1 Introduction

Total shoulder arthroplasty (TSA) has become an increasingly common procedure for patients with various shoulder pathologies, including glenohumeral arthritis, rotator cuff arthropathy, and proximal humerus fractures.^1,2 Due to the increasing demand for this procedure, safe opioid stewardship paired with appropriate pain management is imperative for long-term patient care.¹ Understanding this interplay is crucial due to the growing concern of the opioid epidemic within the United States.³ Superfluous prescription of opioids for pain control after surgery has become one of the leading causes of opioid dependence, as up to 13 % of opioid-naive surgical patients develop an addiction.^3–5 Therefore, finding alternative methods for pain control in the postoperative setting is essential to reduce the risk of dependence while still adequately managing pain.

The use of perioperative corticosteroids is increasing across several orthopaedic subspecialties as it has been found to reduce postoperative pain along with nausea and vomiting.⁶ In the arthroplasty literature, opioid requirements in the postoperative setting have been shown to be minimized in patients who receive methylprednisolone following total knee and total hip arthroplasty.^6–8 Their use has also been proven to have the same impact following distal radius fractures and intertrochanteric femur fractures without any increase in complications.^9,10 This relationship between corticosteroid use and pain has also been found to be dose-dependent, with higher doses being associated with less pain and opioid usage.^6,7 Not only have corticosteroids been found to reduce overall pain, but they also have been found to affect hospital length of stay along with several other morbidity markers.^6,7

The use of corticosteroids in TSA has not been extensively studied. Post-operative multimodal pain control for TSA has most commonly included non-steroidal anti-inflammatory medications, muscle relaxants, and opioids in conjunction with anesthetic blocks.¹¹ A recent randomized control study found that the use of methylprednisolone in combination with other forms of pain management reduced pain and opioid consumption.¹² This study, however, was limited to a single institution and included a limited number of patients, 67, thus necessitating a broader study with a larger sample size to allow for more powered conclusions. However, limited further research exists on methylprednisolone use in TSA.

Our study aims to assess the use of methylprednisolone in the perioperative setting for total shoulder arthroplasty as it relates to postoperative opioid consumption in terms of number of prescriptions and analyze potential complications that may arise from its use. We hypothesize that patients who are given methylprednisolone will have reduced opioid requirements in the post-operative setting.

2 Materials and methods

3 Results

After the initial query on January 2, 2025, to include patients who had surgery at least 1 year prior, 36,724 patients were identified who had no prior history of methylprednisolone use and a minimum follow-up of 90 days. These patients were stratified into those who received methylprednisolone within the 7-day postoperative period and those who didn't (no methylprednisolone). The methylprednisolone group included 1310 patients, and the methylprednisolone group included 35,414 patients. After 1:1 propensity score matching, 1304 were established in each cohort for analysis.

4 Discussion

Perioperative corticosteroid use in total shoulder arthroplasty (TSA) is a promising intervention with the potential to optimize postoperative pain management and reduce opioid exposure. This study represents one of the largest multi-institutional analyses comparing outcomes between patients undergoing TSA with and without perioperative methylprednisolone. Our findings demonstrate that methylprednisolone is associated with a significant reduction in the number of opioid prescriptions at both 30- and 90-day time points without any increase in major surgical or medical complications, highlighting its potential to enhance postoperative pain management while maintaining patient safety.

Consistent with our hypothesis, patients who received methylprednisolone demonstrated a significant reduction in the number of opioid prescriptions at both 30- and 90-day time points despite no differences in the overall risk of opioid utilization between the two groups. In other words, this supports the argument that methylprednisolone may decrease opioid usage in the postoperative period. Although the same percentage of patients in both groups required opioid prescriptions, those who received methylprednisolone postoperatively required fewer opioid prescriptions. This finding aligns with prior studies demonstrating reduced opioid requirements in procedures like total knee and hip arthroplasty following methylprednisolone administration.^13,14 The mechanism underlying this reduction is likely multifactorial. Corticosteroids reduce postoperative pain through their potent anti-inflammatory effects, suppressing proinflammatory cytokine production and reducing central and peripheral pain sensitization.^15,16 Moreover, methylprednisolone may contribute to improved patient comfort by decreasing postoperative nausea and vomiting, common side effects of opioids that can exacerbate discomfort and limit opioid tolerance.¹⁷ These combined effects reduce the reliance on opioids and enhance the overall effectiveness of multimodal pain management.

