Effects of Postoperative Oral Corticosteroids on Infection Rates in Upper Extremity Surgery

Abstract

Background:

The recent trend in administering postoperative oral corticosteroids has proven effective in alleviating pain and improving surgical outcomes for hand and upper extremity procedures. However, concerns persist regarding potential infection risks despite a lack of supporting evidence in the current literature. We propose that a 6-day regimen of low-dose postoperative oral corticosteroids is safe and does not increase the likelihood of surgical site infections (SSIs) in adult upper extremity surgeries.

Methods:

A retrospective study of all adult patients who underwent clean, upper extremity surgery, including both soft tissue and hardware implantation cases, between November 2021 and November 2023, performed at a single institution were included in the study. Primary outcome measures were diagnosis of SSI by 14 days and 30 days. Categorical variables were compared using χ² tests, and continuous variables were compared using Wilcoxon rank-sum tests. A P value less than .05 was considered statistically significant.

Results:

A total of 813 cases were included for analysis—196 received a 6-day course of postoperative oral steroids (methylprednisolone) and 617 did not. Both groups had similar SSI rates of 4.1% and 3.1%, respectively, with no statistical differences between the groups at any postoperative time. Subgroup analysis of patients diagnosed with an SSI identified no statistically different demographic factors or medical comorbidities when comparing patients who received postoperative oral corticosteroids versus those who did not.

Conclusions:

Low-dose, postoperative oral steroid use following adult upper extremity surgery is safe and does not increase the risk of SSI. Further investigations with prospective studies on postoperative oral corticosteroids would prove advantageous.

Introduction

For hand and upper extremity surgeons, navigating the postoperative goliaths of pain and edema due to dysregulated inflammation are seemingly overwhelming. Surgery induces a predictable injury-mediated inflammation by the innate immune system, with the initial magnitude of the response varying in proportion to both the environment of the surgery and the degree of the surgical injury. ¹ During this reaction, both a humoral and cell-mediated response are triggered, and the inflammatory-immune response is balanced: immune-suppressing processes commence at the same time as activation processes.^2,3

The edema that then arises is not only from the inflammatory immune response but also from additional factors.^4,5 In addition, an adverse, cumulative effect can occur due to gravity dependency and perioperative damage to lymphatic vessels. ⁶ Moreover, in some patients, the postoperative systemic inflammation does not resolve to normal levels and instead persists in a much less regulated, pathophysiological state known as hyperinflammation.^7,8

Edema can then, in extreme cases, compound upon itself in a vicious Catch-22 cycle of lymphatic, venous, arterial, and sensibility compromise, resulting in significant joint stiffness, pain, delayed healing, poor function, and poor surgical outcomes. ⁹ Current guidance in the literature on reducing swelling following upper extremity procedures consists of physiotherapeutic treatments in response to the development of edema, rather than attempting to target prevention postoperatively.

Therefore, due to their potent anti-inflammatory properties, oral corticosteroids present a promising option for mediating soft tissue swelling and alleviating pain following hand and upper extremity procedures. However, despite substantial reports in arthroplasty literature, concerns about potential increases in postoperative infection rates due to corticosteroid-induced immunosuppression have hindered their widespread use in the upper extremity outpatient setting.^{10 -12} Studies in various orthopedic subspecialties have shown consistent surgeon hesitancy toward administering corticosteroids, either perioperatively or postoperatively, and the evidence regarding infection risk related explicitly to oral corticosteroids in upper extremity procedures remains inconclusive.^{13 -18}

Although some studies suggest benefits such as reduced pain and improved range of motion with low-dose oral glucocorticoid treatment following upper extremity surgery and other various surgical fields, the scarcity of safety data has left many surgeons cautious on prescribing postoperative corticosteroid courses as an alternative pain and edema management approach.^{19 -22} Therefore, due to the paucity of information on the safety profile of postoperative corticosteroid use in hand and upper extremity procedures, this study aims to evaluate the safety profile of administrating postoperative corticosteroids in this population. Hence, we propose that administering a 6-day methylprednisolone taper (MPT) course following hand or upper extremity procedures does not increase surgical site infection (SSI) rates.

