Influence of Corticosteroid Injections on Postoperative Infections in Carpal Tunnel Release

Are Preoperative Corticosteroid Injections in Large or Intermediate Joints Associated with Surgical Site Infection After Soft Tissue Hand Surgery? A Retrospective Database Analysis

PURPOSE

In this study, we asked the following question: Is intra-articular corticosteroid injection at a distant site prior to hand surgery associated with an increased risk of (1) surgical site infection, (2) reoperation for infection, or (3) wound dehiscence?

METHODS

Using a national administrative claims database, we identified adult patients undergoing carpal tunnel, trigger finger, or DeQuervain release. Patients were divided into four cohorts: intra-articular corticosteroid injection between 0 and 30, 31 and 60, or 61 and 90 days before surgery or no injection within 90 days prior to surgery. Large and intermediate joints were considered. We measured surgical site infection incidence, reoperation, and wound dehiscence within 90 days after surgery. We created multivariable logistic regression models to evaluate the association between preoperative corticosteroid injection and each outcome, adjusting for age, sex, region, insurance plan, Elixhauser comorbidities, and history of tobacco use.

RESULTS

Receiving a large-joint corticosteroid injection between 0 and 30, 31 and 60, or 61 and 90 days before surgery was not associated with surgical site infection or reoperation. Receiving a large-joint corticosteroid injection between 0 and 30 days before surgery was associated with a slightly higher incidence of wound dehiscence compared to no injection (0.5% vs 0.4%). Receiving an intermediate-joint corticosteroid injection between 0 and 30, 31 and 60, or 61 and 90 days before surgery was not associated with the incidence of surgical site infection, reoperation, or wound dehiscence. In patients with diabetes, receiving a corticosteroid injection within 90 days before surgery in a large or intermediate joint was not associated with an increased risk of surgical site infection, reoperation, or wound dehiscence.

CONCLUSIONS

Corticosteroid injections into large- and intermediate-sized joints can be safely administered before hand surgery from a surgical site infection perspective, including in patients with diabetes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis II.

The Mechanisms and Safety of Corticosteroid Injections in Orthopaedic Surgery

» 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.

Main Operating Room Versus Field Sterility in Hand Surgery: A Review of the Evidence

Introduction: Many of the guidelines that are generally accepted as main operating room best practices are not evidence based. They are based on the concept that if some sterility is good, more must be better. They are not derived from evidence-based sterility. Evidence-based sterility is the study of which of our various sterility practices increase or decrease our infection rates, as opposed to guidelines based on how many bacteria are in the operating room. Methods: This article adds the most important evidence we could find that is not included in the first paper on evidence-based sterility in hand surgery published in 2019. In this review, we also balance the evidence with common sense opinion. Results: The 21st century has seen a rapid rise in the number and reports of hand surgery procedures performed with field sterility outside the main operating room. There is now an abundance of good evidence to support that the rate of infection is not higher when many hand operations are performed with field sterility in minor procedure rooms. Conclusion: Moving hand surgery out of the main operating room to minor procedure rooms should be supported by healthcare providers. The higher cost, increased solid waste, and inconvenience of main operating room surgery are not justifiable for many procedures because it does not reduce the risk of postoperative infection.

Hand and Upper Extremity Surgical Site Infection Rates Associated With Perioperative Corticosteroid Injection: A Review of the Literature

BACKGROUND

Corticosteroid injection (CSI) has a relatively high benefit-to-risk ratio and is commonly administered to treat musculoskeletal conditions. However, perioperative CSI has been associated with an increased risk of postoperative infection. The literature suggests delaying surgery after CSI to minimize the risk of postoperative infection. We review the literature to summarize the most current knowledge on the association between perioperative CSI and infection rates for different hand and upper extremity procedures.

METHODS

Two independent reviewers conducted a literature search using PubMed and Web of Science databases (through October 1, 2022). The database searches used were (((injection) AND (infection)) AND (risk)) AND ((hand) OR (wrist) OR (elbow) OR (shoulder)). English-language articles were screened for infection rates associated with CSI given temporally around upper extremity surgery, focusing between 6 months preoperatively and 1 month postoperatively.

RESULTS

Nineteen articles including database queries and retrospective case-control or cohort studies were used after screening 465 articles. Most infection rates were increased in hand, wrist, elbow, and shoulder surgery between 3 months preoperatively and 1 month postoperatively. Intraoperative injection during elbow arthroscopy demonstrated increased infection rate relative to other upper extremity surgeries.

