly lowered the mRNA levels for a subset of pro-inflammatory mediators, and significantly lowered the histological grade. Nine weeks post surgery, DEX treatment significantly lowered the histological scores (presented as effect size) for synovium (3.8), lateral femoral condyle (3.9), and lateral tibial cartilage (5.1) samples. Thus, DEX likely acts to prevent injury induced inflammation that could contribute to subsequent joint damage.

The efficacy of steroid injection in total knee or hip arthroplasty

PURPOSE

A systematic review and meta-analysis based on randomized controlled trials (RCTs) was conducted to evaluate the efficacy and safety of steroid injection in total knee or hip arthroplasty (TKA/THA).

METHODS

A systematical electronic search identified the relevant RCTs in the databases of PubMed, EMBASE, MEDLINE and Cochrane Central Register of Controlled Trials. Two reviewers independently completed data collection and assessment of methodological quality. Meta-analysis was performed for the outcomes of visual analogue pain score, range of motion (ROM), postoperative nausea and vomiting (PONV), morphine consumption, length of stay and complications.

RESULTS

A total of 863 participants were enrolled. Patients who received steroid injection had a significant reduction in the incidence of PONV and improvement in short-term pain score, and ROM (p < 0.05). Regarding morphine consumption and hospitalization time, the steroid group showed a significant reduction in TKA but no statistically significant difference in THA. In addition, there were no significant differences in complications (n.s.).

CONCLUSIONS

The current evidence suggests that steroid injection in TKA/THA provides short-term advantages in pain relief and antiemetic effects. The optimal dose and long-term effects of steroid injection still require numerous studies.

LEVEL OF EVIDENCE

II.

Efficacy of periarticular injection applied trough knee other than posterior capsule in simultaneous bilateral total knee arthroplasty

BACKGROUND

We aimed to evaluate periarticular multimodal drug injection (PMDI) in bilateral total knee arthroplasty.

METHODS

In 154 knees of 77 patients, PMDI was administered intraoperatively through the regions other than posterior capsule to one knee; other knee was control.

RESULTS

Drug-injected knees had lower visual analog scale scores and higher passive range of motion postoperatively (p < 0.05). The active straight leg raise was higher in drug-injected knees (47 [61%] vs 19 [24.7%], p = 0.001).

CONCLUSIONS

PMDI is a safe and effective method of early postoperative pain management in total knee arthroplasty when applied through regions other than posterior capsule.

Efficacy of steroid addition to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis

Background

Total knee arthroplasty (TKA) has been reported to be the most successful treatment for patients with advanced osteoarthritis, however, early postoperative pain has become an unresolved issue. The aim of this Meta-analysis is to evaluate the efficacy and safety of steroid addition to multimodal cocktail periarticular injection (MCPI) in patients undergoing TKA.

Method

Clinical randomized controlled trials concerning the efficacy and safety of MCPI containing steroids in TKA published up to December 2014 were retrieved from PubMed, Cochrane library, EMbase databases. The methodological quality of the included studies was assessed by the 12-item scale. Data analysis was performed using StataSE12.0.

Results

Six randomized controlled trials involving a total of 567 patients were assessed; the steroid group included 305 patients, and the control group included 262 patients. The meta-analysis showed that MCPI with steroids in TKA significantly reduced postoperative pain; duration of time required to perform straight-leg raising and length of hospital stay was (P < 0.05). Neither the early postoperative nor the long-term range of motion of knee showed any statistical difference between the non-steroid and steroid group (P >0.05). For safety, steroids did not increase the incidence of postoperative infection and wound oozing (P >0.05); no tendon rupture was reported up to now. In addition, steroids did not decrease the postoperative drainage through the reduction of prostaglandins (P >0.05).

Conclusion

For patients undergoing TKA, the addition of steroids to MCPI improved the analgesic effect and was proved to be highly safe. The duration of time required to perform straight-leg raising and length of hospital stay was significantly reduced. However, MCPI with steroids neither increased the early postoperative range of motion (ROM) or the long-term ROM of knee, nor did it reduce the postoperative drainage. However, the best results are acquired in patients without any altered immunological status.

Which analgesic mixture is appropriate for periarticular injection after total knee arthroplasty? Prospective, randomized, double-blind study

PURPOSE

Although the analgesic effect of periarticular injection after total knee arthroplasty (TKA) has been well documented, the gold standard for drug combination has not yet been established. In this study, the analgesic effects of six different drug combinations were compared.

