Taking corticosteroids, such as prednisone or dexamethasone, after a total hip arthroplasty (THA) is a major concern for patients managing chronic inflammatory conditions. These powerful anti-inflammatory and immunosuppressive medications are often necessary for conditions like rheumatoid arthritis or lupus. However, their effect on the surgical site and the long-term success of the new joint must be carefully considered. Corticosteroids reduce inflammation but also alter the body’s normal healing and defense mechanisms, requiring a measured approach following major orthopedic surgery.
Impact on Infection Risk and Wound Healing
Corticosteroids suppress the immune system, which is the mechanism that makes them effective for managing autoimmune diseases. After a total hip replacement, this immunosuppressive action significantly elevates the risk of surgical site infection (SSI) and delays incision healing. Patients taking chronic, higher doses (often 15 to 20 mg of prednisone equivalent per day or more) face a higher risk of postoperative infectious complications, including periprosthetic joint infection (PJI).
Corticosteroids interfere with the body’s immediate inflammatory response to injury. They decrease the ability of white blood cells to migrate to the wound site, compromising the initial defense against bacterial pathogens. These drugs also negatively impact the wound healing process beyond the immune response.
The anti-inflammatory effects inhibit fibroblast proliferation and decrease the ability of cells to properly remodel collagen. Fibroblasts synthesize the extracellular matrix and collagen, which are essential for closing the surgical incision and regaining skin strength. When this activity is suppressed, patients risk complications like wound dehiscence, where the surgical wound separates or opens.
Steroids and Bone Health Around the Implant
Long-term use of corticosteroids poses risks related to bone health and the structural integrity of the hip implant. Corticosteroids interfere with normal bone metabolism by inhibiting osteoblasts, the cells responsible for creating new bone tissue. Simultaneously, they increase the activity of osteoclasts, the cells that break down existing bone.
This imbalance leads to reduced overall bone mineral density, resulting in corticosteroid-induced osteoporosis. The primary concern focuses on the bone surrounding the new hip components. Reduced bone density in this area increases the patient’s susceptibility to a periprosthetic fracture.
The long-term success of a hip replacement relies on the stable integration of the implant with the surrounding bone, particularly with cementless prostheses. Reduced bone quality from chronic steroid exposure can compromise this initial fixation and potentially lead to aseptic loosening, where the implant detaches without infection. Corticosteroids are also a known cause of osteonecrosis, or avascular necrosis, which is often the original reason for the hip replacement in some patients.
Navigating Necessary Steroid Use for Chronic Conditions
For many patients, discontinuing corticosteroids is not an option, as they are medically necessary to manage chronic, serious conditions like severe asthma, inflammatory bowel disease, or autoimmune disorders. In these cases, the focus shifts to careful management and communication between the patient, the orthopedic surgeon, and the prescribing specialist.
Pre-operative planning is essential to establish a clear protocol for the days surrounding the hip replacement surgery. For patients on a chronic regimen, the current recommendation suggests continuing the usual daily dose rather than increasing it to a supra-physiologic “stress dose.” This strategy applies particularly to those taking lower doses, such as 16 mg of prednisone equivalent or less for rheumatic conditions.
Single Dose vs. Chronic Regimens
A single, high dose of an intravenous corticosteroid, such as 8 to 10 mg of dexamethasone, is sometimes administered during surgery for multimodal pain management. This single dose is distinct from chronic use and is generally considered safe, helping reduce postoperative pain and nausea without significantly increasing infection risk. Abrupt cessation of a chronic steroid regimen is dangerous due to the risk of adrenal crisis. Therefore, any dosage adjustment must be a coordinated decision between the specialists managing the underlying condition and the surgical team.