Use of Corticosteroid in Intraopertive Injections in Total Knee Replacement Surgery.

Official title

Adjunctive Use of Corticosteroid in Periarticular Injections in Primary Total Knee Arthroplasty

Overview

The goal of this clinical trial is to find out which type of steroid medicine, when added to a standard pain-control injection during total knee replacement surgery, works best at reducing pain, limiting opioid use, and improving recovery in adults undergoing surgery for severe knee arthritis or injury. The main questions it aims to answer are: Does adding a steroid to the injection improve pain control and reduce opioid use after surgery? Is the newer extended-release steroid (Zilretta) more effective and safer-especially for patients with diabetes-than the traditional steroid (methylprednisolone)? Researchers will compare: Standard pain-control injection alone Standard injection plus methylprednisolone Standard injection plus Zilretta to see which option provides better pain relief, less opioid use, and improved knee function. (Patients with diabetes or prediabetes will only be in the standard injection or Zilretta groups so researchers can study whether Zilretta is safer for blood sugar control.) Participants will: Be randomly assigned to one of the study groups during their total knee replacement surgery Receive the assigned pain-control injection around the knee joint Be followed after surgery to measure: Pain levels Opioid pain medication use Knee movement (range of motion) Whether another procedure (such as manipulation under anesthesia) is needed if the knee becomes too stiff Patient-reported outcome surveys about pain and function

Detailed description

Total knee replacement surgery (also called total knee arthroplasty, or TKA) is a common procedure for people with severe knee arthritis or injury. While the surgery often leads to significant pain relief and improved mobility, the days and weeks afterward can be uncomfortable. Managing pain during recovery is important-not just to make patients feel better, but also to help them move their knee sooner, avoid excessive use of opioid medications, and get back to normal activities faster.

One common pain management tool is called a pericapsular injection (PAI). This is a mixture of medications injected around the knee joint during surgery to help control pain after the operation. PAIs usually include a long-lasting numbing medicine, an anti-inflammatory drug, and sometimes other medications that improve pain relief. Corticosteroids-powerful anti-inflammatory drugs-are sometimes added, but the best type of steroid and the ideal way to give it is still debated among doctors.

Why This Study Is Being Done This study will compare two types of corticosteroids, methylprednisolone (a traditional steroid) and Zilretta (a newer, extended-release form of the steroid triamcinolone), to see which works better when added to the standard PAI. Zilretta releases medication slowly over time, which may lead to longer-lasting pain control and fewer side effects such as temporary increases in blood sugar-something especially important for people with diabetes.

How the Study Works

Patients having total knee replacement will be randomly placed into one of three groups:

1. Standard PAI only - This mixture includes a long-acting numbing medicine, an anti-inflammatory (ketorolac), a small dose of adrenaline (epinephrine), clonidine (to help with pain control), and sterile saline. 2. Standard PAI + methylprednisolone - The same standard mixture with the addition of 40 mg of methylprednisolone. 3. Standard PAI + Zilretta - The same standard mixture with 32 mg of Zilretta, the extended-release steroid.

People with diabetes or prediabetes will only be placed in groups 1 or 3 so researchers can compare how Zilretta affects them compared to no steroid at all.

What Will Be Measured

The researchers will check patients' progress at several points after surgery to investigate:

* Pain levels * Opioid pain medication use (measured in morphine-equivalent doses) * Knee movement (range of motion) * Need for further procedures (such as manipulation under anesthesia, or MUA, if the knee becomes too stiff) * Patient-reported outcome surveys (including the Knee Injury and Osteoarthritis Outcome Score and the Single Assessment Numeric Evaluation) Expected Findings

The team believes that adding a corticosteroid to the PAI will:

* Improve pain control * Reduce the need for opioid medications * Lower the risk of needing a manipulation procedure to improve range of motion They also expect that Zilretta, because it lasts longer, will work better than methylprednisolone-especially in people with diabetes, by offering pain relief without causing as much temporary increase in blood sugar.

Why This Matters Past research shows that PAIs can help reduce pain and the need for opioids after knee replacement surgery, without raising the risk of infection or other serious complications. But doctors still don't know which steroid is best to use. If Zilretta works better and causes fewer side effects, it could become the preferred option for many patients-particularly those with other health issues like diabetes.

The results of this study could help guide surgeons toward the safest and most effective pain control strategies for people recovering from knee replacement surgery, ultimately leading to better recoveries, fewer complications, and improved quality of life.

