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

Xinyu Zhao, Jun Qin, Yang Tan, Rahul Mohanan, Dongcai Hu, Liaobin Chen, Xinyu Zhao, Jun Qin, Yang Tan, Rahul Mohanan, Dongcai Hu, Liaobin Chen

Abstract

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.

Figures

Fig. 1
Fig. 1
Flow chart summarizing the selection process of randomized control trials
Fig. 2
Fig. 2
Comparison of knee ROM between the steroid and control group at the first postoperative day
Fig. 3
Fig. 3
Comparison of knee ROM between the steroid and control group on the second postoperative day
Fig. 4
Fig. 4
Comparison of knee ROM between the steroid and control group on the third postoperative day
Fig. 5
Fig. 5
Comparison of knee ROM between the steroid and control group at 3 months postoperatively
Fig. 6
Fig. 6
Comparison of postoperative drainage between the steroid and control group
Fig. 7
Fig. 7
Comparison of the period of time required to perform a straight-leg raise between the steroid and control group
Fig. 8
Fig. 8
Comparison of the length of hospital stay between the steroid and control group
Fig. 9
Fig. 9
Comparison of the rate of postoperative infection between the steroid and control group
Fig. 10
Fig. 10
Comparison of the rate of postoperative wound oozing between the steroid and control group

References

    1. Ng FY, Ng JK, Chiu KY, et al. Multimodal periarticular injection vs continuous femoral nerve block after total knee arthroplasty: a prospective, crossover, randomized clinical trial. J Arthroplasty. 2012;27(6):1234–8. doi: 10.1016/j.arth.2011.12.021.
    1. Fu P, Wu Y, Wu H, et al. Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty - a randomized controlled trial. Knee. 2009;16(4):280–4. doi: 10.1016/j.knee.2008.12.012.
    1. Galimba J. Promoting the use of periarticular multimodal drug injection for total knee arthroplasty. Orthop Nurs. 2009;28(5):250–6. doi: 10.1097/NOR.0b013e3181b822ed.
    1. Fowler SJ, Symons J, Sabato S, et al. Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2008;100(2):154–4. doi: 10.1093/bja/aem373.
    1. Paul JE, Arya A, Hurlburt L, et al. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology. 2010;113(5):1144–62. doi: 10.1097/ALN.0b013e3181f4b18.
    1. Gibbs DM, Green TP, Esler CN. The local infiltration of analgesia following total knee replacement: a review of current literature. J Bone Joint Surg Br. 2012;94(9):1154–9. doi: 10.1302/0301-620X.94B9.28611.
    1. Creamer P. Intra-articular corticosteroid injections in osteoarthritis: do they work and if so, how? Ann Rheum Dis. 1997;56(11):634–6. doi: 10.1136/ard.56.11.634.
    1. Holte K, Kehlet H. Perioperative single-dose glucocorticoid administration: pathophysiologic effects and clinical implications. J Am Coll Surg. 2002;195(5):694–712. doi: 10.1016/S1072-7515(02)01491-6.
    1. Pang HN, Lo NN, Yang KY, et al. Peri-articular steroid injection improves the outcome after unicondylar knee replacement: a prospective, randomised controlled trial with a two-year follow-up. J Bone Joint Surg Br. 2008;90(6):738–44. doi: 10.1302/0301-620X.90B6.20550.
    1. Christensen CP, Jacobs CA, Jennings HR. Effect of periarticular corticosteroid injections during total knee arthroplasty. A double-blind randomized trial. J Bone Joint Surg Am. 2009;91(11):2550–5. doi: 10.2106/JBJS.H.01501.
    1. Ikeuchi M, Kamimoto Y, Izumi M, et al. Effects of dexamethasone on local infiltration analgesia in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2014;22(7):1638–43. doi: 10.1007/s00167-013-2367-5.
    1. Kwon SK, Yang IH, Bai SJ, et al. Periarticular injection with corticosteroid has an additional pain management effect in total knee arthroplasty. Yonsei Med J. 2014;55(2):493–8. doi: 10.3349/ymj.2014.55.2.493.
    1. Furlan AD, Pennick V, Bombardier C, et al. 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine. 2009;34(18):1929–41. doi: 10.1097/BRS.0b013e3181b1c99f.
    1. Yue DB, Wang BL, Liu KP, et al. Efficacy of multimodal cocktail periarticular injection with or without steroid in total knee arthroplasty. Chin Med J (Engl) 2013;126(20):3851–5.
    1. Seah VW, Chin PL, Chia SL, et al. Single-dose periarticular steroid infiltration for pain management in total knee arthroplasty: a prospective, double-blind, randomised controlled trial. Singapore Med J. 2011;52(1):19–23.
    1. Chia SK, Wernecke GC, Harris IA, et al. Peri-articular steroid injection in total knee arthroplasty: a prospective, double blinded, randomized controlled trial.[J] J Arthroplasty. 2013;28(4):620–3. doi: 10.1016/j.arth.2012.07.034.
    1. Vendittoli PA, Makinen P, Drolet P, et al. A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study. J Bone Joint Surg Am. 2006;88(2):282–9. doi: 10.2106/JBJS.E.00173.
    1. Busch CA, Shore BJ, Bhandari R, et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. J Bone Joint Surg Am. 2006;88(5):959–63. doi: 10.2106/JBJS.E.00344.
    1. Ng YC, Lo NN, Yang KY, et al. Effects of periarticular steroid injection on knee function and the inflammatory response following unicondylar knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2011;19(1):60–5. doi: 10.1007/s00167-010-1126-0.
    1. Salerno A, Hermann R. Efficacy and safety of steroid use for postoperative pain relief. Update and review of the medical literature. J Bone Joint Surg Am. 2006;88(6):1361–72. doi: 10.2106/JBJS.D.03018.
    1. Gilron I. Corticosteroids in postoperative pain management: future research directions for a multifaceted therapy. Acta Anaesthesiol Scand. 2004;48(10):1221–2. doi: 10.1111/j.1399-6576.2004.00581.x.
    1. Wang JJ, Ho ST, Lee SC, et al. Intraarticular triamcinolone acetonide for pain control after arthroscopic knee surgery. Anesth Analg. 1998;87(5):1113–6.
    1. Sauerland S, Nagelschmidt M, Mallmann P, et al. Risks and benefits of preoperative high dose methylprednisolone in surgical patients: a systematic review. Drug Saf. 2000;23(5):449–61. doi: 10.2165/00002018-200023050-00007.
    1. Wang Q, Jiang X, Tian W. Does previous intra-articular steroid injection increase the risk of joint infection following total hip arthroplasty or total knee arthroplasty? A meta-analysis. Med Sci Monit. 2014;20:1878–83. doi: 10.12659/MSM.890750.
    1. Marsland D, Mumith A, Barlow IW. Systematic review: the safety of intra-articular corticosteroid injection prior to total knee arthroplasty. Knee. 2014;21(1):6–11. doi: 10.1016/j.knee.2013.07.003.

Source: PubMed

Sponzoři a spolupracovníci

Zdravotní podmínky

Drogové intervence

3
Předplatit