CONCLUSIONS

Corticosteroid injection increased the risk of infection temporally around upper extremity surgeries; however, CSI provides benefits. The consensus regarding CSI timeline perioperatively has yet to be determined. The evidence supports an increased benefit-to-risk ratio when giving corticosteroids greater than 3 months preoperatively and greater than 1 month postoperatively for most upper extremity procedures, with relative contraindications within 1 month of upper extremity surgery.

Does the Number of Preoperative Corticosteroid Injections Affect Clinical and Radiographic Outcomes of Trapeziectomy and Suspensionplasty?

PURPOSE

This study aimed to determine whether an increasing number of preoperative corticosteroid injections is associated with greater radiographic subsidence of the thumb metacarpal at long-term follow-up after abductor pollicis longus suspensionplasty, secondary to steroid-induced pathologic weakening of capsuloligamentous restraints surrounding the thumb carpometacarpophalangeal joint and greater extension of the lunate, but neither affect patient-reported outcomes nor revision rates.

METHODS

A retrospective chart review was performed of patients who underwent primary trapeziectomy and abductor pollicis longus suspensionplasty by a single surgeon over a 10-year period. The number of preoperative corticosteroid injections in the trapeziometacarpal joint was documented, and patients were separated into 4 subgroups: 0, 1, 2, or 3 or more injections. Preoperative and final radiographs were evaluated for a change in the distance between the base of the thumb metacarpal and the distal pole of the scaphoid as a measure of thumb metacarpal subsidence and radiolunate angle as a measure of nondissociative carpal instability, which has been reported as a complication after basal joint arthroplasty. Additionally, the final patient-reported outcomes (Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation) and revision rates were also assessed.

RESULTS

Of a total of 60 patients with an average age of 64 years that were included in the study, 16 (26.7%) received 0, 19 (31.7%) received 1, 12 (20%) received 2, and 13 (21.7%) received 3+ preoperative injections. The median postoperative follow-up was 92 months. The mean distance between the base of the thumb metacarpal and the distal pole of the scaphoid decreased by 2 mm, and the mean radiolunate angle increased by 4° across the entire cohort. When comparing subgroups, no differences were observed in either parameter or the final Patient-Rated Wrist Evaluation and Quick Disabilities of the Arm, Shoulder, and Hand scores.

CONCLUSIONS

This study demonstrates no apparent detrimental effect of an increased number of preoperative corticosteroid injections on radiographic thumb metacarpal subsidence, increase in extension of radiolunate angle (nondissociative carpal instability), patient-reported outcomes, or revision rates at an average of almost 8 years after trapeziectomy and abductor pollicis longus suspensionplasty.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

State of the art review. Complications after carpal tunnel release

Carpal tunnel release (CTR) is the most performed surgery of the upper extremity. It is effective but not without complications. This state-of-the-art review covers most common intra- and postoperative complications after CTR. As endoscopic carpal tunnel release (ECTR) has developed over time, severe complications, such as nerve lesions, have diminished. ECTR still has a higher risk on transient nerve lesions. Open CTR on the other hand has a higher incidence of wound-related problems, including scar tenderness, irrespective of incision used. Most complications, such as pillar pain and infection, are ill-defined in the literature, leaving the exact incidence unknown and proposing challenges in treatment. The same is true for failure of treatment. Optimizing the length and location of incisions has played a vital role in reducing intra- and postoperative complications in CTR. It is expected that technical advances, such as ultrasound-guided percutaneous carpal tunnel release, will continue to play a role in the future.Level of evidence: V.

Corticosteroid Injection in the Operative Hand Prior to a Trigger Finger or Carpal Tunnel Release: If It Is Not at the Surgical Site Then What Is the Big Deal?

BACKGROUND

Patients who have had a corticosteroid injection at the surgical site within 90 days of trigger finger release (TFR) or carpal tunnel release (CTR) have an elevated risk of postoperative infection. Currently, it remains unknown if a preoperative injection in proximity to the surgical site for a separate complaint alters the risk of a postoperative infection.

METHODS

A retrospective chart review was performed on all patients who underwent TFR or CTR between 2010 and 2022. Patients who had a corticosteroid injection at or near the surgical site within 90 days of surgery were included. Outcome measures included uncomplicated healing, superficial infection requiring antibiotics, and deep infection (DI) requiring surgical debridement.

RESULTS

There were 564 cases in which a corticosteroid injection was performed within 90 days of TFR or CTR. Superficial infections occurred in 12 (2.1%), and DIs occurred in 6 (1.1%) cases. There was no significant difference in infection rates between the two groups relative to the location of the injection nor timing of the injection (0-30, 31-60, or 61-90 days prior to surgery).

