Systematic review: the safety of intra-articular corticosteroid injection prior to total knee arthroplasty

Effect of intra-articular corticosteroid injections for knee osteoarthritis on the rates of subsequent knee replacement and post-operative outcomes: a national cohort study of England

BACKGROUND

Intra-articular corticosteroid injection (IACI) is an established treatment option for uncontrolled pain in osteoarthritis. There is a lack of longer-term follow-up in most studies of the effects of IACI, meaning there is scarcity of data on the impact of IACI on the subsequent need for joint replacement. Our aim was to assess the effect of IACI for knee osteoarthritis on the subsequent incidence of knee replacement surgery and on associated post-operative outcomes.

METHODS

We conducted a cohort study of knee osteoarthritis patients registered in the Clinical Practice Research Datalink (CPRD) GOLD database with an incident diagnosis between 2005 and 2019. Exposure was single or repeated IACI use, analysed separately. The primary outcome was knee replacement during 1-year and 5-year follow-ups. Secondary outcomes included post-operative patient-reported outcome measures and adverse events. Primary analyses used general practitioner practice preference for IACI as an instrumental variable given this methodology can account for strong and unmeasured confounding. Secondary analyses used propensity score matching, accounting for measured covariates only.

RESULTS

During 1-year follow-up, 1628/33,357 (4.9%) knee osteoarthritis patients underwent knee replacement, for which single IACI was associated with lower risk, which persisted to 5-year follow-up (incidence rate ratio: 0.52 [0.36, 0.77]). Conversely, in secondary propensity score analyses no association was found between IACI use and knee replacement rate at 1-year follow-up, and an estimated increased rate of knee replacement at 5-year follow-up. Use of IACI pre-joint replacement was not associated with any adverse post-operative outcomes, for example, 1-year complication rates (per 100 person-years) following knee replacement were 4.6 (3.8, 5.8), 4.0 (2.7, 6.0) and 5.0 (3.1, 8.1) among patients with no, single and repeat pre-joint replacement IACI use, respectively.

CONCLUSIONS

Findings from our main analysis suggest that short-term pain reduction following IACI for knee osteoarthritis may translate to lower rates of knee replacement over 5 years follow-up, although contradictory associations were observed in secondary analyses which likely reflected residual confounding by indication. Reassuringly, IACI use before knee replacement was not associated with post-operative adverse outcomes.

Use and safety of corticosteroid injections in joints and musculoskeletal soft tissue: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society

BACKGROUND

Intra-articular corticosteroid (IACS) injection and peri-articular corticosteroid injection are commonly used to treat musculoskeletal conditions. Results vary by musculoskeletal region, but most studies report short-term benefit with mixed results on long-term relief. Publications showed adverse events from single corticosteroid injections. Recommended effective doses were lower than those currently used by clinicians.

METHODS

Development of the practice guideline for joint injections was approved by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine and the participating societies. A Corticosteroid Safety Work Group coordinated the development of three guidelines: peripheral nerve blocks and trigger points; joints; and neuraxial, facet, and sacroiliac joint injections. The topics included safety of the technique in relation to landmark-guided, ultrasound-guided, or radiology-aided injections; effect of the addition of the corticosteroid on the efficacy of the injectate; and adverse events related to the injection. Experts on the topics were assigned to extensively review the literature and initially develop consensus statements and recommendations. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed. A modified Delphi process was adhered to in arriving at a consensus.

RESULTS

This guideline focuses on the safety and efficacy of corticosteroid joint injections for managing joint chronic pain in adults. The joints that were addressed included the shoulder, elbow, hand, wrist, hip, knee, and small joints of the hands and feet. All the statements and recommendations were approved by all participants and the Board of Directors of the participating societies after four rounds of discussion. There is little evidence to guide the selection of one corticosteroid over another. Ultrasound guidance increases the accuracy of injections and reduces procedural pain. A dose of 20 mg triamcinolone is as effective as 40 mg for both shoulder IACS and subacromial subdeltoid bursa corticosteroid injections. The commonly used dose for hip IACS is 40 mg triamcinolone or methylprednisolone. Triamcinolone 40 mg is as effective as 80 mg for knee IACS. Overall, IACS injections result in short-term pain relief from a few weeks to a few months. The adverse events include an increase in blood glucose, adrenal suppression, detrimental effect on cartilage lining the joint, reduction of bone mineral density, and postoperative joint infection.

CONCLUSIONS

In this practice guideline, we provided specific recommendations on the role of corticosteroids in joint, bursa, and peritendon injections for musculoskeletal pain.

Steroid Versus Non-steroid Intraoperative Multimodal Periarticular Injection in Simultaneous Bilateral Total Knee Arthroplasty Using Real Intelligence CORI: Comparative Observational Study on Postoperative Pain and Early Functional Recovery

AIMS AND OBJECTIVES

This study aimed to compare the postoperative pain, early knee range of flexion, and straight leg raise (SLR) outcomes between the right and left knees in patients undergoing simultaneous bilateral primary total knee arthroplasty (TKA). The primary objective of this study was to investigate the comparative effects of a multimodal periarticular cocktail injection injected intraoperatively to both knees, with a specific focus on the impact of adding methylprednisolone to the injection administered to the right knee.

MATERIALS AND METHODS

This prospective observational comparative study enrolled 30 patients (60 knees) who underwent simultaneous bilateral primary TKA. Following strict inclusion and exclusion criteria, all patients were carefully selected for participation. Intraoperatively, a multimodal periarticular cocktail mixture was injected into both knees prior to final implantation. Notably, the right-sided mixture contained methylprednisolone (80 mg). Postoperative follow-up assessments focused on evaluating Visual Analog Scale (VAS) pain scores, degree of range of flexion, and degree of SLR.

RESULTS

The study sample consisted of patients with a mean age of 61.07 years, exhibiting a female-to-male ratio of 16.6:1. Our study demonstrated a significant reduction in VAS scores for the right knee compared to the left knee at all post-operative time points (12, 24, 48, and 72 hours), with p-value < 0.001. Early functional recovery, assessed by knee flexion and SLR, showed improved outcomes in the right knee. At 24, 48, and 72 hours post-operation, the right knee demonstrated a significantly greater range of motion (ROM) compared to the left knee (p < 0.05). The right knee exhibited significantly higher active SLR values than the left knee at 24, 48, and 72 hours post-operation, with statistically significant differences (p < 0.05).

CONCLUSION

This study demonstrated that the adjunctive use of methylprednisolone in a periarticular intraoperative multimodal cocktail injection significantly improved the postoperative pain and functional outcomes following TKA. Specifically, the addition of methylprednisolone resulted in reduced postoperative pain scores with increased ROM (degrees) and greater active SLR (degrees) compared to the conventional multimodal periarticular cocktail injection.

Association of intra-articular injection and knee arthroscopy prior to primary knee replacement with the timing and outcomes of surgery: Retrospective cohort study using data from the Clinical Practice Research Datalink GOLD database

BACKGROUND

Patients with symptomatic knee osteoarthritis may undergo non-surgical interventions such as intra-articular steroid injections and knee arthroscopy. This study aimed to investigate their association with the timing and outcomes of subsequent primary knee replacement.