Although the reduction in opioid prescriptions observed in this study may seem modest on an individual level, its impact at a population level could be substantial. Applied across the growing number of TSA procedures performed annually, even small decreases in opioid prescriptions could result in far fewer opioids in circulation, helping mitigate risks of misuse. By integrating methylprednisolone into multimodal pain management strategies alongside non-opioid analgesics and enhanced recovery protocols, shoulder surgeons can contribute to both improved patient outcomes and broader public health efforts to combat the opioid epidemic.

Importantly, the administration of methylprednisolone was not associated with an increased risk of surgical or medical complications, including prosthetic joint infection, revision surgery, or periprosthetic fracture. These findings align with previous studies in other orthopedic procedures, reinforcing the safety of corticosteroid use when administered appropriately. For example, a prior study on the use of methylprednisolone in total joint arthroplasty also demonstrated no significant increase in infection risk, suggesting that its immunosuppressive effects may be minimal in the perioperative setting when dosed appropriately.¹⁸ However, the trend toward a higher risk of pneumonia (p = 0.075) and an increased likelihood of emergency department visits both at the time point of 90 days postoperatively warrants further investigation. Although we do not see this same trend within the 30 day postoperative time point, it does exist at 90 days. Without any significant medical or surgical complications identified in this study, the drivers behind this increase in ED visits remain uncertain and may involve factors not captured in the current dataset. These unexplored variables could include patient-reported symptoms, anxiety, or other subjective concerns leading to precautionary ED utilization. Addressing these gaps will be crucial in future studies to better understand and mitigate this trend.

While this study provides valuable insights, several limitations should be acknowledged. First, the retrospective design and reliance on the TriNetX database introduce potential sources of bias, including misclassification and incomplete documentation. Although propensity score matching was employed to mitigate confounding, residual bias from unmeasured variables cannot be entirely excluded. Additionally, the database lacks granular clinical details such as pain scores, specific surgical techniques, or implant-related factors, which limits the ability to evaluate certain variables that may influence outcomes. One of the lack of details is whether or not patients who were given a prescription actually took the medication. Furthermore, the TriNetX privacy measure of reporting outcomes with fewer than 10 patients as N = 10 restricted statistical analysis of rare complications. Finally, we are only able to report on what is recorded in the retrospective review. The study is limited by the fact that we are unable to report on objective measures of opioid morphine milligram equivalent usage, as well as additional patient report outcome measures and pain scores that would further elucidate the role of methylprednisolone as an effective method to reduce post-operative pain. Despite these limitations, the large sample size and robust methodology strengthen the generalizability of the findings.

Future prospective studies are needed to confirm these findings and further elucidate the optimal dosing, timing, and patient selection criteria for methylprednisolone use in TSA. Additionally, investigations into the long-term outcomes of corticosteroid use, including its effects on joint health, function, and overall patient recovery, would provide a more comprehensive understanding of its benefits and risks. Studies focusing on specific subpopulations, such as patients with diabetes or significant comorbidities, may also help refine treatment protocols.

5 Conclusion

Methylprednisolone use in the peri-operative period may lead to a decrease in the number of opioid prescriptions needed for patients post-operatively with no increased risk of surgical or medical complications. As opioids carry their own inherent risks, safe stewardship with multimodal pain regimens that include methylprednisolone may be beneficial in both the short and long term for patients.

CRediT authorship contribution statement

Tej Joshi: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. Tuckerman Jones: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. Akhil Katakam: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. Daniella Ogilvie: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. Amanda Azer: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. Sefy A. Paulose: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. Balazs Galdi: Supervision, Conceptualization, Investigation, Methodology, Writing – review & editing.

Consent statement

This study was a retrospective database cohort analysis. No human subjects were directly involved, and all data were de-identified. As such, institutional review board (IRB) approval and informed consent were not required.

Disclaimer

The authors have not received grant support or research funding and have no conflicts of interest to declare.

Ethical statement

This study was a retrospective database cohort analysis. No human subjects were directly involved, and all data were de-identified. As such, institutional review board (IRB) approval and informed consent were not required.

Funding statement

The authors received no financial support for the research, authorship, and/or publication of this article.