High-dose steroids in high pain responders undergoing total knee arthroplasty: a randomised double-blind trial

Abstract

Background Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain despite multimodal opioid-sparing analgesia. Pain catastrophising or preoperative opioid therapy is associated with increased postoperative pain. Preoperative glucocorticoid improves pain after TKA, but dose-finding studies and benefit in high pain responders are lacking. Methods A randomised double-blind controlled trial with preoperative high-dose intravenous dexamethasone 1 mg kg −1 or intermediate-dose dexamethasone 0.3 mg kg −1 in 88 patients undergoing TKA with preoperative pain catastrophising score >20 or regular opioid use was designed. The primary outcome was the proportion of patients experiencing moderate-to-severe pain (VAS >30) during a 5 m walk 24 h postoperatively. Secondary outcomes included pain at rest during nights and at passive leg raise, C-reactive protein, opioid use, quality of sleep, Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, readmission, and complications. Results Moderate-to-severe pain when walking 24 h postoperatively was reduced (high dose vs intermediate dose, 49% vs 79%; P <0.01), along with pain at leg raise at 24 and 48 h (14% vs 29%, P =0.02 and 12% vs 31%, P =0.03, respectively). C-reactive protein was reduced in the high-dose group at both 24 and 48 h (both P <0.01). Quality of Recovery-15 was also improved ( P <0.01). Conclusions When compared with preoperative dexamethasone 0.3 mg kg −1 i.v., dexamethasone 1 mg kg −1 reduced moderate-to-severe pain 24 h after TKA and improved recovery in high pain responders without apparent side-effects. Clinical trial registration NCT03763734 .

Peripheral nerve‐blocks and associations with length of stay and readmissions in fast‐track total hip and knee arthroplasty

“…Thus, although our results do not suggest routine use of PNBs is needed to achieve a short LOS or reduce readmissions, it is not possible to draw any conclusion with regards to the use of PNBs in patients having general anesthesia, as rescue analgesic techniques or in “high‐pain” responders or patients with chronic pain. 21 , 22 In this context, a randomized study‐design would be more suitable for evaluating the benefits of PNB in such patients, whereas the large‐scale observational design in our study may be more appropriate for evaluating general effects in a real‐life clinical setting.…”

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

“…Preoperative dexamethasone decreased postoperative pain and opiate use, increased mobility, and enhanced recovery quality after total knee arthroplasty, according to randomized controlled research [ 16 ]. Dexamethasone decreased moderately to severe pain in high-pain responders after surgery, according to a different trial [ 17 ]. Dexamethasone treatment enhances the postoperative range of motion, according to another meta-analysis, which might be explained by the steroid’s painkilling effects [ 18 ].…”

Study protocol for discharge on day of surgery after hip and knee arthroplasty from the Center for Fast-track Hip and Knee Replacement

“…All patients receive high-dose glucocorticoids preoperatively (24 mg dexamethasone or 125 mg methylprednisolone) except insulin-dependent diabetic patients (19)(20)(21)(22). 1 gram of tranexamic acid is administered intravenously during surgery in all patients and may be repeated 3-4 hours postoperatively (23,24).…”