Multiple Low Doses of Intravenous Corticosteroids to Improve Early Rehabilitation in Total Knee Arthroplasty: A Randomized Clinical Trial

Abstract

Low doses of corticosteroids have been proved to be effective in decreasing the inflammatory cytokines and relieving the pain. However, the optimal dosage of corticosteroids in total knee arthroplasty (TKA) is undetermined. A total of 103 patients were randomly divided into three groups. Group A containing 32 patients received normal saline. Group B including 36 patients used two doses of 100 mg hydrocortisone, given 2 hours before and 8 hours after surgery. Group C involving 35 patients received four doses of 100 mg hydrocortisone, 8 hours apart.

The level of interleukin 6 (IL-6) and C-reactive protein (CRP) were lower in group C than those in group A when detected at 12, 24, and 48 hours after operation and even lower than that in group B at 24 and 48 hours (p < 0.05, all). The visual analog scale (VAS) pain scores were significantly reduced by using two doses of hydrocortisone at the first 12 hours compared with group A (p > 0.05), but it did not show statistic difference 24 hours later (p > 0.05). For comparison, patients with multiple doses achieved continuously better outcomes on pain management than the blank control group within postoperative 36 hours at rest and at 24 hours with activity. In addition, patients using multiple doses of hydrocortisone achieved fewer occurrences of nausea and vomiting, fever, and sleeplessness, better knee function recovery, better patient satisfaction, and shorter length of hospital stays (p < 0.05, all).

Multiple dose of hydrocortisone was benefit to the pain management and early rehabilitation in TKA and may be recommended to the clinical practice.

Keywords

total knee arthroplasty - pain - hydrocortisone - rehabilitation

Ethical Approval

This study was approved by the Clinical Trials and Biomedical Ethics Committee of West China Hospital, and written informed consents were obtained from all participants.

^* Donghai Li and Jinhai Zhao contributed equally to this work.

