Dexamethasone in Total Knee and Total Hip Arthroplasty

Does the Addition of Dexamethasone to a Local Infiltration Analgesia Mixture Improve Functional Outcomes Following Total Joint Arthroplasty?

This study will evaluate if the addition of dexamethasone to a local infiltration analgesia mixture will improve functional outcomes following total hip and knee arthroplasty.

The addition of dexamethasone to an local infiltration analgesia (LIA) mixture for postoperative analgesia following total knee arthroplasty (TKA) has a limited evidence base. Although there is increasing support in the literature for its use in peripheral nerve blockade, there have only been a handful of studies assessing its applicability in periarticular LIA. Moreover, the evidence from peripheral nerve blocks suggests that one of the key benefits of dexamethasone is a prolongation of nerve blockade. Additionally, dexamethasone has been shown to prolong the local analgesic effect of bupivacaine microcapsules. With respect to total hip arthroplasty (THA), there have only been two small studies that included corticosteroids in the LIA mixture; there was analgesic benefit and better early rehabilitation outcomes when compared to placebo. However, there is limited high-quality evidence for either THA or TKA demonstrating an improvement in functional outcomes when dexamethasone is used in an LIA mixture. This study will evaluate if the addition of dexamethasone to a local infiltration analgesia mixture will improve functional outcomes following total hip and knee arthroplasty.

Cumulative systemic opioid consumption measured as oral morphine mg equivalents at 24 hours postoperatively

Pain scores assessed with an 11 point verbal numeric rating scale (NRS) at the following time points: The post-anesthetic care unit (PACU) Postoperative day (POD) 1 at rest between 8-10 AM POD1 during physiotherapy POD 2 at rest between 8 -10 AM POD 2 during physiotherapy g. POD 3 during physiotherapy if still in hospital

Cumulative systemic opioid consumption measured as oral morphine mg equivalents on POD 1, POD2, and, if still in hospital, POD 3, as well as the proportion of patients who required "rescue" intravenous patient controlled analgesia (IV PCA) anytime in the postoperative period

Incidence of opioid-related side effects: Nausea and vomiting requiring treatment with anti-emetic Pruritus requiring treatment with antihistamines Sedation requiring treatment with opioid antagonist

In-hospital complications- Any outcomes such as MI, surgical site infection, neurological complications, etc. that may have occurred during the hospital stay

Hospital length of stay- the total number of days the patient stayed in hospital to recover from elective surgery

Discharge destination- determination of location for which the patient was discharged; either to home or to rehabilitation centre

Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) measured at baseline and at 3 months post-operatively

Inclusion Criteria: Undergoing elective, primary, unilateral total hip or knee arthroplasty under spinal anesthesia ASA-PS I-III 18-85 years of age, inclusive 50-100 kg, inclusive BMI 18 - 40 Exclusion Criteria: Revision hip/knee arthroplasty Bilateral hip/knee arthroplasty Inability or refusal to provide informed consent Any contraindication to spinal anesthesia (e.g., bleeding diathesis, infection, neuropathy) Allergy to local anesthesia, ketorolac or dexamethasone Allergy to opioids Chronic pain state, neuropathic pain Opioid dependence Diabetic patients will NOT be excluded except those with significant peripheral neuropathy

El-Boghdadly K, Short AJ, Gandhi R, Chan V. Addition of dexamethasone to local infiltration analgesia in elective total knee arthroplasty: double-blind, randomized control trial. Reg Anesth Pain Med. 2021 Feb;46(2):130-136. doi: 10.1136/rapm-2020-102079. Epub 2020 Nov 16.

El-Boghdadly K, Short AJ, Gandhi R, Chan VWS. Addition of dexamethasone to local infiltration analgesia in elective total hip arthroplasty: a double-blind, randomized control trial. Reg Anesth Pain Med. 2019 Sep 27:rapm-2019-100873. doi: 10.1136/rapm-2019-100873. Online ahead of print.