The Timing of Total Hip Arthroplasty After Intraarticular Hip Injection Affects Postoperative Infection Risk

Role of Preoperative Intra-Articular Corticosteroid Injections on Periprosthetic Joint Infection in Total Hip Arthroplasty and Its Association With Preoperative Timing: A Single-Center Series of 5,909 Hips

BACKGROUND

Preoperative intra-articular corticosteroid injections to the hip joint increase the risk of periprosthetic joint infection (PJI) during primary total hip arthroplasty (THA). This study aimed to determine the relationship between preoperative timing of intra-articular corticosteroid injections and PJI risk following THA using data from a single-center hospital.

METHODS

This single-center, retrospective cohort study included patients who underwent a THA between 2014 and 2020. Medical records were checked for intra-articular corticosteroid injections and PJI within 1 year of surgery. Patients were categorized into groups based on whether they received "no injection" or "injection 0 to 3 months," "3 to 6 months," and "> 6 months prior to THA." Hazard ratios (HRs) for these groups were calculated using multivariate Cox regression analysis, correcting for potential confounders, and presented with 95% confidence intervals [95% CIs].

RESULTS

In total, 4,507 patients (5,909 THAs) were identified. A total of 1,581 patients (27%) received an injection prior to THA. Without considering the timing factor, no increased risk for PJI following an intra-articular injection was noted (P = .19). Comparing the specified groups using multivariate analysis, corticosteroid injection within 3 months of THA showed an increased risk of PJI (HR 2.63, 95% CI 1.18 to 5.87, P = .018), but this effect was not observed for the "injection 3 to 6 months" group (HR 1.51, 95% CI 0.74 to 3.08, P = .264).

CONCLUSIONS

Corticosteroid injections administered up to 3 months prior to THA increased the risk of PJI within 1 year after THA, with an HR of 2.63; however, injections between 3 and 6 months before surgery did not have a significantly higher infection rate.

Ultrasound-Guided Hip Injections with High Density Hyaluronic Acid: Outcome at One Year Follow Up

Background: The ultrasound-guided viscosupplementation of the hip joint with hyaluronic acid (HA) is considered a standard procedure among the conservative treatments for hip arthritis. The aim of this study was to evaluate the clinical benefit and the incidence of adverse events of the technique in an observational study at one year follow up. Methods: We evaluated a consecutive series of 85 patients with a diagnosis of symptomatic arthritis who underwent intra-articular ultrasound-guided hyaluronic acid injections. The scales used for evaluation were modified Harris Hip Score (mHHS), WOMAC (Western Ontario and McMaster University), and Hip Outcome Score (HOS) with subscale Sport (HOSs), for pain the Visual Analogic Scale (VAS). The patients were classified according to Tonnis' radiological classification of arthritis (range 0-3): 20 patients (grade 0), 32 (grade 1), 18 (grade 2), 15 (grade 3). Results: At last follow up, all the scales increased: mHHS from 59.35 to 82.1, HOS from 69.45 to 78.53, HOss from 47.4 to 58.11, VAS from 6.09 to 3.97, WOMAC from 33.2 to 31.5 (p < 0.05 for all the parameters); the results were elaborated with GraphPad Prism v5.0 (Prism Software La Jolla, CA, USA) using Wilcoxon's test. A total of 13 patients out of 85 needed arthroplasty, all classified as Tonnis grade 3. No serious adverse events were noted due to the procedure. Conclusions: Based on our findings, indication for the use of hyaluronic acid is limited to patients with mild to moderate arthritis. Patients in advanced arthritis refusing replacement surgery and asking for this treatment should be informed about the poor results of the technique even in the short term.

Injections prior to hip arthroscopy are associated with increased risk of repeat hip arthroscopy at 1 and 5 years

INTRODUCTION

Previous studies have shown that intra-articular hip injections prior to hip arthroscopy (HA) can be a helpful diagnostic tool. However, local anesthetic and corticosteroid injections can be chondrotoxic and corticosteroid injections have been shown to increase the risk of infection during subsequent surgical intervention. The purpose of this study was to evaluate whether preoperative injections adversely affect outcomes of HA using a national database.

MATERIALS AND METHODS

The TriNetX database was retrospectively queried. Patients undergoing HA for femoroacetabular impingement with at least 1 year of claims runout were included in the analysis. Patients were grouped by whether they had a hip injection within 1 year prior to HA. The rates of repeat HA, total hip arthroplasty (THA), infection, osteonecrosis, and new onset hip OA at 1- and 5-years postoperatively were compared between groups. Statistical significance was assessed at α = 0.05.

RESULTS

6511 HA patients with previous injection and 1178 HA patients without previous injection were included. Patients with a previous injection were overall younger (32.3 vs. 34.7 years, p < 0.001), more likely to be female (69 vs. 48%, p < 0.001) and had a higher BMI (26.3 vs. 25.7 kg/m2, p = 0.043). At 1 and 5-years postoperatively, patients with any injection were 1.43 (p < 0.001) and 1.89 (p < 0.001) times more likely to undergo repeat HA, respectively. At 1 and 5-years postoperatively, patients who underwent a corticosteroid injection were 2.29 (p < 0.001) and 1.89 (p < 0.001) times more likely to undergo repeat HA than patients with local anesthetic injection only and 1.56 (p < 0.001) and 2.08 (p < 0.001) times more likely to undergo repeat HA than patients with no injection.

CONCLUSIONS

Intraarticular hip injections prior to hip arthroscopy, particularly corticosteroid injections, are associated with increased risk of repeat hip arthroscopy at 1 and 5 years. Additional studies are needed to elucidate this risk.

Incidence of Rapidly Progressive Osteoarthritis Following Intra-articular Hip Corticosteroid Injection: A Systematic Review and Meta-Analysis

Background

The American Academy of Orthopedic Surgery recommends intra-articular corticosteroid injections (CSIs) for managing hip osteoarthritis (OA) based on short-term, prospective studies. Recent retrospective studies have raised concerns that CSIs may lead to rapidly progressive OA (RPOA). We sought to systematically review the literature of CSIs for hip OA to estimate the incidence of RPOA.

Methods

MEDLINE, Embase, and Cochrane Library were searched to identify original research of hip OA patients receiving CSIs. Overall, 27 articles involving 5831 patients published from 1988 to 2022 were included. Study design, patient characteristics, CSI details, follow-up, and cases of RPOA were recorded. Studies were classified by their ability to detect RPOA based on follow-up. Random effects meta-analysis was used to calculate the incidence of RPOA for studies able to detect RPOA.

Results

The meta-analytic estimate of RPOA incidence was 6% (95% confidence interval, 3%-9%) based on 10 articles classified as able to detect RPOA. RPOA definitions varied from progression of OA within 6 months to the presence of destructive changes. These studies were subject to bias from excluding patients with missing post-CSI radiographs. The remaining 17 articles were classified as unable to detect RPOA, including all of the studies cited in the American Academy of Orthopedic Surgery recommendation.

Conclusions

The incidence of RPOA after CSIs remains unknown due to variation in definitions and follow-up. While RPOA following CSIs may be 6%, many cases are not severe, and this may reflect selection bias. Further research is needed to understand whether clinically significant RPOA is incident enough to limit CSI use.

Predicting the Risk of Total Hip Replacement by Using A Deep Learning Algorithm on Plain Pelvic Radiographs: Diagnostic Study

BACKGROUND

Total hip replacement (THR) is considered the gold standard of treatment for refractory degenerative hip disorders. Identifying patients who should receive THR in the short term is important. Some conservative treatments, such as intra-articular injection administered a few months before THR, may result in higher odds of arthroplasty infection. Delayed THR after functional deterioration may result in poorer outcomes and longer waiting times for those who have been flagged as needing THR. Deep learning (DL) in medical imaging applications has recently obtained significant breakthroughs. However, the use of DL in practical wayfinding, such as short-term THR prediction, is still lacking.

OBJECTIVE

In this study, we will propose a DL-based assistant system for patients with pelvic radiographs to identify the need for THR within 3 months.

METHODS

We developed a convolutional neural network-based DL algorithm to analyze pelvic radiographs, predict the hip region of interest (ROI), and determine whether or not THR is required. The data set was collected from August 2008 to December 2017. The images included 3013 surgical hip ROIs that had undergone THR and 1630 nonsurgical hip ROIs. The images were split, using split-sample validation, into training (n=3903, 80%), validation (n=476, 10%), and testing (n=475, 10%) sets to evaluate the algorithm performance.

RESULTS

The algorithm, called SurgHipNet, yielded an area under the receiver operating characteristic curve of 0.994 (95% CI 0.990-0.998). The accuracy, sensitivity, specificity, and F1-score of the model were 0.977, 0.920, 0932, and 0.944, respectively.

CONCLUSIONS

The proposed approach has demonstrated that SurgHipNet shows the ability and potential to provide efficient support in clinical decision-making; it can assist physicians in promptly determining the optimal timing for THR.

Risk of Infection After Total Knee or Hip Arthroplasty After Receipt of Multiple Corticosteroid or Hyaluronic Acid Injections

BACKGROUND

Few studies have assessed the relationship between the quantity of preoperative corticosteroid injections (CSIs) or hyaluronic acid injections (HAIs) and postoperative infection risk after total knee or hip arthroplasty (TKA, THA). We aimed to (1) determine whether the number of injections administered before TKA/THA procedures is associated with postoperative infections and (2) establish whether infection risk varies by injection type.

