Do patients with total knee arthroplasty (TKA) require corticosteroid injections?

From the Guidelines

Patients with total knee replacements generally do not need steroid injections as a routine treatment. After a total knee replacement, the arthritic joint surfaces that previously caused pain have been removed, eliminating the need for steroid injections that might have been helpful before surgery. However, some patients may experience persistent pain after knee replacement due to conditions like soft tissue inflammation or complex regional pain syndrome, in which case a steroid injection might be considered. These injections typically contain corticosteroids like methylprednisolone or triamcinolone, often combined with a local anesthetic like lidocaine, administered directly into the area around the prosthetic joint (not inside it). The decision to use steroid injections should be made cautiously due to potential risks including infection, which is particularly concerning with prosthetic joints, as noted in the 2021 study by the US Department of Veterans Affairs/US Department of Defense clinical practice guideline 1.

There's also concern that repeated injections could potentially damage the prosthetic components over time. Most post-replacement pain management focuses on physical therapy, appropriate activity modification, oral anti-inflammatory medications, and addressing any mechanical issues with the prosthesis rather than relying on steroid injections. The American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee conditionally recommend intraarticular corticosteroid injections for the management of knee OA 1. However, the 2021 guideline suggests that the effects of corticosteroid injections are time-limited and may have potential long-term negative effects on bone health, joint structure, and meniscal thickness associated with repeat administration 1.

Key considerations for the use of steroid injections in patients with total knee replacements include:

• The potential benefits of pain relief and improved function
• The potential risks of infection, damage to prosthetic components, and long-term negative effects on bone health and joint structure
• The importance of cautious decision-making and careful patient selection
• The need for alternative pain management strategies, such as physical therapy, activity modification, and oral anti-inflammatory medications.

From the Research

Patient Needs for Steroid Injections After Total Knee Replacements

• The need for steroid injections in patients with total knee replacements is a topic of ongoing research, with studies yielding mixed results 2, 3, 4.
• Some studies suggest that steroid injections may not increase the risk of infection in patients with total knee replacements, and may even provide relief from pain and inflammation 2, 4.
• However, other studies have found that steroid injections may increase the risk of infection, particularly if administered within a certain time frame before or after surgery 3.
• A study published in 2021 found that corticosteroid injections within 2 weeks before total knee arthroplasty increased the risk of postoperative infection, but injections within 2 to 4 weeks trended toward increased infection in univariate regression 3.
• Another study published in 2019 found that intra-articular corticosteroid injections after total knee arthroplasty were effective in reducing pain and improving function, with no cases of periprosthetic joint infection reported within 1 year of injection 4.

Considerations for Steroid Injections

• The decision to administer steroid injections to patients with total knee replacements should be made on a case-by-case basis, taking into account the individual patient's medical history, symptoms, and risk factors 3, 4.
• Patients who receive steroid injections should be closely monitored for signs of infection or other complications, and alternative treatments should be considered for those who are at high risk of adverse effects 3, 5.
• Further research is needed to determine the optimal timing and dosage of steroid injections for patients with total knee replacements, as well as to fully understand the potential risks and benefits of this treatment approach 3, 4.

Alternative Treatments

• Other treatments, such as tramadol hydrochloride/acetaminophen combination therapy, may be effective for managing perioperative pain after total knee arthroplasty, and may be considered as an alternative to steroid injections 6.
• Non-steroidal anti-inflammatory drugs (NSAIDs) are also commonly used to manage pain and inflammation after total knee arthroplasty, but may be associated with serious adverse events in some patients 6.