Optimizing perioperative intravenous corticosteroid dosing for postoperative outcomes in total joint arthroplasty: a network meta-analysis

Background This study aimed to determine the efficacy of different intravenous steroid doses in reducing postoperative pain and rescue antiemetic use in total hip arthroplasty (THA) or total knee arthroplasty (TKA).Methods PubMed, Cochrane Library, and Web of Science were searched through May 2, 2025. Randomized controlled trials (RCTs) of perioperative intravenous steroid doses in adults undergoing primary THA or TKA were included. A frequentist random-effects network meta-analysis was performed. Steroid doses were categorized by dexamethasone-equivalent dosage: Very Low (VL, 1-9 mg), Low (10-19 mg), Intermediate (IM, 20-29 mg), Intermediate-High (IH, 30-39 mg), High (40-49 mg), and Very High (VH, ≥50 mg). Primary outcomes were 24-hour postoperative pain, and rescue antiemetic use.Results 27 RCTs involving 2,936 participants were identified, with 25 RCTs included in the network meta-analysis. Compared with controls, Low (mean difference [MD]: -2.18; 95% Confidence Interval [CI]: -2.73, -1.63) reduced 24-hour postoperative pain at rest in THA with IM showing borderline significance, whereas VL, Low, and IM were effective in TKA (MDs ranging from -0.68 to -1.14). For 24-hour postoperative pain during movement, Low (MD: -2.13; 95% CI: -2.76, -1.50) and High (MD: -4.30; 95% CI: -5.02, -3.58) most significantly reduced pain in THA, followed by IM and IH, whereas only IM was effective in TKA. Rescue antiemetic use was reduced by 16%-28% in THA and TKA across Low or higher dose groups.Conclusion Low-dose dexamethasone generally provides adequate benefits, while higher doses may provide additional analgesia in TKA or patients at risk of severe postoperative pain.