METHODS

This retrospective cohort study included 230,487 THAs and 371,511 TKAs from the 2017 to 2018 Medicare Limited Data Set. The quantity of CSI or HAI, defined as receiving either CSI or HAI ≤2 years before TKA/THA, was identified and categorized as 0, 1, 2, or >2. The primary outcome was 90-day postoperative infection. Multivariable regression models measured the association between the number of injections and 90-day postoperative infection. Odds ratios and 95% confidence intervals were reported.

RESULTS

The percentage of THA patients receiving 1, 2, and >2 preoperative CSIs was 6.1%, 1.6%, and 0.8%, respectively. Receiving >2 CSIs within 2 years before THA was associated with higher odds of 90-day postoperative infection (odds ratios = 1.74, 95% CI = 1.11 to 2.74, P = 0.02). The percentage of TKA patients receiving 1, 2, and >2 CSIs was 3.0%, 1.2%, and 1.1%, respectively. For HAIs in TKA patients, percentage receiving injections was 98.3%, 0.6%, 0.2%, and 0.9%, respectively. Quantity of CSIs or HAIs administered was not associated with postoperative infection among TKA patients.

CONCLUSION

Patients receiving >2 injections before THA had higher odds of 90-day postoperative infection. This finding was not observed in TKA patients. These results suggest that the use of >2 injections within 2 years of THA should be avoided.

How safe are intra-articular corticosteroid injections to the hip?

BACKGROUND

Intra-articular corticosteroid injections (ICSI) are an effective symptomatic treatment for osteoarthritis of the hip. However, the safety of ICSI has been questioned and a relatively high risk for septic arthritis, rapidly progressive osteoarthritis (RPIO) and periprosthetic joint infections (PJI) in patients undergoing subsequent total hip arthroplasty (THA) have been suggested.

METHODS

This is a retrospective evaluation of 682 hips that underwent ICSI with 40 mg of Triamcinolone for primary osteoarthritis of the hip. All ICSI were performed using sterile techniques, the number of ICSI in each hip and the cumulative corticosteroid dosage were assessed. Pre- and post-injection radiographs were compared to identify cases with RPIO. Native joint septic arthritis, surgical site infections and PJI were identified by chart review.

RESULTS

4 hips (0.6%) developed RPIO 2-4 months following ICSI. The cumulative Triamcinolone dose was not associated with the development of RPIO (p = 0.281). 1 case was diagnosed with septic arthritis and treated with staged THA, there were no signs of infection at a 5 years follow-up. 483 hips (75.7%) underwent THA, including 199 hips with THA less than 3 months following ICSI and 181 hips with > 1 ICSI prior to THA. There were 3 superficial surgical site infections/wound dehiscence and no PJI.

CONCLUSION

The rate of RPIO was 0.6%. The current findings suggest that if ICSI is performed under sterile conditions, the risk for septic arthritis or PJI following THA, even in patients with multiple ICSI or ICSI within 3 months prior to surgery, is minimal.

Musculoskeletal corticosteroid injections: Recommendations of the French Society for Rheumatology (SFR)

Musculoskeletal corticosteroid injections are widely performed, although the exact practice varies greatly due to advances in knowledge and techniques. This justifies updating and drawing up good practice recommendations. Using a consensus model formalized by the French National Authority for Health (HAS) and based on a literature review that resulted in a "white book", 13 recommendations were developed by a group of experts. These recommendations were then sent online to 48 specialists for evaluation, 27 of whom were rheumatologists and 15 of whom were general practitioners. These recommendations were also presented at the 34th annual meeting of the French Society for Rheumatology (SFR) (Paris, December 2021) at a symposium attended by a hundred or so rheumatologists, who voted on these recommendations in person. The results are presented as an overall score out of 10, a median out of 10 and as tertiles. The agreement was excellent for 10 of these 13 recommendations, with mean values of 8.5 to 9.1 out of 10, median values of 9 or 10 out of 10 and agreement of 91.7% to 97.9%, which corresponds to a consensus. The 3 other recommendations were broadly supported but were the subject of more debate. One relates to patient information (mean 7.3/10, median 8/10, upper tertile 72.9%) with discussion about the waiting period. Another related to the summary report (mean 8.4/10, median 9, upper tertile 91.7%) with discussions about its content and the need to specify the lot number of the injected product. The last one related to periprosthetic injections and the need to consult and get approval from a specialist (mean 8.0/10, median 8, upper tertile 83.3%) with mostly the general practitioners having reservations. In all, there is a very strong consensus among the musculoskeletal corticosteroid injection experts and specialists consulted, which justifies them being taken into consideration to improve our daily practice.

How do pre-operative intra-articular injections impact periprosthetic joint infection risk following primary total hip arthroplasty? A systematic review and meta-analysis

INTRODUCTION

Although intra-articular injections (IAIs) serve as the first-line non-surgical management for severe osteoarthritis (OA), recent analyses have suggested they are associated with an increased infection risk following primary total hip arthroplasty (THA). Therefore, our systematic review and meta-analysis explored the relationship between IAIs and periprosthetic joint infection (PJI) following THA reported in the current literature.

METHODS

Five online databases were queried for analyses published from January 1st, 2000-May 1st, 2021 reporting on PJI rates between patients undergoing primary THA who did and did not preoperatively receive an IAI. The overall pooled effect of injection status on PJI incidence was determined using Mantel-Haenszel (M-H) models. This was similarly conducted for segregated preoperative intervals: 0-3 months, > 3-6 months, > 6 + months.

RESULTS

A total of 11 articles were included in our analysis reporting on 278,782 THAs (IAI: n = 41,138; no IAI: n = 237,644). Patients receiving pre-operative injections had a significantly higher risk of PJI (OR: 1.31, 95% CI 1.07-1.62; p = 0.009). However, this finding was not robust. IAI receipt within 3-months of THA was associated with significantly higher PJI rates (OR: 1.68, 95% CI 1.48-1.90; p < 0.001). However, no significant difference was demonstrated in the > 3-6 month (OR: 1.19, 95% CI 0.94-1.52; p = 0.16) and > 6 + month sub-analyses (OR: 1.20, 95% CI 0.96-1.50; p = 0.11). The results of all sub-analyses remained were robust.

DISCUSSION

Our findings suggest that patients requiring THA should wait at least 3-months following IAI to reduce post-operative infection risk. This information can help inform patients considering OA management options, as well as adult reconstruction surgeons during preoperative optimization.

Intra-articular Hip Injections Prior to Total Hip Arthroplasty: Infection and Cost-Related Associations

Intra-articular injections prior to total hip arthroplasty (THA) have been associated with postoperative infections. The purpose of this study was to determine whether a temporal relationship exists between hip injections prior to THA and infection. Specifically, we asked (1) Do patients who receive hip injections within 3 months of THA have a higher incidence of prosthetic joint infections (PJIs) or surgical site infections (SSIs)? and (2) Do these patients incur higher 90-day costs? Patients with hip injections prior to THA were identified using a national database from 2010 to 2019. Three laterality-specific groups (injection 0 to 3 months, 3 to 6 months, and 6 to 12 months prior to THA)were compared with a matched cohort without prior injection (n=277,841). Primary outcomes included PJIs, SSIs, and costs. Patients who had injections within 3 months of THA had a higher incidence of PJIs at 90 days (5.1% vs 1.6%, P<.01) and 1 year (6.8% vs 2.1%, P<.01), when compared with the matched cohort. They also had a higher incidence of SSIs at 90 days (2.8% vs 1.2%, P<.01) and 1 year (3.7% vs 1.7%, P<.01). Mean costs were 13.7% higher in this injection cohort. Patients who had injections between 3 and 6 months prior to THA had higher incidence and odds of postoperative PJIs at 90 days (2.6% vs 1.6%, P<.04), whereas those with injections beyond 6 months had no differences in PJIs (P≥.46). Patients who receive hip injections within 3 months of undergoing primary THA are at increased risk for postoperative PJIs, SSIs, and higher costs. This study reaffirms guidelines for when to perform THAs in these populations. [Orthopedics. 2023;46(1):19-26.].

Can pre-operative intraarticular injection predict pain relief after total hip arthroplasty?

BACKGROUND

To study if pain relief after injection and arthroplasty correlate.

METHODS

A retrospective cohort study included consecutive patients (n = 88; median age 64 (interquartile range (IQR) 22) years, 49 (56%) females) that received fluoroscopic-guided intra-articular hip injection with contrast agent, anaesthetic (diagnostic), and corticosteroid (therapeutic) before implantation of primary total hip arthroplasty. Pain scores were assessed pre-injection, post-injection after 15 min (diagnostic phase) at first clinical follow up (therapeutic phase; median 2 (IQR 2) months), and postoperatively (last follow up (median 15 (IQR 5) months)). Responders had reduction in pain score ≥ 20 (numeric rating scale 0-100) points. The primary outcome was the same (or inverse) response to injection and arthroplasty.

RESULTS

The median pain scores were higher pre-injection (68 (IQR 30) points) compared to the diagnostic phase (18 (IQR 40) points; p < 0.001), therapeutic phase (50 (IQR 40) points; p < 0.001), and post-operatively (2 (IQR 15) points; p < 0.001). On the one hand, 69 (78%) cases had the same response in the diagnostic phase and post-operatively (rho = 0.58; p < 0.001; sensitivity 83%); on the other hand 32 (36%) cases had the same response in the therapeutic phase and post-operatively (rho = 0.25; p < 0.001; sensitivity 33%). Furthermore, 57% and 91% of patients had an even better response post-operatively than in the diagnostic and therapeutic phases.

