Yale Steroid Enhanced Versus Exparel Nerveblock TKA Part 2

Overview

The objective of this study is to investigate the efficacy of Dexamethasone sodium phosphate plus Methylprednisolone acetate in combination with plain bupivacaine ((B-DEX-MPA) compared with Liposomal Bupivacaine in combination with plain bupivacaine (B-LB) on post-surgical pain control among patients undergoing bilateral total knee arthroplasty (TKA) to asses if perineural B-DEX-MPA will result in superior analgesia efficacy as compared to B-LB. This study will also assess if perineural B-DEX-MPA results in improved quality of postoperative recovery as compared to B-LB.

Detailed description

This phase 2 clinical trial will investigate the efficacy of Dexamethasone sodium phosphate (DEX) plus Methylprednisolone acetate (MPA) in combination with plain bupivacaine (B) compared with Liposomal Bupivacaine (LB) in combination with plain bupivacaine on post-surgical pain control among patients undergoing bilateral total knee arthroplasty (TKA).

The primary objective of this study is to investigate the efficacy of Dexamethasone sodium phosphate (DEX) plus Methylprednisolone acetate (MPA) in combination with plain bupivacaine (B) compared with Liposomal Bupivacaine (LB) in combination with plain bupivacaine on post-surgical pain control among patients undergoing total knee arthroplasty (TKA). The secondary objective of this study is to test the effects of perineural use of B-DEX-MPA vs B-LB on the quality of postoperative recovery as well as surgical outcome and neuropathic pain among patients undergoing bilateral TKA.

This study will also assess if perineural B-DEX-MPA results in improved quality of postoperative recovery as compared to B-LB.

This will be a single center study at Yale New Haven Hospital (YNHH) performed at two clinical sites: York St. Campus (York Street, New Haven) and St. Raphael Campus (Chapel Street, New Haven). An anticipated 66 participants who are scheduled for primary, elective bilateral TKA will be enrolled.

Interventions

• Drug Bupivacaine-Liposomal Bupivacaine
  A medication mixture of 40 ml (20 ml LB and 20 ml 0.25% plain bupivacaine) will be prepared, of which 20 ml will be used in Adductor canal block, 10 ml will be used in iPACK block and 5 ml each will be used in medial upper and lateral upper genicular nerve block, respectively.
• Drug Bupivacaine -Dexamethasone Sodium Phosphate-Methylprednisolone Acetate
  A medication mixture of 40 ml (40 ml 0.25% plain bupivacaine, 10 mg DEX and 80 mg MPA) will be prepared, of which 20 ml will be used in Adductor canal block, 10 ml will be used in iPACK block and 5 ml each will be used in medial upper and lateral upper genicular nerve block, respectively.

Primary outcome measures

• Change in Postoperative Knee Pain Score [Time frame: Day 1 and Day 2]
• Postoperative opioid consumption [Time frame: From anesthesia end time to discharge time, up to 48 hours]

Secondary outcome measures (12)

• Average Postoperative Knee Pain Score [Time frame: Day 7]
• Worst and best pain score [Time frame: Day 1, Day 2 and Day 7]
• Change in functional pain using Brief Pain Inventory (BPI) [Time frame: baseline, 6 weeks and 3 months]
• Change in neuropathic pain using PainDetect [Time frame: baseline, 6 weeks and 3 months]
• Persistent opioid use using Yale Postoperative Recovery Scale [Time frame: Day 7, 6 weeks and 3 months]
• Persistent opioid use using NarX [Time frame: 6 weeks and 3 months]
• Change in Quality of Recovery 40 questionnaire [Time frame: Day 1, 2 and 7]
• Prosthetic joint range of motion [Time frame: baseline, day 0, day 1 and day 2]
• Change in Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 [Time frame: 6 weeks and 3 months]
• Change in knee functional status using Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) [Time frame: 6 weeks and 3 months]
• Length of stay [Time frame: from the start of the surgery to discharge from hospital, up to 48 hours]
• Change in glucose [Time frame: baseline, day 0, day 1 and day 2]

Eligibility criteria

Inclusion criteria

• American Society of Anesthesiologists status I, II and III, elective, primary, bilateral TKA planned for spinal anesthesia with plain 0.5% bupivacaine.

Exclusion criteria

• Refusal of consent
• Pregnancy
• Conditions making the patient unable to fill out questionnaire online, through email or over the phone including with cognitive dysfunction, psychiatric disorder, or non-English speaking patients, or lack of internet access which would prevent post discharge follow-up electronically
• Coagulopathy
• Allergy to or for any other reasons cannot use Acetaminophen, Celebrex, local anesthetic bupivacaine, DEX, MPA or LB
• Patients on any amounts of opioids within one month of the surgery date, any substance abuse such as regular marijuana user (more frequent than once per month)
• Insulin dependent or uncontrolled diabetes defined as, day of surgery finger stick glucose >200mg/dl, or HbA1C > 8.0%
• Peripheral Nerve Block site or systemic infection
• Immune compromise (e.g., HIV, chronic glucocorticoid use)
• Severe pre-existing neuropathy
• TKA for indications other than osteoarthritis such as post-traumatic injury or rheumatoid arthritis, history of surgery in the ipsilateral knee joint, revision TKA or bilateral TKA
• Severe hepatic or renal dysfunction (GFR <50 ml/min)
• Actual body weight <60 kg
• Patients with active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and non-specific ulcerative colitis

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Single blind

Primary purpose

Supportive care

Study locations

United States · 2 centers

• Yale New Haven Hospital Saint Raphael Campus — New Haven
• Yale New Haven Hospital York Street Campus — New Haven

Identifiers

NCT: NCT05736549 · 2000031881_a

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