The Effect of Adding Corticosteroid to the Periarticular Injection Cocktail for Pain Control after Total Hip and Total Knee Arthroplasty: A Double-Blinded Randomized Clinical Trial

Document Type : RESEARCH PAPER


Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran


Background: The impact of periarticular corticosteroid injection for pain control after total joint arthroplasty (TJA) is
controversial. The present study aimed to investigate this controversy in patients undergoing total hip arthroplasty
(THA) and total knee arthroplasty (TKA).
Methods: A total of 42 THA and 42 TKA patients were included in this study. The patients of each group were randomly
allocated into group A (cocktail+Depo-Medrol) and group B (cocktail alone). The outcome measures were a Visual
Analog Scale (VAS) for pain at five different time points for both THA and TKA, as well as the knee range of motion
(ROM) and straight leg raise (SLR) for the TKA group only. Patients were followed for three months to observe infection,
wound complications, and any venous thromboembolic event.
Results: In the THA group, the preoperative VAS, 12, 24, 48, and 72h postoperative VAS were not statistically different
between groups A and B (P=0.49, P=0.5, P=0.96, P=0.15, and P=0.11, respectively). In the TKA group, the preoperative
VAS, 12, 24 48h, and 72h postoperative VAS were not statistically different between groups A and B (P=1.0, P=0.47,
P=0.82, P=0.92, P=0.5, respectively). The mean scores of knee range of motion and ability to perform SLR were not
significantly different between TKA patients in the steroid and non-steroid groups (P=0.18 and P=0.58, respectively).
The only observed complication was one surgical site infection in the non-steroid group of the TKA.
Conclusion: The obtained results did not support the benefit of including a steroid (Depo-Medrol) in the periarticular
injection cocktail for pain control after the THA and TKA.
Level of evidence: II


