Intravenous (IV) Hydrocortisone for TKA (Total Knee Arthroplasty)

Hospital for Special Surgery (HSS)

Status and phase: Active, not recruiting; Phase 4

Conditions: Pain; Arthrofibrosis; Osteoarthritis, Knee

Treatments: Drug: Hydrocortisone; Drug: Dextrose 5% in water (D5W)

Study type: Interventional

Funder types: Other

Identifiers

NCT04082533

2018-0660

Details and patient eligibility

About

In this study, total knee replacement patients will be determined to be stiff or non-stiff preoperatively. Stiffness designation is determined by preoperative range of motion (if flexion is < 100 degrees, or extension lag is > 10 degrees). The stiff and non-stiff groups will both be randomized to two groups to receive either intravenous hydrocortisone or a placebo at 3 intervals postoperatively. Patients will be followed up with in hospital and via the phone on postoperative day (POD) 1 and 2, as well as 6 weeks, 6 months, 1 year, and 2 years postoperatively. Patients will also have blood drawn preoperatively in the OR, on POD1, at their 6 week followup, and at their 1 and 2 year follow ups. This blood will be processed and analyzed.

Full description

TKA is the standard of care for treating patients suffering from end-stage knee arthritis and other disabling knee injuries. Indications have increased to ever younger patients and, combined with the aging US population, nearly 700,000 Americans receive TKAs each year. In spite of surgery, many patients experience persistent pain, stiffness or instability that negatively impacts their quality of life; up to 5% experience TKA failure in the first 10 years.

Presently, IV stress dose steroids is an accepted practice for bilateral knee replacement (BTKR) leading to decreased pain 24 hours after surgery and improved range of motion (ROM) on postoperative day 2 (POD2). These benefits are likely due to suppression of inflammation immediately after surgery. It is not clear if IV stress dose steroids improve ROM at later time points. Moreover, it is not clear if IV hydrocortisone improves clinical outcomes in unilateral TKA, where pain and joint stiffness remain significant challenges weeks after surgery. The investigators hypothesize that IV hydrocortisone will increase ROM at 6 weeks following surgery.

This study will enroll 132 patients that will be followed for up to 2 years. By integrating cell and molecular biology, biomechanics, and imaging technologies (including a CT scan at 1 year), this study is designed to comprehensively examine the long term effects of IV hydrocortisone on joint stiffness, pain, clinically relevant inflammatory states, and the synovium following unilateral TKA. Because subjects with variable ROMs will be enrolled in the study and followed over time, the findings may enable the development of biomarker prediction tools and the targeting of appropriate prevention and management measures for patients at highest risk of joint stiffness and subsequent surgical intervention.

Enrollment: 132 estimated patients

Sex: All

Ages: 18 to 83 years old

Volunteers: Accepts Healthy Volunteers

Inclusion criteria

• Elective primary unilateral total knee arthroplasty
• Osteoarthritis (OA) within the affected joint
• Patients of surgeons who have agreed to participate in the study
• Age ≥18 to 83 years
• American Society of Anesthesiologists (ASA) Physical Status 1-3
• Neuraxial Anesthesia
• Adductor canal block (ACB), Interspace between the popliteal artery and capsule of the posterior knee (IPACK) block (unless valgus knee patient), and Periarticular Injection (PAI) for postoperative pain

Exclusion criteria

• Contraindication to regional anesthesia, non-steroidal anti-inflammatory drugs, or steroids
• Pre-operative oral steroid use in the past 3 months
• Body mass index (BMI) greater than or equal to 45
• Intraarticular steroid injections within two months of scheduled surgery in affected joint
• Non-English speaking
• Pre-existing diagnosis of rheumatic disease, autoimmune disease, or immunodeficiency (e.g. rheumatoid arthritis, psoriatic arthritis, inflammatory bowel disease, multiple sclerosis, Type I diabetes)
• Active infection
• History of >6 weeks of daily opioid use and/or any use of non-prescribed opioids within one year
• Pregnant women
• Previous study participants in this study
• Type II Diabetes on insulin
• History of refractory postoperative nausea and vomiting (PONV) or PONV after sedation (can include if nausea only after general anesthesia)
• Previous hardware in affected joint
• Open Reduction and Internal Fixation (ORIF) surgery to affected joint
• Cementless total knee arthroplasty (TKA)

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Triple Blind

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132 participants in 4 patient groups, including a placebo group

Stiffness Intravenous Hydrocortisone

Active Comparator group

Description:

Total knee replacement patients with preoperative knee stiffness (defined as flexion \< 100 degrees or extension lag \> 10 degrees) receive 3 doses of 100mg intravenous hydrocortisone every 8 hours. The first dose is given in the holding area approximately 2 hours prior to first incision.

Treatment:

Drug: Hydrocortisone

Stiffness Intravenous Placebo

Placebo Comparator group

Description:

Total knee replacement patients with preoperative knee stiffness (defined as flexion \< 100 degrees or extension lag \> 10 degrees) receive 3 doses of matched volume diluent every 8 hours. The first dose is given in the holding area approximately 2 hours prior to first incision.

Treatment:

Drug: Dextrose 5% in water (D5W)

Non-stiff Intravenous Hydrocortisone

Active Comparator group

Description:

Total knee replacement patients without preoperative knee stiffness (defined as flexion \< 100 degrees or extension lag \> 10 degrees) receive 3 doses of 100mg intravenous hydrocortisone every 8 hours. The first dose is given in the holding area approximately 2 hours prior to first incision.

Treatment:

Drug: Hydrocortisone

Non-stiff Intravenous placebo

Placebo Comparator group

Description:

Total knee replacement patients without preoperative knee stiffness (defined as flexion \< 100 degrees or extension lag \> 10 degrees) receive 3 doses of matched volume diluent every 8 hours. The first dose is given in the holding area approximately 2 hours prior to first incision.

Treatment:

Drug: Dextrose 5% in water (D5W)