Primary Arthroplasty| Volume 35, ISSUE 2, P394-400, February 2020

Intravenous Dexamethasone Injection Reduces Pain From 12 to 21 Hours After Total Knee Arthroplasty: A Double-Blind, Randomized, Placebo-Controlled Trial

Published:September 07, 2019DOI:



      Pain after total knee arthroplasty (TKA) affects postoperative recovery and patient satisfaction. The analgesic benefits of corticosteroids have not been well studied. We, therefore, investigated the analgesic effects of intravenous (IV) dexamethasone (DEX) in patients undergoing a TKA.


      This was a randomized, double-blind, placebo-controlled trial of 0.15 mg/kg of IV DEX vs saline placebo in unilateral TKA. Fifty patients/arm were recruited. Primary outcomes were pain level, determined by a visual analog scale, and the amount of morphine consumption (mg) ≤48 hours post-TKA. Secondary outcomes were rates of nausea and vomiting, C-reactive protein concentrations, and functional outcomes.


      The DEX group had a significantly lower mean visual analog scale score both at rest and during motion at 12, 15, 18, and 21 hours (P < .05). At 21 hours, the mean difference (Δ) in pain at rest was −11 points (95% confidence interval [CI], −21 to −2 points; P = .02) while the mean difference in pain during motion was −15 points (95% CI, −25 to −5 points; P = .004). The DEX group also had lower rates of nausea and vomiting: 29/50 (58%) vs 42/50 (84%) (P = .008) and lower mean C-reactive protein level: 89 vs 167, Δ = −78 mg/L (95% CI, −100 to −58 mg/L, P < .0001). There were no significant differences in mean morphine consumption by 48 hours, modified Western Ontario and McMaster University Osteoarthritis Index scores, and range of motion of the knee at 3-month follow-up (P > .05).


