Table 3 Articles included in the review analyzing the use of glucocorticosteroids in periarticular infiltrations

Reddy et al. [27]

Prospective randomized controlled trial

140 patients

MP group 70 patients

Non steroid group—70 patients

Periarticular cocktail (PAI)

60 ml of 0.2% Ropivacaine; 8 mg Morphine; 0.3 mg Epinephrine; 60 mg Ketorolac

MP group received an additional 100 mg of MP while the second group received only Saline

Lower VAS score in PAI group with Methylprednisolone 8 h after surgery, POD 1 and POD 2; No difference in ROM between the groups

Not listed

Bilateral of revision total knee arthroplasty procedures; General or Epidural anesthesia; severe renal insufficiency; uncontrolled DM, Bleeding disorders; history of vascular surgery involving the femoral vessels on operative side; History of arrhythmias and seizures; History of chronic pain, or alcohol or drug abuse, Allergies to medication, local infection, sepsis

Kulkarni et al. [28]

Randomized controlled trial

50 patients undergoing bilateral TKA

Both knees received a PAI, but the second knee also received methylprednisolone (40 mg) as part of the PAI

Lower VAS at 24 h and 72 h in the PAI with Methylprednisolone group. Greater ROM at 24 h and 72 h after surgery in the PAI with methylprednisolone group

No infections or further operations in the subsequent 6 months

Renal insufficiency; poorly controlled DM (HBA1C > 7.0); history of inflammatory arthritis;Allergy to medication; history of knee infection or prolonged QT interval

Chia et al. [25]

Randomized Controlled trial

127 patients

3 groups. One control group, 1 low dose steroid group (40 mg Triamcinolone acetonide) and 1 high dose steroid (80 mg) group

No significant differences between pain scores and ROM between the groups

One PJI in the high dose steroid group

Unstable Diabetes, Immunosuppression,Chronic renal failure, Allergic reaction

El-Boghdadly et al. [29]

Randomized controlled trial

140 patients

72 patients—saline group

68 patients—Dexamethasone group

PAI consisted of 300 mg Ropivicaine, 30 mg Ketorolac; 0.6 mg of Epinephrine

Patients randomized to receive 8 mg of Dexamethasone or Saline

Dexamethasone group had lower rates of Nausea + Vomiting POD 0 and 1, They had a shorter hospital stay of 7.7 h; Dexamethasone group demonstrated greater ROM on POD 1 and mobilized a longer distance that the control group; Decrease in total inpatient opioid consumption and need for patient controlled rescue analgesia in the Dexamethasone group. Total morphine consumption in the first 24 h were comparable.No long-term benefits seen with usage of Dexamethasone

No adverse events

Allergic reactions; Bilateral TKA procedures; Chronic opioid usage

Tsukada et al. [35]

Double blinded Randomized Controlled trial

75 patients

38—Methylprednisolone group

37—Saline group

PAI—300 mg Ropivacaine; 8 mg Morphine; 0.3 mg Epinephrine; 50 mg Ketoprofen

In the one group they added 40 mg Methylprednisolone (MP) and the second group they only added Normal Saline

MP group had lower cumulative pain scores in the 24 h postoperative. No difference in VAS score at rest between groups but VAS score lower with activity in the first 24 h in the MP group; Some trend of better flexion and extension angle in the MP in the first 10 days

No adverse events. 5 patients develop a peroneal palsy due to the injection at the area—all resolved within 24 h

Poorly controlled DM(HBA1C > 7); Contraindications to spinal anesthetic;Regular opioid usage, Renal insufficiency; Prolonged Q-interval

Christensen et al. [36]

Double blinded prospective Randomized Controlled trial

76 patients

MP group 39 patients;

No steroid group—37 patients

PAI—80 mg Bupivacaine Hydrochloride; 4 mg Morphine, 0.3 mg Epinephrine; 100ug Clonidine; 750 mg Cefuroxime

MP group received an additional 40 mg MP and the no steroid group received Saline

LOS was statistical better in the MP group; No difference between the groups regarding total narcotic consumption on first day or pain score on the first 24 h or upon discharge between the groups

No difference in ROM between the two groups

Three patient in the MP had complications compared o none in the no steroid group. The complications included joint sepsis with subsequent death; 2 MUA

