June 27, 2021
Timing of Injections and Joint Arthroplasty

TIMING OF INTRA-ARTICULAR INJECTIONS BEFORE JOINT ARTHROPLASTY

INTRODUCTION

Total joint arthroplasty is a successful treatment that improves joint function, relieves pain, and increases the overall quality of life and is becoming increasingly popular. It is important for a sports medicine or orthopedic physician to be aware of the data regarding timing of intra-articular injections and their risk of infection with subsequent procedures.  Most practices do offer intra-articular injections in many joints with the most common being the knee, hip and glenohumeral joint.  Being aware of the preferences of the joint replacement surgeons is also valuable for relationships with your colleagues. Many patients do have a schedule or ideal time to go through a joint replacement and it is important to not cause any undue risks or delays in treatment.

Case Vignette

A 66 year old football coach reports to your office with right knee discomfort over the past year. He has a history of ACL reconstruction when he was in his 30s. He is debating on getting a knee injection to help with his pain and asks you about risk factors for osteoarthritis. Which of the following is NOT a risk factor for osteoarthritis?

A) Female age greater than 55
B) Obesity
C) Family history of osteoarthritis
D) Male age greater than 50

HIP

Intra-articular hip injections are becoming more common with the increased usage of ultrasound-guided injections. Blind injections have been shown to be somewhat unreliable with roughly 60 percent accuracy.  For this reason, many are sent to have this performed under fluoroscopy or ultrasound guidance.  A study by Kaspar and de Beer in 2005 reported an increased risk of infections in patients receiving an intra-articular hip injection before total hip arthroplasty (12/40) compared to control (3/40) [2].  This created debate among orthopedic providers and many studies have been performed since then.   Sreekumar et al. reported rates of infection of 0% in the experimental group (66) and 1.4% in controls (136) [3]. Chitre et al. encountered no infections requiring surgical intervention and one infection requiring IV antibiotics in 36 patients [4]. The rates of infection reported by McIntosh et al were comparable with 22/224 (9.8%) in the experimental group and 20/224 (8.9%) in the control group [5]. McMahon and Lovell reported a deep infection in one patient out of 49 (2.0%) [6].  

Hip Injection and post operative infection

Image 1: Table showing studies and infections rates with intra-articular hip joint injections and infection rate.  Adopted from [8].

More recently, Werner et al [7] and Schairer et al [8] each leveraged large databases to investigate the relationship between the timing of injections and postoperative infections following THA. Werner et al grouped patients who received CSI in 3- month to 6-month intervals prior to THA and found that injections within 3 months before surgery resulted in significantly higher odds of postoperative infection (odds ratio 1.5) ]7]. Schairer et al [8] employed almost identical methodology to Werner et al to examine the state ambulatory surgery and inpatient and also found that injections within 3 months prior to THA increased the risk of periprosthetic joint infection. Of note, these authors did not specify the contents of the injections administered as corticosteroids, and therefore also captured injections of hyaluronic acid, platelet-rich plasma, among others.  Another recent meta-analysis including more than 29,000 patients receiving an intra-articular hip injection within 4 months of a THA was associated with a higher incidence of periprosthetic joint infection at 6-month follow up (1.6% vs 1.1%) [8].

A BMI of more than 35 kg/m2 is associated with an increased rate of positive intra-operative cultures and prosthetic joint infections and a BMI more than 40 kg/m2 is associated with a higher rate of revision for sepsis following THA.  This is something worth noting with hips as some insurance covers are not providing coverage if BMI is greater than 40.  It is important to be aware of these factors also to help your relationship with your patients and colleagues in regards to expectations.

Knee

Periprosthetic joint injections (PJIs) following total knee arthroplasty (TKA) increased mortality with a 71 percent overall survival rate five years after diagnosis.  It is also associated with reduced physical function and imparied quality of life [11].  The number of TKAs performed per year is increasing in general and it is very important to prevent PJIs if possible.  For this reason, many analyses have been done in regards to timing of intra-articular injections and infection risk.  Conflicting evidence exists regarding the association of preoperative intra-articular steroid injection and increased risk of postoperative PJI following TKA [12-15] with three studies reporting injections more than 8 months prior TKA were not associated with increased risk of PJI [12-14], while one study suggested steroid injections within 11 months increase the risk of deep infection [15].

