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Dose optimization of intravenous dexamethasone for total knee arthroplasty: when two is not better than one

Archives of Orthopaedic and Trauma Surgery (2021)Cite this article

Abstract

Background

The optimal dose regimen of dexamethasone in total knee arthroplasty (TKA) has not been determined. This study was performed to evaluate the impact of a single preoperative high-dose dexamethasone compared with two perioperative low-dose dexamethasone in TKA.

Materials and methods

We prospectively studied three regimens on dexamethasone: no dexamethasone (A), a single preoperative dose of 20-mg dexamethasone (B), and two perioperative doses of 10-mg dexamethasone (C). The primary outcome was postoperative pain level. The incidence of postoperative nausea and vomiting (PONV), use of analgesic and antiemetic rescue, interleukin-6 (IL-6) and C-reactive protein (CRP) levels, range of motion (ROM), and complications were also compared.

Results

The dynamic pain scores and CRP and IL-6 levels were significantly lower for Group B compared to Groups A and C on postoperative days 1 and 2 (POD 1 and 2). Such differences were also detected between Groups C and A. Besides, the pain scores at rest were significantly lower in Groups B and C than in Group A on POD 1 and 2. Patients in Groups B and C had a lower incidence of PONV, reduced use of analgesic and antiemetic rescue, and improved ROM than in Group A. No complications occurred in any group.

Conclusion

Dexamethasone in TKA provides short-term advantages in analgesic, antiemetic and anti-inflammatory effects. Besides, regarding the effects of pain and inflammatory control on POD 1 and 2, a single preoperative high dose of 20-mg dexamethasone was more effective than two perioperative low doses of 10-mg dexamethasone.

Level of evidence

I.

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References

  1. Pinsornsak P, Teeyaphudit M, Ruetiwarangkoon C, Chaiwuttisak A (2016) Comparison of ramosetron with ondansetron for prevention of intrathecal morphine-induced nausea and vomiting after primary total knee arthroplasty: a randomized control trial. J Arthroplasty 32:1040

    Article  Google Scholar 

  2. Si HB, Yang TM, Zeng Y, Zhou ZK, Pei FX, Lu YR, Cheng JQ, Shen B (2017) Correlations between inflammatory cytokines, muscle damage markers and acute postoperative pain following primary total knee arthroplasty. BMC Musculoskelet Disord 18(1):265

    Article  Google Scholar 

  3. Eckhard L, Jones T, Collins JE, Shrestha S, Fitz W (2019) Increased postoperative dexamethasone and gabapentin reduces opioid consumption after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 27(7):2167–2172

    Article  Google Scholar 

  4. Zhai L, Song Z, Liu K (2016) The effect of gabapentin on acute postoperative pain in patients undergoing total knee arthroplasty: a meta-analysis. Medicine (Baltimore) 95(20):e3673

    CAS  Article  Google Scholar 

  5. Koh IJ, Chang CB, Jeon YT, Ryu JH, Kim TK (2012) Does ramosetron reduce postoperative emesis and pain after TKA? Clin Orthop Relat Res 470(6):1718–1727

    Article  Google Scholar 

  6. Xu B, Ma J, Huang Q, Huang ZY, Zhang SY, Pei FX (2018) Two doses of low-dose perioperative dexamethasone improve the clinical outcome after total knee arthroplasty: a randomized controlled study. Knee Surg Sports Traumatol Arthrosc 26(5):1549–1556

    Article  Google Scholar 

  7. Kim JK, Ro DH, Lee HJ, Park JY, Han HS, Lee MC (2020) Efficacy of systemic steroid use given one day after total knee arthroplasty for pain and nausea: a randomized controlled study. J Arthroplasty 35(1):69–75

    Article  Google Scholar 

  8. Richardson AB, Bala A, Wellman SS, Attarian DE, Bolognesi MP, Grant SA (2016) Perioperative dexamethasone administration does not increase the incidence of postoperative infection in total hip and knee arthroplasty: a retrospective analysis. J Arthroplasty 31(8):1784–1787

