The Journal of Bone and Joint Surgery, Vol 77, Issue 12 1801-1806, Copyright © 1995 by Journal of Bone and Joint Surgery, Inc
Use of supplemental steroids in patients having orthopaedic operations
RJ Friedman, CF Schiff and JS Bromberg
Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston 29425, USA.
It is commonly thought that patients receiving exogenous glucocorticoids
have suppression of the hypothalamic-pituitary-adrenal axis and need high
supplemental doses of exogenous glucocorticoids (so-called stress steroids)
to meet the demands of operative stress. Several reports have suggested
that clinically important suppression of the hypothalamic-pituitary-adrenal
axis is extremely uncommon and that the levels of glucocorticoids required
for stress are much lower than previously believed. A prospective study of
twenty-eight patients who had thirty-five major orthopaedic operations was
conducted. No patient received stress steroids; they were given only the
baseline immunosuppressive doses of glucocorticoids (mean dose, ten
milligrams of prednisone). Clinical information (based on regular physical
examinations for signs and symptoms of hypotension, myalgia, arthralgia,
ileus, and fever) and laboratory data (serum sodium levels, eosinophil
count, and twenty-four-hour urinary free-cortisol levels, determined at
perioperative and non-stress postoperative time-periods) were obtained to
document any evidence of adrenocortical insufficiency. There was no such
evidence in any of the patients, who were monitored during their entire
hospitalization. The levels of twenty-four-hour urinary free cortisol
showed that all patients had endogenous adrenocortical function and, when
this information was considered together with the clinical outcome, it was
concluded that this level of function was sufficient to meet the demands of
operative stress. Adrenocortical insufficiency in patients who have
orthopaedic operations without receiving supplemental stress steroids
appears to be much less common than previously thought. While biochemical
testing of the function of the hypothalamic-pituitary-adrenal axis may
sometimes reveal evidence of adrenal insufficiency, these tests do not
predict the clinical outcome and may be too sensitive to guide decisions
regarding treatment. Supplemental exogenous stress glucocorticoids may not
be needed to meet the demands of operative stress in these patients.
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