METHODS AND FINDINGS

Observational retrospective analysis of linked Clinical Practice Research Datalink, Hospital Episode Statistics, Patient Reported Outcome Measures (CPRD GOLD-HES-PROMS) data of 38,494 patients undergoing primary knee replacements in England. Prior use of intra-articular steroid injections and knee arthroscopy were identified. Hazard ratios (HRs) with 95% CIs were estimated for primary outcomes of revision and reoperation using Cox regression. Secondary outcomes included time from first diagnosis of ipsilateral knee osteoarthritis to knee replacement, 6-month post-operative Oxford Knee Scores (OKS), mortality (90-days and 3-months), and post-operative surgical site infection (SSI) (3-months) using linear and logistic regression. Prior steroid injections were associated with an increased risk of revision (HR = 1.25 95%CI (1.06 to 1.49)), re-operation (HR = 1.18 95%CI (1.05 to 1.32)), and SSI (HR = 3.10 95%CI (1.14 to 8.46). Timing from diagnosis of knee osteoarthritis to knee replacement was 6 months longer in patients receiving steroid injections. Knee arthroscopy was associated with an increased risk of revision (HR = 3.14 95%CI (2.64 to 3.73)), re-operation (HR = 3.25 95%CI (2.89 to 3.66)), lower post-operative OKS -1.63 95%CI (-2.31 to -0.95). Both interventions were associated with a lower risk of mortality.

CONCLUSIONS

Steroid injection and knee arthroscopy prior to primary knee replacement are each associated with worse outcomes. The observed association of lower mortality risk is suggestive of confounding by indication. The observed associations in this study could be used to inform shared decision making with patients on the treatment pathway for knee osteoarthritis.

Efficacy and safety of intra-articular glucocorticoid injection for postoperative pain control after knee arthroscopy: a systematic review

PURPOSE

Pain following arthroscopic knee surgery remains a controversial clinical problem. Intra-articular (IA) glucocorticoid injections have demonstrated the potential to provide better analgesia in some orthopedic surgeries; however, due to the lack of studies, its role in knee arthroscopies remain unclear. This systematic review aimed to evaluate the efficacy and safety of intra-articular glucocorticoids after arthroscopic knee surgery.

METHODS

A systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline, with literature search performed on Medline, Embase, and the Cochrane Library. This systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO; ID: CRD42024509749). Inclusion criteria included randomized controlled trials published in English comparing IA glucocorticoid to placebo in patients undergoing knee arthroscopy. Risk of bias for all included studies was assessed using the Cochrane Collaboration's risk of bias tool. Clinical outcomes compared were pain score: visual analogue scale (VAS) or International Knee Documentation Committee (IKDC), time to first analgesia requirement, analgesia consumption, range of motion (ROM), patient satisfaction, and complications.

RESULTS

A total of 7 studies (3 and 4 with evidence level I and II, respectively) involving 309 patients were included. All studies showed that IA glucocorticoids significantly decreased subjective pain scores. Three studies showed significantly longer duration to first postoperative analgesia use, while 6 showed significantly reduced postoperative analgesic administration with IA glucocorticoid use. Two studies showed significantly increased patient satisfaction with IA glucocorticoid (P = 0.001 and P = 0.01, respectively). No studies showed significant differences in complications such as nausea, vomiting, bradycardia, hypotension, or procedure-related adverse effects between the groups.

CONCLUSION

Current available randomized controlled trials suggest that IA glucocorticoids can significantly reduce postoperative pain, delay, and minimize postoperative analgesia use, and improve patient satisfaction. No postoperative complications or adverse events were reported, reflecting its safety as a postoperative analgesic modality.

Can ChatGPT Answer Patient Questions Regarding Total Knee Arthroplasty?

The internet has introduced many resources frequently accessed by patients prior to orthopaedic visits. Recently, Chat Generative Pre-Trained Transformer, an artificial intelligence-based chat application, has become publicly and freely available. The interface uses deep learning technology to mimic human interaction and provide convincing answers to questions posed by users. With its rapidly expanding usership, it is reasonable to assume that patients will soon use this technology for preoperative education. Therefore, we sought to determine the accuracy of answers to frequently asked questions (FAQs) pertaining to total knee arthroplasty (TKA).Ten FAQs were posed to the chatbot during a single online interaction with no follow-up questions or repetition. All 10 FAQs were analyzed for accuracy using an evidence-based approach. Answers were then rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."Of the 10 answers given by the chatbot, none received an "unsatisfactory" rating with the majority either requiring minimal (5) or moderate (4) clarification. While many answers required nuanced clarification, overall, answers tended to be unbiased and evidence-based, even when presented with controversial subjects.The chatbot does an excellent job of providing basic, evidence-based answers to patient FAQs prior to TKA. These data were presented in a manner that will be easily comprehendible by most patients and may serve as a useful clinical adjunct in the future.

Risk factors for surgical site infection after percutaneous endoscopic lumbar discectomy

The objective of this study was to investigate the risk factors associated with surgical site infection (SSI) after percutaneous endoscopic lumbar discectomy (PELD) in patients with lumbar disc herniation (LDH). A retrospective analysis was performed on a cohort of 335 patients who underwent PELD between January 2016 and January 2023. Data were derived from the Hospital Information System (HIS), and a comprehensive statistical assessment was performed using IBM SPSS Statistics version 25.0. Both univariate and multivariate logistic regression analyses assessed a range of risk determinants, such as age, body mass index (BMI), comorbidities, laboratory test parameters and surgery-related variables. The incidence of SSI after PELD was 2.7% (9/335). Univariate analysis highlighted BMI, diabetes mellitus, long-term corticosteroid consumption, surgical time and cerebrospinal fluid leakage as significant predictors of SSI. Multivariate logistic regression identified BMI, diabetes mellitus, long-term corticosteroid consumption, surgical time and cerebrospinal fluid leakage as significant risk factors for SSI after PELD. High BMI, diabetes mellitus, long-term corticosteroid consumption, long surgical time and postoperative cerebrospinal fluid leakage are predisposing factors for SSI in patients undergoing PELD. Precise interventions focused on such risk components, including careful preoperative assessment and strategic postoperative care, are essential to reduce the incidence of SSI and improve surgical efficacy.

Evaluation of risk factors for surgical site infections in osteoarthritis patients undergoing total knee arthroplasty

This research sought to delineate risk factors associated with surgical site infections (SSIs) post-total knee arthroplasty (post-TKA) in elderly osteoarthritis patients, aiming to enhance post-surgical outcomes. A retrospective examination was conducted on a cohort of 650 elderly patients who underwent unilateral TKA between January 2018 and August 2022. Data procurement was from the hospital's Electronic Health Record, and a comprehensive statistical evaluation was performed using IBM SPSS Statistics version 24.0. Both univariate and multivariate techniques assessed a spectrum of risk determinants such as age, body mass index (BMI), coexisting medical conditions and surgical variables. The univariate examination spotlighted age, BMI, diabetes prevalence, chronic corticosteroid consumption and American Society of Anesthesiologists (ASA) physical status classification as notable predictors of SSIs. The multivariate logistic regression pinpointed age, BMI, history of smoking and diabetes diagnosis as salient risk attributors for post-TKA infections. Concurrently, parameters like ASA classification, surgical duration and intraoperative haemorrhage further enriched the risk landscape. Geriatric patients undergoing TKA for knee osteoarthritis manifest a tangible infection susceptibility post-surgery. Precision interventions concentrating on amendable risk components, including meticulous preoperative evaluations and strategic postoperative care, are imperative to attenuate SSI incidence, thereby amplifying surgical efficacy and optimizing patient recuperation trajectories.

