A Randomized Controlled Trial Assessing the Effect of Intraoperative Dexamethasone in the Management of Postoperative Pain Control and Stiffness After Distal Radius Fixation 1 2 Ishi Aron, BA , Kate Nellans, MD, MPH ,
1Donald
and Barbara Zucker School of Medicine at Hofstra/Northwell,
Background
2Dept.
of Orthopedic Surgery, Northshore University Hospital
Results
Surgical Procedure
Distal radius fractures are the most common orthopedic injury, making up 17.5% of fractures among adults.
FTP Distance Control vs Treated 4.5 4
Can be treated both non-operatively as well as operatively, depending on the patient’s age, activity level, and features of the fracture. Stiffness is a common post-operative problem
FTP Distance (cm)
3.5
Many studies support dexamethasone administration during surgery as a safe way to reduce post operative stiffness, swelling, pain, and opioid use
No hand surgery literature on the effects of dexamethasone plus a nerve block on post operative pain and stiffness.
Figure 2. X-ray of a normal wrist on the left. X-ray with white arrows pointing to a distal radius fracture on the right.
Figure 3. X-ray showing a plate and screws placed during distal radius fixation to hold the bones in position as they heal.
2 1.5 1 0.5 0 48 hrs post op
1 week post op
2 weeks post op
Figure 7. Average FTP Distances control vs treated from 48 hrs to 2 weeks post op
Conclusions
Hypothesis Figure 4. Portion of the Patient-Rated Wrist Evaluation (PRWE) to measure wrist pain and disability in daily living activities
Results
Methods
VAS Control vs Treatment 5 4.5
Average VAS Score
4 3 2.5 2 1.5 0.5 0 48 hrs
1 wk Time Point Control
2 wks
Treatment
Figure 5. Average VAS scores control vs treated from 48 hrs to 2 weeks post op PRWE Score Control vs Treated 70 60 50 40 30 20 10 0 48 hrs post op
1 week post op
2 weeks post op
Time Point Control Average
• Expanding the use of intraoperative dexamethasone in other hand surgery procedures and evaluating whether post operative pain, stiffness , and opioid consumption are reduced in these procedures as well. • Assessing the efficacy of other medications with similar as well as different mechanisms of action as dexamethasone in reducing post operative pain and opioid consumption to try and curb the opioid crisis. • Trying different combinations of pre-approved pain medications to find an optimal regimen for multimodal pain control.
Resources
80
Average PRWE Score
• So far six patients are represented in the data. We plan to enroll at least 72 patients in the study over the next 8-10months. • The current results show no statisical difference between the means of the control and treatment groups in FTP distance, VAS scores, and PRWE scores. • For PWRE scores, the 2 sample t-test assuming unequal variance gave p values of 0.37 at 48 hrs post op, 0.57 at 1 week post op, 0.54 at 2 weeks post op. • For the FTP distances, the 2 sample t-test assuming unequal variance gave p values of 0.93 at 48 hrs post op, 0.72 at 1 week post op, and 0.81 at 2 weeks post op. • For the VAS scores, the 2 sample t-test assuming unequal variance gave p values of 0.07 for 48 hrs post op, 0.47 one week post op, and 0.79 2 weeks post op • As we enroll more participants we anticipate the data and analysis results will change.
Future Direction
3.5
1
Figure 1. Flowchart showing study methods prior to enrollment to 2 weeks post op
2.5
Time Point Control Average (cm) Treatment Average (cm)
This study is a prospective, randomized, controlled double-blinded trial comparing the use of intraoperative dexamethasone along with a supraclavicular nerve block (treatment) versus supraclavicular nerve block alone (control) for the management of postoperative swelling, pain control and stiffness after open reduction and internal fixation of distal radius fractures.
Patients who receive dexamethasone along with a nerve block will: 1. Have less postoperative pain and stiffness 2. Require less opioids than those who receive a nerve block alone.
3
Treatment Average
Figure 6. Average PWRE scores control vs treated from 48 hrs to 2 weeks post op
1. de Oliveira GS, Almeida MD, Benzon HT, et al. Perioperative Single Dose Systemic Dexamethasone for Postoperative Pain. Anesthesiology. 2011;115:575–588. 2. Fan Z, Ma J, Kuang M, et al. The efficacy of dexamethasone reducing postoperative pain and emesis after total knee arthroplasty: A systematic review and metaanalysis. International Journal of Surgery. 2018;52:149–155. 3. Polderman JA, Farhang-Razi V, Dieren S van, et al. Adverse side effects of dexamethasone in surgical patients (Review). Cochrane Database of Systematic Reviews. 2018;11:CD011940.