Preoperative intravenous glucocorticoids can reduce postoperative acute pain following total knee arthroplasty

Liu, Xiangcheng; Liu, Jinglong; Sun, Ganghe

doi:10.1097/md.0000000000007836

Cited by 18 publications

(12 citation statements)

References 27 publications

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“…Even more interesting, the number of included trials varied between analyses. Thus, the included RCTs varied: n = 4 in [5]; n = 14 in [6]; n = 11 in [7]; n = 6 in [8]; n = 8 in [9]; n = 7 in [10]; n = 4 in [16]; and n = 9 in [17] A detailed assessment of the 28 RCTs included in the TKA-specific systematic reviews [5-10, 16, 17] is presented in Table 1. The trials included in the systematic reviews/ meta-analyses have considerable scientific flaws which make interpretation of these analyses challenging (Table 1).…”

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“…Since 2015, a total of 12 systematic reviews/meta-analyses have been published on the analgesic effects of pre-operative glucocorticoid administration after joint arthroplasty [5][6][7][8][9][10][11][12][13][14][15][16]. Of these, only five [5,6,9,10,16] were prospectively registered and seven studies focused only on TKA [5][6][7][8][9][10]16], while five reviews combined trials of TKA and total hip arthroplasty (THA). The TKA-specific systematic reviews/meta-analyses [5][6][7][8][9][10]16] included all the TKA-related trials in the analyses from the combined THA/TKA reviews.…”

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confidence: 99%

“…Of these, only five [5,6,9,10,16] were prospectively registered and seven studies focused only on TKA [5][6][7][8][9][10]16], while five reviews combined trials of TKA and total hip arthroplasty (THA). The TKA-specific systematic reviews/meta-analyses [5][6][7][8][9][10]16] included all the TKA-related trials in the analyses from the combined THA/TKA reviews. Interestingly, several reviews stated that they were the first in the field.…”

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The systematic review/meta‐analysis epidemic: a tale of glucocorticoid therapy in total knee arthroplasty

Kehlet

Joshi

2019

Anaesthesia

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Optimal peri-operative pain management is one of the key factors to enhance recovery in orthopaedic procedures aiming at early mobilisation. It has demonstrated benefits including decreasing pulmonary and thromboembolic complications as well as facilitating early physiotherapy and rehabilitation [1]. Consequently, we have seen numerous randomised controlled trials (RCT) on different analgesic approaches, but often with limited power to allow definite recommendations. Therefore, as generally accepted, pooling of data from available RCTs into systematic reviews and meta-analyses has become a gold standard [2]. However, at the same time, it has been realised that interpretation of systematic reviews and meta-analyses may be hindered by poor design and inappropriate inclusion of individual RCTs, which may lead to flawed conclusions [3].Often, for some research topics, there appear to be a greater number of systematic reviews/meta-analyses than original RCTs, probably due to the fact that it is easier to perform a systematic review/meta-analysis than perform a high-quality RCT [3]. Unfortunately, even a low-quality systematic review may be published because they are frequently cited which may increase the impact factor of a journal. Consequently, the medical profession, researchers and journal editors are faced with an important dilemma on how to assess the clinical validity of these analyses.This article aims to discuss this problem in detail, using a specific example from the effect of pre-operative glucocorticoids in pain management for total knee arthroplasty (TKA). We used TKA because it has inherent challenges to optimise analgesia and facilitate rehabilitation, and where steroids may have interesting positive effects due to reduction of the inflammatory response to surgery thereby reducing pain and fatigue, and apparently without significant adverse effects on wound healing and infections [4].A PubMed search was performed on 2 September 2019 using the following search strategy: glucocorticoid AND hip OR knee OR total joint AND arthroplasty AND RCT or systematic review or meta-analysis. Since 2015, a total of 12 systematic reviews/meta-analyses have been published on the analgesic effects of pre-operative glucocorticoid administration after joint arthroplasty [5][6][7][8][9][10][11][12][13][14][15][16]. Of these, only five [5,6,9,10,16] were prospectively registered and seven studies focused only on TKA [5-10, 16], while five reviews combined trials of TKA and total hip arthroplasty (THA). The TKA-specific systematic reviews/meta-analyses [5][6][7][8][9][10]16] included all the TKA-related trials in the analyses from the combined THA/TKA reviews. Interestingly, several reviews stated that they were the first in the field. Even more interesting, the number of included trials varied between analyses. Thus, the included RCTs varied: n = 4 in [5]; n = 14 in [6]; n = 11 in [7]; n = 6 in [8]; n = 8 in [9]; n = 7 in [10]; n = 4 in [16]; and n = 9 in [17], which could not be directly related to year of publication. Over...

