Are steroids safe to use after a total hip replacement?

Steroid Use After Total Hip Replacement

Intravenous dexamethasone 8-10 mg is recommended as part of multimodal analgesia for total hip arthroplasty, but routine systemic steroids are not recommended for long-term use after surgery due to potential complications. 1

Perioperative Steroid Use in Total Hip Arthroplasty

Recommended Steroid Use

• A single intra-operative dose of intravenous dexamethasone 8-10 mg is recommended as part of multimodal analgesia for total hip arthroplasty 1
• This single dose provides both analgesic and anti-emetic effects without significant adverse events 1
• Perioperative corticosteroids reduce postoperative pain, opioid requirements, and may have a neutral-to-positive effect on length of stay 2

Timing and Duration

• The safety of a single dose of steroids is well documented 1
• Multiple doses beyond 24 hours are not recommended due to insufficient studies and concern related to potential side effects 1
• Equipotent doses of alternative glucocorticoids appear to be equally effective 1

Management of Patients Already on Steroids

Patients on Chronic Steroid Therapy

• For patients already on chronic steroid therapy (e.g., for rheumatoid arthritis), continue the current daily dose rather than administering perioperative supra-physiologic "stress doses" 1
• This recommendation applies specifically to adults receiving ≤16 mg/day prednisone or equivalent for their rheumatic condition 1
• There is no evidence supporting the need for "stress-dose steroids" in patients undergoing orthopedic procedures 1

Monitoring and Precautions

• If hypotension related to adrenal crisis occurs perioperatively, administer a push dose of 100 mg hydrocortisone 1
• Be aware that chronic steroid therapy is associated with increased risk of surgical complications, including anastomotic leak or wound dehiscence 1

Risks and Considerations

Infection Risk

• Steroid therapy is a known cause of increased morbidity and mortality among surgical patients 1
• Patients undergoing total hip replacement after receiving intra-articular steroid injections may have an increased risk of infection, particularly if the injection was administered within 4 months prior to surgery 3
• There appears to be both a time and dose-dependent association between hip corticosteroid injections and periprosthetic joint infection following total hip arthroplasty 3

Hyperglycemia

• Perioperative corticosteroids may induce hyperglycemia in both diabetic and non-diabetic patients 2
• However, there is no strong evidence indicating that these transient corticosteroid-induced glycemic derangements increase the risk of postoperative infectious complications 2

Resuming Biologic Therapy After Surgery

• For patients on biologic therapy that was withheld prior to surgery, restart once the wound shows evidence of healing (typically ~14 days) 4
• Ensure all sutures/staples are out, there is no significant swelling, erythema, or drainage, and there is no clinical evidence of non-surgical site infections before restarting biologic therapy 4

Practical Recommendations

• Use a single intraoperative dose of dexamethasone 8-10 mg as part of multimodal analgesia 1
• For patients already on chronic steroids, continue their usual dose rather than increasing to "stress doses" 1
• Consider delaying elective total hip arthroplasty if a corticosteroid injection has been administered to the hip within 4 months prior to the planned procedure 3
• Monitor for signs of infection and wound healing complications, particularly in patients on chronic steroid therapy 1