CONCLUSIONS

Pre-operative intraarticular injection can predict pain relief after primary total hip arthroplasty. A positive response to hip arthroplasty may be better predicted by the response to local anaesthetic (diagnostic phase) than corticosteroids. Most patients (91%) with osteoarthritis may expect better pain relief after arthroplasty compared to the therapeutic phase after injection.

When Is It Safe to Operate After Therapeutic Carpal Tunnel Injections?

BACKGROUND

Recent studies suggest increased complications when surgery closely follows corticosteroid injection. The purpose of this study was to understand the occurrence of surgical site infection (SSI), wound complications, and reoperation rates after carpal tunnel release (CTR) when corticosteroid injections were given within 180 days preoperatively.

METHODS

Data were collected from the Truven MarketScan database from 2009 to 2018. Cohorts were created based on preoperative timing of injection (<30, 30-60, 61-90, 91-180 days) and number of injections (0, 1, 2, 3+). Logistic regression was performed to assess the contribution of preoperative injections on 90-day surgical site complications and 1-year reoperation while controlling for demographics and comorbidities.

RESULTS

Overall, 223 899 patients underwent CTR. Of these, 17 391 (7.76%) had a preoperative injection in the 180 days preceding surgery. Univariate analysis demonstrated a relationship between timing of injections and noninfectious wound complications (P = .006) and rate of 1-year reoperation (P = .045). Univariate analysis demonstrated a relationship between number of injections and 1-year reoperation (P < .001). On multivariate analysis, those receiving injections within 30 days preoperatively had increased rates of SSI (P = .034) and noninfectious wound complications (P = .006) compared with those with no injection or at other time points. Patients with 2 (P = .002) or 3 or more injections (P < .001) in the 180-day preoperative period had increased odds of 1-year reoperation.

CONCLUSION

Our study suggests increased risk of SSI, wound complications, and 1-year reoperation when corticosteroid injections are administered in the 30-day preoperative period. In addition, multiple steroid injections may increase the risk of 1-year reoperation.

Infection Risk Increases After Total Hip Arthroplasty Within 3 Months Following Intra-Articular Corticosteroid Injection. A Meta-Analysis on Knee and Hip Arthroplasty

BACKGROUND

Much debate continues regarding the risk of postoperative infection after intra-articular corticosteroid injection prior to total joint arthroplasty. The aim of this study was to evaluate the risk of periprosthetic joint infection (PJI) or other complications after joint arthroplasty in patients who received preoperative corticosteroids injections.

METHODS

A literature search was performed on PubMed, Web of Science, and Cochrane Library through January 4, 2022. Of 4,596 studies, 28 studies on 480,532 patients were selected for qualitative analysis. Studies describing patients receiving corticosteroids injections before joint arthroplasty (hip, knee) were included in the systematic review. A meta-analysis was performed of studies focusing on corticosteroids injections and PJI. Assessment of risk of bias and quality of evidence was based on the "Downs and Black's Checklist for Measuring Quality".

RESULTS

A significant association (odds ratio: 1.55, P = .001, 95% confidence interval: 1.357-1.772) between PJI and corticosteroids injections was found for total hip arthroplasty (THA). No association was found for knee arthroplasty procedures. The risk of PJI is statistically higher (odds ratio: 1.20, P = .045, 95% confidence interval: 1.058-1.347) if the injections are performed within 3 months preoperatively in THA patients.

CONCLUSION

Patients undergoing THA who previously received intra-articular injections of corticosteroids may expect a statistically higher risk of developing PJI. On the contrary, no association between corticosteroids injections and PJI could be seen in total knee arthroplasty patients. In addition, injection timing plays an important role: surgeons should refrain from administering corticosteroids injections within 3 months before hip arthroplasty, as it appears to be less safe than waiting a 3-month interval.

Comparing the Risk of Osteonecrosis of the Femoral Head Following Intra-Articular Corticosteroid and Hyaluronic Acid Injections

BACKGROUND

Although intra-articular corticosteroid injections (CSIs) are a cornerstone in the nonoperative management of hip pathology, recent reports have raised concerns that they may cause osteonecrosis of the femoral head (ONFH). However, these studies might have been limited by nonrepresentative patient samples. Therefore, the purpose of this study was to assess the incidence of ONFH after CSI and compare it with the incidence in a similar patient population that received a non-CSI injection.

METHODS

This was a retrospective propensity-matched cohort study of patients in the MarketScan database who underwent an intra-articular hip injection from 2007 to 2017. Patients receiving hip CSIs were matched 4:1 with patients receiving hip hyaluronic acid injections (HAIs) based on age, sex, geographic region, comorbidities, type of hip pathology, injection year, and baseline and follow-up time using propensity scores. The patients' first injections were identified, and the time to development of ONFH was analyzed using Kaplan-Meier curves and Cox proportional-hazards models. Patients with a history of osteonecrosis or those who received both types of injections were excluded.

RESULTS

A total of 3,710 patients undergoing intra-articular hip injection were included (2,968 CSIs and 742 HAIs; mean [standard deviation] age, 53.1 [9.2] years; 55.4% men). All baseline factors were successfully matched between the groups (all p > 0.57). The estimated cumulative incidence (95% confidence interval [CI]) of ONFH for CSI and HAI patients was 2.4% (1.8% to 3.1%) versus 2.1% (1.1% to 3.5%) at 1 year and 2.9% (2.2% to 3.7%) versus 3.0% (1.7% to 4.8%) at 2 years (hazard ratio, 1.05; 95% CI, 0.59 to 1.84; p = 0.88). The results held across a range of sensitivity analyses.

CONCLUSIONS

The incidence of ONFH after intra-articular hip injection was similar between patients who received CSIs and those who received HAIs. Although this study could not determine whether intra-articular injections themselves (regardless of the drug that was used) lead to ONFH, the results suggest that ONFH after CSI often may be due, in part, to the natural course of the underlying disease. Future randomized controlled trials are needed to definitively answer this question; in the interim, clinicians may be reassured that they may continue judicious use of CSIs as clinically indicated.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk of revision based on timing of corticosteroid injection prior to shoulder arthroplasty

AIMS

Corticosteroid injections are often used to manage glenohumeral arthritis in patients who may be candidates for future total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (rTSA). In the conservative management of these patients, corticosteroid injections are often provided for symptomatic relief. The purpose of this study was to determine if the timing of corticosteroid injections prior to TSA or rTSA is associated with changes in rates of revision and periprosthetic joint infection (PJI) following these procedures.

METHODS

Data were collected from a national insurance database from January 2006 to December 2017. Patients who underwent shoulder corticosteroid injection within one year prior to ipsilateral TSA or rTSA were identified and stratified into the following cohorts: < three months, three to six months, six to nine months, and nine to 12 months from time of corticosteroid injection to TSA or rTSA. A control cohort with no corticosteroid injection within one year prior to TSA or rTSA was used for comparison. Univariate and multivariate analyses were conducted to determine the association between specific time intervals and outcomes.

RESULTS

In total, 4,252 patients were included in this study. Among those, 1,632 patients (38.4%) received corticosteroid injection(s) within one year prior to TSA or rTSA and 2,620 patients (61.6%) did not. On multivariate analysis, patients who received corticosteroid injection < three months prior to TSA or rTSA were at significantly increased risk for revision (odds ratio (OR) 2.61 (95% confidence interval (CI) 1.77 to 3.28); p < 0.001) when compared with the control cohort. However, there was no significant increase in revision risk for all other timing interval cohorts. Notably, Charlson Comorbidity Index ≥ 3 was a significant independent risk factor for all-cause revision (OR 4.00 (95% CI 1.40 to 8.92); p = 0.036).

CONCLUSION

There is a time-dependent relationship between the preoperative timing of corticosteroid injection and the incidence of all-cause revision surgery following TSA or rTSA. This analysis suggests that an interval of at least three months should be maintained between corticosteroid injection and TSA or rTSA to minimize risks of subsequent revision surgery. Cite this article: Bone Joint J 2022;104-B(5):620-626.

Do preoperative intra-articular injections of corticosteroids or hyaluronic acid increase the risk of infection after total knee arthroplasty? A meta-analysis

Aims

There is conflicting evidence on the safety of intra-articular injections of hyaluronic acid (HA) or corticosteroids (CSs) before total knee arthroplasty (TKA). We performed a meta-analysis of the relationship between intra-articular injections and subsequent infection rates after TKA.

Methods

We searched PubMed, EMBASE, and the Cochrane Library for cohort studies that assessed the effect of preoperative injection of drugs into the joint cavity on the infection rate after TKA. The outcomes analyzed included the total infection rate, as well as those for different preoperative injection time periods and different drugs.

Results

Eight studies, including 73,880 in the injection group and 126,187 in the control group, met the inclusion criteria. The injection group had a significantly higher postoperative infection rate than the control group (risk ratio (RR) 1.16; 95% confidence interval (CI) 1.07 to 1.27; p < 0.001; I² = 32%). For patients who received injections up to three months preoperatively, the postoperative infection risk was significantly higher than that in the control group (RR 1.26; 95% CI 1.18 to 1.35; p＜0.001; I² = 0%). There was no significant difference in the infection rates between the four-to-six-month injection and control groups (RR 1.12; 95% CI 0.93 to 1.35; p = 0.240; I² = 75%) or between the seven-to-12-month injection and control groups (RR 1.02; 95% CI 0.94 to 1.12; p = 0.600; I² = 0%).

Conclusion

Current evidence suggests that intra-articular injections of CSs or HA before TKA increase the risk of postoperative infection. Injections administered more than three months before TKA do not significantly increase the risk of infection.

