Effects of Dexamethasone on Nausea, Vomiting, and Inflammatory Indexes After Total Knee Arthroplasty

Abstract

Objective: Postoperative nausea and vomiting (PONV) and abnormal inflammatory markers frequently complicate recovery following total knee arthroplasty (TKA), posing diagnostic challenges in distinguishing between transient inflammatory responses and early infections. This study aimed to evaluate the specific effects of dexamethasone (DXM) on PONV incidence and inflammatory markers after TKA.

Methods: This was a retrospective cohort study including 1853 patients who underwent unilateral TKA from January 2020 to August 2021. Patients were divided into a dexamethasone group (n = 756) and a control group (n = 1097) based on postoperative DXM use. All other perioperative management was consistent between groups. Data collected included PONV incidence, white blood cell count (WBC), C-reactive protein (CRP), and postoperative clinical outcomes. Statistical analysis included the χ² test, t test, and multivariate logistic regression to control for confounding factors.

Results: The DXM group showed significantly lower incidences of PONV and lower postoperative CRP levels. WBC counts and neutrophil percentages were transiently elevated postoperatively in the DXM group without corresponding increases in postoperative complications.

Conclusion: DXM administration after TKA reduces PONV and inflammatory markers but leads to transient leukocytosis, which is not associated with an increased incidence of complications.

Keywords

dexamethasone / leukocytosis / postoperative nausea and vomiting / total knee arthroplasty

References

[1] T. H. Lunn, B. B. Kristensen, L. Ø. Andersen, et al., “Effect of High-Dose Preoperative Methylprednisolone on Pain and Recovery After Total Knee Arthroplasty: A Randomized, Placebo-Controlled Trial,” British Journal of Anaesthesia 106, no. 2 (2011): 230-238.

[2] M. Kulkarni, M. Mallesh, H. Wakankar, R. Prajapati, and H. Pandit, “Effect of Methylprednisolone in Periarticular Infiltration for Primary Total Knee Arthroplasty on Pain and Rehabilitation,” Journal of Arthroplasty 34, no. 8 (2019): 1646-1649.

[3] S. Shen, Z. Gao, and J. Liu, “The Efficacy and Safety of Methylprednisolone for Pain Control After Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials,” International Journal of Surgery 57 (2018): 91-100.

[4] S. Rytter, M. Stilling, S. Munk, and T. B. Hansen, “Methylprednisolone Reduces Pain and Decreases Knee Swelling in the First 24 h After Fast-Track Unicompartmental Knee Arthroplasty,” Knee Surgery, Sports Traumatology, Arthroscopy 25, no. 1 (2017): 284-290.

[5] Z. Fan, J. Ma, M. Kuang, et al., “The Efficacy of Dexamethasone Reducing Postoperative Pain and Emesis After Total Knee Arthroplasty: A Systematic Review and meta-Analysis,” International Journal of Surgery 52 (2018): 149-155.

[6] K. S. Gasbjerg, D. Hagi Pedersen, T. H. Lunn, et al., “Effect of Dexamethasone as an Analgesic Adjuvant to Multimodal Pain Treatment After Total Knee Arthroplasty: Randomised Clinical Trial,” BMJ 376 (2022): e067325.

[7] M. Gantzel, K. S. Gasbjerg, D. Hägi-Pedersen, et al., “Effect of Dexamethasone on Intraoperative Remifentanil Dose in Total Knee Arthroplasty Surgery Under General Anaesthesia,” Acta Anaesthesiologica Scandinavica 66, no. 9 (2022): 1070-1076.

[8] A. K. Molgaard, K. S. Gasbjerg, C. S. Meyhoff, et al., “Effect of Dexamethasone on Myocardial Injury After Total Knee Arthroplasty: A Substudy of the Randomized Clinical DEX-2-TKA Trial,” American Journal of Medicine 136, no. 2 (2023): 193-199.

[9] P. J. Barnes, “Anti-Inflammatory Actions of Glucocorticoids: Molecular Mechanisms,” Clinical Science 94, no. 6 (1998): 557-572.