METHODS

A total of 256 patients undergoing TKA for primary osteoarthritis were randomized into one of six groups: a control group (saline solution, epinephrine, and cefazolin, n = 42), Group 1 (ropivacaine, n = 43), Group 2 (ropivacaine + morphine, n = 43), Group 3 (ropivacaine + ketorolac, n = 42), Group 4 (ropivacaine + morphine + ketorolac, n = 43), and Group 5 (ropivacaine + morphine + ketorolac + methylprednisolone, n = 43). Pain level assessed by visual analogue scale (VAS) and opioid consumption were primary outcomes. The incidence of complications, range of motion (ROM), C-reactive protein (CRP) value, and the amount of post-operative blood drainage were also compared.

RESULTS

Patients in Groups 4 and 5 complained less pain than the control group for the first 12 h after surgery, and the patients in the other groups showed less pain only during the initial 6 h after surgery. Groups 4 and 5 also showed less opioid consumption than the control group during the 24 h period after surgery. Patients in Group 5 showed no significant difference in VAS score and opioid consumption compared with Group 4, but they had lower CRP value and greater ROM than any other groups at post-operative day 2 and day 4.

CONCLUSION

The combination of ropivacaine, morphine, and ketorolac showed a significantly stronger and sufficiently synergistic analgesic effect without adding methylprednisolone in periarticular injection after TKA. The clinical relevance of the study is that the combination of ropivacaine, morphine, and ketorolac can be a good option for periarticular injection following TKA in terms of synergistic analgesic effect and efficiency of drug combination.

Association of surgeon factors with outcome scores after total knee arthroplasty

PURPOSE

To identify preoperative factors (including surgeon factors) associated with outcome scores after total knee arthroplasty (TKA).

METHODS

Medical records of 2848 patients (3458 knees) who underwent primary TKA by 27 orthopaedic specialists were retrieved. Three specialty knee surgeons who had one-year fellowship in TKA performed 1930 TKAs, and 24 general orthopaedic surgeons performed 1528 TKAs. Four of them (including all 3 specialty knee surgeons) were ultrahigh- volume (≥ 100 TKAs a year), and 21 of them were senior consultants (≥ 5 years post residency). At 2 years, 2922 (85%) of knees had complete followup data. Oxford Knee Score, Knee Society knee and function scores, and SF-36 quality-of-life score were assessed by independent physiotherapists before and after surgery. Outcomes were compared in terms of dichotomised specialty, seniority, and surgical volume of surgeons.

RESULTS

Comparing ultra-high-volume (≥ 100 TKAs per year) specialty knee surgeons with general orthopaedic surgeons, the former achieved better outcomes in terms of the Oxford Knee Score at 6 months, Knee Society knee and function scores at 2 years, and SF-36 scores at 6 months and 2 years. Comparing lower-volume (<100 TKAs per year) specialty knee surgeons with general orthopaedic surgeons, the former still achieved better outcome and quality-of-life scores, except for SF-36 Mental Component Score at 2 years.

CONCLUSION

Specialty training and clinical research in TKA improved outcome and quality-of-life scores.

Periarticular multimodal drug injection in total knee arthroplasty

PURPOSE

A systematic review and meta-analysis based on randomized controlled trials (RCTs) were conducted to evaluate the efficiency and safety of periarticular multimodal drug injection in total knee arthroplasty (TKA).

METHODS

Periarticular injection with the use of multimodal drugs is an efficient alternative for postoperative analgesia in TKA. A systematical electronic search was performed to identify the eligible RCTs in the databases of PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science and the Chinese Biomedical Literature Database. Two independent reviewers completed data collection and assessment of methodological quality. The quality of evidence of outcomes was judged using GRADE criteria. Meta-analysis was performed for the outcomes of pain, straight leg raise, operating time, hospital stay and complications.

RESULTS

Ten RCTs including eight studies with 1,216 TKAs in 835 patients met the inclusion criteria. Periarticular injection with multimodal drugs in TKA was associated with short-term benefits in terms of pain relief, straight leg raise, narcotic consumption, and the rates of nausea, vomiting, rash and pruritus. There were no statistically significant differences in operating time, hospital stay, wound complications and deep vein thrombosis between both groups.

CONCLUSIONS

The current evidence suggests that periarticular multimodal drug injection in TKA provides short-term advantages in pain relief, straight leg raise and postoperative complications.

Effects of dexamethasone on local infiltration analgesia in total knee arthroplasty: a randomized controlled trial

PURPOSE

Intraoperative local infiltration analgesia has gained increasing popularity in joint replacement surgery. Because there is considerable variation among drug combinations, analgesic effects of each drug are not well understood. The purpose of this study was to clarify the efficacy of the addition of steroid to local anaesthetics in local infiltration analgesia during total knee arthroplasty.

METHODS

Forty patients were randomly allocated to the steroid or control group. Patients in the steroid group received peri-articular injection of ropivacaine, dexamethasone and isepamicin, while dexamethasone was omitted from the analgesic mixture in the control group. Primary outcome was pain severity at rest using 100 mm visual analogue scale.