Cite this article: Bone Joint Res 2022;11(3):171–179.

Prevention of early complications following total hip replacement

Total hip arthroplasty (THA) has been quoted as "the operation of the century", owing to its efficacy and the substantial improvements evidenced with respect to functional patient outcomes and quality of life. However, early postoperative complications are often inevitable, hence it is imperative to take every step to prevent them and minimise morbidity and mortality. This manuscript focuses on the most common early complications following THA, namely venous thromboembolism (VTE), prosthetic joint infection, periprosthetic fracture, instability, and leg length inequality. It aims to outline effective risk stratification strategies and prevention measures that could apply to the wider Orthopaedic community.

Intraarticular Corticosteroids for Hip Osteoarthritis: A Review

INTRODUCTION

Hip osteoarthritis is a prevalent condition responsible for important pain and disability. Most available guidelines for nonsurgical management of hip osteoarthritis recommend a combination of nonpharmacological and pharmacological treatment modalities. Intraarticular corticosteroid injections have been used for decades, although evidence is quite scarce, and many controversies remain.

METHODS

This article reviews the available literature from Medline and Embase and discusses the evidence for intraarticular corticosteroid injections in hip osteoarthritis, where only 5 randomized controlled trials were found in the literature. These are analyzed in this article, which also aims to explain the main characteristics and features of glucocorticoids, along with their contraindications and potential adverse effects.

RESULTS

Available randomized controlled trials show that intraarticular corticosteroid injections provide pain relief and functional improvement in hip osteoarthritis. This efficacy has not been shown with intraarticular hyaluronic acid injections.

CONCLUSION

This review shows that intraarticular corticosteroid injections are efficacious in hip osteoarthritis and that this benefit can last up to 12 weeks.

Rapidly Destructive Hip Disease Following Intra-Articular Corticosteroid Injection of the Hip

BACKGROUND

While recent reports have suggested that hip corticosteroid injections can hasten joint degeneration, there are few published data on the topic. The purpose of the present study was to evaluate for an association between corticosteroid injection and rapidly destructive hip disease (RDHD) and to determine the rate of, and risk factors for, occurrence.

METHODS

This study was conducted in 2 parts. First, to assess for a potential association between hip corticosteroid injection and RDHD, a case-control analysis was performed. Patients who developed RDHD between 2013 and 2016 served as cases, whereas those who underwent total hip arthroplasty for diagnoses other than RDHD during the same period served as controls, and the exposure of interest was prior intra-articular hip corticosteroid injection. Second, in a retrospective cohort analysis, we analyzed all patients who received a fluoroscopically guided intra-articular hip corticosteroid injection at our institution from 2013 to 2016. The rate of post-injection RDHD was determined, and logistic regression was used to identify risk factors for occurrence.

RESULTS

In the case-control analysis, hip corticosteroid injection was associated with the development of RDHD (adjusted odds ratio, 8.56 [95% confidence interval, 3.29 to 22.3], p < 0.0001). There was evidence of a dose-response curve, with the risk of RDHD increasing with injection dosage as well as with the number of injections received. In the retrospective cohort analysis, the rate of post-injection RDHD was 5.4% (37 of 688). Cases of post-injection RDHD were diagnosed at an average of 5.1 months following injection and were characterized by rapidly progressive joint-space narrowing, osteolysis, and collapse of the femoral head.

CONCLUSIONS

This study documents an association between hip corticosteroid injection and RDHD. While the risk of RDHD following a single low-dose (≤40 mg) triamcinolone injection is low, the risk is higher following high-dose (≥80 mg) injection and multiple injections. These findings provide information that can be used to counsel patients about the risks associated with this common procedure. In addition, caution should be taken with intra-articular hip injections utilizing ≥80 mg of corticosteroid and multiple injections.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prior shoulder surgery and rheumatoid arthritis increase early risk of infection after primary reverse total shoulder arthroplasty

Background

Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular surgery for patients with rotator cuff arthropathy, unreconstructible proximal humeral fracture, and end-stage glenohumeral arthritis. The increased annual volume of RTSAs has resulted in more postoperative complications and revision rates between 3.3% and 10.1%. Postoperative infection is one of the most common complications requiring revision surgery after primary RTSA. This study assesses patient-specific risk factors for development of early infection after primary RTSA in a single high-volume shoulder arthroplasty institution.

Methods

From 2014 to 2019, 902 consecutive primary RTSAs were performed for surgical treatment of rotator cuff arthropathy, glenohumeral arthritis, inflammatory arthropathy, and/or dislocation. Excluding proximal humeral or scapula fractures, 756 cases met the inclusion criteria and had a minimum of 3-month follow-up. All surgeries were performed using the same surgical technique and received similar antibiotic prophylaxis. Age, patient demographics, medical history, smoking history, and prior ipsilateral shoulder treatment and/or surgery were recorded. Multivariable logistic regression analysis was used to determine risk factors associated with development of postoperative shoulder infection.

Results

Thirty-five patients did not meet minimum follow-up criteria and were lost to follow-up. Overall, of 721, 22 patients (3%) developed a postoperative ipsilateral shoulder infection. Previous nonarthroplasty surgery and history of rheumatoid arthritis were significantly associated with the development of postoperative shoulder infection. Amongst 196 patients who had previous nonarthroplasty shoulder surgery, there were 12 postoperative shoulder infections (6%) compared with those without previous shoulder surgery (10 of 525, 2%) (P = .003). Among 58 patients with rheumatoid arthritis, there were 5 postoperative shoulder infections (9%) compared with patients without rheumatoid arthritis (17 of 663, 3%) (P = .010). Patient age, gender, smoking status, history of diabetes mellitus, history of cancer/immunosuppression, and prior cortisone injection did not demonstrate significant associations with the development of postoperative infection.

Conclusion

Prior nonarthroplasty shoulder surgery and/or rheumatoid arthritis are independently associated with the development of postoperative infection after primary RTSA. Patients who demonstrate these risk factors should be appropriately evaluated and preoperatively counseled before undergoing primary RTSA. Strong consideration should be given to avoid minimally invasive nonarthroplasty surgery as a temporizing measure to delay definitive RTSA.

EULAR recommendations for intra-articular therapies

OBJECTIVES

To establish evidence-based recommendations to guide health professionals using intra-articular therapies (IAT) in adult patients with peripheral arthropathies.

METHODS

A multidisciplinary international task force established the objectives, users and scope and the need for background information, including systematic literature reviews) and two surveys addressed to healthcare providers and patients throughout Europe. The evidence was discussed in a face-to-face meeting, recommendations were formulated and subsequently voted for anonymously in a three-round Delphi process to obtain the final agreement. The level of evidence was assigned to each recommendation with the Oxford levels of evidence.

RESULTS

Recommendations focus on practical aspects to guide health professionals before, during and after IAT in adult patients with peripheral arthropathies. Five overarching principles and 11 recommendations were established, addressing issues related to patient information, procedure and setting, accuracy, routine and special aseptic care, safety issues and precautions to be addressed in special populations, efficacy and safety of repeated joint injections, use of local anaesthetics and aftercare.

CONCLUSION

We have developed the first evidence and expert opinion-based recommendations to guide health professionals using IAT. We hope that these recommendations will be included in different educational programmes, used by patient associations and put into practice via scientific societies to help improve uniformity and quality of care when performing IAT in peripheral adult joints.

The risk of early infection following intra-articular corticosteroid injection following shoulder arthroplasty

BACKGROUND

There is little literature examining the association of corticosteroid injections into shoulders with a pre-existing arthroplasty. The aim of the current study was to determine the risk of early infection following intra-articular corticosteroid injection into a pre-existing shoulder arthroplasty.

METHODS

The PearlDiver database was retrospectively reviewed to identify patients with a pre-existing shoulder arthroplasty from 2007 to 2017. Patients with an ipsilateral shoulder corticosteroid injection in the postoperative period were identified. A control group of patients without an injection was matched 4:1 by age, gender, and postoperative timepoint. Periprosthetic infection within six months after the injection was then assessed and compared using a logistic regression analysis.

RESULTS

Nine hundred and fifty-eight patients were identified who underwent a postoperative corticosteroid injection into a pre-existing shoulder arthroplasty and compared to 3832 control patients. After controlling for demographics, comorbidities, and procedure type, the rate of infection in patients who received a postoperative corticosteroid injection (1.77%) was significantly higher than control patients who did not receive an injection (0.91%) (OR 1.98 (95% CI 1.31-2.98), p = 0.0253).

CONCLUSIONS

There is a significant association between intra-articular shoulder corticosteroid injections in patients with pre-existing shoulder arthroplasties and prosthetic joint infection compared to matched controls without postoperative injections.

STUDY DESIGN

Level III, retrospective cohort study.

Impact of Prior Intra-articular Injections on the Risk of Prosthetic Joint Infection Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Objective: The current review was designed to assess the impact of prior intra-articular injections on the risk of prosthetic joint infection (PJI) in patients undergoing total joint arthroplasty (TJA) with a focus on the timing of injection before surgery.

Methods: The databases of PubMed, Embase and Google Scholar were searched up to 15th June 2021. All studies comparing the incidence of PJI with and without prior intra-articular injections were included. Risk ratios (RR) with 95% confidence intervals were calculated for PJI.

