Trying to Make a Dent in Post-THA Pain? Adding Corticosteroids to Periarticular Injections May Work, Study Suggests

by Elizabeth Hofheinz, M.P.H., M.Ed.

“What is the ideal mix of ingredients when it comes to periarticular injections?” asked a team of researchers from Japan, recently. Their study, “Addition of corticosteroid to periarticular injections reduces postoperative pain following total hip arthroplasty under general anaesthesia: a double-blind randomized controlled trial,” appears in the September 30, 2020 edition of The Bone and Joint Journal.

In this prospective, two-arm, randomized controlled trial, 187 patients scheduled for unilateral total hip arthroplasty (THA) were randomly assigned to get a periarticular injection containing either a corticosteroid (CS) or without a corticosteroid (no-CS).

Co-author Kenji Kurosaka, M.D. told OSN, “Periarticular injection plays an important role in multimodal pain management following THA, and generally contains local anesthetics, corticosteroids, opioids, nonsteroidal anti-inflammatory drugs, epinephrine, and/or other agents. However, there is no consensus on the optimal periarticular injection composition, and there is conflicting evidence regarding the inclusion of corticosteroids.”

The researchers, from Hokusuikai Kinen Hospital in Mito, Japan, concentrated on pain at rest during the first 24 hours after surgery. A pain score—visual analogue scale (VAS)—was recorded every three hours until 24 hours (primary outcome was assessed based on the area under the curve [AUC]).

“In both groups, the periarticular injection contained 40 ml of 7.5 mg/ml ropivacaine; 0.8 ml of 10 mg/ml morphine hydrochloride hydrate; 2.5 ml of 20 mg/ml ketoprofen; and 0.3 ml of 1 mg/ml adrenaline,” wrote the authors. “In the CS group, 1 ml of 40 mg/ml methylprednisolone (Solu-Medrol, Pfizer, Tokyo, Japan) was added. The solution was injected into the tensor fascia lata (20 ml), gluteus medius (20 ml), and subcutaneous tissue (4 ml) prior to the arthrotomy.”

All patients received standardized antibiotic prophylaxis (cefazolin 1 g) and 1 g of tranexamic acid, with a second 1 g iv dose of tranexamic acid administered three hours after the first incision. Postop day one, patients received an NSAID (4 mg of lornoxicam three times a day); Diclofenac suppositories (50 mg of diclofenac sodium) were used as a rescue analgesia. In addition, all patients received an anticoagulant (15 mg of oral edoxaban tosylate hydrate) for seven days starting on the day after surgery to prevent deep vein thrombosis. The authors wrote, “In all cases, THA was performed under general anaesthesia without any peripheral nerve block or epidural anaesthesia, in the lateral position using the minimally invasive anterolateral approach.”

“The CS group had a significantly lower AUC postoperatively at zero to 24 hours compared with the no-CS group. In the point-by-point evaluation, the CS group had significantly lower VAS scores than the no-CS group at 12, 15, 18, 21, 24, and 48 hours. The VAS score during activity was significantly better in the CS group on the first and second days after surgery. The consumption of diclofenac sodium was not significantly different between the two groups. The total volumes of fentanyl and remifentanil administered intraoperatively were similar in the two groups and there were no significant differences in the rate of complications between the two groups.”

Dr. Kurosaka told OSN: “Administration of periarticular injections including corticosteroid showed strong analgesic effects in the first 24 hours after THA without increases in complication rates.”