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Caragea M, Essman M, Conger A, Quinlan N, Chalmers P, McCormick Z. Management of post-arthroplasty pain: a narrative review of emerging interventional treatments. Pain Manag 2025; 15:213-226. [PMID: 40211561 PMCID: PMC12054930 DOI: 10.1080/17581869.2025.2490466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2024] [Accepted: 04/04/2025] [Indexed: 04/16/2025] Open
Abstract
Total joint arthroplasties are one of the most common orthopedic procedures with over 1 million total hip and knee arthroplasties performed annually. While the majority of patients experience favorable long-term outcomes, a significant number of patients continue to report persistent pain more than 3 months post-arthroplasty that is unresponsive to conservative treatment. Although current treatment options may seem limited, there are a variety of innovative procedures for the management of post-arthroplasty pain with the overall goal of reducing pain and restoring function. In this review, we outline the work-up for persistent post-arthroplasty pain and provide a review of the literature on interventional treatment modalities consisting of intra-articular steroids, radiofrequency ablation, and neuromodulation for the management of chronic post-arthroplasty pain in the hip, knee, ankle, and shoulder.
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Affiliation(s)
- Marc Caragea
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Matthew Essman
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Noah Quinlan
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Peter Chalmers
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Zachary McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT, USA
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Light JJ, John MP, Bonner KF, Styron JF. The Mechanisms and Safety of Corticosteroid Injections in Orthopaedic Surgery. JBJS Rev 2025; 13:01874474-202502000-00004. [PMID: 39937923 DOI: 10.2106/jbjs.rvw.24.00177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2025]
Abstract
» Corticosteroid injections (CSIs), including intra-articular, perineural, and those involving tendon sheaths or bursae, offer potential relief from osteoarthritic and inflammatory musculoskeletal pain, including gout attacks, as well as tarsal tunnel syndrome, plantar fasciitis, and interdigital neuromas.» CSI for musculoskeletal pain is commonly used as a nonoperative management option for both diagnostic and therapeutic purposes, offering pain relief, typically lasting from days to months.» CSIs are often performed prior to surgery as part of the nonoperative management of many conditions, with multiple CSIs within the year of surgery increasing postoperative infection risk in some major joints.» Despite the potential benefits of CSI, there are risks, including a potential increase in the risk of surgical site infection secondary to bacterial contamination and the immunomodulating effect of corticosteroids when given in the perioperative period.» To date, a multitude of studies across orthopaedic subspecialties has reported on perioperative infection risk associated with CSIs. However, heterogeneity in study design and patient populations has made standardized recommendations challenging. It is, therefore, difficult to elucidate, with a high level of evidence, the most appropriate perioperative timeline for CSI administration for which infection risk is nonsignificant.
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Affiliation(s)
- Jonathan J Light
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York
| | - Mitchell P John
- Hand Surgery, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kevin F Bonner
- Jordan-Young Institute Orthopedic Surgery, Virginia Beach, Virginia
| | - Joseph F Styron
- Hand Surgery, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Schoell K, Crabb R, Simpson E, Deshpande V, Gardner V, Quilligan E, Parvaresh K, Kassam H. Preoperative corticosteroid injections are associated with a higher periprosthetic infection rate following primary total shoulder arthroplasty: a systematic review and meta-analysis. J Shoulder Elbow Surg 2024; 33:2734-2742. [PMID: 39002882 DOI: 10.1016/j.jse.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/01/2024] [Accepted: 05/10/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Corticosteroid injections (CSIs) are commonly used for the treatment of shoulder pain in patients with osteoarthritis and rotator cuff arthropathy. These injections may increase the risk of infection following eventual shoulder arthroplasty. The purpose of this study was to perform a systematic review and meta-analysis of existing data to explore the relationship between preoperative CSI's and postoperative periprosthetic joint infection (PJI) following shoulder arthroplasty. METHODS A literature search was performed on PubMed, Embase, and Web of Science databases through September 29, 2023. Of the 4221 retrieved, 7 studies including 136,233 patients were included for qualitative analysis. Studies describing patients receiving CSI prior to shoulder arthroplasty and the effect on postoperative infection risk were included in the systematic review and subsequent meta-analysis. Assessment of risk of bias was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS Receiving a CSI prior to shoulder arthroplasty was found to have a statistically significant association with increased risk for PJI (odds ratio [OR]: 1.13; 95% confidence interval [CI]: 1.06-1.19; P < .0001). The rate of PJI increased when injections were given closer to the time of surgery. Patients who received an injection at any time point before surgery had a 5.4% risk of PJI compared to 7.9% and 9.0% in patients receiving an injection within 3 months and 1 month of surgery, respectively. This time dependent association however did not reach statistical significance: 1 month OR 1.48; 95% Cl: 0.86-2.53; P = .16, 3 months OR 1.95; 95% Cl: 0.95-4.00; P = .07. CONCLUSION The results of this systematic review and meta-analysis demonstrate that patients receiving corticosteroid shoulder injections prior to shoulder arthroplasty may be at an increased risk for PJI postoperatively. While time dependent stratification did not reach statistical significance, our findings indicate a clear trend of increased risk for patients receiving injections closer to surgery.
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Prkić A, Peet M, Benner JL, Slot K, van der List JP, Temmerman OPP, Vos SJ. Role of Preoperative Intra-Articular Corticosteroid Injections on Periprosthetic Joint Infection in Total Hip Arthroplasty and Its Association With Preoperative Timing: A Single-Center Series of 5,909 Hips. J Arthroplasty 2024; 39:2100-2103. [PMID: 38423259 DOI: 10.1016/j.arth.2024.02.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Preoperative intra-articular corticosteroid injections to the hip joint increase the risk of periprosthetic joint infection (PJI) during primary total hip arthroplasty (THA). This study aimed to determine the relationship between preoperative timing of intra-articular corticosteroid injections and PJI risk following THA using data from a single-center hospital. METHODS This single-center, retrospective cohort study included patients who underwent a THA between 2014 and 2020. Medical records were checked for intra-articular corticosteroid injections and PJI within 1 year of surgery. Patients were categorized into groups based on whether they received "no injection" or "injection 0 to 3 months," "3 to 6 months," and "> 6 months prior to THA." Hazard ratios (HRs) for these groups were calculated using multivariate Cox regression analysis, correcting for potential confounders, and presented with 95% confidence intervals [95% CIs]. RESULTS In total, 4,507 patients (5,909 THAs) were identified. A total of 1,581 patients (27%) received an injection prior to THA. Without considering the timing factor, no increased risk for PJI following an intra-articular injection was noted (P = .19). Comparing the specified groups using multivariate analysis, corticosteroid injection within 3 months of THA showed an increased risk of PJI (HR 2.63, 95% CI 1.18 to 5.87, P = .018), but this effect was not observed for the "injection 3 to 6 months" group (HR 1.51, 95% CI 0.74 to 3.08, P = .264). CONCLUSIONS Corticosteroid injections administered up to 3 months prior to THA increased the risk of PJI within 1 year after THA, with an HR of 2.63; however, injections between 3 and 6 months before surgery did not have a significantly higher infection rate.
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Affiliation(s)
- Ante Prkić
- Department of Orthopaedic Surgery, NorthWest Clinics, Alkmaar, The Netherlands; Centre for Orthopaedic Research Alkmaar (CORAL), Alkmaar, The Netherlands
| | - Marijn Peet
- Centre for Orthopaedic Research Alkmaar (CORAL), Alkmaar, The Netherlands
| | - Joyce L Benner
- Centre for Orthopaedic Research Alkmaar (CORAL), Alkmaar, The Netherlands; Faculty of Behavioral and Movement Sciences, Department of Human Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands
| | - Karin Slot
- Department of Orthopaedic Surgery, NorthWest Clinics, Alkmaar, The Netherlands
| | | | - Olivier P P Temmerman
- Department of Orthopaedic Surgery, NorthWest Clinics, Alkmaar, The Netherlands; Centre for Orthopaedic Research Alkmaar (CORAL), Alkmaar, The Netherlands
| | - Stan J Vos
- Department of Orthopaedic Surgery, NorthWest Clinics, Alkmaar, The Netherlands; Centre for Orthopaedic Research Alkmaar (CORAL), Alkmaar, The Netherlands
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Vicenti G, Albano F, Buono C, Passarelli AC, Pesare E, Colasuonno G, Ladogana T, Moretti B, Solarino G. Risk of Periprosthetic Joint Infection after Intra-Articular Injection: Any Difference among Shoulder, Knee and Hip? Healthcare (Basel) 2024; 12:1060. [PMID: 38891135 PMCID: PMC11171832 DOI: 10.3390/healthcare12111060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/16/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Osteoarthritis is a degenerative joint disease caused by the wear and tear of joint cartilage. The definitive and resolving treatment is prosthetic replacement of the articular surface, the demand of which is on the rise for patients with mild to moderate severity. However, a conservative strategy may be considered that aims to reduce and contain pain symptoms by postponing surgical treatment in the case of worsening that can no longer be otherwise controlled. Intra-articular infiltrations, like other therapeutic strategies, are not without complications, and among these the most feared is joint infection, especially in anticipation of future prosthetic replacement. Is important to avoid periprosthetic joint infections because they represent one of the third most common reasons for revision surgery. Using cases found in the literature, the aim of this article is to determine if there is a real correlation between the type of injections, the number of doses injected and the time between infiltrations and the surgical procedure.
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Affiliation(s)
| | | | - Claudio Buono
- Orthopaedic & Trauma Unit, Department of Translational Biomedicine and Neuroscience (DiBraiN), School of Medicine, University of Bari Aldo Moro, AOU Consorziale “Policlinico”, 70124 Bari, Italy; (G.V.); (F.A.); (A.C.P.); (E.P.); (G.C.); (T.L.); (B.M.); (G.S.)
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Ariyanfar A, Klein K, von Rechenberg B, Darwiche S, Dailey HL. Adaptive Image Segmentation Reveals Substantial Cortical Bone Remodeling During Early Fracture Repair. COMPUTER METHODS IN BIOMECHANICS AND BIOMEDICAL ENGINEERING. IMAGING & VISUALIZATION 2024; 12:2345165. [PMID: 39036745 PMCID: PMC11257215 DOI: 10.1080/21681163.2024.2345165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/15/2024] [Indexed: 07/23/2024]
Abstract
The goal of this study was to develop an image analysis algorithm for quantifying the effects of remodeling on cortical bone during early fracture healing. An adaptive thresholding technique with boundary curvature and tortuosity control was developed to automatically identify the endocortical and pericortical boundaries in the presence of high-gradient bone mineral density (BMD) near the healing zone. The algorithm successfully segmented more than 47,000 microCT images from 12 healing ovine osteotomies and intact contralateral tibiae. Resampling techniques were used to achieve data dimensionality reduction on the segmented images, allowing characterization of radial and axial distributions of cortical BMD. Local (transverse slice) and total (whole bone) remodeling scores were produced. These surrogate measures of cortical remodeling derived from BMD revealed that cortical changes were detectable throughout the region covered by callus and that the localized loss of cortical BMD was highest near the osteotomy. Total remodeling score was moderately and significantly correlated with callus volume and mineral composition (r > 0.64, p < 0.05), suggesting that the cortex may be a source of mineral needed to build callus.
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Affiliation(s)
- Alireza Ariyanfar
- Mechanical Engineering & Mechanics, Lehigh University, Bethlehem, PA, USA
| | - Karina Klein
- Musculoskeletal Research Unit (MSRU), Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Brigitte von Rechenberg
- Musculoskeletal Research Unit (MSRU), Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
| | - Salim Darwiche
- Musculoskeletal Research Unit (MSRU), Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
| | - Hannah L. Dailey
- Mechanical Engineering & Mechanics, Lehigh University, Bethlehem, PA, USA
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Raju R, Holder EK, Dundas M, Liang J, Donham R. Risk of SARS-CoV-2 following joint and epidural corticosteroid injections: A retrospective study. Pain Pract 2024; 24:472-482. [PMID: 37994676 DOI: 10.1111/papr.13321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
OBJECTIVE The immunosuppressive effects of corticosteroid (CS) injections have come under more scrutiny during the coronavirus disease 2019 (COVID-19) pandemic. The aim of the study was to explore any relationship between joint/epidural CS injection and SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) polymerase chain reaction (PCR) positivity. METHODS A retrospective chart review was conducted on patients 18 years or over who received at least one joint or epidural CS injection by physiatrists in a tertiary care center between January 1, 2020, and December 31, 2021. This cohort of patients was then compared to a control group who did not receive any CS injection during this time period. RESULTS A total of 766 patients were identified in the CS injection group and 1546 patients in the control group. Overall, 12.27% of patients turned SARS-CoV-2 PCR positive in the CS injection group, which was similar to 11.90% in the control group (p = 0.797). But 3-month SARS-CoV-2 PCR positivity rate showed a statistically significant higher rate among the CS injection group (3.30% in the CS injection group vs. 2.10% in the control group; p = 0.027). In multivariate regression analysis, after adjusting both groups for Charlson Comorbidity Index (CCI), there was statistically significant higher SARS-CoV-2 PCR positivity rate in the CS injection group (p = 0.024). However, after adjusting both groups for age and total number of comorbidities, there was no difference between the groups in regard to SARS-CoV-2 PCR positivity rate (p = 0.081). In the subgroup analysis of only COVID-19 vaccinated patients, there was an increased 3-month SARS-CoV-2 PCR positivity rate among patients with severe comorbidities in the CS injection group (p = 0.036). CONCLUSION The study was not conclusive on the effect of joint or epidural CS injection on SARS-CoV-2 PCR positivity rate, although adjusted analysis suggests higher 3-month SARS-CoV-2 PCR positivity rate after CS injection in patients with severe comorbidities with significant disease burden when compared to controls.