Renal disease, Allergic reactions to drugs used, chronic opioid usage, Rheumatoid arthritis; history of a knee infection

Wang et al. [30]

Prospective double blind randomized controlled trial

102 patients: 50 control group and 52 in corticosteroid group

PAI—0.2% Ropivacaine; 2ug/ml Epinephrine

Steroid group—0.1 mg/ml Dexamethasone (DM)

VAS scores were statistical lower at 6 + 12 h at rest in the DM group and in the first 24 h with activity. DM had statistical lower overall morphine consumption; IL-6 + CRP was statistical lower in the DM in the first 2 days postoperatively; Longer ambulation and better ROM in the DM only on POD 1.No difference in LOS, nausea + vomiting or glucose levels

No difference in complication rates between the two groups

Other diagnosis than OA (i.e. RA, traumatic arthritis); Allergic reaction; Flexion or varus–valgus deformity >  = 30 degrees; history of knee surgery or infection; history of excessive opioid or alcohol consumption; history of narcotic dependency; Psychiatric illness or cognitive impairment; Thrombotic events

Sean et al. [33]

Prospective double blind randomized controlled trial

100 patients;

50 steroid group and 50 patients in the control group

PAI—0.5 ml/kg of 0.5% Bupivacaine with 1:200 000 Epinephrine;

Steroid group received 40 mg Triamcinolone acetonide

Significant less pain POD 2—5 in the steroid group; Less morphine consumption in the steroid group; in the steroid group they observed decrease LOS,quicker ability to achieve straight leg raise and better ROM which was significant POD 2 onward. The ROM persisted to be better even at 6 months postop. At 2 years no difference in clinical outcome between the groups

Both groups had 1 infection with a no culture in the steroid group while the control group grew MRSA infection

Diabetes, immunodeficiency, previous surgery to the knee; hypothyroidism, renal failure or allergies to medications

Yue et al. [31]

Prospective randomized controlled study

72 patients;

36 in the steroid group and 36 in the control group

PAI—30 ml of 0.75% Ropivicaine; 0.5 ml of 1:1000 Epinephrine

Steroid group—1 ml Betamethasone; The steroid group injected the mixture in thee periarticular tissues but did not inject the steroid in the subcutaneous tissues

No difference in VAs at rest or activity; No difference in ROM or overall morphine consumption; KSS was statistically better at the 1 and 3 month mark in the steroid group but similar after 6 months. Celecoxib usage was shorter in the steroid group

No complications in either group

Know allergies to the medications; Major systemic illnesses (heart failure, renal impairment); psychological problems, narcotic dependence; chronic opioid users

Kwon et al. [26]

Randomized controlled trial

76 staged knee replacements. the first knee was randomized to either receive steroids or no steroids. The second staged knee then received the opposite treatment

PAI—300 mg Ropivicaine; 10 mg Morphine Sulfate; 30 mg Ketorolac, 300ug of 1:1000 Epinephrine

Steroid group—40 mg Triamcinolone Acetonide

Statistical lower pain on the night of the operation in the steroid group; Steroid group demonstrated earlier straight leg raise ability, but no difference in maximal flexion; No difference in rescue medication; No difference in flexion,patient satisfaction or PROMS at 6 months

No difference in complication rates

GI bleeding, congestive heart failure, Delirium or failed spinal anesthesia

Kim et al. [32]

Prospective randomized double blind study

270 patients—divided in 6 groups of 45 patients each

All the groups received 400 mg Ropivicaine + 0.6 mg Epinephrine;

Group 1—as above;

Group 2—Morphine (5 mg) in addition;

Group 3 Ketorolac (30 mg) in addition;

Group 4 Morphine and Ketorolac in addition;

Group5 Morphine, Ketorolac and Methylprednisolone (40 mg) in addition

Lower pain scores first 12 h in Group 4 + 5 compared to the other groups; No difference between Group 4 and 5 however. Lower opioid consumption in the first 24 h in group 4 + 5 but total opioid consumption the same; Group 5 demonstrated lower CRP values until POD 4 and better ROM until POD 2

No difference in complication rates

Inflammatory arthritis, previous surgical procedure to the knee; allergy to the medications