  1. Anderson AS, Loeser RF. Why is osteoarthritis an age-related disease? Best Pract Res Clin Rheumatol. 2010;24(1):15-26. doi: 10.1016/j.berh.2009.08.006.
  2. Bagherifard A, Jabalameli M, Mirzaei A, Khodabandeh A, Abedi M, Yahyazadeh H. Retaining the medial collateral ligament in high tibial medial open-wedge osteotomy mostly results in postoperative intra-articular gap reduction. Knee Surg Sports Traumatol Arthrosc. 2020;28(5):1388-1393. doi: 10.1007/s00167-019-05473-8.
  3. Kremers HM, Larson DR, Crowson CS, et al. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am. 2015;97(17):1386. doi: 10.2106/JBJS.N.01141.
  4. Feng JE, Novikov D, Anoushiravani AA, Schwarzkopf R. Total knee arthroplasty: improving outcomes with a multidisciplinary approach. J Multidiscip Healthc. 2018;11:63. doi: 10.2147/JMDH.S140550.
  5. Society KK. Guidelines for the management of postoperative pain after total knee arthroplasty. Knee Surg Relat Res. 2012;24(4):201. doi: 10.5792/ksrr.2012.24.4.201.
  6. Lee RM, Tey JBL, Chua NHL. Postoperative pain control for total knee arthroplasty: continuous femoral nerve block versus intravenous patient controlled analgesia. Anesth Pain Med. 2012;1(4):239. doi: 10.5812/aapm.3404.
  7. Ilfeld BM, McCartney CJL. Searching for the optimal pain management technique after knee arthroplasty: analgesia is just the tip of the iceberg. Anesthesiology. 2017;126(5):768-770. doi: 10.1097/ALN.0000000000001608.
  8. Jiang J, Teng Y, Fan Z, Khan MS, Cui Z, Xia Y. The efficacy of periarticular multimodal drug injection for postoperative pain management in total knee or hip arthroplasty. J Arthroplasty. 2013;28(10):1882-1887. doi: 10.1016/j.arth.2013.06.031.
  9. Peters CL, Shirley B, Erickson J. The effect of a new multimodal perioperative anesthetic regimen on postoperative pain, side effects, rehabilitation, and length of hospital stay after total joint arthroplasty. J Arthroplasty. 2006;21(6):132-138. doi: 10.1016/j.arth.2006.04.017.
  10. Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty. 2007;22(6):33-38. doi: 10.1016/j.arth.2007.03.034.
  11. Kurosaka K, Tsukada S, Ogawa H, et al. Addition of corticosteroid to periarticular injections reduces postoperative pain following total hip arthroplasty under general anaesthesia: a double-blind randomized controlled trial. Bone Joint J. 2020;102(10):1297-1302. doi 10.1302/0301-620X.102B10.BJJ-2020-0428.R1.
  12. Reddy AVG, Thayi C, Natarajan N, et al. Validating the role of steroid in analgesic cocktail preparation for local infiltration in total knee arthroplasty: a comparative study. Anesth Essays Res. 2018;12(4):903. doi: 10.4103/aer.AER_138_18.
  13. Zhao X, Qin J, Tan Y, Mohanan R, Hu D, Chen L. Efficacy of steroid addition to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis. J Orthop Surg Res. 2015;10(1):1-12. doi: 10.1186/s13018-015-0214-8.
  14. Li Q, Mu G, Liu X, Chen M. Efficacy of additional corticosteroids to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2021;16(1):1-14. doi: 10.1186/s13018-020-02144-0.
  15. Tran J, Schwarzkopf R. Local infiltration anesthesia with steroids in total knee arthroplasty: a systematic review of randomized control trials. J Orthop. 2015;12:S44-S50. doi: 10.1016/j.jor.2015.01.017.
  16. Summers S, Mohile N, McNamara C, Osman B, Gebhard R, Hernandez VH. Analgesia in total knee arthroplasty: current pain control modalities and outcomes. J Bone Joint Surg Am. 2020;102(8):719-727. doi: 10.2106/JBJS.19.01035.
  17. Kelley TC, Adams MJ, Mulliken BD, Dalury DF. Efficacy of multimodal perioperative analgesia protocol with periarticular medication injection in total knee arthroplasty: a randomized, double-blinded study. J Arthroplasty. 2013;28(8):1274-1277. doi: 10.1016/j.arth.2013.03.008.
  18. Vyvey M. Steroids as pain relief adjuvants. Can Fam Physician. 2010;56(12):1295-1297.
  19. Rostaing L, Malvezzi P. Steroid-based therapy and risk of infectious complications. PLoS Med. 2016;13(5):e1002025. doi: 10.1371/journal.pmed. 1002025.
  20. Christensen CP, Jacobs CA, Jennings HR. Effect of periarticular corticosteroid injections during total knee arthroplasty: a double-blind randomized trial. J Bone Joint Surg Am. 2009;91(11):2550-2555. doi: 10.2106/JBJS.H.01501.
  21. Chia SK, Wernecke GC, Harris IA, Bohm MT, Chen DB, MacDessi SJ. Peri-articular steroid injection in total knee arthroplasty: a prospective, double blinded, randomized controlled trial. J Arthroplasty. 2013;28(4):620-623. doi: 10.1016/j.arth.2012.07.034.
  22. Ikeuchi M, Kamimoto Y, Izumi M, et al. Effects of dexamethasone on local infiltration analgesia in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2014;22(7):1638-1643. doi: 10.1007/s00167-013-2367-5.
  23. Kwon SK, Yang IH, Bai SJ, Han CD. Periarticular injection with corticosteroid has an additional pain management effect in total knee arthroplasty. Yonsei Med J. 2014;55(2):493-498. doi: 10.3349/ymj.2014.55.2.493.
  24. Tsukada S, Wakui M, Hoshino A. The impact of including corticosteroid in a periarticular injection for pain control after total knee arthroplasty: a double-blind randomised controlled trial. Bone Joint J. 2016;98(2):194-200. doi: 10.1302/0301-620X.98B2.36596.
  25. Yue D bo, Wang B liang, Liu K peng, Guo W shou. Efficacy of multimodal cocktail periarticular injection with or without steroid in total knee arthroplasty. Chin Med J (Engl). 2013;126(20):3851-3855.
  26. Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes S, Callaghan JJ. Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. J Bone Joint Surg Am. 2013;95(3):193-199. doi: 10.2106/JBJS.K.01682.
  27. Matsueda M, Gustilo RB. Subvastus and medial parapatellar approaches in total knee arthroplasty. Clin Orthop Relat Res. (1976-2007). 2000;371:161-168. doi: 10.1097/00003086-200002000-00020.
  28. Ejaz A, Laursen AC, Kappel A, et al. Faster recovery without the use of a tourniquet in total knee arthroplasty: A randomized study of 70 patients. Acta Orthop. 2014;85(4):422-426. doi: 10.3109/17453674.2014.931197.