Optimizing perioperative systemic dexamethasone use in total knee arthroplasty: a narrative review on current evidence.

backgroundPerioperative corticosteroids, particularly dexamethasone, have become a widely adopted component of multimodal pain management in total knee arthroplasty (TKA). While clinical practice guidelines strongly recommend their use, detailed guidance on optimal dosing, frequency, and safety in special populations, especially patients with diabetes mellitus, is still limited. MAIN TEXT: This narrative review synthesizes the current evidence on systemic perioperative dexamethasone use in TKA, focusing on clinical questions: agent and route selection, dose optimization, dosing frequency, and safety, including considerations for patients with diabetes. A literature search of PubMed, EMBASE, and the Cochrane Library was conducted for studies published between January 2015 and April 2026. Randomized controlled trials, systematic reviews, meta-analyses, clinical practice guidelines, and observational studies addressing systemic corticosteroid use in primary TKA were included. Recent evidence supports intravenous (IV) dexamethasone as the most commonly studied and clinically practical systemic agent. A 16 mg dose provides greater early analgesic and antiemetic benefit than lower doses, and repeat dosing through postoperative day (POD) 1 is supported, with extension to POD 2 emerging but not yet definitive. Perioperative dexamethasone has not been associated with increased infection or wound complications. In patients with well-controlled diabetes, it appears safe with appropriate glycemic monitoring, although safety data are largely limited to doses of 8-10 mg.

conclusionsCurrent evidence supports IV dexamethasone as an effective component of multimodal analgesia after TKA. In the general TKA population, 16 mg appears more effective than lower doses for early postoperative pain, opioid consumption, and postoperative nausea and vomiting (PONV)-related outcomes. Repeat dosing through POD 1 is supported by available evidence, whereas extension to POD 2 remains promising but requires further validation. In patients with well-controlled diabetes, perioperative dexamethasone appears safe with appropriate glycemic monitoring, although safety data are largely limited to doses of 8-10 mg, and the safety of the 16 mg dose in this population remains insufficiently defined.