The Timing of Injections Prior to Arthroscopic Rotator Cuff Repair Impacts the Risk of Surgical Site Infection

Abstract

Background: Corticosteroid injections are a common treatment for rotator cuff tears. Because of concerns of infection, a surgical procedure is often delayed following injections. The purpose of this investigation was to determine if there is a temporal relationship between corticosteroid injections and the risk of surgical site infection after arthroscopic rotator cuff repair. We hypothesized that the incidence of surgical site infection is higher in patients who received a preoperative injection and this relationship exists in a temporal manner as those patients receiving an injection closer to the operative date have a higher risk of infection. Methods: The PearlDiver database was reviewed for patients undergoing arthroscopic rotator cuff repair from 2007 to 2016. Patients were stratified into 2 cohorts: those undergoing arthroscopic rotator cuff repair within 1 year of injection (n = 12,060), and those undergoing arthroscopic rotator cuff repair without prior injection (n = 48,763). Patients with preoperative injections were further stratified by the duration in months that the injection was performed prior to the surgical procedure. Surgical site infection within 6 months of the surgical procedure was recorded. Statistical analysis included chi-square and multivariate binomial logistic regression analyses to identify risk factors for surgical site infection. Results were considered significant at p < 0.05. Results: There was no significant difference in the incidence of surgical site infection in patients receiving a shoulder injection at 0.7% compared with the control cohort at 0.8% (odds ratio [OR], 0.9 [95% confidence interval (CI), 0.7 to 1.1]; p = 0.2). However, patients receiving an injection within 1 month prior to operative management had a significantly higher rate of surgical site infection overall at 1.3% compared with the control group at 0.8% (OR, 1.7 [95% CI, 1.0 to 2.9]; p = 0.04). On multivariate analysis, male sex (OR, 1.7 [95% CI, 1.4 to 1.9]; p = 0.001), obesity (OR, 1.4 [95% CI, 1.2 to 1.6]; p < 0.001), diabetes (OR, 1.3 [95% CI, 1.1 to 1.5]; p < 0.001), smoking status (OR, 1.7 [95% CI, 1.4 to 1.9], p < 0.001), and preoperative corticosteroid injections within 1 month of the surgical procedure (OR, 2.1 [95% CI, 1.5 to 2.7]; p < 0.001) were independent risk factors for development of a surgical site infection. Conclusions: Injections within 1 month of arthroscopic rotator cuff repair significantly increases the risk of surgical site infection. However, there is no increased risk of infection if the surgical procedure is delayed by 1 month following an injection. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Corticosteroid Injections 1 Month Before Arthroscopic Meniscectomy Increase the Risk of Surgical-Site Infection

“…18,19 However, the clinical relevance of wound healing after arthroscopic meniscectomy is likely limited because modern arthroscopic surgery is accomplished through small incisions. 17 Preoperative joint injections have been shown to increase the risk of postoperative infection after shoulder arthroscopy 13 and arthroplasty, 20 hip arthroscopy 21 and arthroplasty, [22][23][24] knee arthroplasty, 25 and elbow arthroscopy. 26 Previous investigations have found preoperative intra-articular injections within 3 months of hip arthroscopy (OR, 6.1) 21 and shoulder arthroscopy (OR, 1.6) 20 to be associated with an increased risk of postoperative infection.…”

“…26 Previous investigations have found preoperative intra-articular injections within 3 months of hip arthroscopy (OR, 6.1) 21 and shoulder arthroscopy (OR, 1.6) 20 to be associated with an increased risk of postoperative infection. Forsythe et al 13 studied patients undergoing arthroscopic rotator cuff repair and found that intra-articular injections within 1 month of shoulder arthroscopy were associated with increased postoperative complications (OR, 1.7). Our investigation used similar methodology and found that a postoperative infection was 1.89 times more likely to develop in patients undergoing knee injection within 1 month of meniscectomy relative to controls.…”

“…Thus, we included only those injections that were coded as being indicated for knee-specific diagnostic codes for osteoarthritis of the knee, meniscal tears, cartilage lesions of the knee, arthrofibrosis, and stiffness of the knee, which were identified by ICD-9 or ICD-10 coding (Appendix Table 1, available at www.arthroscopyjournal.org). 13,14 Patients who received hyaluronic acid injections, which were identified by Healthcare Common Procedure Coding System Q and J codes, were excluded (Appendix Table 1, available at www.arthroscopyjournal.org). 15 The injection cohort constituted patients who received an injection within 1 year prior to arthroscopic meniscectomy.…”

Preoperative Opioid Use Is a Risk Factor for Revision Surgery, Complications, and Increased Resource Utilization After Arthroscopic Rotator Cuff Repair

“…39,49 Furthermore, we add to the literature another risk factor for detrimental postoperative outcomes in those undergoing RCR, which previously included patient age, 29 body mass index, 5 comorbidities, 46,53 open repair, 38 and preoperative and intraoperative steroid injections. 21,52 Moreover, opioid use is a risk factor that is both common and detrimental. Even small differences in the effect size are important in a procedure performed as commonly as arthroscopic RCR, with reports of up to 270,000 of these procedures being performed in the United States each year.…”

Safety and Effectiveness of Intra-articular Corticosteroid Injection Following Arthroscopic Shoulder Surgery

“…Meanwhile,some researchers believe that timing and dose of injections prior to arthroscopic rotator cuff repair impacts the risk of infection [15]. Therefore, there is still great controversy regarding the safety and clinical e cacy of intra-articular corticosteroid injection after shoulder arthroscopy.…”