Testosterone for muscle wasting after surgeryTotal knee arthroplasty is reported to improve the patient's quality of life and mobility. However loss of mobility and pain prior to surgery often results in disuse atrophy of muscle. As a consequence the baseline functional state prior to surgery may result in poorer outcome "post surgery" and extended rehabilitation may be required. The use of anabolic steroids for performance enhancement and to influence muscle sspinal is well established. The positive effects of such treatment on bone and muscle could therefore be beneficial ababolic the rehabilitation of elderly patients.
Steroid use after back Surgery ???
Total knee arthroplasty is reported to improve the patient's quality of life and mobility. However loss of mobility and pain prior to surgery often results in disuse atrophy of muscle.
As a consequence the baseline functional state prior to surgery may result in poorer outcome "post surgery" and extended rehabilitation may be required. The use of anabolic steroids for performance enhancement and to influence muscle mass is well established.
The positive effects of such treatment on bone and muscle could therefore be beneficial in the rehabilitation of elderly patients. The purpose of this study was to investigate the effects of small doses of Nandrolone decanoate on recovery and muscle strength after total knee replacement and to establish the safety of this drug in multimorbid patients.
This study was designed as a prospective double blind randomized investigation. Five patients treatment group with a mean age of The control group five patients; mean age In addition, a bone density scan was used preoperatively and 6 month postoperatively to assess bone mineral density.
Whilst the steroid group generally performed better than the placebo group for all of the functional tests, ANOVA failed to reveal any significant differences.
This project strongly suggests that the use of anabolic steroids result in an improved outcome as assessed by the KSS and significantly increases extensor strength.
No side effects were seen in either the study or control group. Osteoarthritis of the knee is one of the leading causes of pain and disability for the knee [ 1 ]. Total joint replacement is generally accepted as the main treatment for end-stage osteoarthritis. In fact it has revolutionized the treatment of disabling arthritis of the lower extremity [ 2 ]. Whilst patients report an overall improvement after surgery the benefits after surgery are most significant for pain and stiffness 3 months after surgery [ 8 ].
Substantial functional improvement using effect sizes of outcome measures are higher rated by surgeons whereas patients derived measures showed effect smaller effect sizes [ 9 ]. Muscle strength, especially quadriceps strength has been shown to be highly correlated with functional performance and undergoes a decline after surgery [ 10 , 11 ]. Improving postoperative muscle strength could thus be important to accelerate recovery and enhance the potential benefits of total knee arthroplasty [ 10 ].
Anabolic steroids have long been used by athletes to improve their performance [ 12 ]. They have potent anabolic effects on the musculoskeletal system, including an increase in lean body mass, a dose-related hypertrophy of muscle fibers, and an increase in muscle strength and mass [ 13 ]. The use of anabolic steroids in elderly patients after knee replacement could therefore have beneficial effects on postoperative development of muscle strength. This possible may result in faster recovery and earlier mobilization.
In addition anabolic steroids may have an effect on bone mineral density. The purpose of this study was to investigate the effects of small doses of Nandrolone decanoate on recovery and muscle strength after total knee replacement. A research hypothesis was formulated that there would be a difference between the group who received anabolic steroids resulting in faster recovery, higher muscle strength and increased bone mineral density compared to the group that only received normal saline injections.
Patients were recruited from the department of orthopaedic surgery outpatient clinics at a large regional academic teaching hospital. Prior to participation, all subjects were familiarized with the procedures and gave verbal and written informed consent in accordance with the Human Ethics Research Review Panel of the University and the Regional Health District.
The study was designed as a prospective randomized double-blinded pilot project. Patients aged between 50 and 70 years and monolateral primary osteoarthritis were recruited. Those with rheumatoid arthritis were excluded to avoid the introduction of confounding variables. Patients where the administration of Nandrolone could result in severe side effects or in significant interaction with other drugs and possibly cause worsening of pre-existing conditions such as prostate hypertrophy were excluded.
All patients were routinely assessed by a specialist physician prior to enrolment. Recruitment continued until five patients in each group was achieved.
Patients were allocated to either the steroid or control group by closed envelopes on the first day after surgery by the research coordinator. Randomization was carried out by a block of ten envelopes. The protocol was computer generated using an internet based generator http: This was done in order to guarantee continuation of randomization in case one of the patients needed to be excluded within the study period.
All patients received a combination of regional and general anaesthesia. A standard dose of 2 g Cefazolin was administered prior to anaesthesia. Postoperatively patients were admitted to the surgical ward.
A continuous passive motion CPM machine was used from the first postoperative day. All patients were mobilized full weight bearing on day 1 post surgery. As soon as patients were able to straight leg raise, flexion to 90 degrees actively was possible and a safe gait was achieved patients were discharged from the hospital.
Sutures were removed routinely 12 days postoperative by their general practioner. Further follow up was performed by an independent examiner at the gait laboratory of the Musculoskeletal Research Unit of the University 6 weeks, 3, 6, 9 and 12 month following surgery. All subjects were also tested at this institution the week prior to surgery. The operating surgeon was only involved if the patient experienced significant side effects or complications either resulting from surgery such as infections, knee effusions or loss of motion.
