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.

Keywords: anaesthesia; dexamethasone; fast-track surgery; high pain responders; high-dose steroids; multimodal analgesia; postoperative pain; total knee arthroplasty.

Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Figures

Fig 1

Consolidated Standards of Reporting Trials flow diagram. IDDM, insulin-dependent diabetes mellitus.

Fig 2

Proportion of VAS >30 in a 5 m walk test, at rest, at night, and in passive leg raise. HD, high-dose group; ID, intermediate-dose group; PRE, preoperatively; T0, at end of surgery; T4, 4 h after end of surgery; T24, 24 h after end of surgery; T48, 48 h after end of surgery. ∗Significant difference (χ2 test).

Fig 3

Distribution of VAS 24 h after surgery in a 5 m walk test. HD, high-dose group; ID, intermediate-dose group. Solid line represents median and whiskers inter-quartile range. Dotted line at VAS 30 (primary outcome). ∗Statistically significant difference between groups (Mann–Whitney U-test).

Fig 4

Changes in C-reactive protein (CRP) from preoperatively (PRE), 24 h (T24), and 48 h (T48) after end of surgery. Boxes represent inter-quartile range; line is median and whiskers min–max. ∗Statistical significance (Mann–Whitney U-test).