Results: Nineteen studies were included. Both corticosteroids and hyaluronic acid injections were used before TJA in the included studies. Overall, comparing 127,163 patients with prior intra-articular injections and 394,104 patients without any injections, we noted a statistically significant increased risk of PJI in the injection group (RR 1.24 95% CI: 1.11, 1.38 I² = 48% p = 0.002). On subgroup analysis, there was a statistically significant increased risk of PJI in the injection group in studies where intra-articular injections were administered <12 months before surgery (RR 1.18 95% CI: 1.10, 1.27 I² = 7% p < 0.00001). Furthermore, on meta-analysis, we noted non-significant but increased risk of PJI when injections were administered 1 month (RR 1.47 95% CI: 0.88, 2.46 I² = 77% p = 0.14), 0–3 months (RR 1.22 95% CI: 0.96, 1.56 I² = 84% p = 0.11), and 3–6 months (RR 1.16 95% CI: 0.99, 1.35 I² = 49% p = 0.06) before surgery.

Conclusion: Our results indicate that patients with prior intra-articular injections have a small but statistically significant increased risk of PJI after TJA. Considering that PJI is a catastrophic complication with huge financial burden, morbidity and mortality; the clinical significance of this small risk cannot be dismissed. The question of the timing of injections and the risk of PJI still remains and can have a significant impact on the decision making.

Systematic Review Registration: PROSPERO: CRD42021258297.

Preoperative risk factors for postoperative pneumonia following primary Total Hip and Knee Arthroplasty

BACKGROUND

The purpose of this study is to evaluate risk factors for pneumonia following THA and TKA.

METHODS

Patients were identified from the American College of Surgeons National Quality Improvement Database (NSQIP) who experienced postoperative pneumonia after undergoing primary THA and TKA.

RESULTS

Many characteristics including old age, anemia, diabetes, cardiac comorbidities, dialysis, and smoking were independent risk factors for postoperative pneumonia after THA or TKA.

CONCLUSION

This analysis offers new evidence on risk factors associated with the development of pneumonia after THA and TKA. These risk factors can help guide clinicians in preventing postoperative pneumonia after THA and TKA.

Risk of Infection in Thumb Carpometacarpal Surgery After Corticosteroid Injection

PURPOSE

The purpose of this study was to determine whether patients who had an intra-articular corticosteroid injection into the thumb carpometacarpal (CMC) joint for the treatment of arthritis within the 3 months before CMC joint arthroplasty or arthrodesis were at increased risk for wound complication/infection and/or repeat surgery for wound complication/infection in comparison with patients who did not receive an injection within 6 months or who received an injection between 3 and 6 months before surgery.

METHODS

We identified 5,046 patients in the Humana claims database who underwent surgery for CMC joint arthritis. The patients were stratified into 3 groups: (1) no thumb injection within 6 months of CMC joint surgery, (2) thumb injection between 3 and 6 months before CMC joint surgery, and (3) thumb injection within 3 months before CMC joint surgery. The primary outcome was wound complication/infection within 90 days after surgery. The secondary outcome was repeat surgery for wound complication/infection within 90 days after surgery. Multivariable logistic regression was performed to assess the associations between the timing of injection and wound complication/infection and repeat surgery for wound complication/infection.

RESULTS

The rates of wound complication/infection within 90 days after surgery were similar among the 3 study groups. However, patients who received an intra-articular corticosteroid injection within 3 months before surgery had a 2.2 times greater likelihood of repeat surgery for a wound complication/infection compared with patients who did not have an injection within 6 months before surgery.

CONCLUSIONS

Patients who receive an intra-articular corticosteroid injection within the 3 months before surgery for CMC joint arthritis may be at increased risk of repeat surgery to treat a wound complication/infection in the 90-day postoperative period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

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

PURPOSE

To define the incidence of postoperative infections in patients who receive corticosteroid injections prior to arthroscopic meniscectomy, to determine whether there is a temporal relation between injections and the risk of surgical-site infections, and to identify corresponding risk factors.

METHODS

The Humana administrative claims database was reviewed for patients undergoing arthroscopic meniscectomy within 1 year of injection and those undergoing arthroscopic meniscectomy without prior injection. Patients with preoperative injections were further stratified by the duration in months between the injection and the surgical procedure. Surgical-site infection within 6 months of surgery was recorded. Univariate analysis and binary logistic regression were performed to determine independent risk factors for surgical-site infection. Statistical significance was defined as P < .05.

RESULTS

We identified patients with (n = 11,652) and without (n = 37,261) a history of a knee corticosteroid injection within 1 year of arthroscopic meniscectomy with at least 6 months of database activity from 2007 to 2017. In patients who received knee injections within 1 month prior to surgery, the rate of development of postoperative infections was twice that in patients who did not receive an injection (1.28% vs 0.63%; odds ratio [OR], 1.84; 95% confidence interval [CI], 1.24-2.62; P = .001). Multivariate logistic regression identified male sex (OR, 1.39; 95% CI, 1.14-1.71; P = .001), diabetes (OR, 1.48; 95% CI, 1.19-1.85; P < .001), chronic obstructive pulmonary disease (OR, 1.57; 95% CI, 1.27-1.94; P < .001), obesity (OR, 1.32; 95% CI, 1.07-1.63; P = .010), tobacco use (OR, 1.61; 95% CI, 1.30-1.98; P < .001), and preoperative injections within 1 month of surgery (OR, 1.78; 95% CI, 1.21-2.54; P = .002) as significant predictors, whereas injections administered more than 1 month before surgery were not significantly associated with postoperative surgical-site infection after arthroscopic meniscectomy.

CONCLUSIONS

Injections 1 month before arthroscopic meniscectomy significantly increase the risk of surgical-site infection. However, injections can be safely administered more than 1 month prior to surgery because there is no increased risk of postoperative infection at this time point.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Safety of intraarticular corticosteroid injection preceding hip and knee arthroplasty: a systematic review and meta-analysis amid resolving COVID-19 arthroplasty restrictions

Intraarticular corticosteroid injection (ICSI) is a widely practiced management for hip and knee osteoarthritis. Imposed delays to arthroplasty during coronavirus disease 2019 pandemic have led us to postulate that many patients have opted for recent ICSI. We compared the odds of prosthetic joint infection (PJI) in patients who were or were not administered ICSI within 12 months prior to hip or knee arthroplasty. A systematic search of PubMed, Embase, The Cochrane Library and Web of Science was performed in February 2021, with studies assessing the effect of ICS on PJI rates identified. All studies, which included patients that received ICSI in the 12 months prior to primary hip and knee arthroplasty, were included. In total 12 studies were included: four studies with 209 353 hips and eight studies with 438 440 knees. ICSI administered in the 12 months prior to hip arthroplasty increased the odds of PJI [odds ratio (OR) = 1.17, P = 0.04]. This was not the case for knees. Subgroup analysis showed significantly higher odds of PJI in both hip [OR = 1.45, P = 0.002] and knee arthroplasty [OR = 2.04; P = 0.04] when ICSI was within the preceding 3 months of surgery. A significantly higher odds of PJI were seen in patients receiving ICSI within the 12 months prior to hip arthroplasty. Subgroup analysis showed increased odds of PJI in both hip and knee arthroplasty, in patients receiving ICSI within 3 months prior to their arthroplasty. We recommend delaying knee arthroplasty for at least 3 months after ICSI and possibly longer for hip arthroplasty.

Risk of Infection in Knee Arthroscopy Patients Undergoing Corticosteroid Injections in the Perioperative Period

Background:

Recent evidence suggests that there may be an increased risk of infection for patients undergoing a corticosteroid injection before, during, or after knee arthroscopy.

Purpose:

To systematically review the literature to evaluate the risk of postoperative infection in patients undergoing intra-articular corticosteroid injections (CSI) before, during, or after knee arthroscopy.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify studies that evaluated the rate of postoperative infection in patients undergoing knee arthroscopy who received an intra-articular CSI during the perioperative period. The search phrase used was “knee AND arthroscopy AND injection AND (infection OR revision).” A subanalysis was also performed to analyze infection rates based on the timing of the corticosteroid injection in relation to arthroscopy.

Results:

Four studies met the inclusion criteria, representing 11,925 patients undergoing knee arthroscopy with an intra-articular CSI administered during the perioperative period (mean follow-up, 5.3 months) and 247,329 patients without a corticosteroid injection during the perioperative period (mean follow-up, 5.9 months). Patients who received an injection experienced a statistically significantly higher rate of postoperative infection (2.2%) when compared with patients who did not receive an injection (1.1%; P < .001). When analyzed by the timing of the injection, patients receiving an injection preoperatively or intraoperatively experienced a statistically significantly higher rate of postoperative infection (3% and 2.6%, respectively) when compared with patients receiving an injection postoperatively (1.4%; P = .001 for both).

Conclusion:

Patients undergoing knee arthroscopy who receive an intra-articular CSI during the perioperative period can be expected to experience significantly higher postoperative infection rates when compared with patients not receiving an injection. Furthermore, patients receiving a corticosteroid injection pre- or intraoperatively may experience significantly higher rates of postoperative infection when compared with patients receiving an injection postoperatively.

Septic Iliopsoas Bursitis After Intra-articular Methylprednisolone Injection to the Hip: A Case Report

CASE

We describe the case of a 74-year-old man who developed severe hip pain several days after an intra-articular methylprednisolone injection to his right hip. Culture of the ipsilateral iliopsoas bursa revealed a Staphylococcus lugdunensis infection, which was successfully eradicated through irrigation and debridement as well as antibiotics.

CONCLUSION

Infection after hip injection is a known theoretical risk but is rarely reported in the literature. We present a case of septic bursitis after corticosteroid injection. Readers should be mindful that these complications do occur in clinical practice and portend significant morbidity.