Preoperative Corticosteroid Injections Are Not Associated with Deep Infection after Unicompartmental Knee Arthroplasty

Prior to unicompartmental knee arthroplasty (UKA), corticosteroid injections (CSI) are a common nonoperative treatment for arthritis. It is unclear whether CSI prior to UKA impacts the likelihood of postoperative infection. This study sought to determine if there is a time- and/or dose-dependent relationship between preoperative CSI and postoperative infection. An administrative claims database was queried for patients undergoing UKA with more than 1 year of pre-enrollment and follow-up. Of 31,676 patients with a UKA who met enrollment criteria, 8,628 patients had a CSI 0 to 3 months prior to surgery, 111 had a CSI 3 to 12 months prior to surgery, and 22,937 never received an injection. Overall, 246 postoperative deep infections were reported (0.8%). Time-dependent and dose-dependent relationships were modeled using multivariable logistic regressions. Postoperative deep infections occurred in 64 patients with CSI 0 to 3 months prior to surgery (0.7%), compared with 0 patients with CSI 3 to 12 months before surgery (0.0%) and 182 controls (0.8%, p = 0.58). CSI within 1 month prior to UKA was not statistically associated with postoperative infection (p = 0.66). Two or more CSI within 3 months prior to UKA were associated with a twofold elevated odds of infection, compared with receiving a single injection (odds ratio [OR]: 2.08, p = 0.03). Univariable predictors of infection included younger age, increasing Charlson Comorbidity Index, smoking, asthma, chronic obstructive pulmonary disease, chronic kidney disease, diabetes, liver disease, and obesity. Multivariable analysis controlling for these characteristics elicited no relationship between recent CSI administration and postoperative infection. CSI within 3 months of surgery (1.5%) or 3 to 12 months (1.8%) were associated with increased conversion to total knee arthroplasty (TKA) compared with those who did not receive an injection (1.1%, p = 0.01), although TKA for indication of periprosthetic joint infection was not statistically different (p = 0.72). Preoperative CSI within 3 months of UKA is not associated with postoperative infection, although significant medical comorbidity does show an association. Preoperative CSI is associated with increased conversion from UKA to TKA for noninfectious indications.

Is it possible to predict which patients are most likely to benefit from intra-articular corticosteroid injections? A systematic review

AIM

Intra-articular corticosteroid injections (IACIs) can reduce osteoarthritis-related pain, with differing levels of response across patient groups. This systematic review investigates what is known about the positive and negative predictors of outcomes in patients with osteoarthritis who undergo IACIs.

METHODS

We systematically searched the Medline, Embase, and Cochrane databases to May 2023 for studies that evaluated patients undergoing IACIs for osteoarthritis and reported on predictors of outcomes in these patients.

RESULTS

Eight studies were included. Two were placebo-controlled trials, six were observational studies. Due to the heterogeneity of outcomes and variables between the studies, it was not possible to pool the results for formal meta-analysis. Higher baseline pain, older age, higher BMI, lower range of movement, higher Kellgren-Lawrence radiographic score, joint effusion, and aspiration were shown to be predictors of a positive response to IACIs in some of the included studies. However, other studies showed no difference in response with these variables, or a negative correlation with response. Sex, smoking, mental health status, hypertension/ischaemic heart disease, diabetes mellitus, duration of symptoms, and socioeconomic status did not demonstrate any correlation with the prediction of positive or negative outcomes after IACIs.

CONCLUSION

Several patient features have been identified as positive predictors of outcomes following IACIs. However, this systematic review has identified inconsistent and variable findings across the existing literature. Further research with standardization of IACI administration and outcome measures is required to facilitate further analysis of the reliability and significance of predictive factors for response to IACIs.

The temporal effect of corticosteroid injections into large joints prior to trigger finger release on infection

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.

Preoperative intra-articular steroid injections within 3 months increase the risk of periprosthetic joint infection in total knee arthroplasty: a systematic review and meta-analysis

OBJECTIVE

Albeit with no disease-modifying effects, intra-articular steroid injections (IASIs) are still widely used to relieve symptoms of knee osteoarthritis. Previous literature has reported conflicting results regarding the safety of IASI in terms of periprosthetic joint infection (PJI) in total knee arthroplasty (TKA). This study tried to determine whether preoperative IASIs increased the risk of PJI, with different time intervals between the injections and surgery.

METHODS

A computerized search of MEDLINE, EMBASE, and Cochrane Library was conducted for studies published before October 2022, which investigated the PJI rates of patients who received IASIs before TKA and patients who did not. The primary outcome was the association between preoperative IASI and PJI in TKA. The time point from which IASIs could be applied without risking PJI was also assessed.

RESULTS

Fourteen studies, with 113,032 patients in the IASI group and 256,987 patients in the control group, were included. The pooled odds ratio of PJI was 1.13 (95% confidence interval [CI] 1.00-1.27, p = 0.05), indicating no increased risk of PJI. With the time interval < 6 months, the pooled odds ratio was 1.19 (95% CI 0.99-1.43, p = 0.06). However, with the time interval < 3 months, the pooled odds ratio was 1.26 (95% CI 1.06-1.50, p < 0.01).

CONCLUSION

IASI is not a safe procedure for patients who are expected to undergo TKA. The time interval between the injections and surgery was an important factor in assessing the safety of IASI. Preoperative injections that were applied within 3 months increased the risk of PJI in TKA.

Delaying Total Knee Arthroplasty More than 4 Weeks after Intra-Articular Knee Injection Does Not Further Decrease Risk of Septic Revision

Hyaluronic acid (HA) and corticosteroid (CS) injections are utilized in symptom management for patients with osteoarthritis. However, contamination of the joint may increase the risk of infection following total knee arthroplasty (TKA). Therefore, the purpose of this study was to examine 90-day surgical site infection (SSI) and manipulation under anesthesia (MUA) as well as up to 2-year prosthetic joint infection (PJI) in intra-articular knee injection recipients prior to TKA compared with patients who did not have knee injections. We specifically assessed (1) timing of HA and CS prior to TKA; (2) type of intra-articular knee injection; as well as (3) associated risk factors. We queried a national database to identify patients who underwent primary TKA from September 2015 to October 2020 (n = 1.5 million). Patients with prior knee injections were stratified to five cohorts: HA within 4 weeks (n = 140), HA 4 to 6 weeks prior (n = 337), CS within 4 weeks (n = 2,344), CS 4 to 6 weeks (n = 2,422), and a no injection, control, cohort prior to TKA (n = 5,000). Bivariate chi-square analyses of outcomes were conducted, and multivariate regressions were used to adjust for comorbidities and assess associated risk factors. The adjusted analysis showed a significant risk in infection for patients receiving an injection within 4 weeks of TKA (p < 0.023) and showed no difference in type of injection (p > 0.050). Additionally, SSIs were increased 1.58 times in the CS within 4 weeks of TKA cohort (p = 0.023). However, no difference in MUA risk was shown at 90-day postoperative (p > 0.212). Furthermore, tobacco use was identified as a risk factor that further increased likelihood of PJI. Intra-articular knee injection less than 4 weeks before TKA increased the risk for PJI; however, past 4 weeks did not confer infection risk. Tobacco use was identified as an associated risk factor that further increased likelihood for PJI. These results highlight the need for surgeons to wait 4 weeks between knee injection and TKA to decrease risk of septic revision.

Intra-articular injection receipt within 3 months prior to primary total knee arthroplasty is associated with increased periprosthetic joint infection risk

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.

Perioperative use of intra-articular steroids during the COVID-19 pandemic

PURPOSE

There are growing concerns with the widely used glucocorticoids during the Coronavirus disease-19 (COVID-19) pandemic due to the associated immunosuppressive effects, which may increase the risk of COVID-19 infection and worsen COVID-19 patient outcome. Heavily affecting orthopaedics, the pandemic led to delay and cancellation of almost all surgical cases, and procedures including perioperative intra-articular corticosteroid injections (ICIs) saw similar decreases. However, the benefits of ICI treatments during the pandemic may outweigh these potential risks, and their continued use may be warranted.

METHODS

A literature search was conducted, and all relevant articles including original articles and reviews were identified and considered in full for inclusion, and analysed with expert opinion. Epidemiological statistics and medical guidelines were consulted from relevant authorities.

