Risk of Infection in Thumb Carpometacarpal Surgery After Corticosteroid Injection

Hand and Upper Extremity Surgical Site Infection Rates Associated With Perioperative Corticosteroid Injection: A Review of the Literature

BACKGROUND

Corticosteroid injection (CSI) has a relatively high benefit-to-risk ratio and is commonly administered to treat musculoskeletal conditions. However, perioperative CSI has been associated with an increased risk of postoperative infection. The literature suggests delaying surgery after CSI to minimize the risk of postoperative infection. We review the literature to summarize the most current knowledge on the association between perioperative CSI and infection rates for different hand and upper extremity procedures.

METHODS

Two independent reviewers conducted a literature search using PubMed and Web of Science databases (through October 1, 2022). The database searches used were (((injection) AND (infection)) AND (risk)) AND ((hand) OR (wrist) OR (elbow) OR (shoulder)). English-language articles were screened for infection rates associated with CSI given temporally around upper extremity surgery, focusing between 6 months preoperatively and 1 month postoperatively.

RESULTS

Nineteen articles including database queries and retrospective case-control or cohort studies were used after screening 465 articles. Most infection rates were increased in hand, wrist, elbow, and shoulder surgery between 3 months preoperatively and 1 month postoperatively. Intraoperative injection during elbow arthroscopy demonstrated increased infection rate relative to other upper extremity surgeries.

CONCLUSIONS

Corticosteroid injection increased the risk of infection temporally around upper extremity surgeries; however, CSI provides benefits. The consensus regarding CSI timeline perioperatively has yet to be determined. The evidence supports an increased benefit-to-risk ratio when giving corticosteroids greater than 3 months preoperatively and greater than 1 month postoperatively for most upper extremity procedures, with relative contraindications within 1 month of upper extremity surgery.

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.

Does the Number of Preoperative Corticosteroid Injections Affect Clinical and Radiographic Outcomes of Trapeziectomy and Suspensionplasty?

PURPOSE

This study aimed to determine whether an increasing number of preoperative corticosteroid injections is associated with greater radiographic subsidence of the thumb metacarpal at long-term follow-up after abductor pollicis longus suspensionplasty, secondary to steroid-induced pathologic weakening of capsuloligamentous restraints surrounding the thumb carpometacarpophalangeal joint and greater extension of the lunate, but neither affect patient-reported outcomes nor revision rates.

METHODS

A retrospective chart review was performed of patients who underwent primary trapeziectomy and abductor pollicis longus suspensionplasty by a single surgeon over a 10-year period. The number of preoperative corticosteroid injections in the trapeziometacarpal joint was documented, and patients were separated into 4 subgroups: 0, 1, 2, or 3 or more injections. Preoperative and final radiographs were evaluated for a change in the distance between the base of the thumb metacarpal and the distal pole of the scaphoid as a measure of thumb metacarpal subsidence and radiolunate angle as a measure of nondissociative carpal instability, which has been reported as a complication after basal joint arthroplasty. Additionally, the final patient-reported outcomes (Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation) and revision rates were also assessed.

RESULTS

Of a total of 60 patients with an average age of 64 years that were included in the study, 16 (26.7%) received 0, 19 (31.7%) received 1, 12 (20%) received 2, and 13 (21.7%) received 3+ preoperative injections. The median postoperative follow-up was 92 months. The mean distance between the base of the thumb metacarpal and the distal pole of the scaphoid decreased by 2 mm, and the mean radiolunate angle increased by 4° across the entire cohort. When comparing subgroups, no differences were observed in either parameter or the final Patient-Rated Wrist Evaluation and Quick Disabilities of the Arm, Shoulder, and Hand scores.

CONCLUSIONS

This study demonstrates no apparent detrimental effect of an increased number of preoperative corticosteroid injections on radiographic thumb metacarpal subsidence, increase in extension of radiolunate angle (nondissociative carpal instability), patient-reported outcomes, or revision rates at an average of almost 8 years after trapeziectomy and abductor pollicis longus suspensionplasty.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Surgical site infection following surgery for hand trauma: a systematic review and meta-analysis

Surgical site infection is the most common healthcare-associated infection. Surgical site infection after surgery for hand trauma is associated with increased antibiotic prescribing, re-operation, hospital readmission and delayed rehabilitation, and in severe cases may lead to amputation. As the risk of surgical site infection after surgery for hand trauma remains unclear, we performed a systematic review and meta-analysis of all primary studies of hand trauma surgery, including randomized controlled trials, cohort studies, case-control studies and case series. A total of 8836 abstracts were screened, and 201 full studies with 315,618 patients included. The meta-analysis showed a 10% risk of surgical site infection in randomized control trials, with an overall risk of 5% when all studies were included. These summary statistics can be used clinically for informed consent and shared decision making, and for power calculations for future clinical trials of antimicrobial interventions in hand trauma.

Suppurative tenosynovitis with chronic carpal tunnel syndrome due to corticosteroid injections: A case report

INTRODUCTION

Steroid hormone blocking is a common treatment for tenosynovitis. However, local steroid hormone blocking requires careful attention to the local inflammatory response, as infection can cause severe local soft tissue inflammation and damage.