Material and Methods

Study Design

This retrospective cohort study adhered to a protocol approved by the institutional review board. A retrospective chart review was conducted on all patients who underwent hand or upper extremity procedures between November 2021 and November 2023, performed by 5 board-certified hand surgeons at a single institution. Inclusion criteria comprised adult patients who underwent clean upper extremity surgery, with or without the implantation of hardware devices such as plates, screws, Kirschner wires (k-wires), suture anchors, and external fixation devices (Ex-Fix).

Exclusion criteria encompassed patients younger than 18 years old, those diagnosed with an infection prior to surgery, and individuals with fewer than 30 days of follow-up. Additional exclusion criteria comprised procedures due to emergencies or suspected infections (eg, fasciotomies, bite wounds) and patients with incomplete medical records. If a patient had multiple upper extremity procedures, only the earliest was included for analysis. Patients with chronic oral corticosteroid use were also excluded from the study.

Patients were categorized into 2 groups: those who received a 6-day tapered oral postoperative corticosteroid course and those who did not. The oral corticosteroid regimen (MPT) commenced following the day of surgery and consisted of 24 mg on day 1, 20 mg on day 2, 16 mg on day 3, 12 mg on day 4, 8 mg on day 5, and 4 mg on day 6. It is standard of care by 1 of the 5 board-certified hand surgeons (SMK) to routinely administer a MPT course following upper extremity surgery, while the remaining 4 do not.Adherence to the prescription was duly recorded during the patient’s initial postoperative visit.

Outcome Measures

Primary outcome measures comprised the diagnosis of SSI by 14 days or 30 days postoperatively. Secondary outcomes included the type of management employed to treat infection, including operative washout and hardware removal. Demographic factors such as age, sex, race, smoking status, and comorbidities were assessed using the Charlson Comorbidity Index (CCI), and procedural details were extracted from the patient’s electronic medical records.

Statistical Analysis

Statistical analysis was performed using SPSS 29.0 (IBM Corp., Armonk, New York). χ² and Fisher’s exact tests were performed for categorical variables, and Wilcoxon rank-sum tests were performed for continuous variables. A P value of less than .05 was considered statistically significant.

Results

Of the 958 upper extremity cases identified, 813 were included in the analysis—196 received a 6-day course of oral postoperative MPT (“Postoperative Steroids”) and 617 did not (“No Postoperative Steroids”). Except for smoking status and a history of diabetes, there were significant differences between the 2 groups in age, body mass index (BMI), laterality, sex, CCI, and surgery type (Table 1).

Table 1.

Patient Demographics of Those Who Received a 6-Day Course of Methylprednisolone Taper (“Postoperative Steroids”) and Those Who Did Not (“No Postoperative Steroids”).

Demographics	Postoperative steroids (n = 196)	No postoperative steroids (n = 617)	P-value
Median age, y (IQR)	42 (28.25)	52 (25)	<.001
Median BMI (IQR)	27.9 (7.9)	29.1 (7.5)	.030
	N (%)	N (%)
Laterality
Left	105 (54)	258 (42)	.002
Right	83 (42)	346 (56)
Bilateral	8 (4)	13 (2)
Sex			<.001
Male	106 (54)	239 (39)
Female	90 (46)	378 (61)
Smoker
Yes	67 (34)	198 (32)	.586
No	129 (66)	419 (68)
Diabetes
Yes	33 (17)	131 (21)	.355
No	163 (83)	486 (79)
CCI			<.001
0	133 (68)	252 (41)
1	31 (16)	91 (15)
≥2	32 (16)	274 (44)
Surgical type			.003
Soft tissue	154 (79)	417 (68)
Hardware	42 (21)	200 (32)

Note. Hardware cases include the use of plates, screws, nails, k-wires, ex-fixators, and/or anchors. A P-value less than .05 is considered statistically significant. IQR = interquartile range; BMI = body mass index; CCI = Charlson Comorbidity Index.

Overall, the postoperative infection rate in our patient cohort was 3.3%. The 2 groups had no significant differences in infection rates. The infection rate in the postoperative steroid group was 4.1% and in the no postoperative steroid group was 3.1% (P = .528) (Table 2). The odds ratio (OR) for the association of an SSI between those who received an oral regimen of postoperative corticosteroids and those who did not was estimated to be 1.34 (95% confidence interval [CI]: 0.58-3.11). All patients diagnosed with SSI were treated with antibiotics. Furthermore, there were no differences in rates of operative washout and hardware removal between the 2 groups.

