Dose intraarticular steroid injection increase the rate of infection in subsequent arthroplasty: grading the evidence through a meta-analysis

Abstract

BackgroundIntraarticular steroid injections are widely used in joint arthritis. However, the data regarding an association between an increased risk for arthroplasty infection after an intraarticular steroid injection are still conflicting. We conducted a meta-analysis to evaluate the evidence from relevant studies that examine the relation between intraarticular steroid injections and infection rates in subsequent joint arthroplasty and to develop GRADE based recommendations for using the steroid before arthroplasty.MethodsA systematic search of all studies published through August 2014 was conducted using the MEDLINE, EMBASE, OVID, ScienceDirect and Cochrane CENTRAL databases. The relevant studies that examined the relation between intraarticular steroid injections and infection rates in subsequent joint arthroplasty were identified. Demographic characteristics, infection rates and clinical outcomes were manually extracted from all of the selected studies. The evidence quality levels and recommendations were assessed using the GRADE system.ResultsEight studies looking at hip and knee arthroplasties were included. Meta-analysis showed that patients with steroid injection before arthroplasty had a higher deep infection rate than patients without steroid injection (OR = 2.13, 95% CI 1.02-4.45), but no significant effect on superficial infection rate (OR = 1.75, 95% CI 0.74-4.16). The overall GRADE system evidence quality was very low, which lowers our confidence in their recommendations.ConclusionsIntraarticular steroid injections may lead to increased deep infection rates of subsequent joint arthroplasty but not the superficial infection rates. Due to the poor quality of the evidence currently available, further studies are still required.

Safety of intra‐articular steroid injections prior to arthroplasty: Best evidence selection and risk of bias considerations

“…Xing et al . conducted a systematic review and GRADE evidence synthesis, reporting that the overall GRADE evidence quality was very low, which lowered their confidence in making recommendations.…”

“…In spite of several systematic reviews published on this issue, there was still controversy. Such discrepancy leads to some difficulties for decision makers (including clinicians, policymakers and patients, Table 5 AMSTAR criteria for included systematic reviews Items Xing et al 13 Wang et al 14 Charalambous et al 15 McMahon et al 16 Marsland et al 17 Pereira et al 25 Was a prior design provided? 0 0 0 0 0 0 Was there duplicate selection and data extraction?…”

“…A total of 32 titles and abstracts were preliminarily screened after duplicates were removed according to the search strategy, of which six of the published systematic reviews [13][14][15][16][17]25 ultimately met the eligibility criteria ( Fig. 1).…”

“…Subsequently, several systematic reviews were conducted to investigate whether steroid injections increase the risk of joint infection before arthroplasty. However, the pooled results of these systematic reviews were still controversial and could not provide more robust evidence . The following items may account for the discrepancy: (i) flaws or limitations in designing or conducting systematic reviews; (ii) the methodology adopted in performing systematic reviews; and (iii) the eligible criteria for including studies.…”

“…However, the pooled results of these systematic reviews were still controversial and could not provide more robust evidence. [13][14][15][16][17] The following items may account for the discrepancy: (i) flaws or limitations in designing or conducting systematic reviews; (ii) the methodology adopted in performing systematic reviews; and (iii) the eligible criteria for including studies. Thus, the inconsistent conclusions make it difficult for clinical professionals to determine the appropriateness of steroid injections prior to arthroplasty.…”