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Affiliation(s)
- Robin Raju
- Department of Orthopedics and Rehabilitation, Yale New Haven Hospital/Yale University, New Haven, Connecticut, USA
| | - Eric K Holder
- Department of Orthopedics and Rehabilitation, Yale New Haven Hospital/Yale University, New Haven, Connecticut, USA
| | - Mark Dundas
- Department of Orthopedics and Rehabilitation, Yale New Haven Hospital/Yale University, New Haven, Connecticut, USA
| | - Jingchen Liang
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Rebecca Donham
- Clinical Research Fellow, Yale University, Alabama College of Osteopathic Medicine, Dothan, Alabama, USA
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Kamel SI, Rosas HG, Gorbachova T. Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications. AJR Am J Roentgenol 2024; 222:e2330458. [PMID: 38117096 DOI: 10.2214/ajr.23.30458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Corticosteroid injections can be associated with a range of potential side effects, which may be classified as local or systemic and further stratified as immediate or delayed in onset. Radiologists performing image-guided musculoskeletal injections should recognize the potential side effects of corticosteroid medication when counseling patients before injection and consider such side effects in planning individual injections. This Review summarizes the available evidence regarding the local and systemic side effects of corticosteroid injections performed for musculoskeletal indications. Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury. Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis. Additional targeted counseling is warranted regarding side effects that are specific to certain patient populations (i.e., premenopausal women, patients with diabetes, athletes, and pediatric patients). Corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint. Guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. Further research is needed regarding the long-term complications of continuous corticosteroid use, particularly with regard to osseous effects.
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Affiliation(s)
- Sarah I Kamel
- Department of Radiology, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA 19107
| | - Humberto G Rosas
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Cantrell WA, Cox CL, Johnson C, Obuchowski N, Strnad G, Swinehart D, Yalcin S, Spindler KP. The Effect of Aspiration and Corticosteroid Injection After ACL Injury on Postoperative Infection Rate. Am J Sports Med 2023; 51:3665-3669. [PMID: 37975540 DOI: 10.1177/03635465231211606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Injecting bioactive substances into the knee is common in orthopaedic practice, and recently it has been shown to mitigate risk factors for posttraumatic osteoarthritis. Therefore, understanding the influence of these injections on postoperative infection rate is imperative. HYPOTHESIS Postinjury aspiration and corticosteroid injection (CSI) of the knee before anterior cruciate ligament (ACL) reconstruction (ACLR) would not increase the risk of postoperative infection. STUDY DESIGN Cohort Study; Level of evidence, 3. METHODS All patients between the ages of 10 and 65 years who underwent primary bone-patellar tendon-bone ACLR by 1 fellowship-trained sports medicine orthopaedic surgeon between January 1, 2011, and September 8, 2020, at 1 of 2 major academic centers were evaluated for inclusion. A total of 693 patients were included, with 273 patients receiving postinjury and preoperative aspiration and CSI. A postoperative infection was defined as a patient returning to the operating room for an intra-articular washout. The intervals-measured in days-between the CSI and ACLR and between ACLR and the final follow-up were recorded. To further evaluate the infection risk in each cohort (total cohort; aspiration and injection cohort; no aspiration and injection cohort), the upper 95% confidence bound for the infection risk was calculated for each cohort. RESULTS There were no postoperative infections in the 693 patients included in this study. The upper 95% confidence bounds were 0.4%, 1.1%, and 0.7% for the total cohort, the cohort that underwent aspiration and injection, and the cohort that did not, respectively. The median number of days between the surgical date and that of the aspiration and injection was 34 days, and the mean follow-up for the entire cohort was 337.4 days (95% CI, 307.6-367.3). CONCLUSION Postinjury and preoperative aspiration and CSI is a safe intervention that can be used before ACLR. Future studies with larger sample sizes, longer patient follow-ups, and multiple surgeons would be helpful to both better understand infection risk and better identify the influence of CSI on preventing posttraumatic osteoarthritis.
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Affiliation(s)
| | | | | | | | | | | | | | - Kurt P Spindler
- Cleveland Clinic Florida, Sports Medicine, Weston, Florida, USA
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Shelby T, Mills ES, Kang HP, Ton A, Hah RJ, Alluri RK. Preoperative Epidural Steroid Injection Does Not Increase Infection Risk Following Posterior Cervical Surgery. Spine (Phila Pa 1976) 2023; 48:1658-1662. [PMID: 36972151 DOI: 10.1097/brs.0000000000004647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/15/2023] [Indexed: 06/18/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The purpose of this study was to characterize the infection risk of preoperative epidural steroid injection (ESI) in patients undergoing posterior cervical surgery. SUMMARY OF BACKGROUND DATA ESI is a helpful tool for alleviating pain and is often used as a diagnostic tool before cervical surgery. However, a recent small-scale study found that ESI before cervical fusion was associated with an increased risk of postoperative infection. MATERIALS AND METHODS Patients from 2010 to 2020 with cervical myelopathy, spondylosis, and radiculopathy who underwent posterior cervical procedure including laminectomy, laminoforaminotomy, fusion, or laminoplasty were queried from the PearlDiver database. Patients who underwent revision or fusion above C2 or who had a diagnosis of neoplasm, trauma, or preexisting infection were excluded. Patients were divided on whether they received an ESI within 30 days before the procedure and subsequently matched by age, sex, and preoperative comorbidities. The χ 2 analysis was used to calculate the risk of postoperative infection within 90 days. Logistic regression controlling for age, sex, Elixhauser Comorbidity Index, and operated levels was conducted within the unmatched population to assess infection risk for injected patients across procedure subgroups. RESULTS Overall, 299,417 patients were identified with 3897 having received a preoperative ESI and 295,520 who did not. Matching resulted in 975 in the injected group and 1929 in the control group. There was no significant difference in postoperative infection rate in those who received an ESI within 30 days preoperatively and those who did not (3.28% vs. 3.78%, odds ratio=0.86, 95% CI: 0.57-1.32, P =0.494). Logistic regression accounting for age, sex, Elixhauser Comorbidity Index, and levels operated demonstrated that injection did not significantly increase infection risk in any of the procedure subgroups. CONCLUSIONS The present study found no association between preoperative ESI within 30 days before surgery and postoperative infection in patients undergoing posterior cervical surgery.
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Affiliation(s)
- Tara Shelby
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Emily S Mills
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Hyunwoo P Kang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andy Ton
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Raymond J Hah
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ram K Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Raymond HE, Barbera JP, Shah KC, Zubizarreta N, Huang HH, Poeran J, Chen DD, Moucha CS, Hayden BL. Risk of Infection After Total Knee or Hip Arthroplasty After Receipt of Multiple Corticosteroid or Hyaluronic Acid Injections. J Am Acad Orthop Surg 2023; 31:e868-e875. [PMID: 37603685 DOI: 10.5435/jaaos-d-22-01177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 07/05/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Few studies have assessed the relationship between the quantity of preoperative corticosteroid injections (CSIs) or hyaluronic acid injections (HAIs) and postoperative infection risk after total knee or hip arthroplasty (TKA, THA). We aimed to (1) determine whether the number of injections administered before TKA/THA procedures is associated with postoperative infections and (2) establish whether infection risk varies by injection type. METHODS This retrospective cohort study included 230,487 THAs and 371,511 TKAs from the 2017 to 2018 Medicare Limited Data Set. The quantity of CSI or HAI, defined as receiving either CSI or HAI ≤2 years before TKA/THA, was identified and categorized as 0, 1, 2, or >2. The primary outcome was 90-day postoperative infection. Multivariable regression models measured the association between the number of injections and 90-day postoperative infection. Odds ratios and 95% confidence intervals were reported. RESULTS The percentage of THA patients receiving 1, 2, and >2 preoperative CSIs was 6.1%, 1.6%, and 0.8%, respectively. Receiving >2 CSIs within 2 years before THA was associated with higher odds of 90-day postoperative infection (odds ratios = 1.74, 95% CI = 1.11 to 2.74, P = 0.02). The percentage of TKA patients receiving 1, 2, and >2 CSIs was 3.0%, 1.2%, and 1.1%, respectively. For HAIs in TKA patients, percentage receiving injections was 98.3%, 0.6%, 0.2%, and 0.9%, respectively. Quantity of CSIs or HAIs administered was not associated with postoperative infection among TKA patients. CONCLUSION Patients receiving >2 injections before THA had higher odds of 90-day postoperative infection. This finding was not observed in TKA patients. These results suggest that the use of >2 injections within 2 years of THA should be avoided.
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Affiliation(s)
- Hayley E Raymond
- From the Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY
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12
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Chen Z, Bains SS, Dubin JA, Monárrez R, Remily EA, Sax OC, Ingari JV. The temporal effect of corticosteroid injections into large joints prior to trigger finger release on infection. HAND SURGERY & REHABILITATION 2023; 42:419-423. [PMID: 37302572 DOI: 10.1016/j.hansur.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Trigger finger may be treated with open surgical release. Local corticosteroid injections have also demonstrated success. Studies suggest recipients of flexor sheath corticosteroid up to 90-days prior to open surgery are at increased risk of post-operative infection. However, the possible link between large joints corticosteroid prior to trigger finger release remains unexplored. Therefore, this study aimed to provide complication risks for trigger finger release recipients after large joint corticosteroid. METHODS We reviewed a national, all-payer database and examined patients who did not receive and did receive corticosteroid two, four, or six weeks prior to trigger finger release. Primary outcomes assessed were 90-day risk for antibiotics, infection, and irrigations and debridement. Multivariate logistic analyses compared cohorts using odds ratios with 95% confidence intervals. RESULTS No trends were found regarding antibiotic requirements, infection, as well irrigations and debridement within 90-days for recipients of corticosteroid into large joints two, four, or six weeks prior to open trigger finger release. Elixhauser Comorbidity Index, alcohol abuse, diabetes mellitus, and tobacco use were identified as independent risks for requiring antibiotics as well as irrigations and debridement (all Odds Ratios > 1.06, all p ≤ 0.048). CONCLUSIONS Patients who underwent trigger finger release after receiving a corticosteroid into a large joint two, four, or six weeks prior has no association with 90-day antibiotics, infection, or irrigations and debridement. While the comfort levels for individual surgeons vary, optimizing these comorbidities prior to surgery is an important goal discussed with patients to lower risks for infections. RETROSPECTIVE Level III.
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Affiliation(s)
- Zhongming Chen
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, United States
| | - Sandeep S Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, United States
| | - Jeremy A Dubin
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, United States
| | - Rubén Monárrez
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, United States
| | - Ethan A Remily
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, United States
| | - Oliver C Sax
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, United States
| | - John V Ingari
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, United States.
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Streck LE, Braun S, Spilo K, Boettner CS, Brenneis M, Boettner F. How safe are intra-articular corticosteroid injections to the hip? BMC Musculoskelet Disord 2023; 24:665. [PMID: 37608323 PMCID: PMC10463482 DOI: 10.1186/s12891-023-06766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/28/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Intra-articular corticosteroid injections (ICSI) are an effective symptomatic treatment for osteoarthritis of the hip. However, the safety of ICSI has been questioned and a relatively high risk for septic arthritis, rapidly progressive osteoarthritis (RPIO) and periprosthetic joint infections (PJI) in patients undergoing subsequent total hip arthroplasty (THA) have been suggested. METHODS This is a retrospective evaluation of 682 hips that underwent ICSI with 40 mg of Triamcinolone for primary osteoarthritis of the hip. All ICSI were performed using sterile techniques, the number of ICSI in each hip and the cumulative corticosteroid dosage were assessed. Pre- and post-injection radiographs were compared to identify cases with RPIO. Native joint septic arthritis, surgical site infections and PJI were identified by chart review. RESULTS 4 hips (0.6%) developed RPIO 2-4 months following ICSI. The cumulative Triamcinolone dose was not associated with the development of RPIO (p = 0.281). 1 case was diagnosed with septic arthritis and treated with staged THA, there were no signs of infection at a 5 years follow-up. 483 hips (75.7%) underwent THA, including 199 hips with THA less than 3 months following ICSI and 181 hips with > 1 ICSI prior to THA. There were 3 superficial surgical site infections/wound dehiscence and no PJI. CONCLUSION The rate of RPIO was 0.6%. The current findings suggest that if ICSI is performed under sterile conditions, the risk for septic arthritis or PJI following THA, even in patients with multiple ICSI or ICSI within 3 months prior to surgery, is minimal.