• References

• 1 Losina E, Thornhill TS, Rome BN, Wright J, Katz JN. The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic. J Bone Joint Surg Am 2012; 94 (03) 201-207
• 2 Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?. Clin Orthop Relat Res 2010; 468 (01) 57-63
• 3 Scott CE, Howie CR, MacDonald D, Biant LC. Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients. J Bone Joint Surg Br 2010; 92 (09) 1253-1258
• 4 Parvizi J, Miller AG, Gandhi K. Multimodal pain management after total joint arthroplasty. J Bone Joint Surg Am 2011; 93 (11) 1075-1084
• 5 Xie X, Pei F, Huang Z, Tan Z, Yang Z, Kang P. Does patellar denervation reduce post-operative anterior knee pain after total knee arthroplasty?. Knee Surg Sports Traumatol Arthrosc 2015; 23 (06) 1808-1815
• 6 Li D, Tan Z, Kang P, Shen B, Pei F. Effects of multi-site infiltration analgesia on pain management and early rehabilitation compared with femoral nerve or adductor canal block for patients undergoing total knee arthroplasty: a prospective randomized controlled trial. Int Orthop 2017; 41 (01) 75-83
• 7 Li D, Yang Z, Xie X, Zhao J, Kang P. Adductor canal block provides better performance after total knee arthroplasty compared with femoral nerve block: a systematic review and meta-analysis. Int Orthop 2016; 40 (05) 925-933
• 8 Kurosaka K, Tsukada S, Seino D, Morooka T, Nakayama H, Yoshiya S. Local infiltration analgesia versus continuous femoral nerve block in pain relief after total knee arthroplasty: a randomized controlled trial. J Arthroplasty 2016; 31 (04) 913-917
• 9 Jules-Elysee KM, Wilfred SE, Memtsoudis SG. , et al. Steroid modulation of cytokine release and desmosine levels in bilateral total knee replacement: a prospective, double-blind, randomized controlled trial. J Bone Joint Surg Am 2012; 94 (23) 2120-2127
• 10 Cremeans-Smith JK, Soehlen S, Greene K, Alexander T, Delahanty DL. In-hospital levels of C-reactive protein and IL-6 predict post-operative depressive symptoms among patients undergoing total knee replacement surgery. Brain Behav Immun 2009; 23 (08) 1096-1103
• 11 Wirtz DC, Heller KD, Miltner O, Zilkens KW, Wolff JM. Interleukin-6: a potential inflammatory marker after total joint replacement. Int Orthop 2000; 24 (04) 194-196
• 12 Jules-Elysee KM, Lipnitsky JY, Patel N. , et al. Use of low-dose steroids in decreasing cytokine release during bilateral total knee replacement. Reg Anesth Pain Med 2011; 36 (01) 36-40
• 13 Andres BM, Taub DD, Gurkan I, Wenz JF. Postoperative fever after total knee arthroplasty: the role of cytokines. Clin Orthop Relat Res 2003; (415) 221-231
• 14 Koh IJ, Chang CB, Lee JH, Jeon YT, Kim TK. Preemptive low-dose dexamethasone reduces postoperative emesis and pain after TKA: a randomized controlled study. Clin Orthop Relat Res 2013; 471 (09) 3010-3020
• 15 Sculco PK, McLawhorn AS, Desai N, Su EP, Padgett DE, Jules-Elysee K. The effect of perioperative corticosteroids in total hip arthroplasty: a prospective double-blind placebo controlled pilot study. J Arthroplasty 2016; 31 (06) 1208-1212
• 16 Xie J, Ma J, Yao H, Yue C, Pei F. Multiple boluses of intravenous tranexamic acid to reduce hidden blood loss after primary total knee arthroplasty without tourniquet: a randomized clinical trial. J Arthroplasty 2016; 31 (11) 2458-2464
• 17 Memtsoudis SG, Yoo D, Stundner O. , et al. Subsartorial adductor canal vs femoral nerve block for analgesia after total knee replacement. Int Orthop 2015; 39 (04) 673-680
• 18 Sapolsky RM, Romero LM, Munck AU. How do glucocorticoids influence stress responses? Integrating permissive, suppressive, stimulatory, and preparative actions. Endocr Rev 2000; 21 (01) 55-89
• 19 Holte K, Kehlet H. Perioperative single-dose glucocorticoid administration: pathophysiologic effects and clinical implications. J Am Coll Surg 2002; 195 (05) 694-712
• 20 Kardash KJ, Sarrazin F, Tessler MJ, Velly AM. Single-dose dexamethasone reduces dynamic pain after total hip arthroplasty. Anesth Analg 2008; 106 (04) 1253-1257
• 21 Lunn TH, Kristensen BB, Andersen LØ. , et al. Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial. Br J Anaesth 2011; 106 (02) 230-238
• 22 Lunn TH, Andersen LØ, Kristensen BB. , et al. Effect of high-dose preoperative methylprednisolone on recovery after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial. Br J Anaesth 2013; 110 (01) 66-73
• 23 Rytter S, Stilling M, Munk S, Hansen TB. Methylprednisolone reduces pain and decreases knee swelling in the first 24 h after fast-track unicompartmental knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25 (01) 284-290
• 24 Mathiesen O, Jacobsen LS, Holm HE. , et al. Pregabalin and dexamethasone for postoperative pain control: a randomized controlled study in hip arthroplasty. Br J Anaesth 2008; 101 (04) 535-541
• 25 Fujii Y, Nakayama M. Effects of dexamethasone in preventing postoperative emetic symptoms after total knee replacement surgery: a prospective, randomized, double-blind, vehicle-controlled trial in adult Japanese patients. Clin Ther 2005; 27 (06) 740-745
• 26 McLawhorn AS, Beathe J, YaDeau J. , et al. Effects of steroids on thrombogenic markers in patients undergoing unilateral total knee arthroplasty: a prospective, double-blind, randomized controlled trial. J Orthop Res 2015; 33 (03) 412-416
• 27 Bagdade JD, Root RK, Bulger RJ. Impaired leukocyte function in patients with poorly controlled diabetes. Diabetes 1974; 23 (01) 9-15
• 28 Mowat AG, Baum J. Chemotaxis of polymorphonuclear leukocytes from patients with rheumatoid arthritis. J Clin Invest 1971; 50 (12) 2541-2549