Efficacy of periarticular versus intravenous steroid on postoperative pain and nausea in patients undergoing total knee arthroplasty with local infiltration analgesia: A systematic review and network meta-analysis

Background: To compare the effects of postoperative pain relief, nausea relief, and occurrence of adverse effects associated with steroid use between single-dose intravenous steroid (SDIV) and periarticular injection (PAI) of steroid after total knee arthroplasty. Methods: This systematic review and network meta-analysis was conducted in accordance with PRISMA guidelines. Randomized controlled trials involving patients undergoing primary unilateral total knee arthroplasty with local infiltration analgesia were included. Studies comparing SDIV, PAI, or no steroid use were selected through a comprehensive search of PubMed, Embase, and the Cochrane Library (January 1990–March 2024). Non-English articles, case reports, protocols, and non-randomized controlled trials were excluded. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. A frequentist network meta-analysis was performed to synthesize data on quantitative outcomes (visual analog scale scores, range of motion, flexion angle, opioid consumption) and qualitative outcomes (postoperative nausea and vomiting PONV, wound complications). Treatment rankings were estimated using surface under the cumulative ranking area values. Results: Compared to the control group, both SDIV and PAI significantly reduced postoperative visual analog scale scores at rest and during activity up to postoperative day 2. On day 3, SDIV maintained superior pain relief, while PAI effects plateaued. Range of motion and flexion angle were significantly improved in both steroid groups, with PAI showing a slight advantage in early recovery. Opioid consumption was consistently lower in the steroid groups, especially with PAI. Incidence of PONV was lowest in the SDIV group, indicating superior antiemetic effects. No significant differences were observed in wound complication rates across the groups. Conclusion: In clinical practice, intravenous steroids may be considered for patients at higher risk of PONV, while periarticular steroids may be preferred for enhancing localized pain control in the early postoperative period.