Infection Risk with Oral Steroids Following Hip Replacement
Patients on oral corticosteroids at the time of hip replacement surgery face an increased risk of postoperative infections, with the magnitude of risk dependent on both the dose and timing of steroid exposure.
Risk Magnitude and Dose Relationship
The infection risk is clearly dose-dependent:
Patients taking ≥15-20 mg/day of prednisone (or equivalent) have a significantly elevated risk of postoperative infectious complications including periprosthetic joint infection (PJI) and surgical site infections 1.
Meta-analyses demonstrate an odds ratio of 1.68 (95% CI 1.24-2.28) for postoperative infectious complications in IBD patients on steroids, with an adjusted pooled OR of 1.7 (95% CI 1.38-2.09) 1.
Observational studies in arthroplasty patients show increased infection risk specifically with long-term steroid use >15 mg/day 1, 2.
Patients on lower doses (≤10-16 mg/day prednisone equivalent) have a lower but still present infection risk 1, 2.
Mechanism of Increased Risk
Corticosteroids increase infection susceptibility through multiple pathways:
- Direct immunosuppression reducing resistance to bacterial pathogens 1, 3.
- Impaired wound healing capacity 1.
- Masking of early infection signs, potentially delaying diagnosis 3.
Preoperative Optimization Strategy
For elective hip replacement, corticosteroids should be stopped or minimized to the lowest possible dose prior to surgery 1, 4:
- Complete cessation is ideal when medically feasible 1.
- If cessation is not possible, taper to <20 mg/day prednisone equivalent 1.
- The CDC defines the immunosuppression threshold at 20 mg/day for ≥2 weeks 1, 2.
Perioperative Management for Patients on Chronic Steroids
For patients who cannot discontinue steroids:
- Continue the current daily dose perioperatively rather than administering supraphysiologic "stress doses" 1, 2, 5.
- This recommendation applies to patients on ≤16 mg/day prednisone equivalent for rheumatic conditions 1, 2.
- Provide intravenous hydrocortisone in equivalent dosage until oral intake resumes (prednisolone 5 mg = hydrocortisone 20 mg = methylprednisolone 4 mg) 1, 4.
Timing Considerations for Steroid Injections
Intra-articular corticosteroid injections into the hip joint demonstrate both time and dose-dependent infection risk:
- Injections within 3-4 months of THA significantly increase PJI rates (1.58-2.04% vs 1.04-1.47% in controls) 6, 7.
- Each injection within 3 months increases infection odds in a dose-dependent manner (OR 1.45-3.59) 6.
- Elective hip replacement should be delayed at least 3-4 months after any intra-articular steroid injection 4, 6, 7.
Postoperative Monitoring
Critical surveillance parameters include:
- Wound healing assessment for erythema, drainage, or dehiscence 1, 4.
- Signs of deep infection including persistent pain, fever, or elevated inflammatory markers 3.
- Adrenal insufficiency symptoms in patients on chronic steroids (hypotension, weakness) 3.
Common Pitfalls to Avoid
Do not administer unnecessary stress-dose steroids to patients on chronic low-dose therapy for rheumatic conditions, as this increases infection risk without hemodynamic benefit 1, 2, 5.
Do not proceed with elective surgery within 3 months of intra-articular hip injection due to substantially elevated infection risk 4, 6, 7.
Do not abruptly discontinue chronic steroids without appropriate tapering and perioperative coverage, as this risks adrenal crisis 3.
Avoid assuming all steroid-exposed patients have equal risk—dose and duration matter significantly 1, 6.