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Scientific Articles   |    
Effect of Periarticular Corticosteroid Injections During Total Knee ArthroplastyA Double-Blind Randomized Trial
Christian P. Christensen, MD1; Cale A. Jacobs, PhD2; Heath R. Jennings, PharmD3
1 Lexington Clinic, 1221 South Broadway, Lexington, KY 40504
2 ERMI, Inc., 441 Armour Place N.E., Atlanta, GA 30324. E-mail address: calejacobs@hotmail.com
3 Pharmaceutical Services, University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Lexington Clinic, Lexington, Kentucky

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Nov 01;91(11):2550-2555. doi: 10.2106/JBJS.H.01501
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Abstract

Background: Multimodal pain-control protocols that include periarticular injections have been reported to decrease pain and improve early outcomes following total knee arthroplasty. While injections containing a corticosteroid have been demonstrated to be safe and effective, we are not aware of any randomized trials in which the specific effect of the corticosteroid on early postoperative outcomes has been evaluated. The purpose of this double-blind study was to compare the clinical efficacy of periarticular injections consisting of bupivacaine, morphine, epinephrine, clonidine, and cefuroxime as well as a corticosteroid (methylprednisolone acetate) with the efficacy of periarticular injections consisting of the same agents but without the inclusion of a corticosteroid.

Methods: Seventy-six patients were randomized to either the no-steroid group (thirty-seven patients) or the steroid group (thirty-nine patients). Pain and narcotic consumption during the inpatient stay and the length of the hospital stay were recorded. Knee Society scores, the range of motion, and the occurrence of any complications were recorded preoperatively and at six and twelve weeks after the surgery.

Results: The hospital stay was significantly shorter for patients in the steroid group (2.6 days compared with 3.5 days in the no-steroid group; p = 0.01). No significant group differences in terms of pain, narcotic consumption, outcome scores, or motion were identified. There were three complications in the steroid group: two patients required a manipulation under anesthesia, and the knee joint became infected in another patient, leading to numerous complications and ultimately death.

Conclusions: The periarticular injection of a corticosteroid may reduce the length of the hospital stay following total knee arthroplasty, but it does not appear to improve pain relief, motion, or function in the early postoperative period. While we cannot definitively state that the corticosteroid was a causative factor in the development of the infection at the site of the prosthetic joint, we cannot rule it out either, which raises concern regarding the role of corticosteroids in perioperative pain management following total knee arthroplasty.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Cale A. Jacobs, PhD
    Posted on November 18, 2009
    Dr. Jacobs and colleagues respond to Dr. Bronson
    ERMI, Inc.

    We would like to thank Dr. Bronson for his thoughtful comments and remarks. We agree that a direct cause-and-effect relationship cannot be made between the use of the corticosteroid and the post-operative infection that occured in a patient with multiple co-morbidities. It is for this very reason that we attempted to clearly state in the text that a direct connection between the two events could not be made. However, while a direct connection between the two could not be made, it also could not be ruled out.

    Our conclusion that there was no clear benefit of including a corticosteroid as part of a multi-modal periarticular injection was also questioned, based on the significantly reduced length of hospital stay for patients who were treated with the corticosteroid. The length of hospital stay is influenced by many factors, some of which are not related to the peri-operative pain management protocol utilized. For example, an elderly patient living alone may request to be discharged to a skilled nursing or rehabilitation facility, which then requires longer hospitalization. While these social factors are difficult to quantify, the objective measures used to compare inpatient recovery in this study (range of motion, pain scores, and narcotic consumption) did not differ between treatment groups. For this reason, we feel that our conclusion that there was no clear benefit of including a corticosteroid as part of a periarticular injection was justified by the results of this study.

    Michael J. Bronson, MD
    Posted on November 04, 2009
    Effect of Periarticular Corticosteroid Injections During Total Knee Arthroplasty. A Double-Blind...
    The Mount Sinai School of Medicine, New York, New York

    To the Editor:

    I read with interest the article by Christensen et al. (1) on the efficacy of peri-articular steroids in total knee arthroplasty. There are two concerns that arise. The post-operative infection cited occurred in a patient with multiple co-morbidities including liver dysfunction, chronic alcoholism, and chronic urinary tract infections, all of which impact on the immunological competence of the patient. In addition, many would consider chronic active urinary sepsis as a contraindication for arthroplasty precisely because of the complication that arose. While the impact of steroids on this post-operative infection cannot be ruled in or out, it is hard to even indirectly implicate the steroid in a patient who, without steroids, would have been at increased risk of infection.

    Secondly, the statement that steroids should not be included in multi-modal pain management as they had no affect is puzzling without an adequate explanation as to the statistically significant decrease in length of stay in the steroid group.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    Reference

    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;91:2550-5.

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