RESULTS

Pain severity in the steroid group was lower than control group and there were significant differences between groups at post-operative day 1 and 3. Reduction in post-operative pain was associated with a decrease in serum C-reactive protein and interleukin 6 in drainage fluid. The number of patients who were able to perform straight leg raise within post-operative day 2 was 15/20 in the steroid group, which was significantly higher than the control group 5/20.

CONCLUSION

Adding steroid to local anaesthetics in local infiltration analgesia reduced inflammation both locally and systemically, resulting in significant early pain relief and rapid recovery in total knee arthroplasty.

Systematic review: the safety of intra-articular corticosteroid injection prior to total knee arthroplasty

BACKGROUND

Up to 30% of patients undergoing total knee arthroplasty (TKA) have received intra-articular corticosteroid injections prior to surgery. Debate exists as to whether such injections increase the rate of post-operative infection. Given that deep infection is a disastrous complication, a systematic review of the literature was undertaken to evaluate the safety of intra-articular corticosteroid injections given prior to TKA. Other features of corticosteroid use are also discussed including mechanism of action and optimal dosage.

METHODS

Using PRISMA guidelines, EMBASE, CINAHL and MEDLINE databases were searched using the search terms 'total knee arthroplasty', 'replacement', 'corticosteroid', 'steroid', 'infection', 'safety', and relevant articles critically appraised. The Newcastle-Ottawa Scale was used to assess for bias.

RESULTS

No level one or two studies were available for review. Two retrospective case control studies and two cohort studies (level three evidence) which specifically evaluated the risk of infected TKA in association with pre-operative steroid injection were reviewed: three showed that prior steroid injection was not associated with increased infection rates; one article showed that prior steroid injection was associated with a significantly increased risk of deep infection post-TKA.

CONCLUSION

Clinicians commonly administer steroid injections to patients who are candidates for TKA but may be unaware of the potential long term complications. The included studies were underpowered and at risk of selection bias and only one study demonstrated an increased risk of infection post-operatively. We recommend that further research is required to evaluate the safety of steroid injection prior to TKA.

LEVEL OF EVIDENCE

III.

Perioperative glucocorticoids in hip and knee surgery - benefit vs. harm? A review of randomized clinical trials

Glucocorticoids are frequently used to prevent post-operative nausea and vomiting (PONV), and may be part of multimodal analgesic regimes. The objective of this review was to evaluate the overall benefit vs. harm of perioperative glucocorticoids in patients undergoing hip or knee surgery. A wide search was performed in PubMed, Embase, and Cochrane Central to identify relevant randomized clinical trials. A systematic approach was used, starting from the PRISMA recommendations. The Cochrane Collaboration's tool was used for risk of bias assessment. Studies were divided into three groups: systemic glucocorticoid administration analogous to > 10 mg or ≤ 10 mg dexamethasone, and local glucocorticoid administration. Seventeen studies with data from 1081 patients were included in the final qualitative synthesis. Benefit (of any kind) with glucocorticoid vs. placebo was reported in 15 studies. PONV was reduced with systemic glucocorticoid. Pain was reduced with high-dose systemic and local glucocorticoid, but not with low-dose systemic glucocorticoid. Systemic inflammatory markers were reduced with low-dose and high-dose systemic glucocorticoid, and with local glucocorticoid. Functional recovery was improved with local glucocorticoid. All studies were small-sized and none sufficiently powered to meaningfully evaluate uncommon adverse events. Most of the local administration studies had poor scientific quality (high risk of bias). Due to clinical heterogeneity and poor scientific quality, no meta-analysis was performed. In conclusion, in addition to PONV reduction with low-dose systemic glucocorticoid, this review supports high-dose systemic glucocorticoid to ameliorate post-operative pain after hip and knee surgery. However, large-scale safety and dose-finding studies are warranted before final recommendations.

Peri-articular steroid injection in total knee arthroplasty: a prospective, double blinded, randomized controlled trial

Total knee arthroplasty is a painful operation. Peri-articular local anesthetic injections reduce post-operative pain and assist recovery. It is inconclusive whether intra-operative injections of peri-articular corticosteroids are of benefit. Therefore our clinical question was: in patients with osteoarthritis who are undergoing TKA, does the addition of high or low dose corticosteroid to peri-articular injections of local anesthetic and adrenaline improve post-operative pain and range of motion? We performed a prospective, double-blinded, randomized controlled trial of two different doses of triamcinolone acetate (N = 42 in each group) added to local anesthetic in TKA for osteoarthritis. There were no significant differences in pain scores or ROM between the control and corticosteroid groups. Differences in secondary outcomes were also non-significant. Peri-articular corticosteroids do not appear to be of benefit in TKA.