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Affiliation(s)
- Laura Elisa Streck
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Sebastian Braun
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Kimi Spilo
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Cosima Sue Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Marco Brenneis
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, 60528, Frankfurt/Main, Germany
| | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Saracco M, Ciriello V, D’Angelo F, Zagra L, Solarino G, Logroscino G. Do prior intra-articular injections impact on the risk of periprosthetic joint infection in patients undergoing total hip arthroplasty? A meta-analysis of the current evidences with a focus on the timing of injection before surgery. EFORT Open Rev 2023; 8:459-467. [PMID: 37289047 PMCID: PMC10300843 DOI: 10.1530/eor-23-0028] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
PURPOSE Intra-articular injection is a well-established and increasingly used treatment for the patient with mild-to-moderate hip osteoarthritis. The objectives of this literature review and meta-analysis are to evaluate the effect of prior intra-articular injections on the risk of periprosthetic joint infection (PJI) in patients undergoing total hip arthroplasty (THA) and to try to identify which is the minimum waiting time between hip injection and replacement in order to reduce the risk of infection. METHODS The database of PubMed, Embase, Google Scholar and Cochrane Library was systematically and independently searched, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. To assess the potential risk of bias and the applicability of the evidence found in the primary studies to the review, the Newcastle-Ottawa scale (NOS) was used. The statistical analysis was performed by using the software 'R' version 4.2.2. RESULTS The pooling of data revealed an increased risk of PJI in the injection group that was statistically significative (P = 0.0427). In the attempt to identify a 'safe time interval' between the injection and the elective surgery, we conducted a further subgroup analysis: in the subgroup 0-3 months, we noted an increased risk of PJI after injection. CONCLUSIONS Intra-articular injection is a procedure that may increase the risk of developing periprosthetic infection. This risk is higher if the injection is performed less than 3 months before hip replacement.
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Affiliation(s)
- Michela Saracco
- Department of Orthopaedics, ASL Napoli 2 Nord, Naples, Italy
| | - Vincenzo Ciriello
- Department of Surgery, Orthopaedic and Trauma Unit, S. Croce e Carle Hospital, Cuneo, Italy
| | - Fabio D’Angelo
- Division of Orthopaedics and Traumatology, ASST Dei Sette Laghi, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Luigi Zagra
- Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Giuseppe Solarino
- Department of Translational Biomedicine and Neuroscience, School of Medicine, University of Bari Aldo Moro, AOU Consorziale ‘Policlinico’, Bari, Italy
| | - Giandomenico Logroscino
- Department Life, Health and Environmental Sciences—Mininvasive Orthopaedic Surgery, University of L’Aquila, L’Aquila, Italy
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15
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How do pre-operative intra-articular injections impact periprosthetic joint infection risk following primary total hip arthroplasty? A systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:1627-1635. [PMID: 35150302 DOI: 10.1007/s00402-022-04375-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/26/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Although intra-articular injections (IAIs) serve as the first-line non-surgical management for severe osteoarthritis (OA), recent analyses have suggested they are associated with an increased infection risk following primary total hip arthroplasty (THA). Therefore, our systematic review and meta-analysis explored the relationship between IAIs and periprosthetic joint infection (PJI) following THA reported in the current literature. METHODS Five online databases were queried for analyses published from January 1st, 2000-May 1st, 2021 reporting on PJI rates between patients undergoing primary THA who did and did not preoperatively receive an IAI. The overall pooled effect of injection status on PJI incidence was determined using Mantel-Haenszel (M-H) models. This was similarly conducted for segregated preoperative intervals: 0-3 months, > 3-6 months, > 6 + months. RESULTS A total of 11 articles were included in our analysis reporting on 278,782 THAs (IAI: n = 41,138; no IAI: n = 237,644). Patients receiving pre-operative injections had a significantly higher risk of PJI (OR: 1.31, 95% CI 1.07-1.62; p = 0.009). However, this finding was not robust. IAI receipt within 3-months of THA was associated with significantly higher PJI rates (OR: 1.68, 95% CI 1.48-1.90; p < 0.001). However, no significant difference was demonstrated in the > 3-6 month (OR: 1.19, 95% CI 0.94-1.52; p = 0.16) and > 6 + month sub-analyses (OR: 1.20, 95% CI 0.96-1.50; p = 0.11). The results of all sub-analyses remained were robust. DISCUSSION Our findings suggest that patients requiring THA should wait at least 3-months following IAI to reduce post-operative infection risk. This information can help inform patients considering OA management options, as well as adult reconstruction surgeons during preoperative optimization.
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Sax OC, Douglas SJ, Pervaiz SS, Salem HS, Nabet A, Mont MA, Delanois RE. Intra-articular Hip Injections Prior to Total Hip Arthroplasty: Infection and Cost-Related Associations. Orthopedics 2023; 46:19-26. [PMID: 36206513 DOI: 10.3928/01477447-20221003-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Intra-articular injections prior to total hip arthroplasty (THA) have been associated with postoperative infections. The purpose of this study was to determine whether a temporal relationship exists between hip injections prior to THA and infection. Specifically, we asked (1) Do patients who receive hip injections within 3 months of THA have a higher incidence of prosthetic joint infections (PJIs) or surgical site infections (SSIs)? and (2) Do these patients incur higher 90-day costs? Patients with hip injections prior to THA were identified using a national database from 2010 to 2019. Three laterality-specific groups (injection 0 to 3 months, 3 to 6 months, and 6 to 12 months prior to THA)were compared with a matched cohort without prior injection (n=277,841). Primary outcomes included PJIs, SSIs, and costs. Patients who had injections within 3 months of THA had a higher incidence of PJIs at 90 days (5.1% vs 1.6%, P<.01) and 1 year (6.8% vs 2.1%, P<.01), when compared with the matched cohort. They also had a higher incidence of SSIs at 90 days (2.8% vs 1.2%, P<.01) and 1 year (3.7% vs 1.7%, P<.01). Mean costs were 13.7% higher in this injection cohort. Patients who had injections between 3 and 6 months prior to THA had higher incidence and odds of postoperative PJIs at 90 days (2.6% vs 1.6%, P<.04), whereas those with injections beyond 6 months had no differences in PJIs (P≥.46). Patients who receive hip injections within 3 months of undergoing primary THA are at increased risk for postoperative PJIs, SSIs, and higher costs. This study reaffirms guidelines for when to perform THAs in these populations. [Orthopedics. 2023;46(1):19-26.].
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Infection Risk Increases After Total Hip Arthroplasty Within 3 Months Following Intra-Articular Corticosteroid Injection. A Meta-Analysis on Knee and Hip Arthroplasty. J Arthroplasty 2022; 38:1184-1193.e2. [PMID: 36592824 DOI: 10.1016/j.arth.2022.12.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/16/2022] [Accepted: 12/18/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Much debate continues regarding the risk of postoperative infection after intra-articular corticosteroid injection prior to total joint arthroplasty. The aim of this study was to evaluate the risk of periprosthetic joint infection (PJI) or other complications after joint arthroplasty in patients who received preoperative corticosteroids injections. METHODS A literature search was performed on PubMed, Web of Science, and Cochrane Library through January 4, 2022. Of 4,596 studies, 28 studies on 480,532 patients were selected for qualitative analysis. Studies describing patients receiving corticosteroids injections before joint arthroplasty (hip, knee) were included in the systematic review. A meta-analysis was performed of studies focusing on corticosteroids injections and PJI. Assessment of risk of bias and quality of evidence was based on the "Downs and Black's Checklist for Measuring Quality". RESULTS A significant association (odds ratio: 1.55, P = .001, 95% confidence interval: 1.357-1.772) between PJI and corticosteroids injections was found for total hip arthroplasty (THA). No association was found for knee arthroplasty procedures. The risk of PJI is statistically higher (odds ratio: 1.20, P = .045, 95% confidence interval: 1.058-1.347) if the injections are performed within 3 months preoperatively in THA patients. CONCLUSION Patients undergoing THA who previously received intra-articular injections of corticosteroids may expect a statistically higher risk of developing PJI. On the contrary, no association between corticosteroids injections and PJI could be seen in total knee arthroplasty patients. In addition, injection timing plays an important role: surgeons should refrain from administering corticosteroids injections within 3 months before hip arthroplasty, as it appears to be less safe than waiting a 3-month interval.
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Gamaletsou MN, Rammaert B, Brause B, Bueno MA, Dadwal SS, Henry MW, Katragkou A, Kontoyiannis DP, McCarthy MW, Miller AO, Moriyama B, Pana ZD, Petraitiene R, Petraitis V, Roilides E, Sarkis JP, Simitsopoulou M, Sipsas NV, Taj-Aldeen SJ, Zeller V, Lortholary O, Walsh TJ. Osteoarticular Mycoses. Clin Microbiol Rev 2022; 35:e0008619. [PMID: 36448782 PMCID: PMC9769674 DOI: 10.1128/cmr.00086-19] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.
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Affiliation(s)
- Maria N. Gamaletsou
- Laiko General Hospital of Athens and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Blandine Rammaert
- Université de Poitiers, Faculté de médecine, CHU de Poitiers, INSERM U1070, Poitiers, France
| | - Barry Brause
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Marimelle A. Bueno
- Far Eastern University-Dr. Nicanor Reyes Medical Foundation, Manilla, Philippines
| | | | - Michael W. Henry
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Aspasia Katragkou
- Nationwide Children’s Hospital, Columbus, Ohio, USA
- The Ohio State University School of Medicine, Columbus, Ohio, USA
| | | | - Matthew W. McCarthy
- Weill Cornell Medicine of Cornell University, New York, New York, USA
- New York Presbyterian Hospital, New York, New York, USA
| | - Andy O. Miller
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Zoi Dorothea Pana
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Ruta Petraitiene
- Weill Cornell Medicine of Cornell University, New York, New York, USA
| | | | - Emmanuel Roilides
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | | | - Maria Simitsopoulou
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Nikolaos V. Sipsas
- Laiko General Hospital of Athens and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Valérie Zeller
- Groupe Hospitalier Diaconesses-Croix Saint-Simon, Paris, France
| | - Olivier Lortholary
- Université de Paris, Faculté de Médecine, APHP, Hôpital Necker-Enfants Malades, Paris, France
- Institut Pasteur, Unité de Mycologie Moléculaire, CNRS UMR 2000, Paris, France
| | - Thomas J. Walsh
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
- Weill Cornell Medicine of Cornell University, New York, New York, USA
- New York Presbyterian Hospital, New York, New York, USA
- Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
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19
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Avila A, Acuña AJ, Do MT, Samuel LT, Kamath AF. Intra-articular injection receipt within 3 months prior to primary total knee arthroplasty is associated with increased periprosthetic joint infection risk. Knee Surg Sports Traumatol Arthrosc 2022; 30:4088-4097. [PMID: 35325263 DOI: 10.1007/s00167-022-06942-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/08/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE This systematic review and meta-analysis analyzed the influence of pre-operative intra-articular injections (IAI) on periprosthetic joint infection (PJI) rates after primary total knee arthroplasty (TKA). METHODS Studies published between January 1st, 2000 and May 1st, 2021 evaluating PJI rates among TKA patients with and without IAI were identified from PubMed, Cochrane Library, MEDLINE, EBSCO Host, and Google Scholar. The pooled effect of IAI on PJI risk was calculated utilizing Mantel-Haenszel (M-H) models. Sub-analysis comparisons were conducted based on the interval from IAI to TKA: 0-3 months; > 3-6 months; > 6-12 months. The Methodological Index for Non-Randomized Studies (MINORS) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool were utilized to evaluate the quality of each included study. RESULTS The present analysis included 12 studies reporting on 349,605 TKAs (IAI: n = 115,122; No IAI: n = 234,483). Patients receiving an IAI at any point prior to TKA (2850/115,122; 2.48%) had statistically significant increased risk of infection compared to patients not receiving IAIs (4479/234,483; 1.91%; OR: 1.14, 95% CI: 1.08-1.20; p < 0.0001). However, this finding was not demonstrated across sensitivity analyses. Receiving injections within 3 months prior to TKA was associated with increased infection risk (OR: 1.23, 95% CI: 1.14-1.31; p < 0.0001). There were no differences in infection rates when injections were given between > 3 and 6 months (OR: 0.82, 95% CI: 0.47-1.43; p = 0.49) and > 6-12 months prior to TKA (OR: 1.26, 95% CI: 0.89-1.78; p = 0.18). CONCLUSIONS Based on the current literature, the findings of this analysis suggest that patients receiving IAI should wait at least 3 months before undergoing TKA to mitigate infection risk. Orthopaedic surgeons and patients can utilize this information when undergoing shared decision-making regarding osteoarthritis management options and timing. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Amanda Avila
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Orthopaedic and Rheumatologic Institute, Center for Hip Preservation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Alexander J Acuña
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Orthopaedic and Rheumatologic Institute, Center for Hip Preservation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Michael T Do
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Orthopaedic and Rheumatologic Institute, Center for Hip Preservation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Orthopaedic and Rheumatologic Institute, Center for Hip Preservation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Orthopaedic and Rheumatologic Institute, Center for Hip Preservation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA.
