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

Corticosteroid injection of the knee within one month prior to meniscus repair increases the risk of repair failure requiring meniscectomy

OBJECTIVE

Meniscal tears are common knee injuries with limited endogenous healing capacity. This study aimed to investigate the association between the timing and administration of preoperative intra-articular corticosteroid injections (CSIs) and the risk of subsequent meniscectomy following meniscus repair.

METHODS

Using a national insurance claims database, patients aged 18-40 years undergoing meniscus repair within six months of tear diagnosis were studied. Patients were categorized based on whether they received preoperative CSIs within three intervals prior to repair. Multivariable logistic regression was used to analyze the risk of follow-up meniscectomy while controlling for various patient-related variables.

RESULTS

Among 5,390 patients meeting inclusion criteria, 201 received preoperative CSIs. The CSI group was older and had higher rates of diabetes, obesity, and knee osteoarthritis. The overall rate of follow-up meniscectomy did not differ between groups. However, CSIs performed within one month prior to repair were associated with significantly higher odds of subsequent meniscectomy compared to CSIs performed between three and six months prior. Obesity, tobacco use, and knee osteoarthritis were also independently associated with higher risk, while increasing age was associated with lower risk.

CONCLUSION

The study highlights an increased risk of repair failure requiring follow-up meniscectomy for patients receiving intra-articular CSIs within one month prior to meniscus repair. These findings suggest caution when considering CSIs as a treatment option for patients scheduled for meniscus repair. Further research is needed to establish optimal timing guidelines for CSIs in relation to meniscus repair and to understand the underlying mechanisms.

Risk factors for infection in patients undergoing knee arthroscopy: A Systematic Review and Meta-analysis

PURPOSE

The primary aim was to determine the risk of infection after knee arthroscopy and to evaluate the risk factors for surgical site infection (SSI).

METHODS

The PubMed/Medline, Embase and Cochrane Library databases were systematically searched, as were the reference lists of previous systematic reviews and meta-analysis manual studies. A random-effects model was used to calculate the estimated pooled odds ratio (OR).

RESULTS

A total of 38,321 potential articles met the initial inclusion criteria. After a review of the titles, abstracts and full texts, the remaining 41 articles were included in the final analysis. We identified 9,089,578 patients who underwent knee arthroscopy in 41 articles. High-quality (class I) evidence showed that autografts (cruciate ligament reconstruction) (OR, 2.66% CI, 1.84-3.86) or high procedure complexity (OR, 2.02;95% CI, 1.69-2.43) had a higher risk of infection, while medium-quality (class II or class III) evidence showed that obesity (BMI ≥ 30 kg/m2) (OR, 1.27; 95% CI, 1.08-1.49) or male (OR, 1.52; 95% CI, 1.32-1.75) or diabetes (OR, 1.71; 95% CI, 1.36-2.14) or tobacco use (OR, 1.65; 95% CI, 1.38-1.97) or preoperative steroid use (OR, 3.41; 95% CI, 2.10-5.54) had a higher risk of infection. The meta-analysis showed that there was no association between age or antibiotic prophylaxis and infection incidence.

CONCLUSIONS

The meta-analysis showed that significant risk factors for infection after knee arthroscopy included obesity, male sex, diabetes, tobacco use, high procedure complexity, graft type, and preoperative steroid use.

LEVEL OF EVIDENCE

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

The Effect of Aspiration and Corticosteroid Injection After ACL Injury on Postoperative Infection Rate

BACKGROUND

Injecting bioactive substances into the knee is common in orthopaedic practice, and recently it has been shown to mitigate risk factors for posttraumatic osteoarthritis. Therefore, understanding the influence of these injections on postoperative infection rate is imperative.

HYPOTHESIS

Postinjury aspiration and corticosteroid injection (CSI) of the knee before anterior cruciate ligament (ACL) reconstruction (ACLR) would not increase the risk of postoperative infection.