Interventions

• Drug PAI
  Standard PAI: 30 mg Toradol/ketorolac (30mg/ml), 49.25ml 0.5% ropivacaine (5mg/ml), and 0.5 mg
• Drug PAI + steroid
  Standard PAI + 40mg methylprednisolone (n = 40)
• Drug PAI + zilretta
  Standard PAI + 32mg Zilretta (triamcinolone acetonide extended release injectable suspension)

Primary outcome measures

• The primary outcome is to determine whether total knee arthroplasty outcomes are significantly better for Zilretta (Group 3) and methylprednisolone (Group 2) as compared to standard PAI (Group 1) and Zilretta versus methylprednisolone. [Time frame: 24 hours, 72 hours, 7 days, and 28 days post]
• Postoperative ROM [Time frame: 28, 120 and 365 days postop]
• Patient reported outcome measure [Time frame: 120 and 365 days postoperatively]
• Patient reported outcome measures 2 [Time frame: 120 and 365 days postop]
• Postop pain medication usage [Time frame: 24hrs, 72 hours, and 7 days, and 28 days postop]
• MUA rate [Time frame: 28 days postop]

Secondary outcome measures (1)

• Adverse events and subgroup analysis [Time frame: 28 days, 120 days, 365 days postop]

Eligibility criteria

Inclusion criteria

• Patients within the MHS who are DEERS eligible undergoing primary TKA at Walter Reed National Military Medical Center (WRNMMC), Surgery Center of Chevy Chase or District Surgery Center
• Age 18 or older
• successful surgical intervention

Exclusion criteria

• Unicompartmental knee arthroplasty (UKA)
• Revision total knee arthroplasty (rTKA)
• Females who are pregnant or nursing
• Allergic to ingredients in PAI or previous adverse reaction to steroids being used in this study
• Diabetics will be excluded from Group 2 (standard PAI + methylprednisolone)

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

Treatment

Study locations

United States · 1 center

• Walter Reed National Military Medical Center — Bethesda

Publications

• Su C, Liu Y, Wu P, Lang J, Chen L. Comparison Between Periarticular Analgesia Versus Intraarticular Injection for Effectiveness and Safety After Total Knee Arthroplasty. J Perianesth Nurs. 2022 Dec;37(6):952-955. doi: 10.1016/j.jopan.2022.04.010. Epub 2022 Sep 16. PMID 36123240
• Hannon CP, Fillingham YA, Spangehl MJ, Karas V, Kamath AF, Casambre FD, Verity TJ, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty. 2022 Oct;37(10):1928-1938.e9. doi: 10.1016/j.arth.2022.03.045. PMID 36162925
• Wang Y, Li Z, Gao X, Lin J. The efficacy and safety of intra-articular injection of corticosteroids in multimodal analgesic cocktails in total knee arthroplasty-a historically controlled study. Front Surg. 2024 Jun 11;11:1279462. doi: 10.3389/fsurg.2024.1279462. eCollection 2024. PMID 38919978
• Wainwright JD, Gugala Z, Krueger CA, Wenke JC. Adding corticosteroids to intra-operative periarticular injections in total knee arthroplasty: A systematic review. Knee. 2024 Aug;49:87-96. doi: 10.1016/j.knee.2024.05.009. Epub 2024 Jun 13. PMID 38876084
• Wainwright JD, Alaraj S, Wenke JC. Systematic review of intraoperative corticosteroid injections and the risk of infection in arthroscopic surgery. J Clin Orthop Trauma. 2024 Jan 3;48:102332. doi: 10.1016/j.jcot.2024.102332. eCollection 2024 Jan. PMID 38282804
• Sreedharan Nair V, Ganeshan Radhamony N, Rajendra R, Mishra R. Effectiveness of intraoperative periarticular cocktail injection for pain control and knee motion recovery after total knee replacement. Arthroplast Today. 2019 Jul 12;5(3):320-324. doi: 10.1016/j.artd.2019.05.004. eCollection 2019 Sep. PMID 31516975
• Schwartz A, Cochrane NH, Jiranek WA, Ryan SP. Periarticular Injection in Total Knee Arthroplasty. J Am Acad Orthop Surg. 2023 Jun 15;31(12):614-619. doi: 10.5435/JAAOS-D-22-01179. Epub 2023 Apr 14. PMID 37071876
• Russell SJ, Sala R, Conaghan PG, Habib G, Vo Q, Manning R, Kivitz A, Davis Y, Lufkin J, Johnson JR, Kelley S, Bodick N. Triamcinolone acetonide extended-release in patients with osteoarthritis and type 2 diabetes: a randomized, phase 2 study. Rheumatology (Oxford). 2018 Dec 1;57(12):2235-2241. doi: 10.1093/rheumatology/key265. PMID 30203101

Identifiers

NCT: NCT07151417 · 25-21385

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