RESULTS

ICIs allow a targeted approach on the affected joint and are effective in reducing pain while improving functional outcome and patient quality-of-life. ICIs delay the requirement for surgery, accommodating for the increased healthcare burden during the pandemic, while reducing postoperative hospital stay, bringing significant financial benefits. However, ICIs can exert systemic effects and suppress the immune system. ICIs may increase the risk of COVID-19 infection and reduce the efficacy of COVID-19 vaccinations, leading to important public health implications.

CONCLUSION

Perioperative ICI treatments may bring significant, multifaceted benefits during the pandemic. However, ICIs increase the risk of infection, and perioperative COVID-19 is associated with mortality. The use of ICIs during the COVID-19 pandemic should therefore be considered carefully on an individual patient basis, weighing the associated risks and benefits.

The Impact of Corticosteroid Injection Timing on Infection Rates Following Spine Surgery: A Systematic Review and Meta-Analysis

STUDY DESIGN/SETTING

Systematic review/meta-analysis.

OBJECTIVES

The objective of this review was to assess how the risk of infection following lumbar spine surgery varies as a function of the timing of preoperative corticosteroid spinal injections (CSIs).

METHODS

A systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. PubMed and EMBASE databases were searched and data was pooled for meta-analysis.

RESULTS

Six studies were identified for inclusion. Two (33.3%) demonstrated a significant relationship between the timing of preoperative CSIs and the risk of postoperative infection, while 4 (66.7%) demonstrated no impact. A total of 2.5% (110/4,448) of patients who underwent CSI <1 month before surgery experienced a postoperative infection, as compared to 1.2% (1,466/120, 943) of controls, which was statistically significant (RR = 1.986 95% CI 1.202-3.282 P = 0.007). A total of 1.6% (25/1,600) of patients who underwent CSI 0-3 months before surgery experienced a postoperative infection, as compared to 1.6% (201/12, 845) of controls (RR = 0.887 95% CI 0.586-1.341, P = 0.569). A total of 1.1% (199/17 870) of patients who underwent CSI 3-6 months before surgery experienced a postoperative infection, as compared to 1.3% (1,382/102, 572) of controls (RR = 1.053 95% CI 0.704-1.575, P = 0.802). Differences in infection risk for 0-3 months and 3-6 months were not statistically significant.

CONCLUSIONS

CSIs <1 month prior to lumbar spine surgery are a significant risk factor for infection, while CSIs beyond that point showed no such association. Surgeons should consider avoiding CSIs <1 month of the use of CSIs of the spine.

An Injectable Containing Morphine, Ropivacaine, Epinephrine, and Ketorolac Is Not Cytotoxic to Articular Cartilage Explants From Degenerative Knees

PURPOSE

The purpose of this study was to determine the effects of a multidrug injectate containing morphine, ropivacaine, epinephrine, and ketorolac, commonly referred to as the "Orthococktail," on cartilage tissue viability and metabolic responses using an established in vitro model.

METHODS

With institutional review board approval and informed patient consent, tissues normally discarded after total knee arthroplasty (TKA) were recovered. Full-thickness cartilage explants (n = 72, Outerbridge grade 1 to 3) were created and bisected. Paired explant halves were treated with either 1 mL Orthococktail or 1 mL of saline and cultured for 8 hours at 37°C, with 0.5 mL of the treatment being removed and replaced with tissue culture media every hour. Explants were cultured for 6 days, and media were changed and collected on days 3 and 6. After day 6, tissues were processed for cell viability, weighed, and processed for histologic grading. Outcome measures were compared for significant differences between treated and untreated samples.

RESULTS

There were no significant differences in cartilage viability between control and Orthococktail-treated samples across a spectrum of cartilage pathologies. Orthococktail treatment consistently resulted in a significant decrease in the release of PGE2, MCP-1, MMP-7, and MMP-8 on day 3 of culture and PGE2, MMP-3, MMP-7, and MMP-8 on day 6 of culture, compared with saline controls.

CONCLUSION

The results of the present study indicate that an Orthococktail injection composed of morphine, ropivacaine, epinephrine, and ketorolac is associated with a transient decrease in degradative and inflammatory mediators produced by more severely affected articular cartilage and may mitigate perioperative joint pain such that postoperative narcotic drug use could be reduced.

CLINICAL RELEVANCE

The Orthococktail solution used in this study may be a safe intraoperative, intra-articular injection option for patients undergoing joint arthroplasty and other joint preservation surgical procedures.

Irrigation and debridement for knee osteoarthritis patients with suspected infection by intra-articular injection before total knee arthroplasty: a retrospective study

BACKGROUND

Patients suffer from knee osteoarthritis (KOA) pain may seek for intra-articular injections before total knee arthroplasty (TKA), which have a possibility of causing the joint sepsis. However, the management and clinical outcomes of these patients following TKA remain uncertain.

METHODS

Patients with a history of intra-articular injection, in which a joint sepsis was suspected, were included. The patients received joint irrigation and debridement (I&D) and antibiotic treatment until serum inflammatory indicators returned to normal level before TKA. The information of joint fluid routine and culture, synovium section and culture, and serum inflammatory indicator values were collected. Range of motion, Knee Society Scores (KSS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) were used for functional evaluations.

RESULTS

A total of 17 patients with 17 knee joints were included, all with elevated C-reactive protein (CRP) levels (23.5 ± 8.7 mg/L) as well as increased number of white blood cells (WBC) in the aspiration (50.8 ± 15.3) × 109/L, but no positive cultures were found. The culture of synovium detected three positive results: two Staphylococcus epidermidis and one S. aureus. I&D treatment had no obvious effect on the functional outcomes of KOA, but alleviated the joint pain (p < 0.01). Furthermore, we found that I&D pretreatment could increase the operation time with about 10 min longer than the primary TKA (p < 0.01). With respect to TKA outcomes, I&D had a slight influence on the knee flexion (p < 0.01), but no significant difference was identified between the two groups for KSS and WOMAC (all p values > 0.05). In addition, there was no significant difference in complication rates between the two groups in the last follow-up.

CONCLUSION

I&D treatment is a valuable procedure for suspected knee infection, which has a higher incidence of detecting microorganisms while does not influence the functional outcomes and complication rates of TKA. However, further larger studies are required to confirm these findings.

Analysis of the Cost and Efficacy of Intra-Articular Knee Injections

INTRODUCTION

Intra-articular joint injections have been used with the goal of providing patients with symptomatic relief. Recently, however, the efficacy of corticosteroid (CS) and hyaluronic acid (HA) injections in the management of knee osteoarthritis (OA) is questionable. In this analysis, we investigated the costs associated with injections by assessing overall use, conversion and average time to total knee arthroplasty (TKA), and reimbursement.

METHODS

Patients aged 50 to 70 years with a knee-related diagnosis of pain, effusion, or OA were identified in the Humana insurance national data set. Patients who received intra-articular injections were stratified by the type and number of injection(s) received. The subsequent rates of TKA were compared with Kaplan-Meier curves for patients who underwent CS injections, HA injections, and a benchmarking cohort of patients with OA and no history of knee injections in the medical record. Average time to TKA was determined from index diagnosis, and total cost was compared using Wilcoxon rank sum analyses.

RESULTS

A total of 778,686 patients were identified. Of these, 637,112 had no knee injection history, while 124,129 received CS and 17,445 received HA injections. The 10-year conversion to TKA was highest in HA cohort (31.6%), followed by the CS cohort (24.0%) and the noninjection cohort (7.3%) (P < 0.001). Time to TKA increased with number of injections for both injection types. For patients who underwent TKA, median cost was greater in HA ($16,687) and CS ($15,563) cohorts relative to noninjection cohort ($14,733) (P < 0.001).

