The use of steroids in patients undergoing total knee and hip arthroplasties has been extensively described in the literature. A perioperative, systemic single steroid injection has been shown to be effective in the reduction of postoperative pain, postoperative opioid consumption, hospital stay, reduction of postoperative vomiting and nausea.10−12 Some authors report that a perioperative, periarticular single-dose injection can improve short-term functional recovery and clinical parameters, resulting in better outcomes without any increase in perioperative complications.13−16 However, these studies examine short-term administration of steroids and the short-term effects observed during a hospital stay. In contrast, our present study examines the results of postoperative oral prednisolone administration in patients, one year after TKA. Oral application was prescribed depending on the patient weight and continued for up to three months in all cases, regardless of the range of motion limitation. In this case, the main aim of prednisolone administration was not to reduce the postoperative side effects of anesthesia, but gain better functional results and motion: secondary to persistent pain and loss of function, knee stiffness related to joint arthrofibrosis following primary TKA can lead to unsatisfactory patient outcomes. This may require intensive rehabilitation, manipulation under anesthesia (MUA) or even revision knee arthroplasty.6 No similar studies were found by us in the present literature.
Our results indicate that patients who received prednisolone as postoperative therapy gained better outcomes than the controls, as indicated by WOMAC, clinical and functional KSS and ROM scores. This improvement may be associated with the analgesic effect known to be provided by glucocorticoids, which acts by inhibiting peripheral phospholipase; this effect will reduce anxiety and allow better rehabilitation. In addition, steroids have also been found to have anti-inflammatory effects.4,5,10−12
In properly performed TKA postoperative joint contracture is related to the development of intra-articular adhesions, created on the basis of a hematoma, and related to an excessive fibrosis within the articular capsule.4 Glucocorticoids prevent fibroblast migration, as well as their growth and development; they are also known to inhibit the synthesis of collagen. It is possible that glucocorticoids such as prednisolone may act through influencing fibroblast activity, as well as collagen production or degradation, judging from periarticular and intra-articular adhesions, excessive fibroplasia of the cicatrix.4
Interest has recently grown in the perioperative systemic use of steroids in patients undergoing total knee and hip replacement, with a number of well-designed studies, systematic reviews and metanalyses being published.6,11,17 However it is difficult to make comparisons between studies due to the variation in the doses and types of steroids used, as well as the timing of administration. A meta-analysis of randomized trials by Yue et al. confirmed that steroid injections offer positive benefits in terms of lower incidence of postoperative nausea and vomiting, as well as reduction of acute postoperative pain, hospital stay, without significant complications or adverse events. They also note an improvement in early functional rehabilitation and inflammation control. The examined studies focused on perioperative systemic administration of steroids with the aim of shortening recovery time in total knee and hip arthroplasty; medications were given before the operation with one or two doses possibly being given every eight hours following the operation.11,12,17
Lower levels of IL-6 have been found within 24 hours following the operation18, and lower CRP concentrations have been recorded in steroid groups in the 24 hours following THA.12 In addition, lower IL-6 levels have were also observed 12 hours after operation.19 Perioperative systemic steroid administration is associated with reduction of pain shortly after operation, with the effects being well defined within the first 24 hours, following which, the differences disappear.12,19 Another metanalysis of three studies confirmed lower opioid consumption within 48 hours of the operation following steroid administration.11 Metanalyses comparing steroid and non-steroid groups clearly show a low risk of complications such as superficial or deep infection, delayed wound healing, ONFH, venous thromboembolic events and pruritus, and that this risk is similar in both groups.11,17
It would be interesting to investigate whether steroid administration could improve the rehabilitation process. Some studies have shown that, similar to pain reduction, administration also has a positive effect on very early functional outcomes: the effects are seen mostly within the first postoperative days, before discharge from the hospital 10,12, however, no significant difference can be seen between steroid and non-steroid groups at six weeks and one year following the procedure.20 Hence it appears to be logical to prolong steroid administration to gain better rehabilitation results, as confirmed by our research.
Steroids can also be administered through periarticular steroid injections; these can be supplemented with local anesthetics and epinephrine to reduce post-operative pain and inflammation. This route of administration also improves short-term functional recovery and clinical parameters, resulting in better outcomes for patients without being associated with steroid-related complications.16 The short term, local pain-relieving effect of this kind of multimodal cocktail has been confirmed by other authors13,15, for example, a metanalysis by Cui et al. confirms that steroid injection in TKA/THA provides short-term advantages in pain relief and antiemetic effects.14
There are some limitations of the study. The first is that it uses a relatively small group of patients; however, the study is focused on very specific rare cases characterized by severe, advanced osteoarthritis which is primary, secondary or related to autoimmunological diseases. Also, as the material was collected in a center specializing in hip and knee surgery, it would be difficult to collect a larger sample. The second limitation is related to heterogeneity of the prednisolone group: knee pathology comprises a broad spectrum etiologies and deformities that require the use of implants with an adequate level of constraints. The effect of this heterogeneity was reduced as much as possible by matching individual patients from the study group with similar ones from the control group with regard to gender, etiology, range of motion before operation and type of deformity. The third limitation of the study is variety of implant used, what was dependent on bone defects and ligamentous stability. Finally, the fourth limitation is related to the fact that patients from both groups were operated in different time periods: prednisolone treatments began in 2014, and the patients from control group were treated before this period; hence, this can be regarded as a historical group.