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20
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The safety of intraarticular injection prior to total hip arthroplasty: a review. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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21
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Lai YH, Du J, Zhou Z. Letter to the Editor: Prior Intra-articular Corticosteroid Injection Within 3 Months May Increase the Risk of Deep Infection in Subsequent Joint Arthroplasty: A Meta-analysis. Clin Orthop Relat Res 2022; 480:1835-1836. [PMID: 35857300 PMCID: PMC9384926 DOI: 10.1097/corr.0000000000002331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 06/29/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Ya-hao Lai
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Jiayu Du
- School of Clinical Medicine, Chengdu Medical College, Chengdu, China
| | - Zongke Zhou
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
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22
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Khan IA, Small I, Sutton RM, Goh GS, Sherman MB, Mazur DW, Fillingham YA. Cumulative Intraarticular Injections Are Not a Risk Factor for Periprosthetic Joint Infection Following total Knee Arthroplasty. J Arthroplasty 2022; 37:1059-1063.e1. [PMID: 35189290 DOI: 10.1016/j.arth.2022.02.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/03/2022] [Accepted: 02/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND While injections within 90 days prior to total knee arthroplasty (TKA) are associated with an increased risk of periprosthetic joint infection (PJI), there is a paucity of literature regarding the impact of cumulative injections on PJI risk. This study was conducted to assess the association between cumulative corticosteroid and hyaluronic acid (HA) injections and PJI risk following TKA. METHODS This retrospective study using an injection database included patients undergoing TKA with a minimum 1-year follow-up from 2015 to 2020. Patients with injections within 90 days prior to surgery were excluded. The sum of corticosteroid and HA injections within five years prior to TKA was recorded. The primary outcome was PJI within 90 days following TKA. Area under the curve (AUC) values were calculated for a cumulative number of injections. RESULTS 648 knees with no injections and 672 knees with injections prior to TKA were included, among whom 243 received corticosteroids, 151 received HA, and 278 received both. No significant differences in early PJI rates existed between patients who received injections (0.60%) or not (0.93%) (P = .541). No significant differences existed in early PJI rates between patients injected with corticosteroids (0.82%), HA (0.66%), or both (0.36%) (P = .832). No cutoff number of injections was predictive for PJI. DISCUSSION A cumulative amount of steroid or HA injections, if given more than 90 days prior to TKA, does not appear to increase the risk of PJI within 90 days postoperatively. Multiple intraarticular corticosteroid injections and HA injections may be safely administered before TKA, without increased risk for early PJI.
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Affiliation(s)
- Irfan A Khan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Ilan Small
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Ryan M Sutton
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Matthew B Sherman
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Donald W Mazur
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Yale A Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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23
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Stadecker M, Gu A, Ramamurti P, Fassihi SC, Wei C, Agarwal AR, Bovonratwet P, Srikumaran U. Risk of revision based on timing of corticosteroid injection prior to shoulder arthroplasty. Bone Joint J 2022; 104-B:620-626. [PMID: 35491573 DOI: 10.1302/0301-620x.104b5.bjj-2021-0024.r3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Corticosteroid injections are often used to manage glenohumeral arthritis in patients who may be candidates for future total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (rTSA). In the conservative management of these patients, corticosteroid injections are often provided for symptomatic relief. The purpose of this study was to determine if the timing of corticosteroid injections prior to TSA or rTSA is associated with changes in rates of revision and periprosthetic joint infection (PJI) following these procedures. METHODS Data were collected from a national insurance database from January 2006 to December 2017. Patients who underwent shoulder corticosteroid injection within one year prior to ipsilateral TSA or rTSA were identified and stratified into the following cohorts: < three months, three to six months, six to nine months, and nine to 12 months from time of corticosteroid injection to TSA or rTSA. A control cohort with no corticosteroid injection within one year prior to TSA or rTSA was used for comparison. Univariate and multivariate analyses were conducted to determine the association between specific time intervals and outcomes. RESULTS In total, 4,252 patients were included in this study. Among those, 1,632 patients (38.4%) received corticosteroid injection(s) within one year prior to TSA or rTSA and 2,620 patients (61.6%) did not. On multivariate analysis, patients who received corticosteroid injection < three months prior to TSA or rTSA were at significantly increased risk for revision (odds ratio (OR) 2.61 (95% confidence interval (CI) 1.77 to 3.28); p < 0.001) when compared with the control cohort. However, there was no significant increase in revision risk for all other timing interval cohorts. Notably, Charlson Comorbidity Index ≥ 3 was a significant independent risk factor for all-cause revision (OR 4.00 (95% CI 1.40 to 8.92); p = 0.036). CONCLUSION There is a time-dependent relationship between the preoperative timing of corticosteroid injection and the incidence of all-cause revision surgery following TSA or rTSA. This analysis suggests that an interval of at least three months should be maintained between corticosteroid injection and TSA or rTSA to minimize risks of subsequent revision surgery. Cite this article: Bone Joint J 2022;104-B(5):620-626.
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Affiliation(s)
- Monica Stadecker
- Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington D.C., USA
| | - Alex Gu
- Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington D.C., USA
| | - Pradip Ramamurti
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Safa C Fassihi
- Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington D.C., USA
| | - Chapman Wei
- Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington D.C., USA
| | - Amil Raj Agarwal
- Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington D.C., USA
| | - Patawut Bovonratwet
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland, USA
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Lai Q, Cai K, Lin T, Zhou C, Chen Z, Zhang Q. Prior Intra-articular Corticosteroid Injection Within 3 Months May Increase the Risk of Deep Infection in Subsequent Joint Arthroplasty: A Meta-analysis. Clin Orthop Relat Res 2022; 480:971-979. [PMID: 34919065 PMCID: PMC9007211 DOI: 10.1097/corr.0000000000002055] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intra-articular injections containing a corticosteroid are used frequently, and periprosthetic joint infection is a serious complication after total joint arthroplasty. There is debate regarding whether intra-articular corticosteroid injections before arthroplasty increase periprosthetic joint infection after surgery. QUESTIONS/PURPOSES (1) Does a previous intra-articular corticosteroid injection increase the odds of infection after subsequent hip or knee arthroplasty? (2) Does this risk vary based on how soon before the arthroplasty (such as less than 3 months before surgery) the injection is administered? METHODS Using the PubMed, Embase, Cochrane Library, and Web of Science databases from inception to July 2021, we searched for comparative studies in English on patients who received intra-articular corticosteroid injections before arthroplasty and that tracked the frequency of infection after arthroplasty. We extracted data on the risk of infection after subsequent joint arthroplasty. The keywords included "corticosteroid," "steroid," "arthroplasty," "knee replacement," and "hip replacement." Eleven retrospective, comparative studies from four countries were included, of which 10 reported the specific diagnosis criteria and one did not. These articles included data on 173,465 arthroplasties in the hip or knee, as well as of 73,049 injections and 100,416 control patients. The methodologic quality of the included studies was evaluated according to the Newcastle-Ottawa Quality Assessment Scale; the articles' scores ranged from 6 to 7 (the score itself spans 0 to 9, with higher scores representing better study quality). We found no evidence of publication bias based on the Egger test, and tests of heterogeneity generally found heterogeneity, so a random-effects model was used of our meta-analyses. A meta-analysis was performed with Review Manager 5.3 software and Stata version 12.0 software. RESULTS Overall, there were no differences in the odds of periprosthetic joint infection between the injection group and the control group among patients who received any kind of injection (odds ratio 1.22 [95% CI 0.95 to 1.58]; p = 0.12). However, in a subgroup analysis, there was a higher OR for postoperative PJI in patients with an intra-articular corticosteroid injection in the knee or hip within 3 months (OR 1.39 [95% CI 1.04 to 1.87]; p = 0.03). There were no differences in the infection risk in patients who had injections between 3 and 6 months before arthroplasty (OR 1.19 [95% CI 0.95 to 1.48]; p = 0.13) or between 6 and 12 months before arthroplasty. CONCLUSION The current evidence suggests ipsilateral intra-articular corticosteroid injections within 3 months before arthroplasty were associated with an increased risk of periprosthetic joint infection during subsequent joint arthroplasty. We recommend against performing total joint arthroplasty on a patient who has received an intra-articular corticosteroid injection within 3 months. Further high-quality studies on this topic from registries, national databases, or insurance company data are still required to confirm and extend our findings. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Qizhong Lai
- The First Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Graduate School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Kaishen Cai
- The First Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Graduate School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Tianye Lin
- The First Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Graduate School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Chi Zhou
- Department of Orthopedics, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhenqiu Chen
- Department of Orthopedics, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qingwen Zhang
- Department of Orthopedics, the Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Smith LK, Garriga C, Kingsbury SR, Pinedo-Villanueva R, Delmestri A, Arden NK, Stone M, Conaghan PG, Judge A. UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE): what does analysis of linked, routinely collected national data sets tell us about mid-late term revision risk after hip replacement? Retrospective cohort study. BMJ Open 2022; 12:e050877. [PMID: 35264338 PMCID: PMC8915340 DOI: 10.1136/bmjopen-2021-050877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To identify patients at risk of mid-late term revision of hip replacement to inform targeted follow-up. DESIGN Analysis of linked national data sets from primary and secondary care (Clinical Practice Research Datalink (CPRD-GOLD); National Joint Registry (NJR); English Hospital Episode Statistics (HES); Patient-Reported Outcome Measures (PROMs)). PARTICIPANTS Primary elective total hip replacement (THR) aged≥18. EVENT OF INTEREST Revision surgery≥5 years (mid-late term) after primary THR. STATISTICAL METHODS Cox regression modelling to ascertain risk factors of mid-late term revision. HR and 95% CI assessed association of sociodemographic factors, comorbidities, medication, surgical variables and PROMs with mid-late term revision. RESULTS NJR-HES-PROMs data were available from 2008 to 2011 on 142 275 THR; mean age 70.0 years and 61.9% female. CPRD GOLD-HES data covered 1995-2011 on 17 047 THR; mean age 68.4 years, 61.8% female. Patients had minimum 5 years postprimary surgery to end 2016. In NJR-HES-PROMS data, there were 3582 (2.5%) revisions, median time-to-revision after primary surgery 1.9 years (range 0.01-8.7), with 598 (0.4%) mid-late term revisions; in CPRD GOLD, 982 (5.8%) revisions, median time-to-revision 5.3 years (range 0-20), with 520 (3.1%) mid-late term revisions.Reduced risk of mid-late term revision was associated with older age at primary surgery (HR: 0.96; 95% CI: 0.95 to 0.96); better 6-month postoperative pain/function scores (HR: 0.35; 95% CI: 0.27 to 0.46); use of ceramic-on-ceramic (HR: 0.73; 95% CI: 0.56 to 0.95) or ceramic-on-polyethylene (HR: 0.76; 95% CI: 0.58 to 1.00) bearing surfaces.Increased risk of mid-late term revision was associated with the use of antidepressants (HR: 1.32; 95% CI: 1.09 to 1.59), glucocorticoid injections (HR: 1.33; 95% CI: 1.06 to 1.67) and femoral head size≥44 mm (HR: 2.56; 95% CI: 1.09 to 6.02)No association of gender, obesity or Index of Multiple Deprivation was observed. CONCLUSION The risk of mid-late term THR is associated with age at primary surgery, 6-month postoperative pain and function and implant factors. Further work is needed to explore the associations with prescription medications observed in our data.