    Article  Google Scholar 

  9. Xu H, Zhang S, Xie J, Lei Y, Cao G, Pei F (2018) Multiple doses of perioperative dexamethasone further improve clinical outcomes after total knee arthroplasty: a prospective, randomized. Controlled Study J Arthroplasty 33(11):3448–3454

    Article  Google Scholar 

  10. Backes JR, Bentley JC, Politi JR, Chambers BT (2013) Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial. J Arthroplasty 28(8 Suppl):11–17

    Article  Google Scholar 

  11. Bolac CS, Wallace AH, Broadwater G, Havrilesky LJ, Habib AS (2013) The impact of postoperative nausea and vomiting prophylaxis with dexamethasone on postoperative wound complications in patients undergoing laparotomy for endometrial cancer. Anesth Analg 116(5):1041–1047

    CAS  Article  Google Scholar 

  12. Chen CC, Siddiqui FJ, Chen TL, Chan ES, Tam KW (2012) Dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing thyroidectomy: meta-analysis of randomized controlled trials. World J Surg 36(1):61–68

    Article  Google Scholar 

  13. Lunn TH, Kehlet H (2013) Perioperative glucocorticoids in hip and knee surgery—benefit vs. harm? a review of randomized clinical trials. Acta Anaesthesiol Scand 57(7):823–834

    CAS  Article  Google Scholar 

  14. De Oliveira GS, Almeida MD, Benzon HT, McCarthy RJ (2011) Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology 115(3):575–588

    Article  Google Scholar 

  15. Tammachote N, Kanitnate S (2020) Intravenous dexamethasone injection reduces pain from 12 to 21 hours after total knee arthroplasty: a double-blind, randomized Placebo-Controlled Trial. J Arthroplasty 35(2):394–400

    Article  Google Scholar 

  16. Wasko MK, Bobecka-Wesolowska K, Tomasiuk R, Kowalczewski J (2015) Measurement of the inflammatory response in the early postoperative period after hip and knee arthroplasty. Clin Chem Lab Med 53(11):1785–1792

    CAS  Article  Google Scholar 

  17. Chen X, Chai Y, Wang SB, Wang JC, Yue SY, Jiang RC, Zhang JN (2020) Risk factors for corticosteroid insufficiency during the sub-acute phase of acute traumatic brain injury. Neural Regen Res 15(7):1259–1265

    Article  Google Scholar 

  18. Dissanayake R, Du HN, Robertson IK, Ogden K, Wiltshire K, Mulford JS (2018) Does dexamethasone reduce hospital readiness for discharge, pain, nausea, and early patient satisfaction in hip and knee arthroplasty? A randomized Controlled Trial. J Arthroplasty 33(11):3429–3436

    Article  Google Scholar 

  19. Meng J, Li L (2017) The efficiency and safety of dexamethasone for pain control in total joint arthroplasty: a meta-analysis of randomized controlled trials. Medicine (Baltimore) 96(24):e7126

    CAS  Article  Google Scholar 

  20. Xing LZ, Li L, Zhang LJ (2017) Can intravenous steroid administration reduce postoperative pain scores following total knee arthroplasty?: a meta-analysis. Medicine (Baltimore) 96(24):e7134

    CAS  Article  Google Scholar 

  21. DiIorio TM, Sharkey PF, Hewitt AM, Parvizi J (2010) Antiemesis after total joint arthroplasty: does a single preoperative dose of aprepitant reduce nausea and vomiting? Clin Orthop Relat Res 468(9):2405–2409

    Article  Google Scholar 

  22. Bian J, Cai F, Chen H, Tang Z, Xi K, Tang J, Wu L, Xu Y, Deng L, Gu Y, Cui W, Chen L (2021) Modulation of Local Overactive Inflammation via Injectable Hydrogel Microspheres. Nano Lett

