Is adding intra-articular steroid in total knee arthroplasty cocktail obligatory?
Keywords:Opiods, Knee society score, Infection, Visual analogue score, Total knee replacement
Background: The patients can undergo total knee replacement surgery either under general anaesthesia, combined spinal and epidural anaesthesia, nerve root block, spinal combined with intra-articular knee cocktail. There is an ongoing debate amongst Arthroplasty surgeons whether to include steroid in the cocktail or not. The aim of this study is to assess whether there is an added benefit of including steroid in the intraarticular mixture.
Methods: This prospective study was conducted at Sri Ramachandra Institute of Higher education, Chennai between December 2017 to December 2018. The study was conducted in the Arthroplasty unit, Department of Orthopaedics. SRIHER ethics committee clearance was obtained prior to the start of the study. The inclusion criteria were patients who underwent total knee replacement surgery under combined spinal and intra-articular knee cocktail. Patients were divided into two groups based on the use of steroid in the intra-articular mixture. Patients were evaluated using Visual analogue scale, opioids usage as primary endpoint while any joint infection within six months of the surgery and knee society score at 1 month and 6 months as the secondary endpoint.
Results: The mean visual analogue score for the 0 pod for the group I and group II were 2.3 and 2.4 respectively. There was no case of infection in both groups.
Conclusions: There is no fringe benefit of adding steroid to the knee cocktail. So it is not obligatory to add steroid in intra-articular total knee arthroplasty cocktail.
Wood AM, Brock TM, Heil K, Holmes R, Weusten A. A review on the management of hip and knee osteoarthritis. Int J Chronic Dis. 2013;2013:845015.
Singelyn FJ, Ferrant T, Malisse MF, Joris D. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total hip arthroplasty. Reg Anesth Pain Med. 2005;30(5):452-7.
Choi PT, Bhandari M, Scott J, Douketis JD. Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev. 2003;(3):CD003071.
Barrington MJ, Olive D, Low K, Scott DA, Brittain J, Choong P. Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial. Anesth Analg. 2005;101(6):1824-9.
Pang HN, Lo NN, Yang KY, Chong HC, Yeo SJ. 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.
Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Related Res. 2009;467(6):1418.
Kellgren JH, Lawrence JS. Radiological assessment of osteoarthrosis. Ann Rheum Dis. 1957;16(4):494-502.
Dye SF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anaesthesia. Am J Sports Med. 1998;26(6):773-7.
Shah I, Sachin, Kalpesh, Ashish, Deepak. Multimodal Cocktail Injection relieves Postoperative Pain and improves Early Rehabilitation following Total Knee Replacement: A Prospective, Blinded and Randomized Study. J Recent Adv Pain. 2017;3:14-24.
Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty. 2007;22:33-8.
Weinberg JB, Fermor B, Guilak F. Nitric oxide synthase and cyclooxygenase interactions in cartilage and meniscus: relationships to joint physiology, arthritis, and tissue repair. Subcell Biochem. 2007;42:31-62.
Sean VW, Chin PL, Chia SL, Yang KY, Lo NN, Yeo SJ. Single-dose periarticular steroid infiltration for pain management in total knee arthroplasty: a prospective, double-blind, randomised controlled trial. Singapore Med J. 2011;52:19-23.
McMahon SE, LeRoux JA, Smith TO, Hing CB. Total joint arthroplasty following intra-articular steroid injection: a literature review. Acta Orthop Belg. 2013;79:672-9.
Yue DB, Wang BL, Liu KP, Guo WS. Efficacy of multimodal cocktail periarticular injection with or without steroid in total knee arthroplasty. Chin Med J (Engl). 2013;126:3851-5.
Zhao X, Qin J, Tan Y, Mohanan R, Hu D, Chen L. Efficacy of steroid addition to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis. J Orthop Surg Res. 2015;10(1):75.
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.
Gilron I. Corticosteroids in postoperative pain management: future research directions for a multifaceted therapy. Acta Anaesthesiol Scand. 2004;48(10):1221–2.