• Orthopaedic Procedures
• Orthopaedics Clinical Trials

• Orthopaedics
• Orthopaedic Procedures
• Orthopaedics Clinical Trials

Study data was presented by In Jun Koh, MD, Uijeongbu St. Mary's Hospital, Seoul, Republic of Korea, demonstrating that patients who receive preemptive low-dose dexamethasone prior to total knee arthroplasty (TKA) have a reduced incidence of postoperative pain, nausea, and vomiting [Koh IJ et al. Clin Orthop Relat Res 2013].

Although TKA is one of the most effective treatments for advanced knee arthritis, many patients suffer significant pain due to the procedure, as well as postoperative nausea and vomiting (PONV) associated with anesthesia and analgesia. Yet despite the potential clinical benefits of using low-dose dexamethasone to manage these symptoms, there remains little data on its use in this setting. This study therefore set out to compare the preemptive addition of low-dose dexamethasone with a multimodal protocol including the antiemetic ramosetron (Dexa-Ra), with ramosetron alone (Ra). It aimed to determine whether preemptive Dexa-Ra would lead to improved reduction in PONV and additional analgesic effect, and whether dexamethasone increased the risk for wound complications in these patients.

Patients undergoing TKA (n=269) were randomized to Dexa-Ra (dexamethasone 10 mg 1 hour before surgery, and ramosetron immediately post operatively; n=135), or Ra alone (n=134), and were evaluated 0 to 6, 6 to 24, 24 to 48, and 48 to 72 hours after surgery. Symptoms were scored using a 0 to 10 visual analog scale (VAS). At a minimum of 1 year post TKA, patients were also assessed for wound complications and periprosthetic joint infections.

Incidence of PONV was the primary outcome. Secondary outcomes were complete response, pain level, severity of nausea, and incidence of wound complications in addition to use of rescue antiemetics and opioid consumption.

During the 72-hour evaluation period, Dexa-Ra administration was associated with a reduced incidence of postoperative nausea (24% vs 40%; p=0.004), vomiting (7% vs 21%; p=0.001), and use of rescue antiemetics (17% vs 35%; p=0.001), as well as an increased complete response (76% vs 60%; p=0.006), compared with administration of Ra alone. Patients in the Dexa-Ra group also experienced less severe nausea during the first 6 hours (1.6 vs 2.6; p<0.001; Figure 1). However, there was no significant difference in the incidence of PONV or nausea between the treatment groups from 6 to 72 hours.

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Figure 1.

Postoperative Nausea Severity

Dexa-Ra=low-dose dexamethasone with ramosetron; R=ramosetron alone; VAS=visual analog scale.Reproduced from Koh IJ et al. Preemptive Low-dose Dexamethasone Reduces Postoperative Emesis and Pain After TKA: A Randomized Controlled Study. Clin Orthop Relat Res. 2013;471:3010–3020. With permission from Springer.

Dexa-Ra was also associated with less pain (mean VAS pain score 2.4 vs 4.0; p<0.001), and opioid consumption (73.5 vs 128.3 μg; p<0.001) from 6 to 24 hours, and reduced overall opioid consumption during the entire 72-hour period (406.2 vs 500.1 μg; p=0.004).

There was no significant difference in wound complications (1.5% vs 2.2%; p>0.1) between the groups, and one patient in each group had periprosthetic joint infection (0.7% vs 0.7%; p>0.1).

Prof. Koh concluded that the use of dexamethasone in multimodal protocols offers a simple, effective, and inexpensive means of reducing pain and PONV following TKA, without apparent increased risk of wound complications or infection. He stressed, however, that more clinical trial data would be necessary to further evaluate the effect of dexamethasone on wound complications or infection in these patients.

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