Author: Thomas Vingerhoets, et al.
Cureus, May 28, 2026
Postoperative pain after total knee arthroplasty can delay mobilization, increase opioid requirements, and slow functional recovery. Although intravenous dexamethasone is commonly incorporated into multimodal analgesia, the effectiveness and safety of extending corticosteroid treatment with an oral postoperative regimen remain uncertain.
This systematic review evaluated oral corticosteroids started within 48 hours after primary total knee arthroplasty for osteoarthritis. The investigators identified 12 studies, including four randomized controlled trials used in the primary analysis, involving 380 randomized patients.
Key findings
• Postoperative oral corticosteroids reduced cumulative opioid consumption during the first 48 hours by approximately 8.6 oral morphine-equivalent milligrams.
• This reduction represents roughly one to two 5-mg oxycodone tablets and may be clinically modest.
• The opioid finding was based on only two trials, and both required estimated or imputed standard deviations, making the result fragile and exploratory.
• Pain at rest at 48 hours was approximately 7 mm lower on a 100-mm pain scale, but the confidence interval crossed zero, and the result was not statistically significant.
• One trial showed a meaningful pain reduction, while another found essentially no benefit, producing substantial heterogeneity between studies.
• A sensitivity-only analysis suggested an approximately 9-mm improvement in pain with movement at 48 hours. However, the contributing studies did not fully meet the criteria for the primary analysis.
• No consistent improvement was demonstrated in hospital length of stay, knee range of motion, functional scores, or patient satisfaction.
Safety
The combined rate of surgical-site infection or periprosthetic joint infection was indeterminate. There were only two infections among 141 patients receiving oral corticosteroids and one infection among 133 control patients in the primary pooled analysis.
The resulting confidence interval was extremely wide and was compatible with either benefit or substantial harm. The studies were far too small to reliably detect uncommon complications such as periprosthetic joint infection.
No clear short-term safety signal was identified, but the absence of a detected signal should not be interpreted as proof of safety.
Important limitations
The available evidence was highly heterogeneous. Oral corticosteroid regimens included dexamethasone, methylprednisolone, prednisolone, prednisone, and deflazacort. Treatment durations ranged from a single dose to 21 days.
Several trials administered intravenous corticosteroids to both treatment groups. These studies therefore evaluated the additional effect of an oral course on top of intravenous dexamethasone rather than the independent effect of oral corticosteroids.
The authors also identified concerns involving retrospective trial registration, changes between registered and published outcomes, incomplete outcome reporting, small sample sizes, and inconsistent dosing regimens.
The certainty of evidence was rated very low for all six major outcomes:
• Pain at rest
• Pain with movement
• Opioid consumption
• Surgical-site or periprosthetic joint infection
• Hospital length of stay
• Knee range of motion
Clinical implications
Postoperative oral corticosteroids may slightly reduce opioid use during the first 48 hours after total knee arthroplasty, but the benefit appears modest and remains uncertain.
Current evidence does not support routinely adding an oral corticosteroid course to contemporary multimodal analgesia following primary total knee arthroplasty.
Clinicians considering oral corticosteroids should evaluate each patient’s risks, including diabetes, hyperglycemia, infection risk, impaired wound healing, gastrointestinal disease, and concurrent immunosuppressive therapy.
Bottom line
Postoperative oral corticosteroids may reduce early opioid consumption after total knee arthroplasty, but the evidence is very uncertain. A meaningful improvement in pain, mobility, length of stay, or functional recovery has not been established.
No definite short-term safety concern was identified, but the trials were not large enough to exclude uncommon yet serious complications. Routine postoperative oral corticosteroid treatment cannot currently be recommended without better randomized evidence using standardized medications, doses, and treatment durations.
Thank you to Cureus for allowing us to summarize this systematic review.