[10] T. Rhen and J. A. Cidlowski, “Antiinflammatory Action of Glucocorticoids—New Mechanisms for Old Drugs,” New England Journal of Medicine 353, no. 16 (2005): 1711-1723.

[11] R. Newton and N. S. Holden, “Separating Transrepression and Transactivation: A Distressing Divorce for the Glucocorticoid Receptor?,” Molecular Pharmacology 72, no. 4 (2007): 799-809.

[12] P. J. Barnes and I. M. Adcock, “How Do Corticosteroids Work in Asthma?,” Annals of Internal Medicine 139, no. 5 Pt 1 (2003): 359-370.

[13] G. R. Morrow, J. T. Hickok, P. L. R. Andrews, and R. M. Stern, “Reduction in Serum Cortisol After Platinum Based Chemotherapy for Cancer: A Role for the HPA Axis in Treatment-Related Nausea?,” Psychophysiology 39, no. 4 (2002): 491-495.

[14] F. Canovas and L. Dagneaux, “Quality of Life After Total Knee Arthroplasty,” Orthopaedics & Traumatology, Surgery & Research 104, no. 1S (2018): S41-S46.

[15] N. K. Lee, S. Kim, J. S. Kim, C. J. Yon, B. E. Im, and C. B. Chang, “Reduction of Postoperative Nausea and Vomiting Risk in the Second Stage During Bilateral Total Knee Arthroplasty With a 1-Week Interval,” Knee Surgery, Sports Traumatology, Arthroscopy 30, no. 9 (2022): 3114-3119.

[16] J. Vardy, K. S. Chiew, J. Galica, G. R. Pond, and I. F. Tannock, “Side Effects Associated With the Use of Dexamethasone for Prophylaxis of Delayed Emesis After Moderately Emetogenic Chemotherapy,” British Journal of Cancer 94, no. 7 (2006): 1011-1015.

[17] M. Nurok, J. Cheng, G. R. Romeo, S. M. Vecino, K. G. Fields, and J. YaDeau, “Dexamethasone and Perioperative Blood Glucose in Patients Undergoing Total Joint Arthroplasty: A Retrospective Study,” Journal of Clinical Anesthesia 37 (2017): 116-122.

[18] A. P. Czaplicki, J. E. Borger, J. R. Politi, B. T. Chambers, and B. C. Taylor, “Evaluation of Postoperative Fever and Leukocytosis in Patients After Total Hip and Knee Arthroplasty,” Journal of Arthroplasty 26, no. 8 (2011): 1387-1389.

[19] G. K. Deirmengian, B. Zmistowski, C. Jacovides, J. ONeil, and J. Parvizi, “Leukocytosis Is Common After Total Hip and Knee Arthroplasty,” Clinical Orthopaedics and Related Research 469, no. 11 (2011): 3031-3036.

[20] Y. Shoenfeld, Y. Gurewich, L. A. Gallant, and J. Pinkhas, “Prednisone-Induced Leukocytosis. Influence of Dosage, Method and Duration of Administration on the Degree of Leukocytosis,” American Journal of Medicine 71, no. 5 (1981): 773-778.

[21] F.-C. B. M. Wagenaar, C. A. M. Löwik, A. Zahar, et al., “Persistent Wound Drainage After Total Joint Arthroplasty: A Narrative Review,” Journal of Arthroplasty 34, no. 1 (2019): 175-182.

[22] T. J. Gan, P. Diemunsch, A. S. Habib, et al., “Consensus Guidelines for the Management of Postoperative Nausea and Vomiting,” Anesthesia and Analgesia 118, no. 1 (2014): 85-113.

[23] C. C. Horn, W. J. Wallisch, G. E. Homanics, and J. P. Williams, “Pathophysiological and Neurochemical Mechanisms of Postoperative Nausea and Vomiting,” European Journal of Pharmacology 722 (2014): 55-66.

[24] E. A. Diakos, I. D. Gallos, S. el-Shunnar, M. Clarke, R. Kazi, and H. Mehanna, “Dexamethasone Reduces Pain, Vomiting and Overall Complications Following Tonsillectomy in Adults: A Systematic Review and Meta-Analysis of Randomised Controlled Trials,” Clinical Otolaryngology 36, no. 6 (2011): 531-542.