DISCUSSION

Compared with the noninjection cohort, both HA and CS cohorts experienced increased costs and increased time to TKA. However, while the cost incurred in HA cohort was greater than that in CS cohort, no appreciable benefit was demonstrated for conversion or time to TKA. Therefore, if intra-articular knee injections are indicated for the nonsurgical management of knee OA, the results of this study support CS over HA.

Overview of First-Line and Second-Line Pharmacotherapies for Osteoarthritis with Special Focus on Intra-Articular Treatment

Osteoarthritis (OA) can be defined as the result of pathological processes of various etiologies leading to damage to the articular structures. Although the mechanism of degenerative changes has become better understood due to the plethora of biochemical and genetic studies, the drug that could stop the degenerative cascade is still unknown. All available forms of OA therapy are based on symptomatic treatment. According to actual guidelines, comprehensive treatment of OA should always include a combination of various therapeutic options aimed at common goals, which are pain relief in the first place, and then the improvement of function. Local treatment has become more common practice, which takes place between rehabilitation and pharmacological treatment in the hierarchy of procedures. Only in the case of no improvement and the presence of advanced lesions visible in imaging tests, should surgery be considered. Currently, an increasing number of studies are being published suggesting that intra-articular injections may be as effective or even more effective than non-steroidal anti-inflammatory drugs (NSAIDs) and result in fewer systemic adverse events. The most commonly used preparations are hyaluronic acid (HA), glucocorticosteroids (GS), and also platelet-rich plasma (PRP) in recent years. This review aims to present the mechanism of action and clinical effectiveness of different pharmacological options in relieving pain and improving functions in OA as well as the emerging approach in intra-articular treatment with PRP.

The systemic immunosuppressive effects of peripheral corticosteroid injections: A narrative review of the evidence in the context of COVID-19

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.

Intra-Articular Corticosteroid Injection After Total Knee Replacement: Is it Safe?

Recalcitrant pain after total knee replacement (TKR) is sometimes treated with intra-articular steroid injections (IASI), with few studies reporting on the risk of subsequent periprosthetic joint infection (PJI). This is a systematic review to evaluate the incidence and risk of PJI after IASI into a total knee replacement.

We searched online databases using the keywords "total knee replacement," "total knee arthroplasty," "steroids" and "intra-articular injection." A total of 7386 articles (PubMed - 91, Embase - 70, Web of Science - 57, CINAHL - 8, and Google Scholar - 7160) were retrieved on the initial search. After applying exclusion criteria, four articles were included in this review for evaluation and statistical analysis. There were no level one or two studies.

The incidence of infection after IASI at 12 months was 138/6499 or 2.1%, while the incidence of infection rate among controls at 12 months was 158/11256 or 1.4%. A chi-square test showed that the difference in infection rate was significant (p = 0.0002424). A caveat is that simple statistical test results are virtually guaranteed to be statistically significant with large sample size.

IASI into a TKR is not a benign procedure and that may be associated with a significantly increased risk of subsequent periprosthetic joint infection. We, therefore, recommend against IASI into a TKR until better studies can be performed to determine their safety and efficacy.

EULAR recommendations for intra-articular therapies

OBJECTIVES

To establish evidence-based recommendations to guide health professionals using intra-articular therapies (IAT) in adult patients with peripheral arthropathies.

METHODS

A multidisciplinary international task force established the objectives, users and scope and the need for background information, including systematic literature reviews) and two surveys addressed to healthcare providers and patients throughout Europe. The evidence was discussed in a face-to-face meeting, recommendations were formulated and subsequently voted for anonymously in a three-round Delphi process to obtain the final agreement. The level of evidence was assigned to each recommendation with the Oxford levels of evidence.

RESULTS

Recommendations focus on practical aspects to guide health professionals before, during and after IAT in adult patients with peripheral arthropathies. Five overarching principles and 11 recommendations were established, addressing issues related to patient information, procedure and setting, accuracy, routine and special aseptic care, safety issues and precautions to be addressed in special populations, efficacy and safety of repeated joint injections, use of local anaesthetics and aftercare.

CONCLUSION

We have developed the first evidence and expert opinion-based recommendations to guide health professionals using IAT. We hope that these recommendations will be included in different educational programmes, used by patient associations and put into practice via scientific societies to help improve uniformity and quality of care when performing IAT in peripheral adult joints.

Do We Need to Wait 3 Months After Corticosteroid Injections to Reduce the Risk of Infection After Total Knee Arthroplasty?

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.

Local Efficacy of Corticosteroids as an Adjuvant for Periarticular Cocktail Injection in Simultaneous Bilateral Total Knee Arthroplasty: A Prospective Randomized Double-Blind Controlled Trial

Multimodal cocktail periarticular injections comprising corticosteroids are the most suggested therapy for postoperative discomfort and swelling following total knee arthroplasty (TKA). Nevertheless, previous findings cannot be applied to instances of unilateral total knee arthroplasty on bilateral knees. This randomized, prospective, double-blind, controlled clinical study examines the efficacy as well as safety of periarticular multimodal cocktail injection along or sans corticosteroids in certain situations. The 60 patients (120 knees) that experienced concurrent bilateral total knee arthroplasty were provided periarticular injections along additional betamethasone (7 mg) in the randomized knee, as well as the other knee, where corticosteroid was not administered. Key results were “pain scores at rest as well as in action” on a visual analogue scale of 11 pt. Other results included motion range, swelling of the thigh, Hospital for Special Surgery score (HSS score), and adverse effects were measured between the two sides. No statistically promising variations were found in the visual analogue scale ranking, motion range, girth of the thigh, and HSS score, as well as complications between the two sides. The impact on treatment outcomes was maintained between the knees on postoperative day 3 or at 3 months of follow-up. Multimodal periarticular injection without corticosteroid will alleviate postoperative swelling and pain. More studies are needed for the use of betamethasone as a corticosteroid in periarticular multimodal cocktail injections. This Chinese Clinical Trial Registry is registered with ChiCTR-OPC-17013503, dated 2017-11-23, available from http://www.chictr.org.cn/showproj.aspxproj=23146.

Intra-Articular Injections Prior to Total Knee Arthroplasty Do Not Increase the Risk of Periprosthetic Joint Infection: A Prospective Cohort Study

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.

Common Practices in Intra-Articular Corticosteroid Injection for the Treatment of Knee Osteoarthritis: A Survey of the American Association of Hip and Knee Surgeons Membership

BACKGROUND

Knee osteoarthritis nonoperative management options remain limited. Our aim is to define the current American Association of Hip and Knee Surgeons (AAHKS) members' practices and perceptions in terms of the frequency, formulation, use of concomitant aspiration, maximum lifetime number of injections, efficacy, interval between injection and surgery and complication rates.

METHODS

A 22-question survey based on Likert scale response anchors was approved and distributed by the AAHKS Research Committee to its membership by email during the Spring 2019 meeting. Data were managed with REDCap software.

RESULTS

Membership response totaled 537 of 2365 (22.7%) members. Highlights include every respondent using intra-articular corticosteroid injections (ICIs) in their practice, and most use a three-month minimum interval, although the preferred interval is longer. Near consensus was found waiting three months before surgery. There was a great variability in the number of injections allowed, and injections before surgery were very common. Nearly all responders use a local anesthetic mixture with the cortisone injection, but there was great variation in corticosteroid type: methylprednisolone (42%), triamcinolone (41%), betamethasone (13.3%), and dexamethasone (3.7%).

CONCLUSION

The results of our survey indicate the majority of the AAHKS members who completed the survey use ICIs routinely for treatment of knee osteoarthritis. There was near consensus in ICIs, which is effective with decreasing efficacy over serial injections, and an absolute minimum interval between injections was believed by most to be three months with no clearly defined lifetime limit and strong consensus for a three-month preoperative interval. The formulation of steroid, local anesthetic, and skin preparation technique varied greatly.