Preoperative Corticosteroid Injections Demonstrate a Temporal and Dose-Dependent Relationship with the Rate of Postoperative Infection Following Total Hip Arthroplasty

BACKGROUND

Corticosteroid injections (CSI) are commonly used for the treatment of osteoarthritis of the hip. There is concern, however, that these injections may increase the risk of postoperative infection if a subsequent total hip arthroplasty (THA) is performed. The purpose of the present investigation is to determine the relationship between CSI and the risk of periprosthetic joint infection (PJI) and surgical site infections (SSIs) following THA.

METHODS

The PearlDiver database was reviewed for patients undergoing THA from 2011 to 2018. Patients with unilateral hip osteoarthritis who received an intra-articular hip CSI prior to ipsilateral THA were matched in a sequential 1:1 fashion based on age, gender, and Charlson Comorbidity Index with THA patients who did not receive an injection in the preoperative period. PJI and SSI within 6 months of the surgical procedure were recorded. Statistical analysis included chi-squared test and multivariate logistic regression. Results were considered significant at P < .05.

RESULTS

In total, 29,058 patients underwent a hip CSI within 6 months prior to THA. CSI within 4 months of surgery was associated with a higher incidence of PJI at 6-month follow up (1.6% vs 1.1%, P = .040). An injection within 1 month of surgery corresponded to a higher odds of PJI (odds ratio [OR] 1.97) than an injection 4 months prior to surgery (OR 1.24). Furthermore, the quantity of CSI administered within the 3 months prior to THA demonstrated a dose-dependent relationship, with each subsequent injection increasing odds of PJI (OR 1.45-3.59). A similar relationship was observed for SSI.

CONCLUSION

There appears to be both a time and dose-dependent association of hip CSI and PJI following THA. Surgeons should consider delaying elective THA if a CSI has been administered within the 4 months prior to the planned procedure.

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

BACKGROUND

Intra-articular hyaluronic acid (IAHA) can be injected into an osteoarthritic hip joint to reduce pain and to improve functionality. Several studies report IAHA to be safe, with minor adverse effects that normally disappear spontaneously within a week. However, intra-articular corticosteroids prior to total hip arthroplasty (THA) have been associated with increased infection rates. This association has never been investigated for IAHA and THA. We aimed to assess the influence of IAHA on the outcome of THA, with an emphasis on periprosthetic joint infection (PJI).

METHODS

At a mean follow-up of 52 months (±18), we compared complication rates, including superficial and deep PJIs, of THA in patients who received an IAHA injection ≤6 months prior to surgery (injection group) with that of patients undergoing THA without any previous injection in the ipsilateral hip (control group). One hundred thirteen patients (118 hips) could be retrospectively included in the injection group, and 452 patients (495 hips) in the control group.

RESULTS

No differences in baseline characteristics nor risk factors for PJI between the 2 groups were found. The clinical outcomes in terms of VAS pain scores (1.4 vs 1.7 points, P = .11), modified Harris Hip Scores (77 vs 75 points, P = .09), and Hip disability and Osteoarthritis Outcome Scores (79 vs 76 points, P = .24) did not differ between the injection group and the control group. Also, complications in terms of persistent wound leakage (0% vs 1.2%, P = .60), thromboembolic events (0% vs 0.6%, P = 1.00), periprosthetic fractures (1.7% vs 1.2%, P = .65), and dislocations (0% vs 0.4%, P = 1.00) did not differ. However, in the injection group there was a higher rate of PJIs (4% vs 0%, P < .001) and postoperative wound infections (9% vs 3%, P = .01), compared to the control group.

CONCLUSION

Our findings suggest that IAHA performed 6 months or less prior to THA may pose a risk for increased rates of PJI. We recommend refraining from performing THA within 6 months after IAHA administration.

Intra-articular Injections of the Hip and Knee With Triamcinolone vs Ketorolac: A Randomized Controlled Trial

BACKGROUND

Clinicians commonly utilize intra-articular injections to treat symptomatic primary arthritis. Steroid injections are common yet have immune-modulating effects and can alter gene expression which may delay definitive arthroplasty and further damage cartilage. Nonsteroidal anti-inflammatory injections may offer a safer profile due to their differing mechanism of action; however, there is a relative dearth of information regarding their efficacy. This noninferiority study compares the effectiveness of triamcinolone vs ketorolac in treating symptoms of moderate to advanced primary osteoarthritis of the hip and knee.

METHODS

In total, 110 patients (52 hips and 58 knees) with moderate to severe radiographic primary osteoarthritis of the hip or knee were randomized in a double-blinded study to receive an ultrasound-guided intra-articular injection of ketorolac or triamcinolone. Patient-reported outcome measures were collected pre-injection and at 1 week, 1 month, and 3 months.

RESULTS

For hips and knees, intra-articular injections with either ketorolac or triamcinolone led to statistically significant improvements in patient-reported outcome measures. The treatment effect size was largest at 1 week and decreased over time. Primary analysis of variance comparisons revealed no significant differences between ketorolac and triamcinolone. For knee injections, post hoc secondary analysis suggests slight added durability in the triamcinolone group. Adverse effects were minimal with both interventions.

CONCLUSION

Intra-articular ketorolac injections provide comparable improvement to triamcinolone for primary hip and knee osteoarthritis. Ketorolac is an additional low-cost option for conservative management of primary osteoarthritis, and due to its differing mechanism of action, it may not propagate additional cartilage damage or preclude from early surgical intervention if unsuccessful.

TRIAL REGISTRATION NUMBER

NCT04441112.

Do preoperative intra-articular corticosteroid and hyaluronic acid injections affect time to total joint arthroplasty?

INTRODUCTION

Intra-articular corticosteroid (CSI) or hyaluronic acid (HAI) injections alleviate symptoms of osteoarthritis in patients who may be candidates for total hip or total knee arthroplasty (THA/TKA). However, their effect on time to total joint arthroplasty (TJA) and complications remains uncertain. We sought to evaluate (1) delay in time to surgery for patients receiving injections prior to THA/TKA (2) incidence of patients that receive injections, (3) type and number of injections, and (4) compare complication rates between patients with and without injections.

METHODS

We retrospectively reviewed 3340 consecutive TJA (1770 THA and 1570 TKA). Patients were divided into two cohorts depending if they received preoperative intra-articular injection or not. We identified dates of first clinic presentation and index surgery, injection type, total administered, and 90-day complications, including periprosthetic joint infection.

RESULTS

150/1770 THA and 192/1570 TKA patients received injections (8.5%vs.12.2%,p = 0.0004). Time from first presentation to clinic to TJA was significantly greater in patients receiving injections [12.4 ± 11 months vs.7.3 ± 10.7,p < 0.001 for THA; 20.0 ± 17.4 months vs.11.6 ± 15.4,p < 0.001 for TKA]. This delay in time was greater in TKA versus THA (8.4 months vs.5.1,p < 0.001). TKA patients had a higher incidence of receiving HAI versus THA patients (9%vs.0.6%,p < 0.0001). There were no differences in overall complication profiles (p = 0.19 for THA, p = 0.3 for TKA).

CONCLUSION

Injections are associated with an increased time to TJA by a statistically significant amount, however its clinical significance is debatable. Injections are safe if administered at least three months preoperatively. If patients present with appropriate surgical indications and are ready, we do not recommend intra-articular injections to delay surgery.

Impact of Prior Intra-articular Injections on the Risk of Prosthetic Joint Infection Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Objective: The current review was designed to assess the impact of prior intra-articular injections on the risk of prosthetic joint infection (PJI) in patients undergoing total joint arthroplasty (TJA) with a focus on the timing of injection before surgery. Methods: The databases of PubMed, Embase and Google Scholar were searched up to 15th June 2021. All studies comparing the incidence of PJI with and without prior intra-articular injections were included. Risk ratios (RR) with 95% confidence intervals were calculated for PJI. Results: Nineteen studies were included. Both corticosteroids and hyaluronic acid injections were used before TJA in the included studies. Overall, comparing 127,163 patients with prior intra-articular injections and 394,104 patients without any injections, we noted a statistically significant increased risk of PJI in the injection group (RR 1.24 95% CI: 1.11, 1.38 I² = 48% p = 0.002). On subgroup analysis, there was a statistically significant increased risk of PJI in the injection group in studies where intra-articular injections were administered <12 months before surgery (RR 1.18 95% CI: 1.10, 1.27 I² = 7% p < 0.00001). Furthermore, on meta-analysis, we noted non-significant but increased risk of PJI when injections were administered 1 month (RR 1.47 95% CI: 0.88, 2.46 I² = 77% p = 0.14), 0-3 months (RR 1.22 95% CI: 0.96, 1.56 I² = 84% p = 0.11), and 3-6 months (RR 1.16 95% CI: 0.99, 1.35 I² = 49% p = 0.06) before surgery. Conclusion: Our results indicate that patients with prior intra-articular injections have a small but statistically significant increased risk of PJI after TJA. Considering that PJI is a catastrophic complication with huge financial burden, morbidity and mortality; the clinical significance of this small risk cannot be dismissed. The question of the timing of injections and the risk of PJI still remains and can have a significant impact on the decision making. Systematic Review Registration: PROSPERO: CRD42021258297.

Efficacy and safety of viscosupplementation with hyaluronic acid for hip osteoarthritis: results from a cross-sectional study with a minimum follow-up of 4 years

Background and aim of the work:

Osteoarthritis is the most common cause of disability in elderly. Hip osteoarthritis is the second most frequent form affecting a large joint and the social and economic impact on society of its related disability is expected to increase. The purpose of this study was to verify the efficacy and safety of ultrasound-guided viscosupplementation with high weight hyaluronic acid in hip osteoarthritis.