[25] C. C. Chu, C. H. Hsing, J. P. Shieh, C. C. Chien, C. M. Ho, and J. J. Wang, “The Cellular Mechanisms of the Antiemetic Action of Dexamethasone and Related Glucocorticoids Against Vomiting,” European Journal of Pharmacology 722 (2014): 48-54.

[26] A. Pham and G. Liu, “Dexamethasone for Antiemesis in Laparoscopic Gynecologic Surgery: A Systematic Review and Meta-Analysis,” Obstetrics and Gynecology 120, no. 6 (2012): 1451-1458.

[27] DREAMS Trial Collaborators and West Midlands Research Collaborative, “Dexamethasone Versus Standard Treatment for Postoperative Nausea and Vomiting in Gastrointestinal Surgery: Randomised Controlled Trial (DREAMS Trial),” BMJ 357 (2017): j1455.

[28] J. A. Polderman, V. Farhang-Razi, S. Van Dieren, et al., “Adverse Side Effects of Dexamethasone in Surgical Patients,” Cochrane Database of Systematic Reviews 11 (2018): CD011940.

[29] S. Liang, M. Xing, S. Jiang, and W. Zou, “Effect of Intravenous Dexamethasone on Postoperative Pain in Patients Undergoing Total Knee Arthroplasty: A Systematic Review and Meta-Analysis,” Pain Physician 25, no. 2 (2022): E169-e183.

[30] M. M. Harding, S. E. Xavier, T. M. Seyler, and S. P. Ryan, “The Effects of Dexamethasone in Diabetic Patients Undergoing Primary Total Joint Arthroplasty,” Orthopaedic Nursing 40, no. 5 (2021): 301-304.

[31] X. Wang, W. Jiang, Q. Huang, and F. Pei, “Dexamethasone Attenuates the Perioperative Acute Phase Response for Simultaneous Bilateral Total Hip Arthroplasty,” Journal of Arthroplasty 37, no. 5 (2022): 888-891.

[32] Y. Lei, Z. Huang, Q. Huang, F. Pei, and W. Huang, “Dose Optimization of Intravenous Dexamethasone for Total Knee Arthroplasty: When Two Is Not Better Than One,” Archives of Orthopaedic and Trauma Surgery 142, no. 4 (2022): 665-672.

[33] Y. T. Lei, B. Xu, X. W. Xie, J. W. Xie, Q. Huang, and F. X. Pei, “The Efficacy and Safety of Two Low-Dose Peri-Operative Dexamethasone on Pain and Recovery Following Total Hip Arthroplasty: A Randomized Controlled Trial,” International Orthopaedics 42, no. 3 (2018): 499-505.

[34] D. C. Allen, N. A. Jedrzynski, J. D. Michelson, M. Blankstein, and N. J. Nelms, “The Effect of Dexamethasone on Postoperative Blood Glucose in Patients With Type 2 Diabetes Mellitus Undergoing Total Joint Arthroplasty,” Journal of Arthroplasty 35, no. 3 (2020): 671-674.

[35] N. I. Nielsen, H. Kehlet, K. Gromov, et al., “High-Dose Steroids in High Pain Responders Undergoing Total Knee Arthroplasty: A Randomised Double-Blind Trial,” British Journal of Anaesthesia 128, no. 1 (2022): 150-158.

[36] H. Xu, S. Zhang, J. Xie, Y. Lei, G. Cao, and F. Pei, “Multiple Doses of Perioperative Dexamethasone Further Improve Clinical Outcomes After Total Knee Arthroplasty: A Prospective, Randomized, Controlled Study,” Journal of Arthroplasty 33, no. 11 (2018): 3448-3454.

[37] D. Li, J. Zhao, Z. Yang, P. Kang, B. Shen, and F. Pei, “Multiple Low Doses of Intravenous Corticosteroids to Improve Early Rehabilitation in Total Knee Arthroplasty: A Randomized Clinical Trial,” Journal of Knee Surgery 32, no. 2 (2019): 171-179.

RIGHTS & PERMISSIONS

2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.