Steroids in Total Knee Arthroplasty

Overview

The purpose of this study is to evaluate if the use of two small doses of intravenous (IV) steroids around the time of knee replacement surgery decrease a patient's pain or use of pain medication. The investigators will also determine if the subjects receiving the steroid will have better pain control and better postoperative outcomes after their surgery.

Full Title of Study: “Evaluation of Intravenous Glucocorticoid Therapy in Total Knee Arthroplasty”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Treatment
    • Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
  • Study Primary Completion Date: November 2021

Detailed Description

Adequate pain control after total knee replacement (TKA) is of great importance not only to maximize patient comfort, but also to ensure optimal outcomes after surgery. This study is designed to assess whether the use of two small doses of intravenous (IV) steroids around the time of surgery decrease a patient's pain or use of pain medication. Secondly, the investigators will also determine if the use of these steroids as part of a multimodal pain management strategy leads to improved patient outcomes, including pain, nausea and vomiting, knee function and length of stay in the hospital after surgery. The study will compare the effect of two different doses of IV dexamethasone given preoperatively before TKA, when compared to placebo.

Interventions

  • Drug: Dexamethasone 10 mg
    • Two doses of dexamethasone 10 mg will be given intravenously. The first dose will be given preoperatively within 3 hours of surgery and the second dose will be administered 8 hours after the first dose in the inpatient setting.
  • Drug: Dexamethasone 20 mg
    • Two doses of dexamethasone 20 mg will be given intravenously. The first dose will be given preoperatively within 3 hours of surgery and the second dose will be administered 8 hours after the first dose in the inpatient setting.
  • Drug: Standard multimodal pain management regimen
    • The standard multimodal postoperative pain management regimen typically used for total knee arthroplasty consists of the following: Preoperative: Decadron: 10 or 20mg IV x 1 2 doses, 8 hours apart (if randomized to study group) Intraoperative: Ropivacaine: Given intraoperatively. Capsule, subcutaneous tissue/skin. Administered in standard fashion. (300mg) Toradol: 30mg q 6hr for 6 total doses. 1st dose given intraoperatively at incision. (15 mg if older patient or CrCl low) Postoperative Tylenol: 1000mg po q 8hr (scheduled) Oxycodone: 5mg or 10mg q 3-4hr prn pain, If intolerant to Oxycodone: second agent line is Hydrocodone or Oral Dilaudid IV Morphine (or Dilaudid): 1 or 2 mg q 2hr prn breakthrough pain Morphine PCA: only for failure of the above MS Contin: Use as backup prn pain
  • Drug: Placebo
    • Participants in the placebo arm will receive two doses of saline intravenously. The first dose will be given preoperatively within 3 hours of surgery and the second dose will be administered 8 hours after the first dose in the inpatient setting.

Arms, Groups and Cohorts

  • Placebo Comparator: Placebo
    • Subjects undergoing primary total joint arthroplasty of the knee will receive two doses of placebo intravenously in addition to a standard multimodal postoperative pain management regimen typically used for total knee arthroplasty. The first dose of placebo will be given preoperatively within 3 hours of surgery and the second dose will be administered 8 hours after the first dose in the inpatient setting.
  • Experimental: Dexamethasone 10 mg
    • Subjects undergoing primary total joint arthroplasty of the knee will receive two doses of 10 mg dexamethasone. The first dose will be given preoperatively within 3 hours of surgery and the second dose will be administered 8 hours after the first dose in the inpatient setting. Additionally, subjects will also receive a standard multimodal postoperative pain management regimen typically used for total knee arthroplasty.
  • Experimental: Dexamethasone 20 mg
    • Subjects undergoing primary total joint arthroplasty of the knee will receive two doses of 20 mg dexamethasone. The first dose will be given preoperatively within 3 hours of surgery and the second dose will be administered 8 hours after the first dose in the inpatient setting. Additionally, subjects will also receive a standard multimodal postoperative pain management regimen typically used for total knee arthroplasty.

Clinical Trial Outcome Measures

Primary Measures

  • Change in pain scores
    • Time Frame: Baseline, 48 hours post-operatively (average length of inpatient stay)
    • Postoperative pain will be assessed using the well-standardized and accepted visual analog pain scale. The scale shows a series of faces ranging from a happy face at 0= “No hurt”, to a crying face at 10= “Hurts worst”. The subject will be asked to choose the face that best describes their level of pain and their responses will be recorded. Higher scores indicate higher intensities of pain.
  • Pain scores as recorded by the smart device app
    • Time Frame: 7 days post-operatively
    • Subjects will answer questions about their pain and record their responses using the app on their smart device.
  • Change in pain scores
    • Time Frame: 1 month post-operatively, 12 months post-operatively
    • Postoperative pain will be assessed using the well-standardized and accepted visual analog pain scale. The scale shows a series of faces ranging from a happy face at 0= “No hurt”, to a crying face at 10= “Hurts worst”. The subject will be asked to choose the face that best describes their level of pain and their responses will be recorded. Higher scores indicate higher intensities of pain.
  • Opioid analgesic usage
    • Time Frame: Baseline, 2 weeks post-operatively
    • The amount of each subject’s postoperative opioid analgesic usage (converted into milligrams of morphine equivalents per day) will be recorded. The subjects will be asked to use a pain medication usage log to track the use of both prescribed narcotic medications and over the counter non-steroidal anti-inflammatory medications for knee pain.

