Patients
The inclusion criteria were as follows: ①received primary hip or knee replacement due to osteoarthritis; ②ASA class rating below class Ⅱ; ③general anesthesia. Exclusion criteria: ①allergic to dexamethasone; ②a history of high-dose glucocorticoid use; ③combined with other diseases that require glucocorticoid therapy, such as systemic lupus erythematosus; ④combined with other diseases that were inappropriate to use glucocorticoids, such as a peptic ulcer.
According to the above criteria, 100 patients who received TJA in our hospital due to osteoarthritis between April 2018 and December 2020 were enrolled, including 39 males and 61 females. 50 each in the placebo group and Dexa group. The diagnosis of osteoarthritis in all patients meets the diagnostic criteria of the American college of rheumatology (ACR) [16].
Surgical procedure
All arthroplasties were performed by the same experienced surgeon. All patients underwent general anesthesia with tracheal intubation, and 1.5 g cefuroxime sodium was given intravenously 30 minutes before the operation for infection prophylaxis. Dexamethasone (1 ml: 5 mg, Tianjin Kingyork group co., ltd., China) was injected intravenously by an anesthesiologist during induction of anesthesia. The placebo group received 1 ml saline. A midline skin incision, the medial parapatellar approach was applied in total knee arthroplasty. An intramedullary alignment system was used for femoral preparation, and an extramedullary alignment system was used for tibial preparation. For patients who received hip arthroplasty surgery, a small incision was made in the skin along the posterior thigh and incised through the gluteus medius to expose the joint cavity. Choose the most suitable prosthesis according to the specific situation of the patients.
Postoperative management
Postoperative managements of all patients meet the same scheme. After the operation, cefuroxime sodium was used to prevent infection, twice a day, 1.5g each time, for 3 consecutive days. One tablet Xarelto was administered daily to prevent deep vein thrombosis. Flurbiprofen axetil injection was used routinely twice a day (50 mg each time) for preemptive analgesia. If the NRS score was greater than 4, use dezocine (1ml: 5mg, Yangzijiang pharmaceutical group co., ltd.) as an analgesic rescue. When a grade Ⅳ PONV reaction occurred, or the patient required antiemetic drugs, the first-line rescue was metoclopramide (1ml: 10mg, Tianjin Kingyork group co., ltd., China). An intramuscular injection of ondansetron (2ml: 4mg, Qilu Hainan pharmaceutical group co., ltd.) would be used if PONV was not relieved within 30~45 minutes.
The daily functional exercise started the next day after surgery. Intermittent inflation treatment in lower limb for about 30 minutes every morning to prevent deep venous thrombosis. Under the guidance of a professional physiotherapist, all patients adhered to quadriceps exercise and extension–flexion training, and strictly implemented phased muscle strength training to ensure that they can walk within 24 hours if all went well.
Outcome recording
The primary outcomes were PONV level and the amount of rescue drug consumption. The severity of PONV was divided into 4 grades, gradeⅠ: no or mild nausea, no vomiting; grade Ⅱ: mild nausea and vomiting, but no stomach contents out; grade Ⅲ: moderate nausea and vomiting, much stomach contents out, may require medication; grade Ⅳ: severe nausea and vomiting, which causes dizziness, fatigue, and affects activities, must be controlled by medication.
The secondary outcomes were the following: (1) pain level and the amount of dezocine consumption, (2) length of hospital stay (LOS), (3) postoperative complications, (4) patient satisfaction. The pain level was assessed by the numerical rating scales (NRS, 0-10, 0 means no pain, 10 means severe pain). All patients were followed up for at least 3 months after discharge to record whether there were any complications such as surgical site infection, delayed wound healing, and gastrointestinal bleeding. Patient satisfaction was obtained through a questionnaire.
Statistical analysis
All data analyses were performed by SPSS version 23 (SPSS inc., Chicago, IL, USA). Mean values and standard deviations were calculated for continuous variables. Student’s t-test or Wilcoxon–Mann–Whitney u test was used to analyze quantitative data. Pearson chi-squared test or fisher’s exact test was used to compare categorical data. Statistically significant was defined as p < 0.05.