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The systematic review/meta‐analysis epidemic: a tale of glucocorticoid therapy in total knee arthroplasty

Kehlet

Joshi

2019

Anaesthesia

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“…An equivalent dexamethasone dose less than 15 mg was identified as low dose and ≥15 mg was identified as high dose. [ 15 ] A P value less than .05 was considered statistically significant. Mixed meta-regression (methods of moment) was used to assess any potential interaction between dexamethasone dose (or equivalent) in the first 24 hours and the risk of PONV.…”

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Preoperative intravenous glucocorticoids can decrease acute pain and postoperative nausea and vomiting after total hip arthroplasty

Zhang¹,

Xin²,

Li³

2017

Medicine

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Background:A systematic review and meta-analysis of published randomized controlled trials (RCTs) were performed to assess the efficacy and safety of preoperative intravenous glucocorticoids versus controls for the prevention of postoperative acute pain and postoperative nausea and vomiting (PONV) after primary total hip arthroplasty (THA).Methods:A computer literature search of electronic databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, China National Knowledge Infrastructure (CNKI), and China Wanfang database, was conducted to identify the relevant RCTs comparing preoperative intravenous glucocorticoids versus placebos for reducing acute pain and PONV in THA patients. The primary outcomes included the use of the visual analog scale (VAS) with rest or mobilization at 6, 24, 48, and 72 hours and the occurrence of PONV. The secondary outcome was total morphine consumption. We calculated the risk ratio (RR) with a 95% confidence interval (95% CI) for dichotomous outcomes, and the weighted mean difference (WMD) with a 95% CI for continuous outcomes.Results:Pooled data from 7 RCTs (411 THAs) favored preoperative intravenous glucocorticoids against acute pain intensity at 4, 24, and 48 hours (P < .05). There was no significant difference between the VAS with rest or mobilization at 72 hours (P > .05). Subsequently, preoperative intravenous glucocorticoids provided a total morphine-sparing effect of 9.36 mg (WMD = −9.36, 95% CI = −12.33 to −6.38, P = .000). In addition, preoperative intravenous glucocorticoids were associated with a significant reduction of the occurrence of PONV (RR = 0.41, 95% CI = 0.30–0.57, P = .000).Conclusion:Intravenous glucocorticoids can decrease early pain intensity and PONV after THA. However, the low number of studies and variation in dosing regimens limits the evidence for its use. Thus, more high-quality RCTs are still needed to identify the optimal drug and the safety of intravenous glucocorticoids.

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“…Final results indicated that intravenous glucocorticoid can decrease the VAS at 12 and 24 hours and by 8.41 points, 7.46 points, and 13.99 points, respectively, with clinical significance. Liu et al [ 22 ] identified that intravenous glucocorticoids may be as an effective and safe method to reduce postoperative pain in patients following TKA. Meng and Li [ 23 ] found that intravenous dexamethasone could significantly reduce postoperative pain scores following total joint arthroplasty (TJA).…”

Section: Discussionmentioning

confidence: 99%

Intravenous glucocorticoid for pain control after spinal fusion

Wang

Shi

et al. 2018

Medicine

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Objective:Postoperative pain was a common symptom after spinal surgery. This meta-analysis aimed to assess whether intravenous glucocorticoids has a beneficial role in reducing pain in patients following spinal fusion.Methods:We systematically searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and Google databases, from inception to March 2, 2018. Randomized controlled trials (RCTs) that comparing intravenous glucocorticoids with control treatment for spinal fusion were included. A meta-analysis was performed to generate pooled risk ratio (RR) and weighted mean difference with corresponding 95% confidence interval (CI) for discontinuous outcomes (the occurrence of nausea and infection) and continuous outcomes (visual analog scale [VAS] at 12, 24, and 48 h; total morphine consumption; and the length of hospital stay), respectively.Results:Eight clinical trials involving 918 patients (glucocorticoid group = 449, control group = 469) were finally included in this meta-analysis. Compared with control, intravenous glucocorticoids had significantly reduced VAS at 12, 24, and 48 hours with statistically significance (P < .05). Intravenous glucocorticoids can decrease the occurrence of nausea (RR = 0.42, 95% CI 0.29–0.62, P = .000; I2 = 0.0%) and the length of hospital stay. No difference was noticed in the occurrence of infection between glucocorticoids intravenous and control (P > .05).Conclusion:Existing evidence indicated that intravenous glucocorticoids have a beneficial role in decreasing early pain and the occurrence of nausea after spinal fusion surgery. In consideration of the limitation in current meta-analysis, more high-quality RCTs were needed to identify the optimal dose of glucocorticoids in spinal fusion patients.

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Preoperative intravenous glucocorticoids can reduce postoperative acute pain following total knee arthroplasty

Abstract: Supplemental Digital Content is available in the text

Cited by 18 publications

References 27 publications

The systematic review/meta‐analysis epidemic: a tale of glucocorticoid therapy in total knee arthroplasty

The systematic review/meta‐analysis epidemic: a tale of glucocorticoid therapy in total knee arthroplasty

Preoperative intravenous glucocorticoids can decrease acute pain and postoperative nausea and vomiting after total hip arthroplasty

Intravenous glucocorticoid for pain control after spinal fusion

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