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Affiliation(s)
- Lindsay K Smith
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, Bristol, UK
- Trauma and Orthopaedics, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, Bristol, UK
| | - Cesar Garriga
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah R Kingsbury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Antonella Delmestri
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nigel K Arden
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Martin Stone
- Orthopaedics Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Andrew Judge
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Regan P, Elkhalifa S, Barratt P. The systemic immunosuppressive effects of peripheral corticosteroid injections: A narrative review of the evidence in the context of COVID-19. Musculoskeletal Care 2021; 20:431-441. [PMID: 34882956 PMCID: PMC9015551 DOI: 10.1002/msc.1603] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/13/2021] [Indexed: 12/22/2022]
Abstract
Introduction Injected glucocorticoid's (corticosteroids) are commonly used in musculoskeletal practice. The current global COVID‐19 pandemic has increased attention on the potential for locally injected corticosteroids to exert a systemic immunosuppressive effect and the implications this may have in relation to COVID‐19 infection and vaccination. Aim This narrative review summarises the evidence regarding the potential systemic immunosuppressive effects of peripheral corticosteroid injections in relation to the ongoing COVID‐19 pandemic. Method A narrative review was selected to allow inclusion of evidence related to a diverse range of topics relevant to this subject in order to provide the most comprehensive and clinically relevant guidance for clinicians. Results/discussion Current evidence demonstrates that cytotoxic, phagocytic and antigen presenting cells involved in both the innate and adaptive immune responses are suppressed for 48 h post‐injection and messenger cytokines that are integral to immune function are suppressed for over 96 h post‐injection. This potentially reduces an individual's ability to prevent viral infection, limit early viral replication, and delays activation of adaptive immune mechanisms (T and B lymphocytes) and subsequent viral clearance and elimination. The hypothalamic–pituitary–adrenal (HPA) axis can be suppressed for 2–4 weeks or longer following peripheral corticosteroid injections. The role of the HPA axis in immune function is not fully understood, however this could potentially indicate longer lasting immunosuppression. Conclusions This review found evidence of suppression of immune cell numbers for the first 48 h post‐injection, cytokines for over 96 h post‐injection and HPA axis suppression lasting for 2–4 weeks or longer. There is currently no evidence that these physiological changes translate into a clinically meaningful increased risk of COVID‐19 infection or related morbidity or mortality, but there is also no persuasive evidence that they do not. This review discusses the implications of the current evidence in relation to shared decision making, informed consent, risk management and COVID‐19 vaccination to provide clinicians with a pragmatic guide to help navigate the current uncertainty regarding the potential immunosuppressive effects of peripheral corticosteroid injections.
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Affiliation(s)
- Paul Regan
- Musculoskeletal Clinical and Assessment and Treatment Service, Salford Royal NHS Foundation Trust, Salford Care Organisation (Part of the Northern Care Alliance), Salford, UK
| | - Shuayb Elkhalifa
- Department of Immunology, Salford Royal NHS Foundation Trust, Salford Care Organisation (part of the Northern Care Alliance), Salford, UK
| | - Paul Barratt
- Musculoskeletal Clinical and Assessment and Treatment Service, Salford Royal NHS Foundation Trust, Salford Care Organisation (Part of the Northern Care Alliance), Salford, UK
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Fontalis A, Berry DJ, Shimmin A, Slullitel PA, Buttaro MA, Li C, Malchau H, Haddad FS. Prevention of early complications following total hip replacement. SICOT J 2021; 7:61. [PMID: 34851264 PMCID: PMC8634898 DOI: 10.1051/sicotj/2021060] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/29/2021] [Indexed: 01/01/2023] Open
Abstract
Total hip arthroplasty (THA) has been quoted as "the operation of the century", owing to its efficacy and the substantial improvements evidenced with respect to functional patient outcomes and quality of life. However, early postoperative complications are often inevitable, hence it is imperative to take every step to prevent them and minimise morbidity and mortality. This manuscript focuses on the most common early complications following THA, namely venous thromboembolism (VTE), prosthetic joint infection, periprosthetic fracture, instability, and leg length inequality. It aims to outline effective risk stratification strategies and prevention measures that could apply to the wider Orthopaedic community.
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Affiliation(s)
- Andreas Fontalis
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London NW1 2BU, UK - University College London, Division of Surgery and Interventional Science, Gower Street, London, WC1E 6BT, UK
| | | | - Andrew Shimmin
- Melbourne Orthopaedic Group, Windsor, Victoria 3181, Australia - Monash University, Windsor, Ontario N9B 3P4, Australia
| | - Pablo A Slullitel
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin A Buttaro
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Cao Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, 137 South LiYuShan Road, Urumqi, Xinjiang 830054, China
| | - Henrik Malchau
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London NW1 2BU, UK - University College London, Division of Surgery and Interventional Science, Gower Street, London, WC1E 6BT, UK
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Kirby D, Donnelly M, Buchalter D, Gonzalez M, Catalano L, Hacquebord J. Influence of Corticosteroid Injections on Postoperative Infections in Carpal Tunnel Release. J Hand Surg Am 2021; 46:1088-1093. [PMID: 34474948 DOI: 10.1016/j.jhsa.2021.06.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 04/25/2021] [Accepted: 06/30/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Corticosteroid injections (CSIs) are commonly used in carpal tunnel syndrome; however, recent literature has demonstrated risk of postoperative infection associated with preoperative CSIs in other orthopedic fields. The aim of this study was to assess the relationship of CSIs and postoperative infection following carpal tunnel release (CTR). METHODS A single-center retrospective review was conducted from 2010 to 2019 to identify patients who underwent CTR with subsequent antibiotic prescription for chart-documented wound infection. A demographically-matched cohort of 100 patients was identified for comparison. Information on patient demographics, comorbidities, injection history, and presence of postoperative infection was collected. RESULTS Thirty-nine patients (0.67% of all CTR patients) were identified with postoperative infections, 3 of which (0.05% of all CTR patients) were deep infections. In the infection cohort, 16 of 39 (41%) patients received an injection prior to surgery, whereas 16 of 100 (16%) patients in the control cohort received an injection. History of CSI was significantly more common in patients with postoperative infection, and patients in the infection cohort had a significantly shorter average time from injection to surgery by approximately 55 days. CONCLUSIONS Corticosteroid injections in the preoperative period are associated with postoperative infection after CTR. Proximity of injection to time of surgery plays a role, although comorbidities, the corticosteroid dose, and frequency of injection require further study to determine risk contribution. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.
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Affiliation(s)
- David Kirby
- Department of Orthopedic Surgery, New York University Langone Orthopedics Hospital, New York, New York.
| | - Megan Donnelly
- Irvine School of Medicine, University of California, Irvine, California
| | - Daniel Buchalter
- Department of Orthopedic Surgery, New York University Langone Orthopedics Hospital, New York, New York
| | - Matthew Gonzalez
- Department of Orthopedic Surgery, New York University Langone Orthopedics Hospital, New York, New York
| | - Louis Catalano
- Department of Orthopedic Surgery, New York University Langone Orthopedics Hospital, New York, New York
| | - Jacques Hacquebord
- Department of Orthopedic Surgery, New York University Langone Orthopedics Hospital, New York, New York
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Okike K, King RK, Merchant JC, Toney EA, Lee GY, Yoon HC. Rapidly Destructive Hip Disease Following Intra-Articular Corticosteroid Injection of the Hip. J Bone Joint Surg Am 2021; 103:2070-2079. [PMID: 34550909 DOI: 10.2106/jbjs.20.02155] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND While recent reports have suggested that hip corticosteroid injections can hasten joint degeneration, there are few published data on the topic. The purpose of the present study was to evaluate for an association between corticosteroid injection and rapidly destructive hip disease (RDHD) and to determine the rate of, and risk factors for, occurrence. METHODS This study was conducted in 2 parts. First, to assess for a potential association between hip corticosteroid injection and RDHD, a case-control analysis was performed. Patients who developed RDHD between 2013 and 2016 served as cases, whereas those who underwent total hip arthroplasty for diagnoses other than RDHD during the same period served as controls, and the exposure of interest was prior intra-articular hip corticosteroid injection. Second, in a retrospective cohort analysis, we analyzed all patients who received a fluoroscopically guided intra-articular hip corticosteroid injection at our institution from 2013 to 2016. The rate of post-injection RDHD was determined, and logistic regression was used to identify risk factors for occurrence. RESULTS In the case-control analysis, hip corticosteroid injection was associated with the development of RDHD (adjusted odds ratio, 8.56 [95% confidence interval, 3.29 to 22.3], p < 0.0001). There was evidence of a dose-response curve, with the risk of RDHD increasing with injection dosage as well as with the number of injections received. In the retrospective cohort analysis, the rate of post-injection RDHD was 5.4% (37 of 688). Cases of post-injection RDHD were diagnosed at an average of 5.1 months following injection and were characterized by rapidly progressive joint-space narrowing, osteolysis, and collapse of the femoral head. CONCLUSIONS This study documents an association between hip corticosteroid injection and RDHD. While the risk of RDHD following a single low-dose (≤40 mg) triamcinolone injection is low, the risk is higher following high-dose (≥80 mg) injection and multiple injections. These findings provide information that can be used to counsel patients about the risks associated with this common procedure. In addition, caution should be taken with intra-articular hip injections utilizing ≥80 mg of corticosteroid and multiple injections. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kanu Okike
- Department of Orthopaedic Surgery, Hawaii Permanente Medical Group, Honolulu, Hawaii
| | | | - Jason C Merchant
- Department of Diagnostic Imaging, Hawaii Permanente Medical Group, Honolulu, Hawaii
| | - Eugene A Toney
- Department of Orthopaedic Surgery, Hawaii Permanente Medical Group, Honolulu, Hawaii
| | - Gregory Y Lee
- Department of Orthopaedic Surgery, Hawaii Permanente Medical Group, Honolulu, Hawaii
| | - Hyo-Chun Yoon
- Department of Diagnostic Imaging, Hawaii Permanente Medical Group, Honolulu, Hawaii
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Nie F, Li W. Impact of Prior Intra-articular Injections on the Risk of Prosthetic Joint Infection Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. Front Surg 2021; 8:737529. [PMID: 34557517 PMCID: PMC8452968 DOI: 10.3389/fsurg.2021.737529] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/16/2021] [Indexed: 01/11/2023] Open
Abstract
Objective: The current review was designed to assess the impact of prior intra-articular injections on the risk of prosthetic joint infection (PJI) in patients undergoing total joint arthroplasty (TJA) with a focus on the timing of injection before surgery. Methods: The databases of PubMed, Embase and Google Scholar were searched up to 15th June 2021. All studies comparing the incidence of PJI with and without prior intra-articular injections were included. Risk ratios (RR) with 95% confidence intervals were calculated for PJI. Results: Nineteen studies were included. Both corticosteroids and hyaluronic acid injections were used before TJA in the included studies. Overall, comparing 127,163 patients with prior intra-articular injections and 394,104 patients without any injections, we noted a statistically significant increased risk of PJI in the injection group (RR 1.24 95% CI: 1.11, 1.38 I2 = 48% p = 0.002). On subgroup analysis, there was a statistically significant increased risk of PJI in the injection group in studies where intra-articular injections were administered <12 months before surgery (RR 1.18 95% CI: 1.10, 1.27 I2 = 7% p < 0.00001). Furthermore, on meta-analysis, we noted non-significant but increased risk of PJI when injections were administered 1 month (RR 1.47 95% CI: 0.88, 2.46 I2 = 77% p = 0.14), 0–3 months (RR 1.22 95% CI: 0.96, 1.56 I2 = 84% p = 0.11), and 3–6 months (RR 1.16 95% CI: 0.99, 1.35 I2 = 49% p = 0.06) before surgery. Conclusion: Our results indicate that patients with prior intra-articular injections have a small but statistically significant increased risk of PJI after TJA. Considering that PJI is a catastrophic complication with huge financial burden, morbidity and mortality; the clinical significance of this small risk cannot be dismissed. The question of the timing of injections and the risk of PJI still remains and can have a significant impact on the decision making. Systematic Review Registration: PROSPERO: CRD42021258297.
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Affiliation(s)
- Fei Nie
- Department of Orthopedics, Chengdu No. 6 People's Hospital, Chengdu, China
| | - Wei Li
- Department of Orthopedics, Chengdu No. 6 People's Hospital, Chengdu, China
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Do We Need to Wait 3 Months After Corticosteroid Injections to Reduce the Risk of Infection After Total Knee Arthroplasty? J Am Acad Orthop Surg 2021; 29:e714-e721. [PMID: 33229905 DOI: 10.5435/jaaos-d-20-00850] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/23/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Corticosteroid injections administered within 3 months before total knee arthroplasty (TKA) have been linked to increased risk of postoperative infection. However, it would be beneficial to further delineate the timing of injections to determine whether a narrower window exists for safe administration of corticosteroid injections. The purposes of our study were to (1) determine whether there were a different time frame between corticosteroid injection and primary TKA that increased infection risk and (2) determine risk factors associated with infection after TKA. METHODS TKA patients were identified from a national database from 2007 to 2017 and stratified based on their history of corticosteroid injections within the 6-month preoperative period. Patients who received injections were stratified into biweekly cohorts by the timing of their most recent injection. The 1-year rate of postoperative infection treated by surgical débridement was compared between injection and noninjection cohorts. Univariate logistic regressions of risk factors and a multivariate analysis for patient comorbidities and injection cohorts associated with increased infection risk were conducted. RESULTS In the 76,090 TKA patients identified, corticosteroid injection within 2 weeks before TKA increased the risk of postoperative infection (P = 0.02) and injections within 2 to 4 weeks trended toward increased infection in univariate regression. No significant differences were observed in any other injection time frames. In the multivariate analysis, injections within 2 weeks before TKA were identified as an independent risk factor (odds ratio: 2.89; P = 0.04) for postoperative infection. Additional risk factors included chronic obstructive pulmonary disease, coronary artery disease, diabetes, ischemic heart disease, obesity, rheumatoid arthritis, and tobacco, whereas female sex and patient aged older than 65 were protective. DISCUSSION Our results suggest that TKA performed within four weeks of a corticosteroid injection may be associated with a higher risk of postoperative infection; however, delaying surgery more than four weeks may not provide additional infection risk reduction. Further prospective randomized studies are needed to determine the optimal timing of TKA after corticosteroid injections. LEVEL OF EVIDENCE Level III.