      IV DEX relieves postoperative pain between 12 to 21 hours after TKA and may be a useful adjunct for controlling pain in patients undergoing TKA.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bourne R.B.
        • Chesworth B.M.
        • Davis A.M.
        • Mahomed N.N.
        • Charron K.D.
        Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?.
        Clin Orthop Relat Res. 2010; 468: 57-63
        • Salerno A.
        • Hermann R.
        Efficacy and safety of steroid use for postoperative pain relief. Update and review of the medical literature.
        J Bone Joint Surg Am. 2006; 88: 1361-1372
        • Gan T.J.
        • Diemunsch P.
        • Habib A.S.
        • Kovac A.
        • Kranke P.
        • Meyer T.A.
        • et al.
        Consensus guidelines for the management of postoperative nausea and vomiting.
        Anesth Analg. 2014; 118: 85-113
        • De Oliveira Jr., G.S.
        • Almeida M.D.
        • Benzon H.T.
        • McCarthy R.J.
        Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials.
        Anesthesiology. 2011; 115: 575-588
        • Koh I.J.
        • Chang C.B.
        • Lee J.H.
        • Jeon Y.T.
        • Kim T.K.
        Preemptive low-dose dexamethasone reduces postoperative emesis and pain after TKA: a randomized controlled study.
        Clin Orthop Relat Res. 2013; 471: 3010-3020
        • Backes J.R.
        • Bentley J.C.
        • Politi J.R.
        • Chambers B.T.
        Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial.
        J Arthroplasty. 2013; 28: 11-17
        • Lunn T.H.
        • Kristensen B.B.
        • Andersen L.O.
        • Husted H.
        • Otte K.S.
        • Gaarn-Larsen L.
        • et al.
        Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial.
        Br J Anaesth. 2011; 106: 230-238
        • Jules-Elysee K.M.
        • Lipnitsky J.Y.
        • Patel N.
        • Anastasian G.
        • Wilfred S.E.
        • Urban M.K.
        • et al.
        Use of low-dose steroids in decreasing cytokine release during bilateral total knee replacement.
        Reg Anesth Pain Med. 2011; 36: 36-40
        • Jules- Elysee K.M.
        • Wilfred S.E.
        • Memtsoudis S.G.
        • Kim D.H.
        • YaDeau J.T.
        • Urban M.K.
        • et al.
        Steroid modulation of cytokine release and desmosine levels in bilateral total knee replacement: a prospective, double-blind, randomized controlled trial.
        J Bone Joint Surg Am. 2012; 94: 2120-2127
        • Crandell J.T.
        Perineal pruritus after the administration of iv dexamethasone.
        Can J Anaesth. 2004; 51: 398
        • Kuptniratsaikul V.
        • Rattanachaiyanont M.
        Validation of a modified Thai version of the Western Ontario and McMaster (WOMAC) osteoarthritis index for knee osteoarthritis.
        Clin Rheumatol. 2007; 26: 1641-1645
        • Vyvey M.
        Steroids as pain relief adjuvants.
        Can Fam Physician. 2010; 56: 1295-1297
        • Skjelbred P.
        • Lokken P.
        Reduction of pain and swelling by a corticosteroid injected 3 hours after surgery.
        Eur J Clin Pharmacol. 1982; 23: 141-146
        • Schulze S.
        • Moller I.W.
        • Bang U.
        • Rye B.
        • Kehlet H.
        Effect of combined prednisolone, epidural analgesia and indomethacin on pain, systemic response and convalescence after cholecystectomy.
        Acta Chir Scand. 1990; 156: 203-209
        • 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-b: 194-200
        • Kwon S.K.
        • Yang I.H.
        • Bai S.J.
        • Han C.D.
        Periarticular injection with corticosteroid has an additional pain management effect in total knee arthroplasty.
        Yonsei Med J. 2014; 55: 493-498
        • Tammachote N.
        • Seangleulur A.
        • Kanitnate S.
        Lumbar epidural corticosteroid injection reduces subacute pain and improves knee function in the first six weeks after total knee arthroplasty: a double-blinded randomized trial.
        J Bone Joint Surg Am. 2018; 100: 950-957
        • Valeberg B.T.
        • Hovik L.H.
        • Gjeilo K.H.
        Relationship between self-reported pain sensitivity and pain after total knee arthroplasty: a prospective study of 71 patients 8 weeks after a standardized fast-track program.
        J Pain Res. 2016; 9: 625-629
        • Tammachote N.
        • Kanitnate S.
        • Manuwong S.
        • Yakumpor T.
        • Panichkul P.
        Is pain after TKA better with periarticular injection or intrathecal morphine?.
        Clin Orthop Relat Res. 2013; 471: 1992-1999
        • Xing L.Z.
        • Li L.
        • Zhang L.J.
        Can intravenous steroid administration reduce postoperative pain scores following total knee arthroplasty?: a meta-analysis.
        Medicine (Baltimore). 2017; 96: e7134
        • Xu B.
        • Ma J.
        • Huang Q.
        • Huang Z.Y.
