Michelle Kew, MD, Jourdan Cancienne, MD, James Christensen, MD, Brian Werner, MD

Am J Sports Med. 2019;47(4):915-921
https://doi.org/10.1177/0363546518825348

Summary by Manan S. Patel, BA

Arthroscopic rotator cuff repair (aRCR) makes up >50% of all arthroscopic shoulder procedures in the United States.¹ Some patients following aRCR, have continued pain and stiffness that does not respond to physical therapy. For these patients, post-operative injections have been shown to lead to substantial gains in motion and pain relief.^2–4 Recent studies have described increased risk of infection among patients who received pre- or intra-operative steroid injections.^5,6 Little has been published on the risk profile of post-operative injections and development of infection.  

Kew et al., in a retrospective study, sought to investigate whether the timing (i.e. 1-month, 2-month, 3-month, 4-month) of post-operative steroid injections following arthroscopic shoulder surgery was associated with increased risk of infection. The authors queried private payer and Medicare databases for patients that received injections at those time points (n=3,946) and matched those patients to controls who did not receive any injections (n=2,640). The study found the risk of infection increased for patients who received a steroid injection within the first month post-operatively for both payer cohorts. At that 1-month time point, the reported infection rate was 3.5% (OR=2.64; 95% CI 1.32-5.22) and a 6.7% (OR=11.2; 95% CI 2.33-53.77) for the private payer and Medicare groups, respectively.

The authors concluded that injections in the immediate post-operative period following shoulder arthroscopy should be administered with caution given the increased risk of infection. This study is limited in its retrospective nature. Additionally, the study population, Medicare and private payer patients, is not representative of all patients undergoing arthroscopic shoulder surgery. Lastly, it is difficult to evaluate low-grade infection from pain and stiffness secondary to non-infectious etiology, leading to potential misclassification bias.

References:

1. Jain NB, Higgins LD, Losina E, Collins J, Blazar PE, Katz JN. Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States. BMC Musculoskelet Disord. 2014. doi:10.1186/1471-2474-15-4
2. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD. Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Jt Surg – Ser A. 1996. doi:10.2106/00004623-199611000-00007
3. Griesser MJ, Harris JD, Campbell JE, Jones GL. Adhesive capsulitis of the shoulder: A systematic review of the effectiveness of intra-articular corticosteroid injections. J Bone Jt Surg – Ser A. 2011. doi:10.2106/JBJS.J.01275
4. Skedros JG, Adondakis MG, Knight AN, Pilkington MB. Frequency of Shoulder Corticosteroid Injections for Pain and Stiffness After Shoulder Surgery and Their Potential to Enhance Outcomes with Physiotherapy: A Retrospective Study. Pain Ther. 2017. doi:10.1007/s40122-017-0065-6
5. 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 Elb Surg. 2016. doi:10.1016/j.jse.2015.08.039
6. Cancienne JM, Brockmeier SF, Carson EW, Werner BC. Risk Factors for Infection After Shoulder Arthroscopy in a Large Medicare Population. Am J Sports Med. 2018. doi:10.1177/0363546517749212