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Forlenza EM, Burnett RA, Korrapati A, Yang J, Forsythe B, Della Valle CJ. Preoperative Corticosteroid Injections Demonstrate a Temporal and Dose-Dependent Relationship with the Rate of Postoperative Infection Following Total Hip Arthroplasty. J Arthroplasty 2021; 36:2033-2037.e1. [PMID: 33618958 DOI: 10.1016/j.arth.2021.01.076] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/01/2021] [Accepted: 01/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Corticosteroid injections (CSI) are commonly used for the treatment of osteoarthritis of the hip. There is concern, however, that these injections may increase the risk of postoperative infection if a subsequent total hip arthroplasty (THA) is performed. The purpose of the present investigation is to determine the relationship between CSI and the risk of periprosthetic joint infection (PJI) and surgical site infections (SSIs) following THA. METHODS The PearlDiver database was reviewed for patients undergoing THA from 2011 to 2018. Patients with unilateral hip osteoarthritis who received an intra-articular hip CSI prior to ipsilateral THA were matched in a sequential 1:1 fashion based on age, gender, and Charlson Comorbidity Index with THA patients who did not receive an injection in the preoperative period. PJI and SSI within 6 months of the surgical procedure were recorded. Statistical analysis included chi-squared test and multivariate logistic regression. Results were considered significant at P < .05. RESULTS In total, 29,058 patients underwent a hip CSI within 6 months prior to THA. CSI within 4 months of surgery was associated with a higher incidence of PJI at 6-month follow up (1.6% vs 1.1%, P = .040). An injection within 1 month of surgery corresponded to a higher odds of PJI (odds ratio [OR] 1.97) than an injection 4 months prior to surgery (OR 1.24). Furthermore, the quantity of CSI administered within the 3 months prior to THA demonstrated a dose-dependent relationship, with each subsequent injection increasing odds of PJI (OR 1.45-3.59). A similar relationship was observed for SSI. CONCLUSION There appears to be both a time and dose-dependent association of hip CSI and PJI following THA. Surgeons should consider delaying elective THA if a CSI has been administered within the 4 months prior to the planned procedure.
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Affiliation(s)
- Enrico M Forlenza
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Robert A Burnett
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Avinaash Korrapati
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - JaeWon Yang
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Brian Forsythe
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Intra-Articular Injections Prior to Total Knee Arthroplasty Do Not Increase the Risk of Periprosthetic Joint Infection: A Prospective Cohort Study. Antibiotics (Basel) 2021; 10:antibiotics10030330. [PMID: 33801092 PMCID: PMC8004162 DOI: 10.3390/antibiotics10030330] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/11/2021] [Accepted: 03/19/2021] [Indexed: 01/28/2023] Open
Abstract
Periprosthetic joint infections (PJI) occur in 0.5 to 2.8% of total knee arthroplasties (TKA) and expose them to an increase of morbidity and mortality. TKA are mainly performed after failure of non-surgical management of knee osteoarthritis, which frequently includes intra-articular injections of corticosteroids or hyaluronic acid. Concerning the potential impact of intra-articular injections on TKA infection, literature provides a low level of evidence because of the retrospective design of the studies and their contradictory results. In this prospective cohort study, we included patients after a total knee arthroplasty, at the time of their admission in a rehabilitation center, and we excluded patients with any prior knee surgery. 304 patients were included. Mean follow-up was 24.9 months, and incidence proportion of PJI was 2.6%. After multivariate logistic regression, male was the only significant risk factor of PJI (OR = 19.6; p = 0.006). The incidence of PJI did not differ between patients who received prior intra-articular injections and others, especially regarding injections in the last 6 months before surgery. The use of intra-articular injection remains a valid therapeutic option in the management of knee osteoarthritis, and a TKA could still be discussed.
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Intra-Articular Hyaluronic Acid Injections Less Than 6 Months Before Total Hip Arthroplasty: Is It Safe? A Retrospective Cohort Study in 565 Patients. J Arthroplasty 2021; 36:1003-1008. [PMID: 33097337 DOI: 10.1016/j.arth.2020.09.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Intra-articular hyaluronic acid (IAHA) can be injected into an osteoarthritic hip joint to reduce pain and to improve functionality. Several studies report IAHA to be safe, with minor adverse effects that normally disappear spontaneously within a week. However, intra-articular corticosteroids prior to total hip arthroplasty (THA) have been associated with increased infection rates. This association has never been investigated for IAHA and THA. We aimed to assess the influence of IAHA on the outcome of THA, with an emphasis on periprosthetic joint infection (PJI). METHODS At a mean follow-up of 52 months (±18), we compared complication rates, including superficial and deep PJIs, of THA in patients who received an IAHA injection ≤6 months prior to surgery (injection group) with that of patients undergoing THA without any previous injection in the ipsilateral hip (control group). One hundred thirteen patients (118 hips) could be retrospectively included in the injection group, and 452 patients (495 hips) in the control group. RESULTS No differences in baseline characteristics nor risk factors for PJI between the 2 groups were found. The clinical outcomes in terms of VAS pain scores (1.4 vs 1.7 points, P = .11), modified Harris Hip Scores (77 vs 75 points, P = .09), and Hip disability and Osteoarthritis Outcome Scores (79 vs 76 points, P = .24) did not differ between the injection group and the control group. Also, complications in terms of persistent wound leakage (0% vs 1.2%, P = .60), thromboembolic events (0% vs 0.6%, P = 1.00), periprosthetic fractures (1.7% vs 1.2%, P = .65), and dislocations (0% vs 0.4%, P = 1.00) did not differ. However, in the injection group there was a higher rate of PJIs (4% vs 0%, P < .001) and postoperative wound infections (9% vs 3%, P = .01), compared to the control group. CONCLUSION Our findings suggest that IAHA performed 6 months or less prior to THA may pose a risk for increased rates of PJI. We recommend refraining from performing THA within 6 months after IAHA administration.
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Do preoperative intra-articular corticosteroid and hyaluronic acid injections affect time to total joint arthroplasty? J Clin Orthop Trauma 2021; 16:49-57. [PMID: 33680829 PMCID: PMC7919945 DOI: 10.1016/j.jcot.2020.12.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/29/2020] [Accepted: 12/15/2020] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Intra-articular corticosteroid (CSI) or hyaluronic acid (HAI) injections alleviate symptoms of osteoarthritis in patients who may be candidates for total hip or total knee arthroplasty (THA/TKA). However, their effect on time to total joint arthroplasty (TJA) and complications remains uncertain. We sought to evaluate (1) delay in time to surgery for patients receiving injections prior to THA/TKA (2) incidence of patients that receive injections, (3) type and number of injections, and (4) compare complication rates between patients with and without injections. METHODS We retrospectively reviewed 3340 consecutive TJA (1770 THA and 1570 TKA). Patients were divided into two cohorts depending if they received preoperative intra-articular injection or not. We identified dates of first clinic presentation and index surgery, injection type, total administered, and 90-day complications, including periprosthetic joint infection. RESULTS 150/1770 THA and 192/1570 TKA patients received injections (8.5%vs.12.2%,p = 0.0004). Time from first presentation to clinic to TJA was significantly greater in patients receiving injections [12.4 ± 11 months vs.7.3 ± 10.7,p < 0.001 for THA; 20.0 ± 17.4 months vs.11.6 ± 15.4,p < 0.001 for TKA]. This delay in time was greater in TKA versus THA (8.4 months vs.5.1,p < 0.001). TKA patients had a higher incidence of receiving HAI versus THA patients (9%vs.0.6%,p < 0.0001). There were no differences in overall complication profiles (p = 0.19 for THA, p = 0.3 for TKA). CONCLUSION Injections are associated with an increased time to TJA by a statistically significant amount, however its clinical significance is debatable. Injections are safe if administered at least three months preoperatively. If patients present with appropriate surgical indications and are ready, we do not recommend intra-articular injections to delay surgery.
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Nie F, Li W. Impact of Prior Intra-articular Injections on the Risk of Prosthetic Joint Infection Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. Front Surg 2021. [PMID: 34557517 DOI: 10.3389/fsurg.2021.737529/full] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
Objective: The current review was designed to assess the impact of prior intra-articular injections on the risk of prosthetic joint infection (PJI) in patients undergoing total joint arthroplasty (TJA) with a focus on the timing of injection before surgery. Methods: The databases of PubMed, Embase and Google Scholar were searched up to 15th June 2021. All studies comparing the incidence of PJI with and without prior intra-articular injections were included. Risk ratios (RR) with 95% confidence intervals were calculated for PJI. Results: Nineteen studies were included. Both corticosteroids and hyaluronic acid injections were used before TJA in the included studies. Overall, comparing 127,163 patients with prior intra-articular injections and 394,104 patients without any injections, we noted a statistically significant increased risk of PJI in the injection group (RR 1.24 95% CI: 1.11, 1.38 I2 = 48% p = 0.002). On subgroup analysis, there was a statistically significant increased risk of PJI in the injection group in studies where intra-articular injections were administered <12 months before surgery (RR 1.18 95% CI: 1.10, 1.27 I2 = 7% p < 0.00001). Furthermore, on meta-analysis, we noted non-significant but increased risk of PJI when injections were administered 1 month (RR 1.47 95% CI: 0.88, 2.46 I2 = 77% p = 0.14), 0-3 months (RR 1.22 95% CI: 0.96, 1.56 I2 = 84% p = 0.11), and 3-6 months (RR 1.16 95% CI: 0.99, 1.35 I2 = 49% p = 0.06) before surgery. Conclusion: Our results indicate that patients with prior intra-articular injections have a small but statistically significant increased risk of PJI after TJA. Considering that PJI is a catastrophic complication with huge financial burden, morbidity and mortality; the clinical significance of this small risk cannot be dismissed. The question of the timing of injections and the risk of PJI still remains and can have a significant impact on the decision making. Systematic Review Registration: PROSPERO: CRD42021258297.
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Affiliation(s)
- Fei Nie
- Department of Orthopedics, Chengdu No. 6 People's Hospital, Chengdu, China
| | - Wei Li
- Department of Orthopedics, Chengdu No. 6 People's Hospital, Chengdu, China
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Schiavi P, Calderazzi F, Pedrini MF, Tacci F, Vaienti E, Pogliacomi F. Efficacy and safety of viscosupplementation with hyaluronic acid for hip osteoarthritis: results from a cross-sectional study with a minimum follow-up of 4 years. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020032. [PMID: 33559627 PMCID: PMC7944698 DOI: 10.23750/abm.v91i14-s.11110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022]
Abstract
Background and aim of the work: Osteoarthritis is the most common cause of disability in elderly. Hip osteoarthritis is the second most frequent form affecting a large joint and the social and economic impact on society of its related disability is expected to increase. The purpose of this study was to verify the efficacy and safety of ultrasound-guided viscosupplementation with high weight hyaluronic acid in hip osteoarthritis. Methods: 183 patients with painful hip OA (Kellgren-Lawrence 1-2-3) were treated from January 2014 to December 2016 with viscosupplementation. Patients were evaluated before injection (T0) and after 1,2,3,4 (T1-T2-T3-T4) years through the VAS scale and Harris Hip Score (HHS). Patients who underwent to subsequent injections were followed and assessed. Subjects who underwent prosthesis were analyzed for a minimum of 6 months in order to detect any early postoperative complication. Results: The mean improvement of HHS and VAS between T0 and T1 was statistically significant. Patients who underwent subsequent injections showed a higher improvement even if statistical significance was not observed. Results showed that patients with grade 2 of osteoarthritis had the higher change in the scores. No adverse effects were registered. No early complications were reported in those patients who needed prosthesis. Discussion and Conclusions: Results observed confirm that ultrasound-guided viscosupplementation with high weight hyaluronic acid could be a possibility in the treatment of hip osteoarthritis, especially in patients with Kellgren-Lawrence grade 2 of disease. Subsequent injections are not characterized by similar positive effects. Outcomes of prosthetic surgery are not influenced by viscosupplementation.