Patients were visited by the research nurse on day 2 or 3 after surgery whilst still hospitalized. Procedures were explained in detail and questions were answered. On day 5 patients received either 50 mg of Nandrolone decanoate or the equivalent volume of normal saline as an intramuscular injection. Patients were then visited every 2 weeks and injections with either normal saline or nandrolone was continued for a total of six months.
A modified "sit to stand" and "timed walking test" as described by Bohannon [ 14 ] was performed" pre-operatively" and "post-surgery" as described earlier. Bohannon [ 14 ] measured the time in seconds subjects needed as they stood up and sat down from a firm padded armless chair of which the seat was We modified the protocol in consideration that elderly patients after total knee replacement would not be strong enough to repeatedly rise from a chair within 3 months after surgery.
Patients were asked to stand up and sit down only once from a firm padded armless chair. Subjects were instructed to fold their arms across their chests before beginning the test. Subjects performed one timed trial. The stopwatch was started after the word "go" and stopped when the subject returned to the seated position. Speed of ambulation was assessed via electronic timing gates to record time to perform two laps between points 10 meters apart.
A single set of gates was used. Subjects walked through the timing gates, to a marked position 10 meters from the start, pivoted and walked back. Total time to perform the task was recorded at two cadences. Initial cadence was at self-selected speed as described by Pollo et al [ 15 ] to familiarize and warm-up.
Three trials were performed at maximal speed and average values were used for analysis. Subjects were then instructed to walk the same course at maximum speed. Reliability and responsiveness of this test has been demonstrated in healthy elderly populations [ 15 , 16 ]. The Knee Society Score knee and function scores was used in all cases. This rating system was introduced by Insall etal [ 17 ] and has become the standard evaluation system for reporting results after total knee replacement surgery.
The KSS was found to have high intra- and interobserver variation [ 18 , 19 ] and reliable use necessitates evaluation by an experienced observer. However as this score is still the most commonly outcome system used and has adequate construct validity [ 19 ] we felt that the use of the rating system in combination with the other outcome measures would be sufficient to detect in between group differences.
Each subject performed one set of five maximal extension and flexion repetitions. On each test occasion the non-involved limb was tested before the involved limb.
Peak torque generated by quadriceps and hamstring muscles were calculated from the three best trials. Peak torque was corrected for percentage bodyweight. BMD was measured the week prior to surgery and repeated at six month following total knee replacement. DEXA was performed on the lower spine and neck of femur of the involved limb.
The results were not matched for age, weight, gender and ethnic origin as the influence of nandrolone on BMD over the six month interval was the measured variable. Means and standard deviations were calculated for age, height and mass and for the dependant variables derived from the functional assessment, quadriceps and hamstring muscle strength testing, knee society score evaluation and BMD assessment for the nandrolone and control groups.
Independant samples t-tests were used to compare subject groups for age, height and mass and the knee society scores at pre-surgery, 3 months, 6 months, 9 months and 12 months. Similarly, an independant samples t-test was used to compare the BMD results at the spine and hip at pre-surgery and 12 months post-surgery.
For the functional and the isokinetic tests a repeated measures ANOVA design was used to compare test limbs of the nandrolone and control groups across test occasions.
Alpha level correction using Bonferroni or other such adjustments was not conducted so as to maintain statistical power. It is recognised that, whilst all the variables were carefully chosen, they are numerous and hence there is an increased risk of Type 1 error. However, the cost of incurring a Type 1 error was deemed minimal and therefore appropriate given the exploratory nature of the study.
The results of this study indicate there are definite beneficial effects of Nandrolone for patients undergoing knee replacement surgery.
The most obvious benefit is retention and significant improvement of quadriceps muscle strength as measured by isokinetic testing "pre-" and "post-operative". The outcome is associated with many factors. Marked functional limitations, a poor baseline status, low mental health scores and comorbidity are important pre-operative predictors [ 23 , 24 ].
Preoperative muscle strength has been identified to be one of the factors that influences functional outcome [ 25 ]. Patients with osteoarthritis have quadriceps weakness [ 22 ] which persists after surgery.
Hsieh et al [ 26 ] demonstrated in patients with rheumatoid arthritis that minor joint involvement can cause muscle imbalance and joint instability.
Berman et al [ 25 ] reported that patients with near normal quadriceps strength at minimum of 2 years after surgery had a more normal gait. He could also demonstrate that relatively greater quadriceps strength was associated with a better functional score. Huang et al [ 28 ] reported that even after years after surgery muscle balance still existed. It may thus be important to address muscle weakness following surgery to improve outcome [ 30 ].
However there are only a few studies published assessing strength training after knee replacement. Rossi et al [ 31 ] investigated the effect of an 8-week resistive training protocol immediately after surgery and found torque production lower at 30 days post surgery compared to pre-operative levels but greater at 60 days.