Unicompartmental knee arthroplasties implanted for osteoarthritis with partial loss of joint space have high re-operation rates

The indications and contraindications for unicompartmental knee arthroplasty (UKA) are controversial. The aim of the study was to determine the risk factors for re-operation in our practice. A series of 113 medial UKAs with mean follow-up of 63 months were reviewed retrospectively. Pre-operatively all knees had radiographic or arthroscopic evidence of severe cartilage damage. The re-operation rate was not related to age, gender, arthroscopic finding or body mass index. It was related to the joint space on pre-operative standing weight bearing radiographs taken in extension. The re-operation rate was 6 (95% CI 2.1-17, P<0.001) times higher when the thickness of the pre-operative medial joint space was >2 mm rather than ≤2 mm. It was 8 (95% CI 2.8-22.5, P<0.001) times higher when the thickness of the pre-operative medial space was >40% of the thickness of the lateral space. The ratio of pre-operative joint spaces has a greater influence on revision rate than the absolute measurement and is independent of radiographic magnification or the patient's normal cartilage thickness. We therefore recommend that, in medial knee osteoarthritis, UKA should only be used if the pre-operative medial joint space on standing radiographs is ≤40% of the lateral joint space, even if severe cartilage damage is seen arthroscopically.

The efficacy, accuracy and complications of corticosteroid injections of the knee joint

PURPOSE

Corticosteroid knee injections are being increasingly used in the conservative management of knee osteoarthritis. The procedure is usually performed in secondary care by orthopaedic surgeons and rheumatologists, but as the role of general practitioners in chronic disease management expands, joint injections are now frequently being performed in primary care. It is commonly perceived amongst clinicians that the benefits of corticosteroid knee joint injections in treating symptomatic knee osteoarthritis significantly outweigh the risks of complications.

METHODS

The evidence in the literature for the benefits, accuracy, safety and complications of corticosteroid knee injections in osteoarthritis is reviewed. The perception that serious complications are rare is addressed, and the incidence of infectious complications is estimated.

RESULTS AND CONCLUSIONS

Short-term symptomatic relief is the only evidence-based benefit of corticosteroid injection of an osteoarthritic knee. Accurate intra-articular placement is not achieved in up to 20% of injections and varies considerably with the anatomical approach used. There is no evidence that a medial approach is more accurate. The incidence of serious infectious complications following knee joint injections ranges widely, and may be as high as 1 in 3,000 and potentially far higher in high-risk patients for whom specialist management is advised.

Reduced opioid consumption and improved early rehabilitation with local and intraarticular cocktail analgesic injection in total hip arthroplasty: a randomized controlled clinical trial

OBJECTIVE

Postoperative pain after total hip arthroplasty (THA) is not well tolerated. We assessed postoperative pain relief and the need for opioid use after using a cocktail of local and intraarticular analgesic injection (LIA) after THA.

METHODS

Eighty patients undergoing THA under spinal anesthesia were randomly assigned to receive either LIA or placebo. The LIA was composed of 5 mg morphine, 30 mg bupivacaine (15 mg/1.5 mL), 1 mL betamethasone, and 0.5 mL epinephrine (1:1,000) intraoperatively. We compared three outcomes total morphine consumption, visual analog scale (VAS) at rest and during activity, and hip flexion angle while standing.

RESULTS

When compared with placebo, opioid consumption was significantly reduced in the trial group, as well as VAS at rest and during mobilization. Earlier rehabilitation and better range of motion (ROM) were achieved in the trial group. There were no significant differences in side effects or postoperative wound healing between groups.

CONCLUSION

In patients undergoing THA, LIA may reduce postoperative systemic opioid use and offer better pain control and earlier rehabilitation, without observable risks.

Effects of periarticular steroid injection on knee function and the inflammatory response following Unicondylar Knee Arthroplasty

There is little information on the values of CRP and ESR as markers for inflammation in Unicondylar Knee Arthroplasty. The effect of periarticular steroid injection in post-operative pain relief and clinical recovery has not been well studied. Eighty-three consecutive patients undergoing primary UKAs were randomized to receive either an intra-operative periarticular injection with a local anaesthetic and adrenaline or with the addition of triamcinolone acetonide. CRP and ESR values, pain VAS and other scores, as well as clinical functional parameters, were obtained and analysed. Patients were assessed daily till discharge and up to 6 months post-operatively. Plasma CRP and ESR fluctuate after a UKA, with normalizing values indicating uneventful recovery. Periarticular steroid injections reduce post-operative pain and inflammation, and are clinically relevant as they improve short-term functional recovery and clinical parameters, resulting in better outcomes for patients without having major complications.