Perioperative Dexamethasone in Periprosthetic Joint Infection Surgery: Diabetes-Stratified Results From a Propensity Score–Matched Retrospective Cohort Study

BACKGROUND: Dexamethasone is used in primary total joint arthroplasty (TJA) to reduce postoperative nausea and vomiting, and there is emerging evidence that it also ameliorates adverse events more broadly. Despite a lack of supporting data, a vocal minority has continued to question the appropriateness of dexamethasone in cases where the hyperglycemic burden and/or risk of infection are increased. This study sought to assess the benefits and potential harms of dexamethasone in a cohort of patients undergoing revision TJA for periprosthetic joint infection (PJI). We hypothesize that perioperative dexamethasone exposure is associated with fewer postoperative complications, regardless of diabetes status. METHODS: An all-payer, US hospital-based dataset was queried. Patients ≥18 years with a diagnosis of hip or knee PJI between 2015 and 2023 were identified using billing and procedural codes, and verified using hospital charges for antibiotics and spacers. The primary outcome was composite complications. Secondary outcomes (wound and infectious complications, as well as mortality) were evaluated to probe for potential safety signals. RESULTS: In total, 61,527 patients were identified. A total of 30,644 nondiabetic patients and 14,996 diabetic patients were 1:1 matched based on dexamethasone exposure, with good balance. Dexamethasone-treated patients had fewer aggregate complications in both cohorts (nondiabetic: adjusted odds ratio [aOR], 0.934 and 95% confidence interval [CI], 0.760-0.978; diabetic: aOR, 0.814 and 95% CI, 0.746-0.889). Dexamethasone was also associated with fewer wound complications (nondiabetic: aOR, 0.891 and 95% CI, 0.823-0.964; diabetic: aOR, 0.879 and 95% CI, 0.787-0.981) and infectious complications (nondiabetic: aOR, 0.891 and 95% CI, 0.823-0.964; diabetic: aOR, 0.827 and 95% CI, 0.754-0.908) . Only diabetic patients saw a statistically significant decrease in mortality (aOR, 0.692 and 95% CI, 0.532-0.901). CONCLUSIONS: As with any retrospective study, findings should be interpreted cautiously due to the possibility of residual confounding. Nevertheless, dexamethasone appears to be safe to use in patients undergoing first-stage revision for TJA for PJA regardless of diabetic status. Further, findings suggest that dexamethasone is associated with lower odds of aggregate complications, and contrary to conventional wisdom, these benefits may be even greater among diabetics.