Methods:

183 patients with painful hip OA (Kellgren-Lawrence 1-2-3) were treated from January 2014 to December 2016 with viscosupplementation. Patients were evaluated before injection (T0) and after 1,2,3,4 (T1-T2-T3-T4) years through the VAS scale and Harris Hip Score (HHS). Patients who underwent to subsequent injections were followed and assessed. Subjects who underwent prosthesis were analyzed for a minimum of 6 months in order to detect any early postoperative complication.

Results:

The mean improvement of HHS and VAS between T0 and T1 was statistically significant. Patients who underwent subsequent injections showed a higher improvement even if statistical significance was not observed. Results showed that patients with grade 2 of osteoarthritis had the higher change in the scores. No adverse effects were registered. No early complications were reported in those patients who needed prosthesis.

Discussion and Conclusions:

Results observed confirm that ultrasound-guided viscosupplementation with high weight hyaluronic acid could be a possibility in the treatment of hip osteoarthritis, especially in patients with Kellgren-Lawrence grade 2 of disease. Subsequent injections are not characterized by similar positive effects. Outcomes of prosthetic surgery are not influenced by viscosupplementation.

Incidence of Cutibacterium acnes from shoulder arthroplasties in Asians: ethnic differences should be considered

BACKGROUND

Most studies on Cutibacterium acnes in shoulder surgery have been conducted in the Western population, and studies on Asians are rare. We evaluated the incidence and risk factors of C acnes in shoulder arthroplasty in Asians.

METHODS

We retrospectively analyzed 154 patients between January 2017 and May 2019 who underwent shoulder arthroplasty. Swabs were taken after skin preparation from the skin surface of the anterior acromion, axilla, and joint fluid to study the incidence of C acnes. Before skin preparation we also collected swabs from the anterior acromion, axilla, and thigh from 59 of the 154 patients.

RESULTS

Eight of 154 patients after and 6 of 59 patients before skin preparation were positive for C acnes. C acnes were found in 2 patients at the anterior acromion and in 6 at the synovial joint after skin preparation and in 1 patient at the axilla, in 5 at the anterior acromion, and in 3 at the thigh before preparation. History of steroid injection and number of steroid injections were significantly associated with C acnes isolation (P = .039 and P = .006, respectively), whereas age, sex, body mass index, shoulder surgery history, hypertension, diabetes, and cerebrovascular disease were not, as were serum inflammatory markers, including white blood cell count, C-reactive protein level, and erythrocyte sedimentation rate.

CONCLUSION

A total of 5.2% of the patients after skin preparation and 10.2% of patients before skin preparation were found to be positive for C acnes. The incidence of C acnes in patients who underwent shoulder arthroplasties in Asia was low and, thus, ethnic differences should be considered for C acnes. The history and number of steroid injections were associated with isolation of C acnes.

Increased Use of Intra-Articular Steroid Injection to Treat Osteoarthritis is Associated With Chronic Opioid Dependence After Later Total Knee Arthroplasty But Not Total Hip Arthroplasty

BACKGROUND

Intra-articular (IA) injections of corticosteroid (CO) and hyaluronic acid (HA) are commonly used for osteoarthritis. The efficacy of these interventions is controversial. Furthermore, research regarding the potential association of IA injection with later postoperative pain trajectories is lacking.

METHODS

We performed analysis on Truven Health MarketScan database (2012-2016) in total hip arthroplasty (THA) and total knee arthroplasty (TKA). Trends over time were assessed. Multivariable logistic regression analyses were executed to evaluate the impact of IA injections on postoperative chronic opioid use.

RESULTS

Preoperative CO and HA injections decreased throughout the study period in both THA and TKA. Preoperative CO and HA injections, regardless of frequency, had no significant impact on the odds of THA patients becoming chronic opioid users postoperatively. TKA patients who had 1 CO injection in the year before surgery experienced lower odds of postoperative chronic opioid use (odds ratio [OR], 0.89; 95% confidence interval [95% CI], 0.82-0.97), whereas patients who had 2 or more CO injections experienced significantly greater odds (OR, 1.14; 95% CI, 1.04-1.24). TKA patients who received 2 or more HA injections before surgery had significantly lower odds of chronic opioid use (OR, 0.90; 95% CI, 0.81-0.99).

CONCLUSION

The utilization of IA injections in patients with hip and knee osteoarthritis appears to be decreasing over time. TKA patients who received 2 or more preoperative CO injections experienced greater odds of chronic opioid utilization, whereas TKA patients with 2 or more HA injections in the year before surgery had decreased odds of chronic opioid use.

Autologous Mesenchymal Stem Cell Treatment is Consistently Effective for the Treatment of Knee Osteoarthritis: The Results of a Systematic Review of Treatment and Comparison to a Placebo Group

Background: Numerous studies have used autologous mesenchymal stem cell injections (AMSCI) to treat osteoarthritis. We hypothesized that AMSCI is an effective osteoarthritis treatment with increasing efficacy at higher doses. Methods: We conducted a PubMed search for human clinical studies using AMSCI for the treatment of osteoarthritis (OA) and a second search for placebo arms of injectate OA treatment. Inclusion criteria included treatment outcomes ratings both pre-treatment and at least 6 months post-treatment. Results: 45 AMSCI cohorts from 34 studies met criteria. All AMSCI cohorts showed improvement at mean 15.3 months post-treatment. Mean WOMAC and VAS scores improved at 6-months and at final follow-up (p < 0.0001 for all). Scores > 2 years were also significant (WOMAC p = 0.001/VAS p = 0.004). Results greatly exceeded the minimal clinically important difference (MCID) at each time point. AMSCI improvement also substantially exceeded previously published 6-month placebo-treatment improvement. No dose-response relationship was seen. AMSCI cohorts showed continuing improvement ≥ 6 months, and continued upward at one year. Placebo scores were already trending downward by 6 months. Conclusions: AMSCI is a consistently significantly effective treatment for osteoarthritis. It should no longer be stated that data is insufficient to establish AMSCI efficacy for OA. Given its excellent safety profile, AMSCI should be widely used for the treatment of osteoarthritis.

Autologous Biologic Treatment with Fat, Bone Marrow Aspirate and Platelet Rich Plasma Is an Effective Alternative to Total Knee Arthroplasty for Patients with Moderate Knee Arthrosis

Background: Osteoarthrosis (OA) of the knee afflicts millions worldwide. Total Knee Arthroplasty (TKA) is common, but associated with substantial cost and morbidity. Prior studies of intra-articular injection of fat, bone marrow aspirate (BMA), and platelet rich plasma (PRP) have shown clinical benefit. We hypothesized that injection of autologous adipose tissue, BMA, and PRP would provide significant benefit for patients with moderate knee OA resulting in avoidance of total knee arthroplasty (TKA) in most, with discontinuance of NSAIDs and other drugs. Methods: 42 TKA candidate patients (47 knees) with moderate (Kellgren-Lawrence 2 and 3) knee OA who had failed conservative treatment had autologous adipose tissue, BMA, and PRP injection as an alternative to TKA in office using only local anesthetic. Patients had discontinuance of all nonsteroidal anti-inflammatory medicines (NSAIDs) and other analgesics, except acetaminophen, prior to treatment. Patients were evaluated with Knee injury and Osteoarthritis Outcome Score Physical Shortform (KOOS-PS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Single Assessment Numeric Evaluation (SANE) prior to treatment, and at 6 months, 1, and 2 years after treatment. Results: Follow up exceeded 80% at all time points. There were no significant adverse events. TKA was avoided in 97% at one and 86% at two years after treatment. Mean SANE, KOOS-PS, and WOMAC scores significantly improved at 6 months, 1, and 2 years post-treatment. WOMAC and SANE scores were higher at two versus one year post-treatment. Conclusions: Combined fat, BMA, and PRP injection is a safe and effective treatment for moderate knee OA, with reliable avoidance of TKA and possible continued improvement at two year follow-up.

The Lawrence D. Dorr Surgical Techniques & Technologies Award: Aseptic Reoperations Within One Year of Primary Total Hip Arthroplasty Markedly Increase the Risk of Later Periprosthetic Joint Infection

BACKGROUND

Despite the success of primary total hip arthroplasties (THAs), some patients will require an aseptic reoperation within 1 year of the index THA. The goal of this study is to evaluate the risk of subsequent periprosthetic joint infection (PJI) in patients undergoing an aseptic reoperation within 1 year of a primary THA.

METHODS

A retrospective review utilizing our institutional joint registry identified 211 primary THAs requiring aseptic reoperation within 1 year following index arthroplasty. A control group of 15,357 primary THAs not requiring reoperation within 1 year was identified. Patients were divided into groups based on time from primary THA to reoperation: (1) within 90 days (n = 112 THAs; 40% for dislocation, 34% for periprosthetic fracture) or (2) 91-365 days (n = 99 THAs; 37% for dislocation, 29% for periprosthetic fracture). Mean follow-up was 7 years.

RESULTS

Patients undergoing an aseptic reoperation within 90 days had a PJI rate of 4.8% at 2 years, while the 91-365 day group had a PJI rate of 3.2% at 2 years. The control group had a PJI rate of 0.2% at 2 years. Employing a multivariate analysis, reoperation within 90 days of index arthroplasty had an elevated risk of PJI (hazard ratio 8, P < .001) as did a reoperation between 91 and 365 days (hazard ratio 13, P < .001).

