Effectiveness of Peri-operative Combined Use of 2 Doses of Dexamethasone With Tranexamic Acid in Lower Limb Joint Replacements- A Randomized Controlled Trial.

1 INTRODUCTION/BACKGROUND Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are highly effective interventions 45 for end-stage arthritis of the knee and hip. Controlling postoperative pain and nausea after total joint arthroplasty remains an important challenge. Perioperative corticosteroids are safe, facilitate earlier discharge, and improve patient recovery following unilateral total knee arthroplasty and total hip arthroplasty. Higher doses (15-20 mg of dexamethasone) are associated with further reductions in dynamic pain and PONV, and repeat dosing may further reduce LOS. It was found that neither one nor two doses of 24 mg intravenous dexamethasone demonstrated prolonged effects on overall pain or sleep quality on postoperative days 3-7 after total knee arthroplasty, also have no effect on patients satisfaction, but it reduced the opioid consumption. Tranexamic acid (TXA) reduces rates of blood transfusion for total hip arthroplasty (THA) and total knee arthroplasty (TKA) . Hence, it was proved that the combination of TXA and DEX has positive impacts on the usage of oxycodone and metoclopramide, postoperative range of motion, postoperative nausea and vomiting and reduces the length of hospital stay .The administration of 10 mg dexamethasone 1 h before the surgery, and repeated at 6 h postoperatively can significantly reduce the level of postoperative CRP and IL-6. There is insufficient evidence on perioperative dexamethasone in primary TJA to determine the optimal dose, number of doses, or risk of postoperative adverse events.

2. .Background of interventional procedure: Total joint arthroplasty (TKA) is viewed as one of the most successful orthopedic surgeries for most end-stage joint diseases. In recent years, the concept of enhanced recovery after surgery (ERAS) has greatly improved the speed of rehabilitation after total joint arthroplasty. Patients feel more comfortable during the perioperative period and have shorter hospital stays with the administration of steroidal administration. Dexamethasone plays an important role in ERAS due to its anti-inflammatory and pain reduction role. As, TXA can prevent the activation of plasminogen and delay fibrinolysis and reduce blood loss and the rate of blood transfusion perioperatively. Recent studies showed that dexamethasone may be administered multiple times peri operatively. A large number of studies confirmed that dexamethasone can reduce post operative pain and inflammation and shortens the length of hospital stay and combination pre operative tranexamic acid with dexamethasone reduces the limb swelling that improves the joint range of motion. There will be no risk of the interventional drug Benefits will include that the drug is cost effective, easily available, reduce the post operative complications

3. Rationale: Previous studies showed the effects of peri-operative use of single dose of dexamethasone, and there is very little data available on effects of peri-op use of multiple doses of dexamethasone. There is no study that has been conducted yet, which compared the effects of peri-op use of 1 dose of dexamethasone and tranexamic acid with 2 doses of dexamethasone and tranexamic acid, on post operative range of motion and pain during rest and weight bearing on operated limb, length of stay in hospital and C-reactive protein.

4. Study Objectives:

Primary Objective: