Shoulder injections for osteoarthritis and other disorders

Do Preoperative Corticosteroid Injections Increase the Risk of Infection after Shoulder Arthroscopy or Shoulder Arthroplasty? A Systematic Review

INTRODUCTION

Corticosteroid injections have demonstrated short-term benefits for shoulder pain. This symptomatic treatment method is used in various inflammatory conditions that affect the shoulder joint. Corticosteroid joint injections are not without risks and complications. Adverse effects have been documented, including damage to the articular cartilage, tendon rupture, and attenuation of the subject's immune response. The aim of this study was to examine the timing of preoperative corticosteroid injections on infectious outcomes of shoulder arthroscopies and shoulder arthroplasty.

MATERIALS AND METHODS

In accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the PubMed, Cochrane, and Science Direct databases were systematically reviewed by two independent authors in January 2024. After full-text reading and checking the reference lists, 11 article were included.

RESULTS

Patients who received a shoulder injection within three months prior to undergoing shoulder arthroplasty exhibited a markedly elevated incidence of infection. In addition, a significantly increased risk of periprosthetic joint infection (PJI) at 90 days postoperatively in patients who received CSIs (corticosteroid injections) within 1 month prior to shoulder arthroplasty was found. Different authors consider CSI injections within the 2 weeks prior to shoulder arthroscopy surgery principally associated with an increased risk of postoperative infection.

DISCUSSION

There is still no consensus on the correct timing of preoperative CSIs in both arthroscopic and arthroplasty procedures. The literature does not identify whether the number of preoperative injections could increase the risk of periprosthetic infection. Obesity, sex, and smoking did not have a significant effect on PJIs; alcohol abuse could be considered as a risk factor for PJIs with CSIs. Both in prosthetic surgeries and in arthroscopy procedures, modifiable and unmodifiable factors play secondary roles. The risk of postoperative infection is greater within 3 months, although it is almost comparable at one- and two-year follow-ups.

Usefulness of a Hanging Position With Internal Rotation of Shoulder in Ultrasonography-Guided Intra-articular Steroid Injection for Adhesive Capsulitis

Objective

To evaluate the feasibility of a new position (internal rotation in hanging) in ultrasonography, we compared the length of the glenohumeral joint space and the effectiveness of steroid injection with the hanging position and with the commonly used abdomen or cross position.

Methods

A prospective, randomized controlled trial was performed in 42 patients with adhesive capsulitis of shoulder. We used three arm positions for the posterior approach as follows: the patient's palm on thigh, other hand on abdomen (abdomen position); hand on patient's opposite shoulder (cross position); arm in hanging position with internal rotation of shoulder (hanging position). The order of shoulder position was randomized and blinded. Real-time ultrasonography-guided intra-articular steroid injection was performed by posterior approach at the first position in each patient. The Brief Pain Inventory (BPI), the Shoulder Pain and Disability Index (SPADI), and range of motion (ROM) were measured before steroid injection and 2 weeks after injection.

Results

The lengths of the joint space were 2.88±0.75, 2.93±0.89, and 2.82±0.79 mm in abdomen, cross, and hanging position respectively, with no significant difference among the three positions (p=0.429). Treatment efficacy was significantly improved in ROM, total BPI, and SPADI in all three positions (p<0.001). The changes in ROM for shoulder abduction were 23.6°±19.7°, 22.2°±20.9°, and 10.0°±7.8° in abdomen, cross, and hanging position, respectively. Changes in total BPI scores were 25.1±15.7, 23.6.±18.0, 11.6±6.1, and changes in total SPADI score were 35.0±14.2, 30.9±28.9, and 16.5±10.3 in abdomen, cross, and hanging position, respectively. There were no significant difference among the three positions for all parameters (p=0.194, p=0.121, and p=0.108, respectively.

Conclusion

For patients with adhesive capsulitis who cannot achieve or maintain abdomen or cross position, scanning and injection with the shoulder in internal rotation with hanging position may be a useful alternative.

The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients

BACKGROUND

The goal of this study was to employ a national database to evaluate the association of preoperative injection before shoulder arthroscopy and arthroplasty with the incidence of postoperative infection.

METHODS

A national database of Medicare patients was queried for patients who underwent shoulder arthroscopy or arthroplasty after ipsilateral shoulder injection. Three arthroscopy cohorts were created: arthroscopy within 3 months of injection (n = 3625), arthroscopy between 3 and 12 months after injection (n = 7069), and matched control arthroscopy without prior injection (n = 186,678). Three arthroplasty cohorts were created: arthroplasty within 3 months of injection (n = 636), arthroplasty between 3 and 12 months after injection (n = 1573), and matched control arthroplasty (n = 6211). Infection rates within 3 and 6 months postoperatively were assessed.

RESULTS

The incidence of infection after arthroscopy at 3 months (0.7%; odds ratio [OR], 2.2; P < .0001) and 6 months (1.1%; OR, 1.6; P = .003) was significantly higher in patients who underwent injection within 3 months before arthroscopy compared with controls. The incidence of infection after arthroplasty at 3 months (3.0%; OR, 2.0; P = .007) and 6 months (4.6%; OR, 2.0; P = .001) was significantly higher in patients who underwent injection within 3 months before arthroplasty compared with controls.

CONCLUSIONS

There was a significant increase in postoperative infection in Medicare patients who underwent injection within 3 months before shoulder arthroscopy and arthroplasty. This association was not noted when shoulder arthroscopy or arthroplasty occurred >3 months after injection.

Glenohumeral joint injections: a review

Context:

Intra-articular injections into the glenohumeral joint are commonly performed by musculoskeletal providers, including orthopaedic surgeons, family medicine physicians, rheumatologists, and physician assistants. Despite their frequent use, there is little guidance for injectable treatments to the glenohumeral joint for conditions such as osteoarthritis, adhesive capsulitis, and rheumatoid arthritis.

Evidence Acquisition:

We performed a comprehensive review of the available literature on glenohumeral injections to help clarify the current evidence-based practice and identify deficits in our understanding. We searched MEDLINE (1948 to December 2011 [week 1]) and EMBASE (1980 to 2011 [week 49]) using various permutations of intra-articular injections AND (corticosteroid OR hyaluronic acid) and (adhesive capsulitis OR arthritis).

Results:

We identified 1 and 7 studies that investigated intra-articular corticosteroid injections for the treatment of osteoarthritis and adhesive capsulitis, respectively. Two and 3 studies investigated the use of hyaluronic acid in osteoarthritis and adhesive capsulitis, respectively. One study compared corticosteroids and hyaluronic acid injections in the treatment of osteoarthritis, and another discussed adhesive capsulitis.

Conclusion:

Based on existing studies and their level of evidence, there is only expert opinion to guide corticosteroid injection for osteoarthritis as well as hyaluronic acid injection for osteoarthritis and adhesive capsulitis.

Indirect ultrasound guidance increased accuracy of the glenohumeral injection using the superior approach: a cadaveric study of injection accuracy

Objective

To investigate whether or not indirect ultrasound guidance could increase the accuracy of the glenohumeral joint injection using the superior approach.

Methods

Twelve shoulders from 7 adult cadavers were anatomically dissected after a dye injection had been performed, while the cadavers were in the supine position. Before the injection, a clinician determined the injection point using the ultrasound and the more internal axial arm rotation was compared to how it was positioned in a previous study. Injection confidence scores and injection accuracy scores were rated.

Results

The clinician's confidence score was high in 92% (11 of 12 shoulders) and the injection accuracy scores were 100% (12 of 12 shoulders). The long heads of the biceps tendons were not penetrated.

Conclusion

Indirect ultrasound guidance and positioning shoulder adducted at 10° and internally rotated at 60°-70° during the superior glenohumeral joint injection would be an effective method to avoid damage to the long head of biceps tendons and to produce a highly accurate injection.