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Affiliation(s)
- Paolo Schiavi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Filippo Calderazzi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | | | - Fabrizio Tacci
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Enrico Vaienti
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Francesco Pogliacomi
- PARMA UNIVERSITY DEPARTMENT OF SURGICAL SCIENCES ORTHOPAEDIC AND TRAUMATOLOGY SECTION.
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Effect of Methylprednisolone on Pain Management in Total Knee or Hip Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin J Pain 2019; 34:967-974. [PMID: 29595528 DOI: 10.1097/ajp.0000000000000614] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Total joint arthroplasty (TJA) has been reported to be a successful strategy for patients with advanced osteoarthritis; however, early postoperative pain has become an unresolved issue. Perioperative methylprednisolone (MP) administration in TJA is an important and controversial topic. This study was conducted to assess the efficacy and safety of MP for pain management after total knee or hip arthroplasty (TKA/THA). MATERIALS AND METHODS PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials comparing MP versus placebo for patients undergoing TKA/THA. Related indicators that reflected the efficacy and safety for pain management were evaluated by meta-analysis. RESULTS Six randomized controlled trials involving a total of 350 patients met the inclusion criteria. The outcomes showed that intravenous MP significantly reduced pain scores at 6 and 24 hours during activity after TKA and THA but local use of MP had no clear benefit in reducing pain scores compared with the control group. There was no significant difference in VAS at 24 hours at rest and 48 hours during activity after TKA and THA. In addition, MP was associated with a reduction of morphine consumption at 24 hours after TKA. Furthermore, patients receiving MP had an obvious inflammatory control and improving postoperative nausea and vomiting and the use of MP was not associated with a significant increase in the risk of complications. There was no significant difference in the range of knee motion and length of hospital stay in both groups. CONCLUSIONS This study showed that intravenous MP significantly alleviated early postoperative pain and the incidence of postoperative nausea and vomiting after TKA and THA. For safety, intravenous MP as a promising strategy in rapid recovery to TJA.
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Stout A, Friedly J, Standaert CJ. Systemic Absorption and Side Effects of Locally Injected Glucocorticoids. PM R 2019; 11:409-419. [PMID: 30925034 DOI: 10.1002/pmrj.12042] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022]
Abstract
Local glucocorticoid injections are often used to treat joint, soft tissue, or spinal pain, but the systemic side effects associated with these injections are poorly understood and not well recognized. There are significant known risks to systemic administration of glucocorticoids. However, there are no guidelines that address issues of systemic absorption, overall systemic risks, or other side effects of locally injected glucocorticoids. For this review, a literature search was performed, and the available evidence on systemic absorption and clinical side effects of intra-articular and epidural glucocorticoids was synthesized. The goal was to improve clinical understanding of risks associated with these injections. Existing data suggest there is significant individual variability in the amount of systemic absorption and clinical effects of locally injected glucocorticoids. However, it is clear that both intra-articular and epidural injections can have systemic effects for weeks and that complications may be associated with their use, including Cushing syndrome, loss of bone density, infection, and hyperglycemia. The concurrent use of oral steroids, the number of injections, and the type and dose of glucocorticoids used all are important considerations in estimating risks. The total dose calculation of cumulative glucocorticoid exposure should include all local injections. Caution should be exercised when local glucocorticoid injections are used in higher risk patients, such as postmenopausal women, people with diabetes, and those considering surgery in the near term. Better provider awareness of possible systemic risks should improve decision making and informed consent with patients when considering intra-articular and epidural steroid injections for painful conditions. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Alison Stout
- Evergreen Healthcare, 12039 NE 128th St Suite 500, Kirkland, WA 98034
| | - Janna Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Christopher J Standaert
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA
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Prosthetic Joint Infection Trends at a Dedicated Orthopaedics Specialty Hospital. Adv Orthop 2019; 2019:4629503. [PMID: 30881702 PMCID: PMC6387727 DOI: 10.1155/2019/4629503] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/05/2019] [Accepted: 01/15/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction Historically, a majority of prosthetic joint infections (PJIs) grew Gram-positive bacteria. While previous studies stratified PJI risk with specific organisms by patient comorbidities, we compared infection rates and microbiologic characteristics of PJIs by hospital setting: a dedicated orthopaedic hospital versus a general hospital serving multiple surgical specialties. Methods A retrospective review of prospectively collected data on 11,842 consecutive primary hip and knee arthroplasty patients was performed. Arthroplasty cases performed between April 2006 and August 2008 at the general university hospital serving multiple surgical specialties were compared to cases at a single orthopaedic specialty hospital from September 2008 to August 2016. Results The general university hospital PJI incidence rate was 1.43%, with 5.3% of infections from Gram-negative species. In comparison, at the dedicated orthopaedic hospital, the overall PJI incidence rate was substantially reduced to 0.75% over the 8-year timeframe. Comparing the final two years of practice at the general university facility to the most recent two years at the dedicated orthopaedics hospital, the PJI incidence was significantly reduced (1.43% vs 0.61%). Though the overall number of infections was reduced, there was a significantly higher proportion of Gram-negative infections over the 8-year timeframe at 25.3%. Conclusion In transitioning from a multispecialty university hospital to a dedicated orthopaedic hospital, the PJI incidence has been significantly reduced despite a greater Gram-negative proportion (25.3% versus 5.3%). These results suggest a change in the microbiologic profile of PJI when transitioning to a dedicated orthopaedic facility and that greater Gram-negative antibiotic coverage could be considered.
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Agarwalla A, Puzzitiello RN, Mascarenhas R, Sumner S, Romeo AA, Forsythe B. Preoperative Injections May Be an Iatrogenic Cause of Reoperation After Arthroscopic Rotator Cuff Repair. Arthroscopy 2019; 35:325-331. [PMID: 30611584 DOI: 10.1016/j.arthro.2018.08.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/15/2018] [Accepted: 08/16/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To determine whether an association exists between preoperative shoulder injections and reoperations in patients undergoing arthroscopic rotator cuff repair (aRCR). METHODS The PearlDiver Patient Records Database was reviewed for Humana-insured patients undergoing aRCR after a shoulder injection. Two matched groups were created: aRCR within 1 year of injection (n = 12,054) and aRCR without prior injection within 1 year of surgery (n = 12,054). Reoperation rates within 3 months, at 3 to 6 months, and at 6 to 12 months postoperatively were assessed. Statistical analysis was performed with the χ-square test. RESULTS The rate of reoperation within 3 months of the index procedure was higher in the control group (3.7% vs 3.1%, P = .01); however, 3 to 6 months after the index procedure, the rate of reoperation was higher in patients who received an injection within 1 year of the index procedure (1.8% vs 1.4%, P = .03). During the same intervals, the rate of revision rotator cuff repair (RCR) within 3 months of the index procedure was higher in the control group (2.9% vs 2.6%) and the rate of revision RCR 3 to 6 months after the index procedure was higher in patients who received an injection within 1 year of the index procedure (1.1% vs 0.9%); however, these results were not statistically significant (P = .3 and P = .8, respectively). The incidence of revision RCR (1.6% vs 1.1%; odds ratio, 1.4; P = .003) and incidence of subacromial decompression (1.5% vs 1.1%; odds ratio, 1.3; P = .01) 6 to 12 months after the index procedure were significantly higher in patients receiving an injection within 1 year before surgery. CONCLUSIONS Preoperative shoulder injections may increase the risk of revision RCR and subacromial decompression by up to 150% in patients 6 to 12 months after index surgery compared with patients who did not receive a preoperative injection. However, the absolute increase in these revision procedures is only 0.5%. LEVEL OF EVIDENCE Level III, comparative study.
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Affiliation(s)
- Avinesh Agarwalla
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Richard N Puzzitiello
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Randy Mascarenhas
- McGovern Medical School, University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Shelby Sumner
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, The Rothman Institute, Philadelphia, Pennsylvania, U.S.A
| | - Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A..
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Richardson SS, Schairer WW, Sculco TP, Sculco PK. Comparison of Infection Risk with Corticosteroid or Hyaluronic Acid Injection Prior to Total Knee Arthroplasty. J Bone Joint Surg Am 2019; 101:112-118. [PMID: 30653040 DOI: 10.2106/jbjs.18.00454] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent studies have shown that intra-articular injections ≤3 months before total knee arthroplasty increase the risk of periprosthetic joint infection. We are aware of no previous study that has differentiated the risk of periprosthetic joint infection on the basis of the type of medication injected. In addition, we are aware of no prior study that has evaluated whether hyaluronic acid injections increase the risk of infection after total knee arthroplasty. In this study, we utilized pharmaceutical data to compare patients who received preoperative corticosteroid or hyaluronic acid injections and to determine whether a specific injection type increased the risk of periprosthetic joint infection. METHODS Patients undergoing unilateral primary total knee arthroplasty were selected from a nationwide private insurer database. Ipsilateral preoperative injections were identified and were grouped by medication codes for corticosteroid or hyaluronic acid. Patients who had received both types of injections ≤1 year before total knee arthroplasty were excluded. The outcome of interest was periprosthetic joint infection that occurred ≤6 months following the total knee arthroplasty. The risk of periprosthetic joint infection was compared between groups (no injection, corticosteroid, hyaluronic acid) and between patients who received single or multiple injections. Statistical comparisons were performed using logistic regression controlling for age, sex, and comorbidities. RESULTS A total of 58,337 patients underwent total knee arthroplasty during the study period; 3,249 patients (5.6%) received hyaluronic acid and 16,656 patients (28.6%) received corticosteroid ≤1 year before total knee arthroplasty. The overall infection rate was 2.74% in the no-injection group. Multivariable logistic regression showed independent periprosthetic joint infection risk for both corticosteroid (odds ratio [OR], 1.21; p = 0.014) and hyaluronic acid (OR, 1.55; p = 0.029) given ≤3 months before total knee arthroplasty. There was no increased risk with injections >3 months prior to total knee arthroplasty. Direct comparison of corticosteroid and hyaluronic acid showed no significant difference (p > 0.05) between medications or between single and multiple injections. CONCLUSIONS Preoperative corticosteroid or hyaluronic acid injection ≤3 months before total knee arthroplasty increased the risk of periprosthetic joint infection. There was no difference in infection risk between medications or between multiple and single injections. On the basis of these data, we recommend avoiding both injection types in the 3 months prior to total knee arthroplasty. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Keely Boyle K, Rachala S, Nodzo SR. Centers for Disease Control and Prevention 2017 Guidelines for Prevention of Surgical Site Infections: Review and Relevant Recommendations. Curr Rev Musculoskelet Med 2018; 11:357-369. [PMID: 29909445 PMCID: PMC6105476 DOI: 10.1007/s12178-018-9498-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW The associated patient morbidity and resource-intensive nature of managing surgical site infections (SSI) has focused attention toward not only improving treatment protocols but also enhancing preventative measures. The purpose of this review was to summarize the relevant updated CDC guidelines for the prevention of SSI that were released in 2017. The CDC recommends the integration of the guidelines for improvement in quality metrics, reportable outcomes, and patient safety. RECENT FINDINGS The updated guidelines include generalized recommendations for parenteral antimicrobial prophylaxis, non-parenteral antimicrobial prophylaxis, glycemic control, normothermia, oxygenation, and antiseptic prophylaxis. The arthroplasty section includes recommendations for blood transfusion, systemic immunosuppressive therapy, and antibiotics during drain use. There was low-quality evidence precluding recommendations for preoperative intra-articular corticosteroid injections, orthopedic surgical space suits, and biofilm management. The recommendations provided throughout this review, including more recent guidelines from other organizations such as the AAOS and ACR, should assist clinicians in developing and/or refining surgical site prevention protocols for their patients undergoing total joint arthroplasty procedures.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopaedics, State University of New York at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY, 14215, USA.
| | - Sridhar Rachala
- Department of Orthopaedics, Buffalo General Medical Center, 100 High Street, Buffalo, NY, 14203, USA
| | - Scott R Nodzo
- Department of Orthopaedics, Mike O'Callaghan Medical Center, 4700 N. Las Vegas Blvd, Las Vegas, NV, 89191, USA
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Li H, Xing D, Ke Y, Lin J. Safety of intra-articular steroid injections prior to arthroplasty: Best evidence selection and risk of bias considerations. Int J Rheum Dis 2018; 21:982-991. [PMID: 29878619 DOI: 10.1111/1756-185x.13314] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIM Several systematic reviews have been performed to investigate whether intra-articular steroid injections can increase the risk of infection in subsequent arthroplasty. However, the conclusions of these systematic reviews are discordant. The purpose of the present study was to select best evidence and consider risk of bias of these systematic reviews and to provide recommendations through the best evidence. METHODS The systematic reviews that compared the infection rates of arthroplasty with or without previous intra-articular steroid injection were identified. The methodological quality and risk of bias of included systematic reviews were assessed by the AMSTAR instrument and ROBIS tool, respectively. Heterogeneity information within each variable was extracted from the included studies. The Jadad algorithm was then used to determine which systematic reviews can provide the best evidence. RESULTS Six systematic reviews were eligible for inclusion. The Jadad decision-making tool suggested that two reviews with highest AMSTAR score should be selected. According to the ROBIS tool, there were three systematic reviews with low risk of bias and three with high risk of bias. As a result, two systematic reviews conducted by Charalambous et al. and Marsland et al. with highest AMSTAR scores and low risk of bias were selected as the best evidence. CONCLUSIONS The present study demonstrates that intra-articular steroid injections prior to arthroplasty did not increase infection rates severely after the operation. However, the strength of recommendation is weak due to the limitations of current evidence. Further high-quality primary studies are still required.
