Abstract
Dear editor,
We read with great interest the article entitled “Intraoperative intravenous versus periarticular glucocorticosteroid injections in improving clinical outcomes after total knee arthroplasty: a prospective, randomised controlled study” published in the Journal of Orthopaedic Surgery (Hong Kong). 1 The authors conducted a randomised controlled study to determine whether intravenous and topical dexamethasone provide different clinical outcomes for patients undergoing primary total line knee arthroplasty (TKA). They concluded that intraoperative periarticular glucocorticoid injections provided better clinical outcomes in early postoperative pain management after TKA, especially on postoperative day 2. We acknowledge the work of the authors and appreciate the objective discussion of their findings, including some of the inherent limitations noted. However, after extensive discussion with our professional peer group, we have several salient and pertinent questions that we hope you will address:
Firstly, in the " Study assessments” section, the authors state that knee pain was assessed using the Visual Analogue Scale (VAS) at rest and walking (5 m) with the assistance of a walker, and that the VAS is moderately reproducible but requires some level of training to administer accurately. At the same time, measurement of the VAS relies on subjective patient-reported outcomes or clinical assessments, and this subjectivity introduces the potential for bias and variability in symptom interpretation. However, in the present study it is unclear who collected the data regarding the VAS scores or whether the VAS assessment scores were repeatedly measured by two independent evaluators. This may have led to additional bias in the study results.
Secondly, as a randomised controlled study, the design of the intravenous (IV) and periarticular injection (PI) groups is of particular importance. Li et al. 2 conducted a randomised, double-blind, controlled study similar to that of the authors, with the aim of determining the optimal use of IV and topical dexamethasone for the treatment of total knee arthroplasty. In this study, the intravenous (IV) group received 10 mg of IV dexamethasone at the time of induction of anaesthesia, whereas the periarticular injection (PI) group received 0.9% saline at the same time point with the same appearance as the study drug. We believe that the implementation of this initiative will undoubtedly increase the accuracy and reliability of the results of the study to a certain extent, which is worthwhile in subsequent studies.
Thirdly, in the Surgical Procedures section, we found that drains were routinely placed after knee arthroplasty in this study to reduce postoperative haematoma. However, Accelerated Rehabilitation Surgery (ERAS) requires patients to start functional recovery as early as possible, so routine placement of drains is not recommended for TKA patients. In addition, knee swelling used to be a common complication after TKA due to local haemorrhage, and nowadays the use of tranexamic acid is more commonly recommended clinically for the reduction of postoperative haematomas so that the postoperative blood loss can also be well controlled. 3
In conclusion, we would like to thank Li and his colleagues once again for an important study. We hope that our reflections may contribute to the field of multimodal postoperative analgesia research in TKA and inspire future scientific studies.