Predictors of success of corticosteroid injection for the management of rotator cuff disease

BACKGROUND

The use of subacromial corticosteroid injection (CSI) to treat rotator cuff tendinopathy is controversial. We hypothesized that characteristics such as activity level, American Shoulder and Elbow Surgeons (ASES) score, duration of symptoms, and status of the rotator cuff may be prognostic factors for resolution of symptoms postinjection.

METHODS

During a 12-month period, consecutive patients with rotator cuff disease were analyzed. Patients received subacromial CSI, oral NSAIDs, and physical therapy. Baseline ASES score, simple shoulder test, an activity scale, and demographic data were recorded. Patients who remained symptomatic and were indicated for surgery were considered failures. Patients that did not undergo surgery were reassessed after a minimum of 1 year.

RESULTS

Forty-nine patients met our criteria. Follow-up was obtained for 81.6%. Sixteen cases (40%) failed conservative treatment at final follow-up (22.4 ± 11 months). CSI were successful in 76.2% of males and 45% of females (p = 0.04). Full-thickness tears were present in 8% of the patients with symptom resolution and 25% of those that failed conservative treatment (p = 0.29). No significant difference was found in age, hand dominance, duration of symptoms, or any of the scoring systems.

CONCLUSION

It is difficult to predict outcomes after CSI. Our treatment strategy showed a 40% failure rate.

Accuracy of intra-articular injections of the glenohumeral joint through an anterior approach: arthroscopic correlation

BACKGROUND

Intra-articular injections of the glenohumeral joint are an important tool for orthopedic surgeons who treat the spectrum of shoulder disorders. Previous studies, however, have suggested that these injections may not be reliably placed intra-articularly in the glenohumeral joint when performed in the office setting and that radiographic assistance may be necessary. This study assessed the accuracy of a glenohumeral injection through an anterior approach with arthroscopic confirmation.

MATERIALS AND METHODS

The study included 75 consecutive patients who were undergoing routine shoulder arthroscopy for a variety of shoulder disorders. All underwent anterior placement of a 1.5-inch, 21-gauge needle using a location just lateral to the coracoid and angled 45° toward the glenohumeral joint. After injection of sterile saline, a diagnostic arthroscopy was initiated through a standard posterior portal. The needle was considered intra-articular if fluid was expressed from the eyelet of the needle when the arthroscopy pump was turned on or with direct visualization of the needle with the arthroscope, or both.

RESULTS

The needle was visualized with the arthroscope in all 75 patients (100%). In 70 patients (93.3%), fluid was expressed through the eyelet of the needle when the arthroscopy pump was turned on.

CONCLUSIONS

The results of this study show that an anterior injection into the glenohumeral joint can be accurately placed without radiographic assistance using standard landmarks. The technique used is similar to making a standard rotator interval portal during shoulder arthroscopy; therefore, it is most successful in the hands of experienced shoulder arthroscopists.

Osteoarthritis of the Acromioclavicular Joint

Shoulder pain is a frequent presenting complaint to physiatrists. Commonly encountered pathogeneses include rotator cuff pathology, bursitis, biceps tendonitis, and labral tears. Because the majority of shoulder pain originates within the subacromial region and the glenohumeral joint, the acromioclavicular, sternoclavicular, and scapulothoracic articulations may be overlooked. Osteoarthritis of the acromioclavicular joint is a common source of shoulder pain that is often neglected by clinicians and researchers. The proper diagnosis of acromioclavicular joint osteoarthritis requires a thorough physical exam, plain-film radiograph, and a diagnostic local anesthetic injection. Current treatment options are rather limited. Initial therapies are similar to that of osteoarthritis in other joints and include oral analgesics or anti-inflammatories and an emphasis on activity modification. Physical therapy, unfortunately, has little to offer, as therapeutic exercise and range of motion play only a minor role. If a diagnostic local anesthetic injection provides relief, there may be a role for corticosteroid injections. It seems that the administration of local corticosteroids into the acromioclavicular joint may provide short-term pain relief. The judicious administration of such injections remains controversial, and most experts agree that steroid injections do not alter the natural progression of the disease. Surgical options, indicated typically after a minimum of 6 mos of unsuccessful conservative treatment consist of open or arthroscopic distal clavicle resection.