Table 2.

Primary and Secondary Outcomes Following Those Who Received a 6-Day Course of Methylprednisolone Taper (“Postoperative Steroids”) and Those Who Did Not (“No Postoperative Steroids”).

Outcomes	Postoperative steroids (n = 196)	No postoperative steroids (n = 617)	P-value
Any postoperative infection, n (%)	8 (4.1)	19 (3.1)	.528
Infection by 14 days, n (%)	7 (3.6)	11 (1.8)	.138
Infection between 15 and 30 days, n (%)	1 (0.5)	8 (1.3)	.442
Operative washout, n (%)	5 (2.6)	7 (1.1)	.064
Hardware removal, n (%)	1 (0.5)	2 (0.3)	.105

Note. A P-value less than .05 is considered statistically significant.

Given the demographic heterogeneity in the 2 comparative groups, additional subgroup analysis was conducted to include only patients who were diagnosed with an SSI. In this case, there were no differences in age, BMI, laterality, sex, smoking use, a history of diabetes, comorbidities, or surgical type between patients who were administered oral postoperative corticosteroids and those who were not (Table 3).

Table 3.

Comparison of Characteristics in Those With a Diagnosis of an SSI Following a 6-Day Course of Methylprednisolone Taper (“SSI With Postoperative Steroids”) and Those With an SSI Who Did Not Receive a 6-Day Course of Methylprednisolone Taper (“SSI With No Postoperative Steroids”).

Characteristics	SSI with postoperative steroids (n = 8)	SSI with no postoperative steroids (n = 19)	P-value
Median age, y (IQR)	36.5 (15)	45 (26)	.276
Median BMI (IQR)	29 (4.3)	28 (8.0)	.472
	N (%)	N (%)
Laterality			.068
Left	5 (62.5)	11 (58)
Right	3 (37.5)	7 (37)
Bilateral	0 (0)	1 (5)
Sex			1
Male	5 (62.5)	13 (68)
Female	3 (37.5)	6 (32)
Smoker			.675
Yes	4 (50)	7 (37)
No	4 (50)	12 (63)
Diabetes			.633
Yes	1 (12.5)	5 (26)
No	7 (87.5)	14 (74)
CCI			.236
0	6 (75)	9 (47)
1	0 (0)	0 (0)
≥2	2 (25)	10 (53)
Surgical type			.405
Soft tissue	6 (75)	10 (53)
Hardware	2 (25)	9 (47)

Note. Hardware cases include the use of plates, screws, nails, k-wires, ex-fixators, and/or anchors. A P-value less than .05 is considered statistically significant. SSI = surgical site infection; IQR= interquartile range; BMI = body mass index; CCI = Charlson Comorbidity Index.

Discussion

The inflammatory response is regulated by increased levels of cortisol (glucocorticoid) at the site of surgery. ²³ It has been demonstrated that surgical stress, pain, and inflammation directly stimulate the hypothalamic-pituitary-adrenal (HPA) axis, resulting in cortisol levels rising up to 4-fold and remaining elevated for up to 7 days. ²⁴ Corticosteroid administration in the perioperative period, particularly an initial dexamethasone injection on the day of surgery and a 6-day tapering dose covering those 7 days, has the potential for enormous impact. Their effects are directly dependent on the level of systemic inflammation, molecular signals, and the status of the HPA axis.

Corticosteroids have biphasic actions that are dose-responsive. They are both: (1) pro-inflammatory, reinforcing the innate immune system in the primary phase of pro-inflammation before the acute inflammatory response; and (2) anti-inflammatory, in which they repress and resolve inflammation with the adaptive immune system to restore homeostasis.^25,26 The latter has prompted anesthesiologists to establish a regular practice of administering corticosteroids to prevent postoperative nausea. Extrapolated from that use, extended intravenous use in total arthroplasty patients has demonstrated reduced postoperative pain and fatigue without any increase in harm or infection risk.^{27 -32} Yet these studies were limited to low-risk patients who were hospitalized and administered intravenous steroids for short time periods.

