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

Abstract

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.

Keywords

knee arthroplasty - unicompartmental - corticosteroid injection - periprosthetic joint infection

Authors Contribution

All authors significantly contributed to the document and have reviewed the final manuscript.

Publication History

Received: 23 January 2023

Accepted: 13 March 2023

Accepted Manuscript online:
24 March 2023

Article published online:
11 April 2023

• References

• 1 Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ 2004; 328 (7444): 869
• 2 Marsland D, Mumith A, Barlow IW. Systematic review: the safety of intra-articular corticosteroid injection prior to total knee arthroplasty. Knee 2014; 21 (01) 6-11
• 3 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; 30 (11) 1879-1882
• 4 Hansen EN, Ong KL, Lau E, Kurtz SM, Lonner JH. Unicondylar knee arthroplasty in the U.S. patient population: prevalence and epidemiology. Am J Orthop 2018;47(12):
• 5 Hernandez NM, Petis SM, Hanssen AD, Sierra RJ, Abdel MP, Pagnano MW. Infection after Unicompartmental Knee Arthroplasty: A High Risk of Subsequent Complications. Clin Orthop Relat Res 2019; 477 (01) 70-77
• 6 Dyrhovden GS, Lygre SHL, Badawy M, Gøthesen Ø, Furnes O. Have the causes of revision for total and unicompartmental knee arthroplasties changed during the past two decades?. Clin Orthop Relat Res 2017; 475 (07) 1874-1886
• 7 Hansen EN, Ong KL, Lau E, Kurtz SM, Lonner JH. Unicondylar knee arthroplasty has fewer complications but higher revision rates than total knee arthroplasty in a study of large United states Databases. J Arthroplasty 2019; 34 (08) 1617-1625
• 8 Kim KT, Lee S, Lee JI, Kim JW. Analysis and treatment of complications after unicompartmental knee arthroplasty. Knee Surg Relat Res 2016; 28 (01) 46-54
• 9 Bolognesi MP, Greiner MA, Attarian DE. et al. Unicompartmental knee arthroplasty and total knee arthroplasty among Medicare beneficiaries, 2000 to 2009. J Bone Joint Surg Am 2013; 95 (22) e174
• 10 Riddle DL, Jiranek WA, McGlynn FJ. Yearly incidence of unicompartmental knee arthroplasty in the United States. J Arthroplasty 2008; 23 (03) 408-412
• 11 Morris MJ, Molli RG, Berend KR, Lombardi Jr AV. Mortality and perioperative complications after unicompartmental knee arthroplasty. Knee 2013; 20 (03) 218-220
• 12 Wilson HA, Middleton R, Abram SGF. et al. Patient relevant outcomes of unicompartmental versus total knee replacement: systematic review and meta-analysis. BMJ 2019; 364: l352
• 13 Bhattacharjee S, Wallace S, Luu HH, Shi LL, Lee MJ, Chen AF. Do we need to wait 3 months after corticosteroid injections to reduce the risk of infection after total knee arthroplasty?. J Am Acad Orthop Surg 2021; 29 (14) e714-e721
• 14 Rhode DT, Siegel MA, Volchenko E. et al. Do intra-articular corticosteroid injections prior to total knee arthroplasty increase postoperative complication rates: a retrospective review. J Knee Surg 2023; 36 (03) 231-235
• 15 Baums MH, Aquilina J, Pérez-Prieto D, Sleiman O, Geropoulos G, Totlis T. Risk analysis of periprosthetic knee joint infection (PJI) in total knee arthroplasty after preoperative corticosteroid injection: a systematic review: a study performed by the Early-Osteoarthritis group of ESSKA-European Knee Associates section. Arch Orthop Trauma Surg 2022
• 16 Wang H, Ma Q, Ma B. Unicompartmental versus total knee arthroplasty for knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trial. Int J Surg Global Health 2021; 4 (02) e51
• 17 Vasso M, Corona K, D'Apolito R, Mazzitelli G, Panni AS. Unicompartmental knee arthroplasty: Modes of failure and conversion to total knee arthroplasty. Joints 2017; 5 (01) 44-50
• 18 Yang X, Li L, Ren X, Nie L. Do preoperative intra-articular injections of corticosteroids or hyaluronic acid increase the risk of infection after total knee arthroplasty? A meta-analysis. Bone Joint Res 2022; 11 (03) 171-179
• 19 Kandil A, Werner BC, Gwathmey WF, Browne JA. Obesity, morbid obesity and their related medical comorbidities are associated with increased complications and revision rates after unicompartmental knee arthroplasty. J Arthroplasty 2015; 30 (03) 456-460
• 20 Kunutsor SK, Whitehouse MR, Blom AW, Beswick AD. INFORM Team. Patient-related risk factors for periprosthetic joint infection after total joint arthroplasty: a systematic review and meta-analysis. PLoS One 2016; 11 (03) e0150866
• 21 Nakazawa F, Matsuno H, Yudoh K, Watanabe Y, Katayama R, Kimura T. Corticosteroid treatment induces chondrocyte apoptosis in an experimental arthritis model and in chondrocyte cultures. Clin Exp Rheumatol 2002; 20 (06) 773-781
• 22 Farkas B, Kvell K, Czömpöly T, Illés T, Bárdos T. Increased chondrocyte death after steroid and local anesthetic combination. Clin Orthop Relat Res 2010; 468 (11) 3112-3120