CONCLUSIONS

Patients who had an injection at the surgical site within 90 days of TFR or CTR had an elevated rate of postoperative infection compared with published rates in the literature. This study is unique in that preoperative injections at an adjacent site in the palm also correlated with an elevated rate of infection, similar to patients who had an injection at the surgical site.

LEVEL OF EVIDENCE

Level 4.

The Influence of Corticosteroid Injections on Postoperative Outcomes of Carpal Tunnel Release: A Systematic Review

Background  Carpal tunnel syndrome can be treated with corticosteroid injections (CIs) and surgery. In this systematic review, the influence of previous CI on different postoperative outcomes after carpal tunnel release is evaluated. Methods  A systematic literature search using several databases was performed to include studies that examined patients diagnosed with carpal tunnel syndrome who received preoperative or intraoperative CIs. Results  Of 2,459 articles, 9 were eligible for inclusion. Four papers reported outcomes of preoperative and four outcomes of intraoperative CIs. One study evaluated patients who received both intraoperative and preoperative corticosteroids. Conclusion  Intraoperative CIs are associated with reduced postoperative pain after carpal tunnel release and support earlier recovery of the hand function that can be objectified in a faster median nerve conduction speed recovery and lower Boston Carpal Tunnel Questionnaire (BCTQ) scores. Using preoperative CIs did not lead to enhanced recovery after carpal tunnel release, and both preoperative and intraoperative CIs might be predisposing factors for infections.

Is Hand Surgery in the Procedure Room Setting Associated with Increased Surgical Site Infection? A Cohort Study of 2,717 Patients in the Veterans Affairs Population

PURPOSE

Procedure rooms (PRs) are increasingly used for hand surgeries, but few studies have directly compared surgical site infection (SSI) rates between the PR and operating room. We tested the hypothesis that procedure setting is not associated with an increased SSI incidence in the VA population.

METHODS

We identified carpal tunnel, trigger finger, and first dorsal compartment releases performed at our VA institution from 1999 to 2021 of which 717 were performed in the main operating room and 2,000 were performed in the PR. The incidence of SSI, defined as signs of wound infection within 60 days of the index procedure, which was treated with oral antibiotics, intravenous antibiotics, and/or operating room irrigation and debridement, was compared. We constructed a multivariable logistic regression analysis to assess the association between procedure setting and SSI incidence, adjusting for age, sex, procedure type, and comorbidities.

RESULTS

Surgical site infection incidence was 55/2,000 (2.8%) in the PR cohort and 20/717 (2.8%) in the operating room cohort. In the PR cohort, five (0.3%) cases required hospitalization for intravenous antibiotics of which two (0.1%) cases required operating room irrigation and debridement. In the operating room cohort, two (0.3%) cases required hospitalization for intravenous antibiotics of which one (0.1%) case required operating room irrigation and debridement. All other SSIs were treated with oral antibiotics alone. The procedure setting was not independently associated with SSI (adjusted odds ratio, 0.84 [95% confidence interval, 0.49, 1.48]). The only risk factor for SSI was trigger finger release (odds ratio, 2.13 [95% confidence interval, 1.32, 3.48] compared with carpal tunnel release), which was independent of setting.

CONCLUSIONS

Minor hand surgeries can be performed safely in the PR without an increased rate of SSI.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Injections for treatment of carpal tunnel syndrome: A narrative review of the literature

Background

Carpal tunnel syndrome is an extremely common condition in the general population. Nonoperative treatment is a mainstay of management prior to surgical carpal tunnel release. Injections are frequently used as treatment, especially corticosteroid injections, but there is little consensus in the literature regarding injection number, volume, corticosteroid dose, and technique.

Methods

A comprehensive literature search was performed of PubMed to identify papers relating to corticosteroid injections as well as other injections performed in patients with carpal tunnel syndrome.

Results

A total of 45 articles were selected for inclusion in this review. Corticosteroid injections for carpal tunnel syndrome are discussed in detail, including injection number, volume, and technique as well as corticosteroid dose. Alternative injections for management of carpal tunnel syndrome are also discussed.

Conclusions

Corticosteroid injections have been identified as a safe, effective short term management option for carpal tunnel syndrome. However, there is no standardized recommendation for specifics of their use in relation to corticosteroid dose, number of injections, injectate volume, and use of ultrasound guidance. Further research is required to better establish the optimal role for corticosteroid injections in the treatment of carpal tunnel syndrome. Platelet rich plasma, lidocaine, and hyaluronic acid, among others, are additional injections that warrant further exploration for use in management of carpal tunnel syndrome.