More recently, a meta-analysis with almost 36,000 patients included showed an increase of infection 3 months (2.6%) and 6 months (3.41%) after TKA when injections were performed within 3 months prior and this was shown to be significantly higher than the control group.  There was no significant difference in infection rates in patients who underwent TKA between 3–6 months or 6–12 months after ipsilateral knee injection compared to the control cohort [16].  Wang et. al conducted a meta-analysis with 6 retrospective cohort studies and 1474 patients. Compared to the control, there was no significant increase in the rate of postoperative PJIs [17].  Two recent trials echoed these results with 442 patients and 1628 patients showing no increased risk of PJI, complications or poor functional outcomes with corticosteroid injections prior to TKA [18-19]. 

shoulder

The number of patients diagnosed with infection after shoulder arthroplasty is a growing concern, given the increased prevalence of antibiotic-resistant organisms and failed arthroplasty with positive cultures.  The evidence with total shoulder arthroplasty (TSA) and risk with pre-operative corticosteroid injections is extremely limited. One study showed no causal link between intra-articular shoulder injections and infective complications with total shoulder arthroplasty.  One total infection was reported in 83 total patients with the infection in a patient that received an intra-articular injection 75 days prior to TSA.  One large multi-center trial with medicare patients showed a significant increase in postoperative infection who underwent injections within 3 months before both shoulder arthroscopy and arthroplasty [20]. 

Shoulder Injections and post operative infection

Image 2: Chart showing relationship between timing of intra-articular glenohumeral joint injections and total shoulder arthroscopy and arthroplasty.  Adopted from 

The number of patients diagnosed with infection after shoulder arthroplasty is a growing concern, given the increased prevalence of antibiotic-resistant organisms and failed arthroplasty with positive cultures.  The evidence with total shoulder arthroplasty (TSA) and risk with pre-operative corticosteroid injections is extremely limited. One study showed no causal link between intra-articular shoulder injections and infective complications with total shoulder arthroplasty.  One total infection was reported in 83 total patients with the infection in a patient that received an intra-articular injection 75 days prior to TSA.  One large multi-center trial with medicare patients showed a significant increase in postoperative infection who underwent injections within 3 months before both shoulder arthroscopy and arthroplasty [20].  

Summary

In summary, total joint arthroplasty procedures are increasing and it is important for sports medicine physicians to be aware of the risks.  Each orthopedic surgeon may have preferences or more local data that shapes their expectations with joint injections prior to joint arthroplasty.  Intra-articular hip injections have limited data available but most recommendations include either at least a one month or three month span between CSI and THA.  Most recommendations for CSI and TKA recommend waiting three months after intra-articular injections.  There is great paucity of data with intra-articular injections and TSA but the general guideline remains three months.

Case Conclusion

D is the correct answer. Risk factors for osteoarthritis include female age greater than 55, male age greater than 65, obesity, prior trauma, family history of OA and occupation with repetitive loads or high physical demands.
Crosby J. Osteoarthritis: Managing without surgery. J Fam Prac. 2009;58(7):354–361.

References

  1. Leopold SS, Battista V, Oliverio JA. Safety and efficacy of intraarticular hip injection using anatomic landmarks. Clin Orthop Relat Res 2001;391:192–197.

 

  1. Kaspar S, de V de Beer J. Infection in hip arthroplasty after previous injection of steroid. J Bone Joint Surg [Br] 2005;87-B:454–457.

 

  1. Sreekumar R, Venkiteswaran R, Raut V. Infection in primary hip arthroplasty after previous steroid infiltration. Int Orthop 2007;31:125–128.

 

  1. Chitre AR, Fehily MJ, Bamford DJ. Total hip replacement after intra-articular injection of local anaesthetic and steroid. J Bone Joint Surg [Br] 2007;89-B:166–168.