  23. Motififard M, Omidian A, Badiei S (2017) Pre-emptive injection of peri-articular-multimodal drug for post-operative pain management in total knee arthroplasty: a double-blind randomized clinical trial. Int Orthop 41(5):939–947

    Article  Google Scholar 

  24. De Luca ML, Ciccarello M, Martorana M, Infantino D, Letizia Mauro G, Bonarelli S, Benedetti MG (2018) Pain monitoring and management in a rehabilitation setting after total joint replacement. Medicine (Baltimore) 97(40):e12484

    Article  Google Scholar 

  25. Fu PL, Xiao J, Zhu YL, Wu HS, Li XH, Wu YL, Qian QR (2010) Efficacy of a multimodal analgesia protocol in total knee arthroplasty: a randomized, controlled trial. J Int Med Res 38(4):1404–1412

    CAS  Article  Google Scholar 

  26. Ibrahim MS, Khan MA, Nizam I, Haddad FS (2013) Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review. BMC Med 11:37

    Article  Google Scholar 

  27. Hall GM, Peerbhoy D, Shenkin A, Parker CJ, Salmon P (2001) Relationship of the functional recovery after hip arthroplasty to the neuroendocrine and inflammatory responses. Br J Anaesth 87(4):537–542

    CAS  Article  Google Scholar 

  28. Godshaw BM, Mehl AE, Shaffer JG, Meyer MS, Thomas LC, Chimento GF (2019) The effects of peri-operative dexamethasone on patients undergoing total hip or knee arthroplasty: Is it safe for diabetics? J Arthroplasty 34(4):645–649

    Article  Google Scholar 

  29. Tseng CL, Chen YT, Huang CJ, Luo JC, Peng YL, Huang DF, Hou MC, Lin HC, Lee FY (2015) Short-term use of glucocorticoids and risk of peptic ulcer bleeding: a nationwide population-based case-crossover study. Aliment Pharmacol Ther 42(5):599–606

    CAS  Article  Google Scholar 

  30. Kardash KJ, Sarrazin F, Tessler MJ, Velly AM (2008) Single-dose dexamethasone reduces dynamic pain after total hip arthroplasty. Anesth Analg 106(4):1253–1257 (Table of contents)

    CAS  Article  Google Scholar 

  31. Lei Y, Huang Q, Xu B, Zhang S, Cao G, Pei F (2018) Multiple low-dose dexamethasone further improves clinical outcomes following total hip arthroplasty. J Arthroplasty 33(5):1426–1431

    Article  Google Scholar 

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Funding

This study was funded by the National Health and Family Planning Commission of the People's Republic of China (CN) program (201302007).

Author information

Author notes

  1. Wei Huang and Fuxing Pei contributed equally to this work and should be considered as equal corresponding authors.

Affiliations

  1. Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China

    Yiting Lei & Wei Huang

  2. Department of Orthopedics, West China Hospital, Sichuan University, 37# WainanGuoxue Road, Chengdu, 610041, People’s Republic of China

    Yiting Lei, Zeyu Huang, Qiang Huang & Fuxing Pei

Authors
  1. Yiting Lei
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  2. Zeyu Huang
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  3. Qiang Huang
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  4. Fuxing Pei
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  5. Wei Huang
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Corresponding authors

Correspondence to Fuxing Pei or Wei Huang.

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Conflict of interest

All authors declare no conflict of interest.

Ethical approval

The trial was approved by the institutional review board (2017-128) and registered the International Clinical Trial Registry (ChiCTR1800016865).

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Informed consent was obtained from all individual participants included in the study.

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Cite this article

Lei, Y., Huang, Z., Huang, Q. et al. Dose optimization of intravenous dexamethasone for total knee arthroplasty: when two is not better than one. Arch Orthop Trauma Surg (2021). https://doi.org/10.1007/s00402-021-03859-3

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  • DOI: https://doi.org/10.1007/s00402-021-03859-3

Keywords

  • Total knee arthroplasty
  • Dexamethasone
  • Dose optimization
  • Randomized controlled study