Total knee arthroplasty (TKA) has been associated with severe pain in the acute
postoperative period. Studies have demonstrated highest pain scores on POD 1 following
TKA, however over 50% of patients describe the first two weeks at home as the most
painful period of recovery marked by moderate to severe pain. This is an important
finding as higher levels of acute pain have been associated with chronic opioid use,
disturbed sleep, and impaired early mobilization, which can prolong recovery time and
increase rates of adverse events, including venous thromboembolism.
Therefore, extensive research in pain management has been conducted with the purpose of
reducing acute postoperative pain. This is of particular interest because over the past
two decades average length of hospital stay has decreased while rates of outpatient TKAs
with same day discharge has increased. A multimodal pain regimen enables the on-boarding
of several medications, including anesthesia and analgesics working at varied pathways to
target pain and inflammation, and has proven to be efficacious. This not only decreases
patient reported pain scores but is also associated with improved sleep and functional
recovery. Despite efficacious multimodal pain regimens, including periarticular injection
cocktails, rebound pain in the early postoperative period and medication-induced nausea
and vomiting can be problematic.
Corticosteroids are potent anti-inflammatory and pain pathway modulators, and therefore
have become an important component of multimodal pain regimens. Corticosteroids have been
shown to decrease postoperative levels of inflammatory mediators, such as IL-6 and
C-reactive protein. Corticosteroids also block the synthesis of prostaglandins, a
nociceptive pain receptor sensitizer and inflammatory mediator that is associated with
edema via increased vascular permeability.
The administration of perioperative steroids to mitigate potential impairments in
postoperative TKA recovery has been studied extensively in the orthopedic literature. The
addition of corticosteroids to multimodal pain regiments, including systemic
corticosteroids or perioperative periarticular joint cocktails, has demonstrated improved
acute postoperative pain scores function and decreased opioid use without an increase in
adverse outcomes, as compared to controls.
Researchers have investigated the effect of additional doses of corticosteroids in the
immediate postoperative period. Administration of IV dexamethasone 24 hours
postoperatively correlated with lower acute opioid and antiemetic use, and improved pain
scores, nausea, length of stay and range of motion, as compared to controls or
perioperative corticosteroids alone. The addition of a second postoperative
corticosteroid dose, at 24 and 48 hours, have been associated with even greater
improvements in pain and function scores, without an increase in complications.
The addition of a methylprednisolone taper within a standard multimodal pain regimen in
the immediate postoperative period has been evaluated in other orthopedic subspecialties.
A methylprednisolone taper following lumbar laminectomy and distal radius repair
demonstrated acute reductions in patient reported pain scores, without an increase in
adverse events. The current literature supports these findings, demonstrating the safety
of short term and low dose corticosteroid treatments, including a methylprednisolone
taper.
To the best of our knowledge, no prior study has compared the administration of a
methylprednisolone taper to a placebo in the immediate postoperative period following
TKA. Therefore, the purpose of this double-blind randomized placebo-controlled trial is
to evaluate the efficacy of a methylprednisolone taper within a standard postoperative
multimodal pain regimen. The authors predict improved pain and decreased opioid use and
nausea from POD 1 to POD 7, as well as improved pain, function, and complication rate at
3- and 6-weeks postoperatively.