Comparison of Infection Risk with Corticosteroid or Hyaluronic Acid Injection Prior to Total Knee Arthroplasty

Abstract

Background: Recent studies have shown that intra-articular injections ≤3 months before total knee arthroplasty increase the risk of periprosthetic joint infection. We are aware of no previous study that has differentiated the risk of periprosthetic joint infection on the basis of the type of medication injected. In addition, we are aware of no prior study that has evaluated whether hyaluronic acid injections increase the risk of infection after total knee arthroplasty. In this study, we utilized pharmaceutical data to compare patients who received preoperative corticosteroid or hyaluronic acid injections and to determine whether a specific injection type increased the risk of periprosthetic joint infection. Methods: Patients undergoing unilateral primary total knee arthroplasty were selected from a nationwide private insurer database. Ipsilateral preoperative injections were identified and were grouped by medication codes for corticosteroid or hyaluronic acid. Patients who had received both types of injections ≤1 year before total knee arthroplasty were excluded. The outcome of interest was periprosthetic joint infection that occurred ≤6 months following the total knee arthroplasty. The risk of periprosthetic joint infection was compared between groups (no injection, corticosteroid, hyaluronic acid) and between patients who received single or multiple injections. Statistical comparisons were performed using logistic regression controlling for age, sex, and comorbidities. Results: A total of 58,337 patients underwent total knee arthroplasty during the study period; 3,249 patients (5.6%) received hyaluronic acid and 16,656 patients (28.6%) received corticosteroid ≤1 year before total knee arthroplasty. The overall infection rate was 2.74% in the no-injection group. Multivariable logistic regression showed independent periprosthetic joint infection risk for both corticosteroid (odds ratio [OR], 1.21; p = 0.014) and hyaluronic acid (OR, 1.55; p = 0.029) given ≤3 months before total knee arthroplasty. There was no increased risk with injections >3 months prior to total knee arthroplasty. Direct comparison of corticosteroid and hyaluronic acid showed no significant difference (p > 0.05) between medications or between single and multiple injections. Conclusions: Preoperative corticosteroid or hyaluronic acid injection ≤3 months before total knee arthroplasty increased the risk of periprosthetic joint infection. There was no difference in infection risk between medications or between multiple and single injections. On the basis of these data, we recommend avoiding both injection types in the 3 months prior to total knee arthroplasty. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intra-Articular Hyaluronic Acid Injections Less Than 6 Months Before Total Hip Arthroplasty: Is It Safe? A Retrospective Cohort Study in 565 Patients

“…Comparable findings have been reported for total knee arthroplasty (TKA), with a systematic review (2014) showing 1 out of 4 available studies reporting an increased risk of PJI after prior CS injections [27]. However, more recently Richardson et al [6] performed a database study including 58,337 TKAs, including IAHA injections for the first time. Prior injection with either CS or IAHA 3 months of TKA was an independent risk factor for PJI, with ORs of 1.21 and 1.55 respectively.…”

“…Intra-articular injections of HA and CS within 3 months prior to knee arthroplasty have been associated with an increased risk of periprosthetic joint infection (PJI) [6]. Several studies have analyzed the effect of previous intra-articular injections of CS on THA infection rates [7].…”

Myofascial pain treatment; local anesthesia injection versus corticosteroids. (ramdomized controlled clinical trial)

“…And it has been also stated that an injection protocol is at most effectiveness when adjunct with other pharmacologic and rehabilitation measures. (13,23)…”

Effectiveness of intramuscular gluteal glucocorticoid injection versus intra-articular glucocorticoid injection in knee osteoarthritis: design of a multicenter randomized, 24 weeks comparative parallel-group trial

“…Patients who have been referred to an orthopedic surgeon will also be excluded from participation considering that these patients could become candidates for total knee or hip arthroplasty during the follow-up period of the study. The risk of periprosthetic joint infection (PJI) is increased in patients who received an IA glucocorticoid injection in the 3 months prior to arthroplasty [22,23]. It is not known if IM glucocorticoid injection increases the risk of PJI.…”