Postoperative Oral Corticosteroids for Pain Management and Recovery After Total Knee Arthroplasty: A Systematic...

Total knee arthroplasty (TKA) for osteoarthritis is associated with substantial postoperative pain that drives opioid use and delays recovery. Perioperative intravenous corticosteroids reduce early pain, but the role of postoperative oral corticosteroids is less clear. We aimed to evaluate the efficacy and safety of postoperative oral corticosteroids after primary TKA for osteoarthritis. This systematic review was prospectively registered on PROSPERO (CRD420261369550) and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. We searched PubMed, Embase (Ovid), the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 28 April 2026 with no language or date restrictions. Randomised controlled trials of oral corticosteroids initiated within 48 hours after primary TKA versus placebo, no oral corticosteroid, or standard care were eligible for primary synthesis; quasi-randomised and non-randomised comparative studies contributed only to sensitivity or narrative analysis. Two reviewers independently screened, extracted data, and assessed risk of bias using the revised Cochrane tool for randomised trials (Risk of Bias (RoB) 2.0). Random-effects meta-analyses (DerSimonian-Laird) were performed where studies were sufficiently homogeneous, and certainty of evidence was rated with GRADE. In total, 12 studies were included: four randomised controlled trials in primary synthesis (380 randomised participants), three trials in sensitivity analysis only, and five non-randomised reports for narrative synthesis. Postoperative oral corticosteroids reduced cumulative opioid consumption in the first 48 hours by approximately 9 oral morphine equivalent milligrams (mean difference = -8.59, 95% confidence interval = -14.59 to -2.60; two trials, 173 participants), but the effect on pain at rest at 48 hours was uncertain (mean difference = -7.17 mm on a 0-100 mm scale, 95% confidence interval = -18.71 to +4.38; two trials, 178 participants). The composite of surgical site or periprosthetic joint infection was indeterminate (risk ratio = 1.37, 95% confidence interval = 0.22 to 8.56; three contributing trials, 274 participants). Length of stay and knee range of motion were reported narratively only. Certainty of evidence was very low for all six prioritised outcomes. Postoperative oral corticosteroids may reduce 48-hour opioid consumption after primary TKA, but the evidence remains very uncertain across all outcomes. No short-term safety signal was observed; rare harms cannot be excluded because the included trials were underpowered for adverse-event detection. Adequately powered randomised trials with standardised dose, duration, and molecule are needed before routine use can be recommended.