What is the role of intravenous (IV) steroids, such as dexamethasone (corticosteroid) or methylprednisolone (corticosteroid), in patients undergoing total joint replacement surgery?

IV Steroids in Total Joint Replacement

A single intraoperative dose of IV dexamethasone 8-10 mg is recommended for patients undergoing total joint arthroplasty to reduce postoperative pain, nausea, and length of hospital stay, with minimal adverse effects. 1, 2

Perioperative Steroid Administration

For Patients NOT on Chronic Steroids

Single intraoperative dose:

• Administer dexamethasone 8-10 mg IV at induction of anesthesia or intraoperatively 1, 2
• This provides multimodal analgesia with anti-emetic properties 2
• Reduces postoperative pain scores, opioid consumption, and length of hospital stay 1
• Side effects are limited to physiological rise in blood glucose levels, which is clinically manageable 1

Evidence supporting safety:

• Multiple systematic reviews demonstrate no increased risk of postoperative wound infections or anastomotic leakage with single-dose dexamethasone 1
• Meta-analysis of 17 RCTs in total joint arthroplasty confirmed reduced pain, stress response, and length of stay without significant complications 1

Alternative glucocorticoids:

• Equipotent doses of other glucocorticoids (methylprednisolone 125 mg, prednisolone 20 mg, or hydrocortisone) appear equally effective 1, 2
• Methylprednisolone 125 mg reduced 24-hour pain scores compared to placebo 1

For Patients on Chronic Steroid Therapy

Continue current regimen without stress dosing:

• Patients on ≥5 mg prednisolone equivalent for ≥4 weeks should continue their usual daily dose 2, 3
• Do NOT administer supraphysiologic "stress doses" - there is no evidence supporting this practice in orthopedic procedures 2, 3

Perioperative management:

• While nil by mouth, give equivalent IV hydrocortisone (prednisolone 5 mg = hydrocortisone 20 mg = methylprednisolone 4 mg) 1, 3
• Resume oral steroids once patient can take medications enterally 1

Important caveat:

• Patients on chronic steroids have increased risk of surgical complications including wound dehiscence and infections 1, 2, 3
• For elective surgery, minimize steroid dose preoperatively whenever possible without causing disease flare 1

Postoperative Steroid Administration

Additional postoperative dosing may be beneficial:

• One RCT demonstrated that dexamethasone 0.1-0.2 mg/kg IV given 24 hours postoperatively provided superior pain and nausea control for 48 hours compared to preoperative dosing alone 4
• Preoperative dexamethasone effects lasted only 24 hours, while pain and nausea persisted beyond 48 hours post-TKA 4
• This suggests consideration of repeat dosing at 24 hours postoperatively for enhanced recovery 4

However, routine postoperative steroids are not standard practice and the single intraoperative dose remains the guideline recommendation 1, 2

Critical Timing Considerations with Intra-articular Corticosteroid Injections

Avoid total joint arthroplasty within 3 months of intra-articular corticosteroid injection:

• Meta-analysis showed increased odds of periprosthetic joint infection when surgery performed within 3 months of injection (OR 1.39,95% CI 1.04-1.87) 5
• No increased infection risk when surgery delayed beyond 3 months 5, 6
• This applies to diagnostic/therapeutic joint injections, NOT to perioperative IV steroids 1, 5

Common Pitfalls to Avoid

Do not:

• Administer "stress dose" steroids to patients on chronic low-dose steroids undergoing joint replacement 2, 3
• Perform total joint arthroplasty within 3 months of intra-articular steroid injection 1, 5
• Use multiple doses of perioperative steroids routinely (single dose is standard) 1
• Withhold the patient's usual steroid dose on day of surgery if they are on chronic therapy 1, 2

Do:

• Integrate dexamethasone as part of multimodal analgesia protocol including paracetamol and NSAIDs/COX-2 inhibitors 1, 7
• Monitor blood glucose in diabetic patients receiving dexamethasone 1
• Ensure aseptic technique if performing any injections 6, 8