Secondary Measures

  • Soft tissue swelling
    • Time Frame: Baseline, 1 day post-operatively
    • Soft tissue swelling will be evaluated using a measurement of knee circumference at the midpoint of the patella, with the knee in the maximum amount of extension allowed by the patient. This measurement will be completed twice, and the average of the two measurements will be used as the value for that day.
  • Soft tissue swelling
    • Time Frame: 1 month post-operatively, 12 months post-operatively
    • Soft tissue swelling will be evaluated using a measurement of knee circumference at the midpoint of the patella, with the knee in the maximum amount of extension allowed by the patient. This measurement will be completed twice, and the average of the two measurements will be the value for that day.
  • Change in range of motion (ROM)
    • Time Frame: Baseline, 1 day post-operatively
    • Maximum passive ROM allowed by the patient will be measured using a goniometer. The ROM measurement is the amount of flexion and extension recorded in degrees. An increased ROM is indicative of better joint mobility.
  • Change in range of motion (ROM)
    • Time Frame: 1 month post-operaively, 12 months post-opreatively
    • Maximum passive ROM allowed by the patient will be measured using a goniometer. The ROM measurement is the amount of flexion and extension recorded in degrees. An increased ROM is indicative of better joint mobility.
  • Time to clearance from physical therapy
    • Time Frame: 2 days post-operatively
    • The post-operative day when the subject is cleared by the physical therapy staff to go home will be recorded. A shorter clearance time is indicative of better joint function.
  • Post-operative nausea
    • Time Frame: Up to 1 month post-operatively
    • The use of as-needed antiemetics will be recorded for each subject. Subjects will also be specifically asked about episodes of emesis using the BARF scale where each item is scored from 0= no nausea to 10= emesis.
  • Post-operative vomiting
    • Time Frame: Up to 1 month post-operatively
    • The use of as-needed antiemetics will be recorded for each subject. Subjects will also be specifically asked about episodes of emesis using the BARF scale where each item is scored from 0= no nausea to 10= emesis.
  • Levels of blood glucose
    • Time Frame: Baseline, 48 hours post-operatively
    • The subject’s blood glucose level will be analyzed using a Hemocue analyzer.
  • Functionality scores using Short Form using (SF)-36
    • Time Frame: Baseline, 12 months post-operatively
    • The subjects’ functional ability will be assessed using the Short Form (SF)-36 questionnaire. The Short Form-36 Health Survey is a 36-item, self-reported survey of patient health and is a measure of health status. The SF-36 consists of eight scaled scores, which are the weighted sums of the questions in their section. Each scale is directly transformed into a 0-100 scale. The lower the score the more disability.
  • Functionality scores using (WOMAC)
    • Time Frame: Baseline, 12 months post-operatively
    • The and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire will be used to assess joint function. administered to patients at the baseline visit and at each follow up clinic visit. The WOMAC measures five items for pain (score range 0-20), two for stiffness (score range 0-8), and 17 for functional limitation (score range 0-68). Higher scores on the WOMAC indicate worse pain, stiffness, and functional limitations.
  • Length of hospital stay
    • Time Frame: 12 months post-operatively
    • The length of each subject’s hospital stay in days will be recorded. Higher number of days in the hospital indicate slower recovery.
  • Number of hospital readmissions
    • Time Frame: 12 months post-operatively
    • The number of subjects who need readmission to the hospital will be recorded.
  • Number of subjects with wound infections
    • Time Frame: 1 month post-operatively, 12 months post-operatively
    • The number of subjects with the clinical presence of wound drainage and periprosthetic infection will be recorded.

Participating in This Clinical Trial

Inclusion Criteria

  • Patients undergoing primary total joint arthroplasty of the knee
  • Adult patients ages 18-100 years
  • Patients must have smart phone and/or device for app usage

Exclusion Criteria

  • Current chronic steroid use
  • Patients undergoing revision knee surgery
  • Patients ambulating preoperatively with assistive devices
  • Patients with avascular necrosis of the operative knee
  • Patients with a history of an adverse reaction to glucocorticoid steroids
  • Patients unable to provide informed consent
  • Patients with inflammatory arthritis
  • Prisoners
  • Current smokers
  • Patients <18 years of age
  • Any patient with a complicated postoperative course that requires transfer to the Intensive Care Unit (ICU) or to another facility for further management will be removed from the study.
  • Any contraindication that would prevent the patient from being treated with the standard multimodal postoperative pain management regimen History of infection of surgical knee.
  • Patients with diabetes.
  • Patients that have an intolerance to Toradol.
  • Patients that do not have smart phone and/or device for app usage

Gender Eligibility: All

Minimum Age: 18 Years

Maximum Age: 100 Years

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Emory University
  • Provider of Information About this Clinical Study
    • Principal Investigator: Thomas L Bradbury, MD, Thomas L Bradbury MD – Emory University
  • Overall Official(s)
    • Thomas L Bradbury, MD, Principal Investigator, Emory University

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