STUDY DESIGN

Cohort Study; Level of evidence, 3.

METHODS

All patients between the ages of 10 and 65 years who underwent primary bone-patellar tendon-bone ACLR by 1 fellowship-trained sports medicine orthopaedic surgeon between January 1, 2011, and September 8, 2020, at 1 of 2 major academic centers were evaluated for inclusion. A total of 693 patients were included, with 273 patients receiving postinjury and preoperative aspiration and CSI. A postoperative infection was defined as a patient returning to the operating room for an intra-articular washout. The intervals-measured in days-between the CSI and ACLR and between ACLR and the final follow-up were recorded. To further evaluate the infection risk in each cohort (total cohort; aspiration and injection cohort; no aspiration and injection cohort), the upper 95% confidence bound for the infection risk was calculated for each cohort.

RESULTS

There were no postoperative infections in the 693 patients included in this study. The upper 95% confidence bounds were 0.4%, 1.1%, and 0.7% for the total cohort, the cohort that underwent aspiration and injection, and the cohort that did not, respectively. The median number of days between the surgical date and that of the aspiration and injection was 34 days, and the mean follow-up for the entire cohort was 337.4 days (95% CI, 307.6-367.3).

CONCLUSION

Postinjury and preoperative aspiration and CSI is a safe intervention that can be used before ACLR. Future studies with larger sample sizes, longer patient follow-ups, and multiple surgeons would be helpful to both better understand infection risk and better identify the influence of CSI on preventing posttraumatic osteoarthritis.

Corticosteroid injections 2 months before arthroscopic meniscectomy increases the rate of postoperative infections requiring surgical irrigation and debridement

PURPOSE

Consensus guidelines recommend administering a corticosteroid injection (CSI) for patients with a symptomatic degenerative meniscus lesion prior to arthroscopic partial meniscectomy (APM). A recent study found that CSI administered within 1 month prior to meniscectomy is associated with an increased risk of postoperative infection. However, infections may range in severity from superficial infections to serious infections requiring surgical interventions. The aim of this analysis was to define the rate of infections requiring surgery after APM and determine its relationship to preoperative CSI.

METHODS

The PearlDiver Mariner administrative claims database was queried for patients > 35 years old who had a CSI in the year prior to isolated APM. Rates of deep infection and infection requiring surgery within 6 months were reported between matched patients with a CSI and no injection.

RESULTS

After matching, there were 16,009 patients per group with a mean age of 59.4 years (SD = 9.6), 53.5% obesity, and 40% male. Forty-four of 113 patients who developed a postoperative deep infection went on to have a reoperation for irrigation and/or debridement (0.1% of all APM). Of these 44 patients, 30 had a preoperative CSI and 14 were controls unadjusted odds ratio (unadj-OR) if given CSI = 1.95, 95% CI 1.03-3.68, P = 0.04). Having a CSI within the month before surgery conferred a 4.56-fold increase in odds of an infection warranting surgery (95% CI 1.96-10.21, P < 0.01), whilst having a CSI 4-8 weeks before surgery conferred a 2.42-fold increase in odds (95% CI 1.04-5.42, P = 0.03). Receiving multiple CSI in the year prior to APM was associated with 5.27-fold increased odds of an infection requiring surgery (95% CI 1.19-23.27, P = 0.03), compared to having a single CSI.

CONCLUSIONS

Serious infections requiring a surgical intervention are rare after a meniscectomy, occurring in 0.1% of APMs in a matched cohort of patients over 35. Patients were five times more likely to return to the operating room for infection after APM if they had a CSI in the month before or had multiple CSIs in the year before surgery. The risk of infection was no longer significant if there was at least a 2-month interval between preoperative CSI and APM.

LEVEL OF EVIDENCE

Level III.

Postoperative Infection: Prevention, Diagnosis, and Treatment Guidelines for the Sports Surgeon

Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.