 

  1. McIntosh AL, Hanssen AD, Wenger DE, Osmon DR. Recent intraarticular steroid injection may increase infection rates in primary THA. Clin Orthop Relat Res 2006;451:50–54.

 

  1. McMahon SE, Lovell ME. Total hip arthroplasty after ipsilateral intra-articular steroid injection: 8 years follow up. Acta Orthop Belg 2012;78:333–336.

 

  1. Werner, Brian C., Jourdan M. Cancienne, and James A. Browne. “The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk.” The Journal of arthroplasty 31.4 (2016): 820-823.

 

  1. Schairer, William W., et al. “Preoperative hip injections increase the rate of periprosthetic infection after total hip arthroplasty.” The Journal of arthroplasty 31.9 (2016): 166-169.

 

  1. Forlenza, Enrico M., et al. “Preoperative Corticosteroid Injections Demonstrate a Temporal and Dose-Dependent Relationship with the Rate of Postoperative Infection Following Total Hip Arthroplasty.” The Journal of Arthroplasty 36.6 (2021): 2033-2037.

 

  1. Font-Vizcarra L, Tornero E, Bori G, et al. Relationship between intraoperative cultures during hip arthroplasty, obesity, and the risk of early prosthetic joint infection: a prospective study of 428 patients. Int J Artif Organs 2011;34:870–875.

 

  1. McCalden RW, Charron KD, MacDonald SJ, Bourne RB, Naudie DD. Does morbid obesity affect the outcome of total hip replacement?: an analysis of 3290 THRs. J Bone Joint Surg [Br] 2011;93-B:321–325.

 

  1. Kurtz, S.M.; Lau, E.C.; Son, M.-S.; Chang, E.T.; Zimmerli, W.; Parvizi, J. Are We Winning or Losing the Battle With Periprosthetic Joint Infection: Trends in Periprosthetic Joint Infection and Mortality Risk for the Medicare Population. J. Arthroplast. 2018, 33, 3238–3245.

 

  1. Horne G, Devane P, Davidson A, et al. The influence of steroid injections on the incidence of infection following total knee arthroplasty. N Z Med J 2008;121(1268): U2896. 

 

  1. Joshy S, Thomas B, Gogi N, et al. Effect of intra-articular steroids on deep infections following total knee arthroplasty. Int Orthop 2006;30(2):91. 

 

  1. Desai A, Sreekumar R, Board T, et al. Does intraarticular steroid infiltration increase the rate of infection in subsequent total knee replacements? Knee 2009;16(4):262. 

 

  1. Papavasiliou AV, Isaac DL, Marimuthu R, et al. Infection in knee replacements after previous injection of intra-articular steroid. J Bone Joint Surg (Br) 2006; 88(3):321.

 

  1. Cancienne JM, Werner BC, Luetkemeyer LM, Browne JA. Does Timing of Previous Intra-Articular Steroid Injection Affect the Post-Operative Rate of Infection in Total Knee Arthroplasty? J Arthroplasty. 2015 Nov;30(11):1879-82

 

  1. Wang Q, Jiang X, Tian W. Does previous intra-articular steroid injection increase the risk of joint infection following total hip arthroplasty or total knee arthroplasty? A meta-analysis. Med Sci Monit 2014;20:1878. 

 

  1. Amin NH, Omiyi D, Kuczynski B, Cushner FD, Scuderi GR. The Risk of a Deep Infection Associated With Intraarticular Injections Before a Total Knee Arthroplasty. J Arthroplasty. 2016 Jan;31(1):240-4.

 

  1. Roecker Z, Quinlan ND, Browne JA, Werner BC. Risk of Periprosthetic Infection Following Intra-Articular Corticosteroid Injections After Total Knee Arthroplasty. J Arthroplasty. 2020 Apr;35(4):1090-1094.

 

  1. Werner BC, Cancienne JM, Burrus MT, Griffin JW, Gwathmey FW, Brockmeier SF. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. J Shoulder Elbow Surg. 2016 Mar;25(3):390-7.

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