Intra-Articular Hyaluronic Acid Injections Less Than 6 Months Before Total Hip Arthroplasty: Is It Safe? A Retrospective Cohort Study in 565 Patients

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.

Increased Use of Intra-Articular Steroid Injection to Treat Osteoarthritis is Associated With Chronic Opioid Dependence After Later Total Knee Arthroplasty But Not Total Hip Arthroplasty

BACKGROUND

Intra-articular (IA) injections of corticosteroid (CO) and hyaluronic acid (HA) are commonly used for osteoarthritis. The efficacy of these interventions is controversial. Furthermore, research regarding the potential association of IA injection with later postoperative pain trajectories is lacking.

METHODS

We performed analysis on Truven Health MarketScan database (2012-2016) in total hip arthroplasty (THA) and total knee arthroplasty (TKA). Trends over time were assessed. Multivariable logistic regression analyses were executed to evaluate the impact of IA injections on postoperative chronic opioid use.

RESULTS

Preoperative CO and HA injections decreased throughout the study period in both THA and TKA. Preoperative CO and HA injections, regardless of frequency, had no significant impact on the odds of THA patients becoming chronic opioid users postoperatively. TKA patients who had 1 CO injection in the year before surgery experienced lower odds of postoperative chronic opioid use (odds ratio [OR], 0.89; 95% confidence interval [95% CI], 0.82-0.97), whereas patients who had 2 or more CO injections experienced significantly greater odds (OR, 1.14; 95% CI, 1.04-1.24). TKA patients who received 2 or more HA injections before surgery had significantly lower odds of chronic opioid use (OR, 0.90; 95% CI, 0.81-0.99).

CONCLUSION

The utilization of IA injections in patients with hip and knee osteoarthritis appears to be decreasing over time. TKA patients who received 2 or more preoperative CO injections experienced greater odds of chronic opioid utilization, whereas TKA patients with 2 or more HA injections in the year before surgery had decreased odds of chronic opioid use.

Do Corticosteroid Injections Before or After Primary Rotator Cuff Repair Influence the Incidence of Adverse Events? A Subjective Synthesis

PURPOSE

To determine the influence of corticosteroid injections (CSIs) before or after primary rotator cuff repair (RCR) on the risk of (1) revision RCR, (2) retears, and (3) infections.

METHODS

The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and MEDLINE databases were queried in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Data pertaining to the use of CSIs before or after primary RCR and adverse events were extracted. A subjective synthesis of these outcomes and bias was performed.

RESULTS

A total of 10 studies including 240,976 patients were identified; 20.0% received a perioperative CSI. Of the 48,235 patients who received a CSI, 66.2% did so preoperatively whereas 33.8% did so postoperatively. A total of 78 patients received both preoperative and postoperative CSIs. Three studies examined the influence of preoperative CSIs on revision RCR; the incidence ranged from 3.8% to 10.5% with preoperative CSIs and from 3.2% to 3.4% for controls. Two of these studies analyzed outcomes of patients from the same databases over the same period. Five studies examined the influence of postoperative CSI use on retears; the incidence ranged from 5.7% to 19.0% in patients who received postoperative CSIs and from 10.0% to 18.4% for controls. Three studies examined the influence of CSI use on infection; 2 studies examined the risk of infection after postoperative CSI use, which ranged from 0.0% to 6.7% with CSIs and from 0.0% to 0.5% for controls.

CONCLUSIONS

The use of preoperative CSIs could be associated with an increased risk of revision RCR. There were no conclusive data to suggest an increased risk of retear or infection with CSI use based on a subjective synthesis of ranges. There is currently poor-quality literature surrounding this topic. Given that the current literature is limited and heterogeneous, no definitive recommendations can be made on perioperative CSI use for RCR.

LEVEL OF EVIDENCE

Level III, systematic review of Level I and III studies.

The efficiency and safety of steroid addition to multimodal cocktail periarticular injection in knee joint arthroplasty: a meta-analysis of randomized controlled trials

Steroids are frequently used for postoperative pain relief without definite evidence. This study was conducted to assess the pain management effect of the addition of steroids to a multimodal cocktail periarticular injection (MCPI) in patients undergoing knee arthroplasty and evaluate their safety. Pubmed, Embase, and Cochrane Library were searched through April, 2018. A total of 918 patients from ten randomized controlled trials (RCTs) were ultimately included. Compared with placebo groups, steroids application could effectively relieve pain on postoperative day (POD)1; decrease C-Reactive protein (CRP) level on POD3; improve range of motion (ROM) in postoperative 5 days; reduce morphine consumption, achieve earlier straight leg raising (SLR), and shorten the length of stay (LOS) in hospital. With regards to adverse effects, it did not increase the risk of postoperative infection, postoperative nausea and vomiting (PONV), or other complications. However, no significant difference in pain relief, ROM, or increased Knee Society Knee Function Scores were found during long-term follow up. Overall, this meta-analysis ensured the efficiency and safety of steroids with MCPI in knee arthroplasty patients during the early postoperative period.

Intra-articular Corticosteroid Injection Following Total Knee Arthroplasty: Is It Effective?

BACKGROUND

Total knee arthroplasty (TKA) for the majority of patients with severe knee osteoarthritis provides relief of symptoms and improved function. However, there remains a subset of dissatisfied patients despite an unremarkable workup. A corticosteroid injection (CSI) is a commonly used nonsurgical treatment for painful knee osteoarthritis but its efficacy in a replaced knee remains unknown.

METHODS

A retrospective chart review identified primary TKA patients who subsequently received a CSI into a replaced knee from 2015 to 2016 by a single surgeon. Patients receiving a CSI underwent clinical examination, laboratory analysis to rule out infection, and radiographic evaluation before CSI. Patient variables were recorded and a patient satisfaction survey assessed the efficacy of the injection. The survey response rate was 70.1%.

RESULTS

Of the 129 responders, 82.9% remembered the injection. The average time from index arthroplasty to injection was median 5.3 months (interquartile range, 2.1-23.4) and 30.8% of patients received more than 1 injection (range, 1-5). Overall, 76.6% reported decreased pain, 57.9% reported increased motion, and 65.4% reported long-term decreased swelling. Improvement lasted greater than 1 month for 56.1% of patients, and overall 84.1% reported improvement (slight to great) in the knee following CSI. No patient developed a periprosthetic joint infection (PJI) within 1 year of injection.

CONCLUSION

This study suggests that certain patients following TKA may benefit from a CSI. However, this should only be performed once clinical, radiographic, and laboratory examination has ruled out conditions unlikely to improve long term from a CSI.

Intra-articular, single-shot co-injection of hyaluronic acid and corticosteroids in knee osteoarthritis: A randomized controlled trial

The aim of the present study was to investigate whether the co-injection of hyaluronic acid (HA) and corticosteroids (CS) was superior to HA alone in the treatment of knee OA. A total of 120 participants with symptomatic knee OA were recruited and formed the intention-to-treat population for a 6-month follow-up. In the HA group, patients received a single-shot injection of 4 ml HA. In the HA&CS group, patients received a co-injection of 3 ml compound betamethasone solution and 4 ml HA. Visual analog scale (VAS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and knee flexion motion were assessed as primary outcomes. Patients in the HA&CS group exhibited better pain relief and knee function at the time points of week 1, month 1 and month 3 (P<0.05). For the last follow-up at month 6, the values did not differ significantly between these two groups. Patients in both groups exhibited improvement in pain, knee function, and range of motion following injection. For the final follow-up at month 6, the mean VAS score, WOMAC score and knee flexion motion were still superior to that prior to treatment, but the values did not differ significantly. The co-injection of HA and CS provided a rapid improvement in pain relief, knee function, and range of motion, but did not differ significantly from that of HA alone in the long term effect.

