What are the guidelines for steroid injections after total shoulder replacement?

Steroid Injections After Total Shoulder Replacement

Avoid corticosteroid injections within 3 months before total shoulder arthroplasty (TSA), and exercise extreme caution with any intra-articular steroid injections after TSA due to infection risk.

Critical Timing Considerations

Pre-operative Window

• Corticosteroid injections should be avoided for at least 3 months preceding joint replacement surgery 1
• Patients receiving steroid injections within 4 weeks of TSA have significantly increased periprosthetic joint infection (PJI) risk at 1 year (OR 2.29) and 2 years (OR 2.03) 2
• TSA should be deferred at least 4 weeks after a patient receives a corticosteroid injection to mitigate PJI risk 2
• Injections given 4-8 weeks or 8-12 weeks before TSA do not show significantly increased PJI risk 2

Post-operative Context

The available guidelines address steroid injections for pre-operative glenohumeral osteoarthritis, not post-arthroplasty management 3. The American Academy of Orthopaedic Surgeons states they are "unable to recommend for or against the use of injectable corticosteroids" even for native joint osteoarthritis due to lack of evidence (Grade I recommendation, Level V evidence) 3.

Key Risk Factors

Infection Risk

• Repeated intra-articular steroid injections are a predisposing factor for prosthetic joint infection 3
• Infection after TSA occurs in 0.7-2.9% of cases, with higher rates (0.8-10%) in reverse total shoulder arthroplasty 3
• Patients undergoing surgery while on corticosteroids have increased risk of postoperative infectious complications 1

Chronic Steroid Use Complications

• Chronic steroid use is independently associated with increased odds of major complications (OR 2.20), minor complications (OR 2.32), and infectious complications (OR 1.90) after shoulder surgery 4
• Patients on chronic steroids have higher rates of wound healing complications and anastomotic leaks 1

Clinical Decision Algorithm

For Patients Already on Chronic Steroids at Time of TSA

If patient has been on oral corticosteroids for >4 weeks:

• Continue equivalent intravenous hydrocortisone while nil by mouth perioperatively 1
• Prednisolone 5 mg = hydrocortisone 20 mg = methylprednisolone 4 mg 1
• Do not increase steroid dosage to "cover stress" in the perioperative period - this has no proven benefit 3
• Implement standardized steroid-taper protocols postoperatively to avoid inappropriate prolongation 1

For elective surgery:

• Stop corticosteroids preoperatively or minimize dose wherever possible to reduce postoperative complication risk 1

For Post-operative Pain Management After TSA

Preferred approach:

• A 6-day oral methylprednisolone taper starting immediately postoperatively (not as an injection) reduces pain and opioid consumption without increasing complications 5
• This systemic approach showed 70% reduction in opioid consumption (5.5 vs 17.6 tablets) with no increase in infection rates at mean 21-month follow-up 5

Avoid intra-articular injections post-TSA:

• No evidence supports safety or efficacy of intra-articular steroid injections into a prosthetic shoulder joint
• The infection risk profile makes this approach inadvisable given the catastrophic consequences of prosthetic joint infection

Important Caveats

Evidence Limitations

• No high-quality evidence exists specifically addressing steroid injections after TSA - the guidelines only address pre-operative osteoarthritis management 3
• Evidence from rotator cuff repair (showing safety of post-operative injections at 8 weeks) 6, 7 cannot be extrapolated to prosthetic joints due to fundamentally different infection risk profiles

Monitoring Requirements

• Monitor for signs of wound healing complications, infection, and adrenal insufficiency in patients who received corticosteroids before surgery 1
• Maintain high clinical suspicion for prosthetic joint infection in any patient with persistent pain after TSA, especially those with prior steroid exposure 3

The safest approach is to avoid intra-articular corticosteroid injections entirely in the post-TSA setting, using systemic oral steroid tapers for pain management when needed, while ensuring adequate time (≥3 months) between any pre-operative injections and the surgical procedure.