The facial reconstructive and otolaryngology surgery literature has found that injected and oral corticosteroid administration following reconstructive surgery is associated with short- and long-term reductions of complications.^21,22 Aldhabaan et al ²² conducted a meta-analysis of postoperative steroid complication reduction and discovered long-term reduced edema and ecchymoses for postoperative doses following preoperative doses. The meta-analysis found a reduction in standard mean difference of −0.82, −0.95, and −29.79 mL for unspecified edema, ecchymosis, and intraoperative bleeding, respectively, when comparing the corticosteroids group with placebo. ²² Kubala et al ²¹ demonstrated that oral steroids reduced overall pain and nausea/vomiting within the first 2 weeks following tonsillectomy. Furthermore, in orthopedic research, the findings of Vuorinen et al ³³ demonstrated that postoperative dexamethasone did not increase the rate of SSI in arthroplasty orthopedic surgery, while preventing postoperative nausea and vomiting.

However, within the hand and upper extremity surgery literature, studies present conflicting evidence regarding the benefits and complications of preoperative and postoperative oral corticosteroid use. In one study that analyzed preoperative steroid use in wrist salvage operations, the rate of SSI was nearly 4 times as high in the steroid cohort (0.6% vs 2.2%); however, it was not statistically significant. ¹⁶ Desai et al ¹⁹ demonstrated that short-term perioperative and postoperative corticosteroid use resulted in beneficial effects on recovery following elbow surgery without an apparent increase in infection risk. In addition, a randomized prospective controlled trial involving 56 patients who either did or did not receive a 6-day MPT following surgical fixation of distal radius fracture showed early improvement in pain and reduced opioid consumption without an increased risk of adverse events, including infection or wound complications. ²⁰

This study addresses a gap in the current literature by examining SSIs following a short-term, low-dose oral MPT regimen. In the present study, we found no significant differences in the SSI rate in patients who either received or did not receive oral postoperative corticosteroids following hand and upper extremity surgery. Furthermore, in the present study, a 1% difference (3.1% vs 4.1%) between exposure groups is not enough to conclude clinical significance. The small patient cohort and elevated baseline infection rates compared with previous literature factor into this decision. However, with that being stated, a full percentage point difference does lend itself to clinically relevant discussions and serves as a basis for further exploration.

In addition, differences were not discovered for postoperative SSI rates at 14-day or at 30-day follow-up, operative washout, and hardware removal among the 2 cohorts. As an alternative to assess for post hoc power, the OR with analysis of the width and magnitude of the 95% CI was employed to assess for statistical power. Although there was a moderate positive association observed among those receiving oral postoperative corticosteroids and infection rates, concerning for an increased risk in the exposed group, the association was not statistically significant as the width of the CI was very wide indicating that the size of the cohort was too small to identify a true difference among the groups. In addition, no individual variable was determined to predict postoperative SSI among those who received oral postoperative corticosteroids and those who did not.

Despite these findings, the study has several limitations. First, the small sample size limits the generalizability of the findings and precludes the identification of specific variables predicting SSIs in patients receiving MPT postoperatively. In addition, the overall SSI rates in this study were higher than those reported in previous literature, possibly due to factors beyond the study’s scope. However, considering a large, recent analysis of infection rates in the Veteran’s Administration System demonstrated an infection rate of about 3% in the main operating room for clean hand surgery, our rates are within the range of normality when viewed in a broad scope. ³⁴ Moreover, reporting infection rates was limited to 30 days postsurgery, and further complications, such as reoperation due to continued pain or hardware complications, were not fully addressed. Finally, the retrospective design relies on existing data, which may introduce bias in data selection and interpretation. Although statistically significant differences were discovered for demographic variables when comparing the 2 groups, these are most likely attributable to the retrospective nature of the study design. When comparing the demographic characteristics between those who had an SSI with postoperative corticosteroids and those without postoperative corticosteroids, differences in demographics between the groups were not clinically significant.

Nonetheless, this study lays the groundwork for further research to explore the benefits and risks associated with short-term oral postoperative corticosteroid use. Further research should use the present study as a basis to drive a randomized controlled trial, to demonstrate both the safety and benefits for postoperative pain and edema. Future studies with larger sample sizes should analyze low-dose, short-term oral corticosteroids following hand and upper extremity surgery and identify associations between variables or comorbidities and SSIs in these patients.