Trends in Opioid Utilization Before and After Total Knee Arthroplasty

BACKGROUND

Opioids are a mainstay in perioperative pain management among patients undergoing total knee arthroplasty (TKA). However, patterns in opioid use before and after TKA have not been well-studied. The objectives of this study are to characterize prescribing trends preoperatively and postoperatively and identify risk factors for chronic postoperative opioid use.

METHODS

A review of the prescription-tracking database of a large private payer from 2007 to 2013 was performed using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Chronic opioid use was defined as opioid prescriptions over 6 contiguous months postoperatively.

RESULTS

We identified 66,950 patients who underwent TKA with minimum 2-year follow-up and medication codes. Of those taking opioids preoperatively (n = 36,668), 34.8% became chronic users postoperatively compared to only 5.0% of the opioid-naïve cohort (n = 30,282). Major risk factors for chronic postoperative opioid use included preoperative opioid use (relative risk [RR] 3.75, 95% confidence interval [CI] 3.59-3.93), female gender (RR 1.23, 95% CI 1.20-1.25), and younger age (≤44 vs ≥60: RR 1.41, 95% CI 1.32-1.49; 45-59 vs ≥60: RR 1.42, 95% CI 1.40-1.46). From 2007 to 2013, there was a significant linear increase in opioid use preoperatively (odds ratio [OR] 1.04, 95% CI 1.03-1.05, P < .001) and postoperatively (OR 1.20, 95% CI 1.18-1.21, P < .001), but chronic postoperative opioid use increased only marginally (OR 1.01, 95% CI 1.00-1.02, P = .021).

CONCLUSION

The greatest risk factors for chronic postoperative opioid use were preoperative use, younger age, female gender, greater length of stay, and worse health status. Although the use of opioids continues to grow significantly preoperatively and postoperatively, chronic opioid use post-TKA has remained clinically unchanged.

Safety of intra-articular steroid injections prior to arthroplasty: Best evidence selection and risk of bias considerations

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.

Risk factors and clinical characteristics of deep knee infection in patients with intra-articular injections: A matched retrospective cohort analysis

BACKGROUND

Deep knee infection (DKI), consisting of sepsis arthritis (SA) and chronic low-grade infection (CLGI), is a rare but catastrophic adverse event that can result from intra-articular (IA) injections. The purpose of this study was to assess the risk factors for DKI and describe the clinical characteristics of DKI in patients who received IA injections.

METHODS

Fifty patients with IA injection-induced DKI who underwent surgical treatment between January 2010 and May 2016 served as cases and were matched with non-infected controls who received IA injections in a proportion of 1:5 based on age, gender, and date of admission. All IA injections (both cases and controls) were performed within 6 months of admission at our institution or at a referring institution. Risk factors for injection-induced DKI were analyzed, and the clinical characteristics between SA and CLGI were compared.

RESULTS

The final multivariate logistic regression analysis demonstrated that body mass index ≥25kg/m2 [odds ratio (OR) = 2.3; 95% confidence interval (CI): 1.1-4.7], corticosteroid injections (OR = 3.21; 95% CI: 1.63-6.31), rheumatoid arthritis (OR = 2.61; 95% CI: 1.20-5.68) and injections performed by general practitioners (OR = 5.23; 95% CI: 2.00-13.67) increased the risk of DKI following IA injections. Of 50 cases, there were 21 SA cases and 29 CLGI cases. SA cases had significantly higher metrics in the categories of fever, local warmth, swelling, rest pain, night pain, limited motion, serum WBC, and CRP levels than CLGI cases.

CONCLUSIONS

We identified risk factors and clinical characteristics of injection-induced DKI, which may offer improved guidance on IA injections and knowledge of DKI in patients with IA injections, especially in CLGI patients.

The AAHKS Clinical Research Award: What Are the Costs of Knee Osteoarthritis in the Year Prior to Total Knee Arthroplasty?

BACKGROUND

Despite American Academy of Orthopaedic Surgeons Clinical Practice Guidelines (CPGs) related to the non-arthroplasty management of osteoarthritis (OA) of the knee, non-recommended treatments remain in common use. We sought to determine the costs associated with non-arthroplasty management of knee OA in the year prior to total knee arthroplasty (TKA) and stratify them by CPG recommendation status.

METHODS

The Humana database was reviewed from 2007 to 2015 for primary TKA patients. Costs for hyaluronic acid (HA) and corticosteroid injections, physical therapy, braces, wedge insoles, opioids, non-steroidal anti-inflammatories, and tramadol in the year prior to TKA were calculated. Cost was defined as reimbursement paid by the insurance provider. Costs were analyzed relative to the overall non-inpatient costs for knee OA and categorized based on CPG recommendations.

RESULTS

In total 86,081 primary TKA patients were analyzed and 65.8% had at least one treatment in the year prior to TKA. Treatments analyzed made up 57.6% of the total non-inpatient cost of knee OA in the year prior to TKA. Only 3 of the 8 treatments studied have a strong recommendation for their use (physical therapy, non-steroidal anti-inflammatories, tramadol) and costs for these interventions represented 12.2% of non-inpatient knee OA cost. In contrast, 29.3% of the costs are due to HA injections alone, which are not supported by CPGs.

CONCLUSION

In the year prior to TKA, over half of the non-inpatient costs associated with knee OA are from injections, therapy, prosthetics, and prescriptions. Approximately 30% of this is due to HA injections alone. If only interventions recommend by the CPG are utilized then costs associated with knee OA could be decreased by 45%.

Factors That Affect Outcome Following Total Joint Arthroplasty: a Review of the Recent Literature

PURPOSE OF REVIEW

It is well established that certain patient-specific risk factors affect outcomes following total joint arthroplasty. The goal of this paper is to summarize the latest data on several variables that have been investigated in the last 3 years and to characterize the effects these factors have on the success of hip and knee replacement.

RECENT FINDINGS

Preoperative diagnoses of depression and anxiety, liver disease, hypoalbuminemia, vitamin D deficiency, and diabetes mellitus are associated with increased risk of postoperative complications and can lead to worse outcomes after joint replacement surgery. Recent investigations have clearly established a link between these patient-specific factors and poor outcomes after hip and knee arthroplasty, but future research is needed to determine best practices for stratifying and mitigating these risks for patients.

Intra-Articular Knee Injections Before Total Knee Arthroplasty: Outcomes and Complication Rates

BACKGROUND

The relationship between intra-articular injections and complication rates after total knee arthroplasty (TKA) remains controversial. This study's purpose was to determine the relationship between the number and timing of intra-articular injections with complications and outcomes after TKA from a single surgeon's database.

METHODS

We retrospectively reviewed a series of 442 patients who underwent primary TKA from 2008-2015. Patient demographics, comorbidities, number and timing of ipsilateral intra-articular injections, and preoperative and postoperative functional outcome scores were recorded. Complications and infection rates at a minimum of 12-month follow-up were compared between patients who received 3 or less preoperative injections and those who received 4 or greater before TKA. Multivariate logistic regression analysis was performed to identify independent risk factors for complications and poor short-term outcomes after TKA.

RESULTS

Of the 442 patients enrolled in the study, 390 patients (90%) received an ipsilateral injection before TKA. Patients receiving 4 or more injections (175 patients, 40%) did not have a difference in complication rate (14% vs 17%, P = .346), poor functional outcomes (6% vs 9%, P = .299), or infection rate (2% vs 4%, P = .286). When controlling for confounding variables, intra-articular corticosteroid, viscosupplementation, and any injection within 90 days were not associated with an increase in complications, infection, or poor functional outcomes after TKA (all P > .05).