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Affiliation(s)
- Hu Li
- Arthritis Clinic & Research Center, Peking University People's Hospital, Beijing, China.,Arthritis Institute, Peking University, Beijing, China
| | - Dan Xing
- Arthritis Clinic & Research Center, Peking University People's Hospital, Beijing, China.,Arthritis Institute, Peking University, Beijing, China
| | - Yan Ke
- Arthritis Clinic & Research Center, Peking University People's Hospital, Beijing, China.,Arthritis Institute, Peking University, Beijing, China
| | - Jianhao Lin
- Arthritis Clinic & Research Center, Peking University People's Hospital, Beijing, China.,Arthritis Institute, Peking University, Beijing, China
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Martin SD, Conaway WK, Lei P. Use of Intra-Articular Corticosteroids in Orthopaedics. J Bone Joint Surg Am 2018; 100:885-891. [PMID: 29762289 DOI: 10.2106/jbjs.17.00289] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Scott D Martin
- Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - William K Conaway
- Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Pengfei Lei
- Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Orthopaedic Surgery, Xiangya Hospital, Central South University, Changsha, People's Republic of China
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Seavey JG, Balazs GC, Steelman T, Helgeson M, Gwinn DE, Wagner SC. The effect of preoperative lumbar epidural corticosteroid injection on postoperative infection rate in patients undergoing single-level lumbar decompression. Spine J 2017; 17:1209-1214. [PMID: 28428080 DOI: 10.1016/j.spinee.2017.04.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/14/2017] [Accepted: 04/10/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar epidural corticosteroid injections (LECIs) are frequently used in the treatment of lumbar intervertebral disc herniation with radiculopathy and lumbar spinal stenosis. Although widely used, their effect on the outcomes and complications of subsequent surgery is unclear. Postoperative infection can be a morbid complication following spine surgery, and recent literature has suggested that the risk may be increased in patients undergoing lumbar spinal surgery who had previously received LECIs. PURPOSE The purpose of this study is to define the overall postoperative infection rate in patients undergoing lumbar spine decompression surgery in the Military Health System (MHS) patient population and examine the effects of LECIs on postoperative infection rates. STUDY DESIGN/SETTING This is a retrospective case control database study (Level III study). PATIENT SAMPLE The sample comprised all patients in the MHS who had a LECI before single-level lumbar decompression surgery from 2009 to 2014. OUTCOME MEASURES Postoperative infection within 90 days of surgery was used as the primary outcome measure for this study. Postoperative infection was identified using the International Classification of Diseases, 9th revision (ICD-9) diagnosis codes for postoperative infection. METHODS The Military Health System Data Repository (MDR) database was searched for all patients who underwent single-level lumbar spine decompression surgery from 2009 to 2014 using Current Procedural Terminology (CPT) codes. Current Procedural Terminology codes were used to identify the subset of patients who received preoperative LECIs. For patients receiving an injection, cohorts were established based on the timing of the preoperative injection: <30 days, 30-90 days, 91-180 days, 181-365 days, and >365 days. An age-based cohort, composed of patients 65 years of age and older, was also analyzed. A subgroup analysis of patients receiving more than one preoperative injection was performed. Postoperative infection within 90 days of surgery was identified using ICD-9 codes, and infection rates for all groups were calculated and compared with the control group who did not receive preoperative LECIs. No external funding was received for this study. RESULTS We identified 6,535 patients (847 preoperative LECI and 5,688 control) for analysis. The overall infection rate for patients undergoing single-level lumbar decompression surgery in the MHS was 0.81%. The rate ranged from 0% to 1.57% in the injection groups, with an overall infection rate in the injection group of 1.18% versus 0.76% in the control group. Despite an increased odds ratio of 1.57 following injection, no statistically significant differences were found between the control group and any injection group based on timing of injection, patient age, or number of preoperative injections. CONCLUSIONS The results of this study suggest that within the MHS, preoperative LECIs do not significantly increase the risk of postoperative infection after single-level lumbar decompression. If a difference does exist, it is likely small.
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Affiliation(s)
- Jonathan G Seavey
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA; Department of Surgery, Uniformed Services University of the Health Sciences, 8901 Wisconsin Ave, Bethesda, MD 20889, USA
| | - George C Balazs
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA; Department of Surgery, Uniformed Services University of the Health Sciences, 8901 Wisconsin Ave, Bethesda, MD 20889, USA
| | - Theodore Steelman
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA; Department of Surgery, Uniformed Services University of the Health Sciences, 8901 Wisconsin Ave, Bethesda, MD 20889, USA
| | - Melvin Helgeson
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA; Department of Surgery, Uniformed Services University of the Health Sciences, 8901 Wisconsin Ave, Bethesda, MD 20889, USA
| | - David E Gwinn
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA; Department of Surgery, Uniformed Services University of the Health Sciences, 8901 Wisconsin Ave, Bethesda, MD 20889, USA
| | - Scott C Wagner
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA; Department of Surgery, Uniformed Services University of the Health Sciences, 8901 Wisconsin Ave, Bethesda, MD 20889, USA; Department of Orthopaedics, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, Philadelphia, PA 19107, USA.
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47
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Donohue NK, Prisco AR, Grindel SI. Pre-operative corticosteroid injections improve functional outcomes in patients undergoing arthroscopic repair of high-grade partial-thickness rotator cuff tears. Muscles Ligaments Tendons J 2017; 7:34-39. [PMID: 28717609 DOI: 10.11138/mltj/2017.7.1.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Subacromial corticosteroid injections (CSI's) are a common non-surgical treatment for rotator cuff tears. Few studies have assessed the effects of pre-operative CSI's on postoperative functional outcomes. METHODS A retrospective analysis was conducted of 132 patients with high-grade, partial-thickness rotator cuff tears (PTRCT's). The subjects were divided into two groups based on whether they received a CSI or not. The CSI group was further divided into three subgroups based on when they received a pre-operative injection: 0-3 months, 3-6 months, >6 months before surgery. The Visual Analog Scores (VAS), American Shoulder and Elbow Surgeon scores (ASES), and Constant scores were recorded prior to surgery and at a one-year post-operative follow-up appointment for each subject. RESULTS Patients who received a pre-operative CSI (n=92) improved significantly more than the non-injection group (n=40) in all outcome measures. The 0-3 months injection subgroup experienced a significant increase in ASES and Constant score (p=0.019 and 0.014, respectively) compared to the other two subgroups, but the VAS score decrease only trended toward significance (p=0.091). The sample as a whole experienced significant improvement in all three outcome measures. CONCLUSION Patients undergoing arthroscopic repair of a high-grade PTRCT may benefit from a pre-operative CSI 0-3 months before surgery. LEVEL OF EVIDENCE IIb.
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Affiliation(s)
- Nicholas K Donohue
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - Anthony R Prisco
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Steven I Grindel
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, USA
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Chambers AW, Lacy KW, Liow MHL, Manalo JPM, Freiberg AA, Kwon YM. Multiple Hip Intra-Articular Steroid Injections Increase Risk of Periprosthetic Joint Infection Compared With Single Injections. J Arthroplasty 2017; 32:1980-1983. [PMID: 28237216 DOI: 10.1016/j.arth.2017.01.030] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/04/2017] [Accepted: 01/17/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients with hip osteoarthritis often temporize their symptoms with multiple intra-articular steroid hip injections (IASHIs) before undergoing total hip arthroplasty (THA). Although there is recent evidence to suggest that IASHI can lead to an increased risk of future periprosthetic joint infection (PJI), the potential increase in risk of PJI after multiple IASHIs compared with single IASHI remains largely unknown. The aim of the study was to evaluate whether multiple IASHIs are associated with increased risk of PJI compared with single IASHI in THA patients. METHODS We evaluated 2 cohorts of patients consisting of 106 patients who received 2 or more IASHI in the year before THA and a matched group of 350 patients who received one IASHI in the 12 months before THA. RESULTS The single and multiply-injected patient cohorts had an infection rate of 2.0% and 6.6% (7/350 and 7/106), respectively (P = .04, odds ratio 3.30) and average follow-up of 28.9 and 24.2 months. The 2 cohorts did not differ with regard to age, gender, American Society of Anesthesiologist score, presence of diabetes mellitus, or body mass index. CONCLUSION In comparison with patients with single IASHI, multiple IASHIs are associated with an increased risk of PJI significantly higher than the elevated risk reported with single injection before THA. The present study findings would be clinically useful in counseling patients who are considering temporizing their symptoms with multiple IASHIs before undergoing THA.
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Affiliation(s)
- Andrew W Chambers
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kyle W Lacy
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John Paul M Manalo
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew A Freiberg
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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George DA, Drago L, Scarponi S, Gallazzi E, Haddad FS, Romano CL. Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification. World J Orthop 2017; 8:400-411. [PMID: 28567344 PMCID: PMC5434347 DOI: 10.5312/wjo.v8.i5.400] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/05/2017] [Accepted: 03/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To undertook a systematic review to determine factors that increase a patient's risk of developing lower limb periprosthetic joint infections (PJI). METHODS This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November 2016. A variety of keywords were used to identify studies through international databases referencing hip arthroplasty, knee arthroplasty, infection, and risk factors. Studies were only included if they included greater than 20 patients in their study cohort, and there was clear documentation of the statistical parameter used; specifically P-value, hazard ratio, relative risk, or/and odds ratio (OR). Furthermore a quality assessment criteria for the individual studies was undertaken to evaluate the presence of record and reporting bias. RESULTS Twenty-seven original studies reviewing risk factors relating to primary total hip and knee arthroplasty infections were included. Four studies (14.8%) reviewed PJI of the hip, 3 (11.21%) of the knee, and 20 (74.1%) reviewed both joints. Nineteen studies (70.4%) were retrospective and 8 (29.6%) prospective. Record bias was identified in the majority of studies (66.7%). The definition of PJI varied amongst the studies but there was a general consensus to define infection by previously validated methods. The most significant risks were the use of preoperative high dose steroids (OR = 21.0, 95%CI: 3.5-127.2, P < 0.001), a BMI above 50 (OR = 18.3, P < 0.001), tobacco use (OR = 12.76, 95%CI: 2.47-66.16, P = 0.017), body mass index below 20 (OR = 6.00, 95%CI: 1.2-30.9, P = 0.033), diabetes (OR = 5.47, 95%CI: 1.77-16.97, P = 0.003), and coronary artery disease (OR = 5.10, 95%CI: 1.3-19.8, P = 0.017). CONCLUSION We have highlighted the need for the provider to optimise modifiable risk factors, and develop strategies to limit the impact of non-modifiable factors.
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Parvizi J, Shohat N, Gehrke T. Prevention of periprosthetic joint infection: new guidelines. Bone Joint J 2017; 99-B:3-10. [PMID: 28363888 DOI: 10.1302/0301-620x.99b4.bjj-2016-1212.r1] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/04/2017] [Indexed: 12/13/2022]
Abstract
The World Health Organization (WHO) and the Centre for Disease Control and Prevention (CDC) recently published guidelines for the prevention of surgical site infection. The WHO guidelines, if implemented worldwide, could have an immense impact on our practices and those of the CDC have implications for healthcare policy in the United States. Our aim was to review the strategies for prevention of periprosthetic joint infection in light of these and other recent guidelines. Cite this article: Bone Joint J 2017;99-B(4 Supple B):3-10.
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Affiliation(s)
- J Parvizi
- Thomas Jefferson University, Rothman Institute Sheridan Building, Suite 1000, 25 S 9th Street, Philadelphia, PA 19107, USA
| | - N Shohat
- Tel Aviv University, Tel Aviv, Israel and Thomas Jefferson University, Rothman Institute at Sheridan Building, Suite 1000, 125 S 9th Street, Philadelphia, PA 19107, USA
| | - T Gehrke
- HELIOS ENDO-Klinik Hamburg, Holstrenstraße 2, 22767 Hamburg, Germany
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