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 intraarticular
gap reduction. Knee Surg Sports Traumatol
Arthrosc. 2020;28(5):1388-1393. doi: 10.1007/
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:
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/
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/
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/
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.
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-
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:
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/
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.
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.
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:
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.
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/
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:
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:
Volume 10, Issue 12
December 2022
Pages 1049-1055
  • Receive Date: 27 July 2020
  • Revise Date: 13 September 2022
  • Accept Date: 15 September 2022
  • First Publish Date: 14 November 2022