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 CME 4: October, November, December 2003
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The Journal of Bone and Joint Surgery (American) 85:2163-2167 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.

Endogenous Cortisol Production in Response to Knee Arthroscopy and Total Knee Arthroplasty

Seth S. Leopold, MD1, Michael T. Casnellie, MD2, Winston J. Warme, Lieutenant Colonel2, Paul J. Dougherty, Lieutenant Colonel2, Susan T. Wingo, Major2 and Susan Shott, PHD3

1 Department of Orthopaedic Surgery and Sports Medicine, University of Washington Medical Center, 1959 N.E. Pacific Street, Box 356500, Seattle, WA 98195. E-mail address: leopold{at}u.washington.edu
2 Orthopaedic Surgery Service (M.T.C., W.J.W., and P.J.D.) and Endocrinology Service (S.T.W.), William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79920
3 Biostatistics Unit, Rush-Presbyterian-St. Luke's Medical Center, 1725 West Harrison Street, Chicago, IL 60612

Investigation performed at the William Beaumont Army Medical Center, El Paso, Texas, and the University of Washington Medical Center, Seattle, Washington

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from William Beaumont Army Medical Center, Department of Clinical Investigation (Grant WBAMC 01/20). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The views expressed in this manuscript are those of the authors and do not reflect the official policy of the Department of Defense or the United States Government.

Background: There is controversy about whether patients who take exogenous glucocorticoids, such as prednisone, require supplemental (exogenous) glucocorticoids in order to meet the physiological demands of surgery. In this study, we sought to define the magnitude of the surgical stress response in normal patients undergoing major and minor elective orthopaedic surgery.

Methods: A prospective, observational study of thirty patients who had not taken exogenous glucocorticoids and who underwent either elective knee arthroscopy or elective unilateral total knee arthroplasty was performed. Regional anesthesia was used for all patients, and all patients treated with total knee arthroplasty had continuous epidural anesthesia for forty-eight hours after the surgery. The stress response was assessed on the basis of serum and twenty-four-hour urine cortisol levels; comparisons of the urine values were made after correcting for renal function by calculating the cortisol-to-creatinine clearance ratio.

Results: Preoperatively, patients undergoing arthroscopy and total knee arthroplasty had similar cortisol-to-creatinine clearance ratios. Patients treated with total knee arthroplasty had a significant (p < 0.001) surgical stress response on the day of the surgery, compared with baseline, whereas patients treated with arthroscopy did not. The mean cortisol-to-creatinine clearance ratio in patients treated with total knee arthroplasty was highest on the day of the surgery and decreased on the third postoperative day. However, on the third postoperative day, the cortisol-to-creatinine clearance ratio still was significantly higher than the baseline value (p < 0.001). Significant differences in the serum cortisol levels also were detected between the patients treated with arthroscopy and those treated with total knee replacement.

Conclusions: Patients undergoing total knee arthroplasty had a significant surgical stress response (a seventeenfold increase in the cortisol-to-creatinine clearance ratio); patients treated with arthroscopy did not. Additional studies, including a prospective trial of patients taking exogenous glucocorticoids, are warranted. Until they are performed, the significantly increased cortisol production observed in non-steroid-dependent patients following total knee arthroplasty leaves open the possibility that steroid-dependent patients undergoing this procedure could benefit from perioperative glucocorticoid supplementation. Since the non-steroid-dependent patients in the present series did not mount a substantial stress response to knee arthroscopy, our results do not support the use of supplemental steroids for that less-invasive procedure.

Level of Evidence: Therapeutic study, Level II-1 (prospective cohort study). See Instructions to Authors for a complete description of levels of evidence.


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