Sarah Bhattacharjee, Sara Wallace, MD, Hue H. Luu, MD, Lewis L. Shi, MD, Michael J. Lee, MD, Antonia F. Chen, MD, MBA.

Journal of the American Academy of Orthopaedic Surgeons: July 15, 2021 – Vol 29 – Issue 14 – p e714-e721
doi: 10.5435/JAAOS-D-20-00850

Summary by Arun Kanhere, MD

Intra-articular corticosteroid injections (CI) are a common non-surgical intervention that reduces inflammation and relieves pain.¹ Although they are a useful adjunct before total knee arthroplasty (TKA), their risks include an increased risk of post-operative infection, likely due to the immunosuppressive effects of corticosteroids.² Standard practice among arthroplasty surgeons is to wait 3 months after an injection in order to reduce this risk, however Bhattacharjee et al. investigated more discrete time periods to identify if there was a narrower window between injection and TKA.^3,4

They performed a retrospective review of 76,970 patients undergoing TKA (8,226 with CI <6 months before surgery and 68,744 without CI), in which subjects were stratified into biweekly cohorts based on when they had a CI. Outcomes included rate of revision surgery due to surgical site infection (SSI), adjusted for demographics and comorbidities.

The study found similar overall infection rates within 1 year of surgery (0.77% with CI vs 1.01% without), however, univariate regression showed injections within 2 weeks of surgery had an increased risk (3.1%, P=0.024), injections between 2-4 weeks had a nonsignificant increased risk (1.21%, P=0.377), and all other groups beyond 4 weeks had no difference in infection rate. Multivariate logistic regression of comorbidity risk factors for SSI included ischemic heart disease, COPD, diabetes, obesity, tobacco use, and rheumatoid arthritis. Protective variables were female sex and age greater than 65 years.

The authors conclude that TKA within 2 weeks of a CI may increase post-operative infection risk, but waiting longer than 4 weeks may not provide additional risk reduction. Limitations included the susceptibility of the record review to billing and coding errors and the inability to account for type, amount, and indication for corticosteroid. This study also only included SSI that required revision surgery and did not account for infections treated non-surgically. Despite the 2-4 week time period not showing a significant increase in infection risk, arthroplasty surgeons may choose to avoid performing TKA within 4 weeks due to the high cost and morbidity of SSIs.

References:

1. Sean VWT, Chin PL, Chia SL, Yang KY, Lo NN, Yeo SJ. Single-dose periarticular steroid infiltration for pain management in total knee arthroplasty: a prospective, double-blind, randomised controlled trial. Singap Med J. 2011;52(1):19-23.
2. Papavasiliou AV, Isaac DL, Marimuthu R, Skyrme A, Armitage A. Infection in knee replacements after previous injection of intra-articular steroid. Bone Joint J. 2006;88-B(3):321-323. doi:10.1302/0301-620x.88b3.17136
3. Marsland D, Mumith A, Barlow IW. Systematic review: The safety of intra-articular corticosteroid injection prior to total knee arthroplasty. Knee. 2014;21(1):6-11. doi:10.1016/j.knee.2013.07.003
4. 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 Arthroplast. 2015;30(11):1879-1882. doi:10.1016/j.arth.2015.05.027