CONCLUSION

Aseptic reoperations within 1 year following primary THA resulted in an 8- to 13-fold increased risk of subsequent PJI. The risk was similar whether the aseptic reoperation was early (within 90 days) or later (91-365 days).

LEVEL OF EVIDENCE

Level III (Prognostic).

Do Corticosteroid Injections Before or After Primary Rotator Cuff Repair Influence the Incidence of Adverse Events? A Subjective Synthesis

PURPOSE

To determine the influence of corticosteroid injections (CSIs) before or after primary rotator cuff repair (RCR) on the risk of (1) revision RCR, (2) retears, and (3) infections.

METHODS

The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and MEDLINE databases were queried in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Data pertaining to the use of CSIs before or after primary RCR and adverse events were extracted. A subjective synthesis of these outcomes and bias was performed.

RESULTS

A total of 10 studies including 240,976 patients were identified; 20.0% received a perioperative CSI. Of the 48,235 patients who received a CSI, 66.2% did so preoperatively whereas 33.8% did so postoperatively. A total of 78 patients received both preoperative and postoperative CSIs. Three studies examined the influence of preoperative CSIs on revision RCR; the incidence ranged from 3.8% to 10.5% with preoperative CSIs and from 3.2% to 3.4% for controls. Two of these studies analyzed outcomes of patients from the same databases over the same period. Five studies examined the influence of postoperative CSI use on retears; the incidence ranged from 5.7% to 19.0% in patients who received postoperative CSIs and from 10.0% to 18.4% for controls. Three studies examined the influence of CSI use on infection; 2 studies examined the risk of infection after postoperative CSI use, which ranged from 0.0% to 6.7% with CSIs and from 0.0% to 0.5% for controls.

CONCLUSIONS

The use of preoperative CSIs could be associated with an increased risk of revision RCR. There were no conclusive data to suggest an increased risk of retear or infection with CSI use based on a subjective synthesis of ranges. There is currently poor-quality literature surrounding this topic. Given that the current literature is limited and heterogeneous, no definitive recommendations can be made on perioperative CSI use for RCR.

LEVEL OF EVIDENCE

Level III, systematic review of Level I and III studies.

Adverse Impact of Corticosteroid Injection on Rotator Cuff Tendon Health and Repair: A Systematic Review

PURPOSE

To assess adverse effects of preoperative corticosteroid injections (CSIs) in patients with rotator cuff disease, especially before rotator cuff repair (RCR).

METHODS

A systematic review of the MEDLINE database was performed according to guidelines from the Preferred Reporting Item for Systematic Reviews and Meta-Analyses for all studies reporting on adverse clinical effects of CSIs on rotator cuff tendon.

RESULTS

A total of 8 articles were identified that report on adverse outcomes and risks associated with corticosteroid injections in the setting of rotator cuff tendinosis. Among these included articles, a single CSI for rotator cuff tendinosis was associated with increased risk of revision rotator cuff repair (odds ratio [OR]: range 1.3 [1.1-1.7] to 2.8 [2.2-3.4]) when administered up to a year before surgery and postoperative infections (OR: 2.1 [1.5-2.7]) when administered within a month before RCR. The risk of adverse outcomes after rotator cuff repair are greatest if a CSI is administered within 6 months of surgery (OR: 1.8 [1.3-2.6]) or if ≥2 injections are given within a year of surgery (OR: range 2.1 [1.8-2.5] to 3.3 [2.7-4.0]).

CONCLUSION

Several recent clinical trials have demonstrated that CSIs are correlated with increased risk of revision surgery after RCR in a temporal and dose dependent matter. Caution should be taken when deciding to inject a patient, and this treatment should be withheld if an RCR is to be performed within the following 6 months.

LEVEL OF EVIDENCE

IV, systematic review of Level III and IV studies.

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

Background

The knee is symptomatically the most frequent affected joint in osteoarthritis and, in the Netherlands and other Western countries, is mainly managed by general practitioners (GPs). An intra-articular glucocorticoid injection is recommended in (inter) national guidelines for patients with knee osteoarthritis as an option for a flare of knee pain and/or for those who are not responding well to pain medication. An innovative approach that could replace the intra-articular injection is an intramuscular gluteal glucocorticoid injection. An intramuscular injection is easier to perform than an intra-articular injection with lesser risk of severe local adverse reactions. We hypothesize that intramuscular gluteal glucocorticoid injection is non-inferior in reducing knee pain compared to intra-articular glucocorticoid injection, with potentially a longer lasting effect than intra-articular injection.

Methods/design

The study will be a pragmatic randomized controlled non-inferiority trial with two parallel groups. A total of 140 patients aged 45 years and older with knee osteoarthritis who contacted their general practitioner and have persistent knee pain (score ≥ 3 on 0–10 numerical rating scale; 0 = no knee pain) will be included.

Patients will be randomly allocated (1:1) to an injection of 40 mg triamcinolone acetonide intra-articular in the knee joint or intramuscular in the ipsilateral ventrogluteal area.

The effect of treatment will be evaluated by questionnaires at 2, 4, 8, 12, and 24 weeks after injection. The primary outcome is patients’ reported severity of knee pain measured with the pain subscale of the Knee injury and Osteoarthritis Outcome Score 4 weeks after injection. Statistical analysis will be based on both the per-protocol and the intention-to-treat principle.

Discussion

This study will evaluate non-inferiority of intramuscular glucocorticoid injection compared to intra-articular glucocorticoid injection for knee osteoarthritis symptoms.

Trial registration

This trial is registered in the Dutch Trial Registry (number NTR6968) at 2018-01-22 (https://www.trialregister.nl/trial/6784). Issue date: 1 October 2019.

Trial sponsor

Erasmus MC University Medical Center Rotterdam.

PO-box 2040.

3000 CA Rotterdam.

The Netherlands.

Risk of Infection in Trigger Finger Release Surgery Following Corticosteroid Injection

PURPOSE

To determine the risk for infection in trigger finger release surgery after preoperative corticosteroid injection.

METHODS

We retrospectively evaluated all patients undergoing trigger finger release by 16 surgeons over a 2-year period. Data collected included demographic information, medical comorbidities, trigger finger(s) operated on, presence of a prior corticosteroid injection, date of most recent corticosteroid injection, postoperative signs of infection, and need for surgery owing to deep infection. Superficial infection was defined per Centers for Disease Control criteria. Deep infection was defined as the need for surgery related to a surgical site infection.

RESULTS

In this cohort of 2,480 fingers in 1,857 patients undergoing trigger release surgery, 53 (2.1%) developed an infection (41 superficial [1.7%] and 12 deep [0.5%]). Before surgery, 1,137 fingers had no corticosteroid injection. These patients developed 1 deep (0.1%) and 17 superficial (1.5%) infections. In contrast, 1,343 fingers had been given a corticosteroid injection before surgery. These patients developed 11 deep (0.8%) and 24 superficial (1.8%) infections. Median time from corticosteroid injection to trigger release surgery was shorter for fingers that developed a deep infection (63 days) compared with those that developed no infection (183 days). The risk for developing a deep infection in patients who were operated on within 90 days of an injection (8 infections in 395 fingers) was increased compared with patients who were operated on greater than 90 days after an injection (3 infections in 948 fingers).

CONCLUSIONS

Preoperative corticosteroid injections are associated with a small but statistically significantly increased rate of deep infection after trigger finger release surgery. The risk for postoperative deep infection seems to be time dependent and greater when injections are performed within 90 days of surgery, especially in the 31- to 90-day postinjection period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

What Are the Costs of Hip Osteoarthritis in the Year Prior to a Total Hip Arthroplasty?

BACKGROUND

The majority of the cost analysis literature on total hip arthroplasties (THAs) has been focused around the perioperative and postoperative period, with preoperative costs being overlooked.

METHODS

The Humana Administrative Claims database was used to identify Medicare Advantage (MA) and Commercial beneficiaries undergoing elective primary THAs. Preoperative healthcare resource utilization in the year prior to a THA was grouped into the following categories: office visits, X-rays, magnetic resonance imagings, computed tomography scans, intra-articular steroid and hyaluronic acid injections, physical therapy, and pain medications. Total 1-year costs and per-patient average reimbursements for each category have been reported.

RESULTS

Total 1-year preoperative costs amounted to $21,022,883 (average = $512/patient) and $4,481,401 (average = $764/patient) for MA and Commercial beneficiaries, respectively. The largest proportion of total 1-year costs was accounted for by office visits (35% in Commercial; 41% in MA) followed by pain medications (28% in Commercial; 35% in MA). Conservative treatments (steroid injections, hyaluronic acid injections, physical therapy, and pain medications) alone accounted for 40%-44% of the total 1-year costs prior to a THA. A high healthcare utilization within the last 3 months prior to surgery was noted for opioids and steroid injections.

CONCLUSION

On average, $500-$800/patient is spent on hip osteoarthritis-related care in the year prior to a THA. Despite their potential risks, opioids and steroid injections are often utilized in the last 3 months prior to surgery.

Lower limb joint repair and replacement: an overview

In the last few years, much has been published concerning total joint arthroplasty, and debates and discussions to new questions and points of view started many years ago. In this commentary, we report the latest evidence of best practice in the field of lower limb arthroplasty; this evidence is based on a literature search conducted by using PubMed and Scopus databases with a time limit of five years. We found novel evidence regarding cemented and not cemented implant, implant design, anticoagulant use, tourniquets, and other aspects of joints replacement surgery that we consider a common part of modern orthopedic practice. We specifically focus on lower limb joint replacement.