The Effect of Preoperative Intra-Articular Methylprednisolone on Pain After TKA: A Randomized Double-Blinded Placebo Controlled Trial in Patients With High-Pain Knee Osteoarthritis and Sensitization

• Published in: The journal of pain Vol. 18; no. 12; p. 1476
• Main Authors: Luna, Iben E, Kehlet, Henrik, Jensen, Claus M, Christiansen, Thorbjørn G, Lind, Thomas, Stephensen, Snorre L, Aasvang, Eske K
• Format: Journal Article
• Language: English
• Published: United States 01-12-2017
• Subjects: Aged; Aged, 80 and over; Arthroplasty, Replacement, Knee - methods; Double-Blind Method; Female; Follow-Up Studies; Glucocorticoids - administration & dosage; Glucocorticoids - pharmacology; Humans; Injections, Intra-Articular; Male; Methylprednisolone - administration & dosage; Methylprednisolone - pharmacology; Middle Aged; Osteoarthritis, Knee - drug therapy; Osteoarthritis, Knee - surgery; Outcome Assessment (Health Care); Pain, Postoperative - prevention & control; Preoperative Period; methylprednisolone; Total knee arthroplasty; inflammation; osteoarthritis; postoperative pain
• ISSN: 1528-8447
• DOI: 10.1016/j.jpain.2017.07.010

In a randomized, double-blind, placebo controlled trial, we investigated the postoperative analgesic effect of a single intra-articular injection of 40 mg methylprednisolone acetate (MP) administered 1 week before total knee arthroplasty (TKA). Forty-eight patients with high pain osteoarthritis (≥5 on a numeric rating scale during walk) and sensitization (pressure pain threshold <250 kPa), aged 50 to 80 years and scheduled for primary unilateral TKA under spinal anaesthesia were included. The primary outcome was the proportion of patients with moderate/severe pain during a 5-m walk test 24 hours postoperatively. Secondary outcomes included pain at 48 hours, during the first 14 days, sensitization (quantitative sensory testing with pressure pain threshold and wind-up from temporal summation), and inflammatory changes (systemic C-reactive protein, intra-articular interleukin [IL]-6). No difference in the proportion of patients with moderate/severe pain was found between MP/placebo groups at 24 hours (67% and 74%, χ
 = .2, P = .63, odds ratio = .7, 95% confidence interval = .2-2.8) or at 48 hours (57% and 68%, χ
 = .5, P = .46, odds ratio = .6, 95% confidence interval = .2-2.3), and no difference between groups in postoperative sensitization was found (P > .4) despite reduced preoperative intra-articular inflammation (IL-6) in the MP group versus placebo (median change in IL-6 = -70 pg/mL, interquartile range = -466 to 0 vs. 32 pg/mL, interquartile range = -26 to 75, P = .029). Alternative central or peripheral analgesic interventions in this high-risk group are required.
Peripherally driven inflammatory pain and nociceptive changes before TKA has been suggested to be a cause for increased acute postoperative pain. However, preoperative intra-articular MP in patients with high pain osteoarthritis and sensitization did not reduce acute post-TKA pain or sensitization despite a preoperative reduction of intra-articular inflammatory markers.