CONCLUSION

Our data suggest that there is no relationship between timing and number of intra-articular injections with complication rate, infection, or poor short-term functional outcomes. Further larger studies are needed to confirm these findings.

The John N. Insall Award: Do Intraarticular Injections Increase the Risk of Infection After TKA?

BACKGROUND

Infection after total knee arthroplasty (TKA) can result in disastrous consequences. Previous research regarding injections and risk of TKA infection have produced conflicting results and in general have been limited by small cohort size.

QUESTIONS/PURPOSES

The purpose of this study was to evaluate if intraarticular injection before TKA increases the risk of postoperative infection and to identify if time between injection and TKA affect the risk of TKA infection.

METHODS

The Humana data set was reviewed from 2007 to 2014 for all patients who received a knee injection before TKA. Current Procedural Terminology (CPT) codes and laterality modifiers were used to identify patients who underwent knee injection followed by ipsilateral TKA. Postoperative infection within 6 months of TKA was identified using International Classification of Diseases, 9^th Revision/CPT codes that represent two infectious endpoints: any postoperative surgical site infection (encompasses all severities of infection) and operative intervention for TKA infection (surrogate for deep TKA infection). The injection cohort was stratified into 12 subgroups by monthly intervals out to 12 months corresponding to the number of months that had elapsed between injection and TKA. Risk of postoperative infection was compared between the injection and no injection cohorts. In total, 29,603 TKAs (35%) had an injection in the ipsilateral knee before the TKA procedure and 54,081 TKA cases (65%) did not. The PearlDiver database does not currently support line-by-line output of patient data, and so we were unable to perform a multivariate analysis to determine whether other important factors may have varied between the study groups that might have had a differential influence on the risk of infection between those groups. However, the Charlson Comorbidity index was no different between the injection and no injection cohorts (2.9 for both) suggesting similar comorbidity profiles between the groups.

RESULTS

The proportion of TKAs developing any postoperative infection was higher among TKAs that received an injection before TKA than in those that did not (4.4% versus 3.6%; odds ratio [OR], 1.23; 95% confidence interval [CI], 1.15-1.33; p < 0.001). Likewise, the proportion of TKAs developing infection resulting in return to the operating room after TKA was also higher among TKAs that received an injection before TKA than those that did not (1.49% versus 1.04%; OR, 1.4; 95% CI, 1.3-1.63; p < 0.001). Month-by-month analysis of time between injection and TKA revealed the odds of any postoperative infection remained higher for the injection cohort out to a duration of 6 months between injection and TKA (ORs ranged 1.23 to 1.46 when 1-6 months between injection and TKA; p < 0.05 for all) as did the odds of operative intervention for TKA infection when injection occurred within 7 months of TKA (OR ranged from 1.38 to 1.88 when 1-7 months between injection and TKA; p < 0.05 for all). When the duration between injection and TKA was longer than 6 or 7 months, the ORs were no longer elevated at these endpoints, respectively.

CONCLUSIONS

Injection before TKA was associated with a higher risk of postoperative infection and appears to be time-dependent with closer proximity between injection and TKA having increased odds of infection. Further research is needed to better evaluate the risk injection before TKA poses for TKA infection; a more definitive relationship could be established with a multivariate analysis to control for other known risk factors for TKA infection.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Therapeutic Review of Methylprednisolone Acetate Intra-Articular Injection in the Management of Osteoarthritis of the Knee - Part 2: Clinical and Procedural Considerations

The use of an intra-articular methylprednisolone acetate (MPA) injection has been shown to have benefits for symptoms of knee osteoarthritis (OA). However, considerations beyond drug efficacy can influence the appropriateness, clinical effectiveness and potential harm of an injection. A review of research evidence and published literature on clinical and procedural factors influencing the effectiveness and safety of a knee injection has been undertaken. Factors include dose, frequency, contraindications, precautions, drug interactions, side-effects, and procedural and patient-related considerations. An evaluation of evidence indicated that a 40 mg dose provides clinical benefit. No strong predictors of response were evident, with the exception of pain severity. Additional benefit for outcomes from higher doses, local anaesthetic, ultrasound guidance or particular anatomical approaches is yet to be demonstrated. Evidence for dose- and duration-related detrimental effects suggests judicious use and frequency. The evaluation showed that there are a number of contraindications and precautions arising from the drug pharmacology, concurrent medications, comorbidities and adverse events which need consideration and monitoring. There was limited safety evidence concerning anticoagulation. The review found that specialist guidance and limited evidence suggests that injection safety concerning warfarin may be enhanced by ensuring that the international normalized ratio level is within therapeutic range. However, the risk-benefit evaluation concerning non vitamin K antagonist oral anticoagulants remains challenging. Although there is published guidance, a lack of clinical studies, safety evidence and reversibility advocates caution. Overall, the review indicates that injection decisions and procedures need an individualized approach and supporting evidence is limited in many areas. Evaluation and discussion of benefits and risks, peri-procedural and post-injection management, and tailoring to the context and individuals' preferences are important in optimizing the benefits and safety of a knee injection.

The Role of miRNAs in Common Inflammatory Arthropathies: Osteoarthritis and Gouty Arthritis

MicroRNAs (miRNAs) are small, non-coding RNA species that are highly evolutionarily conserved, from higher invertebrates to man. Up to 1000 miRNAs have been identified in human cells thus far, where they are key regulators of the expression of numerous targets at the post-transcriptional level. They are implicated in various processes, including cell differentiation, metabolism, and inflammation. An expanding list of miRNAs is known to be involved in the pathogenesis of common, non-autoimmune inflammatory diseases. Interestingly, osteoarthritis (OA) is now being conceptualized as a metabolic disease, as there is a correlation among hyperuricemia and metabolic syndrome (MetS). Experimental evidence suggests that metabolic deregulation is a commonality between these different pathological entities, and that miRNAs are key players in the modulation of metabolic routes. In light of these findings, this review discusses the role of miRNAs in OA and gouty arthritis, as well as the possible therapeutic targetability of miRNAs in these diseases.

Preoperative Hip Injections Increase the Rate of Periprosthetic Infection After Total Hip Arthroplasty

BACKGROUND

Intraarticular injections are both diagnostic and therapeutic for patients with osteoarthritis. A potential risk of periprosthetic joint infection (PJI) after total hip arthroplasty (THA) may occur from direct inoculation and/or immune suppression by corticosteroids. Large population-level databases were used to evaluate hip injection on the 1-year rate of PJI in patients undergoing primary THA.

METHODS

State-level ambulatory surgery and inpatient databases for Florida and California (2005-2012) were used to identify primary THA patients with 1-year preoperative and postoperative windows to evaluate possible injections or PJI, respectively. Patients were grouped as no injection or as THA performed 6-12 months, 3-6 months, or 0-3 months after injection. Risk adjustment was performed with multivariable regression.

RESULTS

A total of 173,958 patients were included; 5421 (3.1%) underwent THA after an injection: 1395 (1.1%) of patients after 6-12 months, 1863 patients after 3-6 months, and 2163 (1.2%) after 0-3 months. In the 0-3 month group, PJI was significantly increased at 3 months (1.58%, P = .015), 6 months (1.76%, P = .022), and 1 year (2.04%, P = .031) compared with the noninjection control group (1.04%, 1.21%, and 1.47%, respectively). There were no differences in the 3- to 6-month and 6- to 12-month injection groups.

CONCLUSION

There is an increased risk of PJI when THA is performed within 3 months of hip injection. We recommend that patients and their surgeons consider delaying elective THA until 3 months after an injection to avoid this elevated risk of infection.