Peri-operative steroids reduce pain, inflammatory response and hospitalisation length following knee arthroplasty without increased risk of acute complications: a meta-analysis
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There is no consensus regarding the risks and benefits of peri-operative steroid supplementation in total knee arthroplasty (TKA). The aim of this meta-analysis is to compare TKA protocols implemented with or without steroids in terms of pain, inflammatory response, hospitalisation length, and complications.
A systematic literature search was performed on July 2019 in PubMed, Medline, Embase, Web of Science, Cochrane library, and the grey literature for a meta-analysis of RCTs comparing peri-operative analgesia protocols implemented with or without steroids. Sub-analyses considering the administration route, steroid type, and dosage were performed. The inverse variance method and the Mantel–Haenszel test were used for pooling continuous variables and for dichotomous variables, respectively. Risk of bias and quality of evidence were defined according to the Cochrane guidelines.
Twenty articles were included. Steroid supplementation provides significantly lower post-operative pain from day 1 to day 4 (p < 0.05), with less opioid consumption (p = 0.05), less nausea and vomiting (p < 0.05), and greater knee range of motion (p < 0.001), thus resulting in a shorter hospitalisation length (p = 0.01). Moreover, lower C-reactive protein (p < 0.05), and IL-6 (p < 0.05) levels, but a higher blood glucose level at day 1 (p = 0.004), were documented. No significant differences were documented in all the outcomes after 4 days of follow-up. These results were achieved without an increased incidence of complications. According to the results of the sub-analyses, the intravenous administration of 200 steroid equivalents of a long-acting steroid was associated with better results.
Steroid supplementation of peri-operative drug protocols is effective in decreasing post-operative pain, opioid consumption, nausea and vomiting, range of motion limitation, and inflammatory markers without increasing short- and mid-term complications. Although these benefits last only the peri-operative period, steroid supplementation can reduce the length of hospitalisation after TKA.
Level of evidence
Systematic review and meta-analysis, level II.
KeywordsTKA Prosthesis Total knee replacement Steroid Post-operative pain Hospitalisation
Total knee arthroplasty
Randomised controlled trial
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Patient reported outcome measures
Post-operative nausea and vomit
Range of motion
We would like to thank Guido Ascenso for the help with the English version of the manuscript.
DP conceived the methods of the study, performed the database search, the article selection and data extraction processes, performed the statistical analysis and drafted the manuscript. GDLF conceived the methods of the study, performed the database search, the article selection and data extraction processes, and drafted the manuscript. GF conceived the methods of the study, helped with the data extraction process, and drafted the manuscript. LD, MD, and CC helped to draft the manuscript. All authors read and approved the manuscript.
Compliance with ethical standards
Conflict of interest
Dr. Previtali, Dr. Di Laura Frattura, Dr. Deabate and Dr. Delcogliano declare they have no conflict of interest. Dr. Filardo reports institutional support from Finceramica Faenza SPA, Fidia Farmaceutici SPA, CartiHeal (2009) ltd, EON medical SRL, IGEA clinical biophysics, BIOMET, and Kensey nash outside the submitted work. Dr. Candrian reports grants from Medacta International SA, Johnson & Johnson, Lima Corporate, Zimmer Biomet, and Oped AG, outside the submitted work.
No funding were avaliable for this study.
This meta-analysis and all the included studies meet all the ethical standards described in the declaration of Helsinki. No ethical commitee approval was required for this study.
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