        • Zhang S.Y.
        • Pei F.X.
        Two doses of low-dose perioperative dexamethasone improve the clinical outcome after total knee arthroplasty: a randomized controlled study.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 1549-1556
        • Hartman J.
        • Khanna V.
        • Habib A.
        • Farrokhyar F.
        • Memon M.
        • Adili A.
        Perioperative systemic glucocorticoids in total hip and knee arthroplasty: a systematic review of outcomes.
        J Orthop. 2017; 14: 294-301
        • Dissanayake R.
        • Du H.N.
        • Robertson I.K.
        • Ogden K.
        • Wiltshire K.
        • Mulford J.S.
        Does dexamethasone reduce hospital readiness for discharge, pain, nausea, and early patient satisfaction in hip and knee arthroplasty? A randomized, controlled trial.
        J Arthroplasty. 2018; 33: 3429-3436
        • Xu H.
        • Zhang S.
        • Xie J.
        • Lei Y.
        • Cao G.
        • Pei F.
        Multiple doses of perioperative dexamethasone further improve clinical outcomes after total knee arthroplasty: a prospective, randomized, controlled study.
        J Arthroplasty. 2018; 33: 3448-3454
        • Henzi I.
        • Walder B.
        • Tramer M.R.
        Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review.
        Anesth Analg. 2000; 90: 186-194
        • Chu C.C.
        • Hsing C.H.
        • Shieh J.P.
        • Chien C.C.
        • Ho C.M.
        • Wang J.J.
        The cellular mechanisms of the antiemetic action of dexamethasone and related glucocorticoids against vomiting.
        Eur J Pharmacol. 2014; 722: 48-54
        • Ho C.M.
        • Ho S.T.
        • Wang J.J.
        • Tsai S.K.
        • Chai C.Y.
        Dexamethasone has a central antiemetic mechanism in decerebrated cats.
        Anesth Analg. 2004; 99: 734-739
        • Chen P.
        • Li X.
        • Sang L.
        • Huang J.
        Perioperative intravenous glucocorticoids can decrease postoperative nausea and vomiting and pain in total joint arthroplasty: a meta-analysis and trial sequence analysis.
        Medicine (Baltimore). 2017; 96: e6382
        • Brekke A.C.
        • Amaro E.J.
        • Posey S.L.
        • Engstrom S.M.
        • Polkowski G.G.
        • Schoenecker J.G.
        Do corticosteroids attenuate the peri-operative acute phase response after total knee arthroplasty?.
        J Arthroplasty. 2019; 34: 27-35
        • Thienpont E.
        • Grosu I.
        • Jonckheere S.
        • Yombi J.C.
        C-reactive protein (CRP) in different types of minimally invasive knee arthroplasty.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 2603-2610
        • Yue C.
        • Wei R.
        • Liu Y.
        Perioperative systemic steroid for rapid recovery in total knee and hip arthroplasty: a systematic review and meta-analysis of randomized trials.
        J Orthop Surg Res. 2017; 12: 100
        • van Raalte D.H.
        • Ouwens D.M.
        • Diamant M.
        Novel insights into glucocorticoid-mediated diabetogenic effects: towards expansion of therapeutic options?.
        Eur J Clin Invest. 2009; 39: 81-93
        • Low Y.
        • White W.D.
        • Habib A.S.
        Postoperative hyperglycemia after 4- vs 8-10-mg dexamethasone for postoperative nausea and vomiting prophylaxis in patients with type II diabetes mellitus: a retrospective database analysis.
        J Clin Anesth. 2015; 27: 589-594
        • Nazar C.E.
        • Echevarria G.C.
        • Lacassie H.J.
        • Flores R.A.
        • Munoz H.R.
        [Effects on blood glucose of prophylactic dexamethasone for postoperative nausea and vomiting in diabetics and non-diabetics].
        Rev Med Chil. 2011; 139: 755-761
        • Bolac C.S.
        • Wallace A.H.
        • Broadwater G.
        • Havrilesky L.J.
        • Habib A.S.
        The impact of postoperative nausea and vomiting prophylaxis with dexamethasone on postoperative wound complications in patients undergoing laparotomy for endometrial cancer.
        Anesth Analg. 2013; 116: 1041-1047
        • Assante J.
        • Collins S.
        • Hewer I.
        Infection associated with single-dose dexamethasone for prevention of postoperative nausea and vomiting: a literature review.
        AANA J. 2015; 83: 281-288
        • Vuorinen M.A.
        • Palanne R.A.
        • Makinen T.J.
        • Leskinen J.T.
        • Huhtala H.
        • Huotari K.A.
        Infection safety of dexamethasone in total hip and total knee arthroplasty: a study of eighteen thousand, eight hundred and seventy two operations.
        Int Orthop. 2019; 43: 1787-1792
        • Aubrun F.
        • Langeron O.
        • Quesnel C.
        • Coriat P.
        • Riou B.
        Relationships between measurement of pain using visual analog score and morphine requirements during postoperative intravenous morphine titration.
        Anesthesiology. 2003; 98: 1415-1421