High-dose glucocorticoid before hip and knee arthroplasty: To use or not to use—that’s the question

During the last decade, “fast-track” or “enhanced recovery” programs have been introduced in hip and knee arthroplasty (THA/TKA) with a continuing improvement in recovery and consequently reduction in length of stay (LOS) (Zhu et al. 2017). Importantly, LOS may depend on early organ dysfunction, appearance of complications, or organizational factors. Early postoperative organ dysfunction including pain, orthostatic intolerance, cardiovascular and thromboembolic morbidity, cognitive disturbances, nausea and vomiting, sleep disturbances, fatigue, and loss of muscle function may all depend on factors involved in the global surgical stress response. Two main mechanisms include the neuro-endocrine responses and the inflammatory-immunological responses, where the latter may be most important to determine post THA/TKA recovery (Gaudilliere et al. 2014). Of the various pharmacological interventions to reduce the inflammatory responses, glucocorticoids are the most powerful (de la Motte et al. 2014, Steinthorsdottir et al. 2017, Toner et al. 2017). Notably, systemic perioperative glucocorticoid administration has been the subject of 7 systematic reviews and/or meta-analyses in THA/TKA since December 2016, summarizing that glucocorticoids may reduce nausea and vomiting as well as acute early postoperative pain. Interestingly, all of the 7 reviews (Hartman et al. 2017, Li et al. 2017, Liu et al. 2017, Meng and Li 2017, Yue et al. 2017, Li et al. 2018, Mohammad et al. 2018) claim to be the first and even more interestingly they include between 4 and 14 studies, thereby questioning the search methodology. Although all reviews agree that additional glucocorticoid may provide more analgesia, a critical assessment of efficacy was not done in relation to basic anesthetic/analgesic principles with different regimes in the different RCTs and a dose-finding analysis was only discussed in one review, but was not possible (Yue et al. 2017). Overall, most pain studies have used a limited dose of glucocorticoid (about 6–12 mg dexamethasone), but the most detailed studies discussed below have used a higher dose (125 mg methylprednisolone/∼ 25 mg dexamethasone). Nevertheless, a more critical update on the use of perioperative glucocorticoid in THA and TKA may be appropriate in the light of more recent findings of specific pathophysiological responses to surgery and safety aspects.