Should a Course of Oral Corticosteroids Be Used Routinely After TKA?

We commend Kanitnate et al. for their completion of a randomized controlled trial (RCT) on the important topic of pain control after total knee arthroplasty (TKA). The study randomized 120 patients undergoing primary TKA to receive either 16 or 8 mg of dexamethasone orally or a placebo for 5 days, starting the morning of the operation. The higher-dose dexamethasone group had significantly less pain at rest and during motion, although both doses improved pain at rest. Many institutions are routinely administering intravenous corticosteroids at the time of the TKA1–3, but using oral corticosteroids for several days perioperatively has not become routine practice. The advantages of perioperative corticosteroid use include lower pain levels, lower opioid requirements, and a potentially lower incidence of postoperative nausea or vomiting. There is even some evidence that perioperative use of corticosteroids can improve range of motion and prevent arthrofibrosis4. However, concerns regarding increased infection risk and difficulty with perioperative glucose control have limited the implementation of prolonged corticosteroid administration after TKA. This well-executed RCT with 3 arms provides valuable information to orthopaedic surgeons and the entire care team on the benefit and safety of the higher dose of oral corticosteroid following primary TKA. The authors conclude that oral corticosteroids, and specifically the higher 16-mg dexamethasone dosage, can be an effective and inexpensive intervention for improving pain control both at rest and during motion, while not resulting in dangerous rises in glucose levels. They also mention that this could be a useful alternative in patients who cannot tolerate nonsteroidal anti-inflammatory drugs (NSAIDs). This is an interesting point, as there is growing evidence that patients who either are not prescribed or cannot use NSAIDs are at increased risk for arthrofibrosis and manipulation under anesthesia (MUA). A prolonged course of oral corticosteroids, at a higher dose as was used in this study, may be a necessary action to mitigate the risk of arthrofibrosis in patients who are prescribed blood thinners stronger than aspirin, as we know that these patients are at increased risk for MUA5. In the present study, the benefit of the higher-dose oral corticosteroid was greatest in the first 2 days following TKA, despite the treatment being administered for 4 days postoperatively. A separate study in select patients at high risk for arthrofibrosis and MUA would be valuable to determine what dose and duration of oral corticosteroids would be safe and efficacious. We have also seen improvements in range-of-motion gains by initiating a high-dose oral corticosteroid regimen in patients who are struggling to reach 90° of motion at 3 weeks or later after primary TKA. Prior to widespread adoption of a 5-day protocol for oral corticosteroid use, however, surgeons should consider the limitations of this study. It was a relatively small RCT of patients who all stayed in the hospital for 2 nights following surgery. The study was not powered to detect differences in morphine consumption. Furthermore, there is cultural variation in perioperative opioid utilization6, and the overall opioid consumption was quite low in this study’s population in Thailand compared with the average usage in the United States following TKA (Table II). While patients with a hemoglobin A1c of >7% were excluded, we do not know how many of the included patients had well-controlled diabetes. Similarly, patients with a body mass index of >40 kg/m2 were excluded. Therefore, it is difficult to know how well this population compares with the common patient population in most of the United States. Furthermore, as patients who may be especially prone to glucose intolerance with high doses of corticosteroids were excluded, we do not know if such patients would have higher rates of periprosthetic joint infection if the oral corticosteroid strategy was used routinely. While this study is great initial work, we believe that a larger RCT that would be better powered for many of these outcomes would put surgeons further at ease in adopting this oral corticosteroid strategy.