PRESENTATION OF CASE

A 46-year-old female patient received local steroid hormone blocking treatment for tenosynovitis of the right thumb at another hospital 3 months earlier. Five days later, the patient gradually experienced redness, swelling, and pain in her right hand. By day 7, the symptoms worsened with increased swelling, wrist pain, and finger numbness. After the carpal tunnel incision, the patient's symptoms improved upon admission to the local hospital's emergency department. However, 2 weeks post-operation, she experienced recurring numbness, pain, discomfort, and local sinus exudation in her right hand, which worsened over 2 months, prompting the patient to seek outpatient treatment at our hospital.

DISCUSSION

An increase in local content within the wrist joint content is a major cause of carpal tunnel syndrome. Repeated stimulation of the inflamed tissues often leads to the development of granulomatous hyperplasia. Hyperplastic granulomas often produce local compression. If located in the peripheral nerve duct, it may cause nerve entrapment and lead to peripheral nerve injury. Surgery is often required to excise the hyperplastic tissue and release the entrapped nerve.

CONCLUSION

Prompt and thorough debridement is necessary for addressing local soft tissue infections caused by suppurative tenosynovitis. Failure to do so may result in recurrent local granuloma hyperplasia and the development of local compression diseases, especially in wrist median nerve compression cases.

Readmission and Reoperation Following Carpometacarpal Arthroplasty

Purpose

Carpometacarpal (CMC) arthroplasty is an effective surgical treatment for osteoarthritis of the CMC joint. Risk factors for readmission and reoperation have been studied for other joint arthroplasty procedures but have not yet been studied for CMC arthroplasty. The purpose of this study was to identify patient demographics and comorbidities associated with 30-day readmission and 30-day reoperation after CMC arthroplasty.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all records of patients who underwent CMC arthroplasty between 2015 and 2020. Variables collected in this study included patient demographics, comorbidities, surgical characteristics, and 30-day postsurgical complication data. Multivariate logistic regression was used to identify independent associations between patient characteristics and readmission and reoperation after CMC arthroplasty.

Results

In total, 6,432 records were included in this study: 34 (0.5%) were readmitted within 30 days, and 27 (0.4%) underwent reoperation within 30 days. Compared with the non-readmission cohort, the readmission cohort was significantly associated with higher rates of age ≥ 75 years (P = .003), body mass index (BMI) ≥ 40 kg/m2 (P = .005), American Society of Anesthesiologists classification (ASA) ≥ 3; P < .001), insulin-dependent diabetes (P = .016), and chronic obstructive pulmonary disease (COPD; P = .009). Compared with the non-reoperation cohort, the reoperation cohort was significantly associated with higher rates of age ≥ 75 years (P = .003), BMI ≥ 40 kg/m2 (P = .005), ASA ≥ 3 (P < .001), insulin-dependent diabetes (p = .016), and COPD (P = .009).

Conclusion

The clinically significant predictors for 30-day readmission and 30-reoperation after CMC arthroplasty were age ≥ 75 years, BMI ≥ 40 kg/m2, ASA ≥ 3, insulin-dependent diabetes, and COPD. Of these risk factors, age and BMI were identified as independent predictors for 30-day readmission. A better understanding of presurgical risk factors for postsurgical complications may help surgeons with risk stratification and optimization of outcomes.

Type of study/level of evidence

Prognostic III.

Injections for treatment of carpal tunnel syndrome: A narrative review of the literature

Background

Carpal tunnel syndrome is an extremely common condition in the general population. Nonoperative treatment is a mainstay of management prior to surgical carpal tunnel release. Injections are frequently used as treatment, especially corticosteroid injections, but there is little consensus in the literature regarding injection number, volume, corticosteroid dose, and technique.

Methods

A comprehensive literature search was performed of PubMed to identify papers relating to corticosteroid injections as well as other injections performed in patients with carpal tunnel syndrome.

Results

A total of 45 articles were selected for inclusion in this review. Corticosteroid injections for carpal tunnel syndrome are discussed in detail, including injection number, volume, and technique as well as corticosteroid dose. Alternative injections for management of carpal tunnel syndrome are also discussed.

Conclusions

Corticosteroid injections have been identified as a safe, effective short term management option for carpal tunnel syndrome. However, there is no standardized recommendation for specifics of their use in relation to corticosteroid dose, number of injections, injectate volume, and use of ultrasound guidance. Further research is required to better establish the optimal role for corticosteroid injections in the treatment of carpal tunnel syndrome. Platelet rich plasma, lidocaine, and hyaluronic acid, among others, are additional injections that warrant further exploration for use in management of carpal tunnel syndrome.

Efficacy, Safety, and Accuracy of Intra-articular Therapies for Hand Osteoarthritis: Current Evidence

The lifetime risk of symptomatic hand osteoarthritis (OA) is 39.8%, with one in two women and one in four men developing the disease by age 85 years and no disease-modifying drug (DMOAD) available so far. Intra-articular (IA) therapy is one of the options commonly used for symptomatic alleviation of OA disease as it can circumvent systemic exposure and potential side effects of oral medications. The current narrative review focuses on the efficacy and safety profiles of the currently available IA agents in hand OA (thumb-base OA or interphalangeal OA) such as corticosteroids and hyaluronic acid (HA), as well as the efficacy and safety of IA investigational injectates in phase 2/3 clinical trials such as prolotherapy, platelet-rich plasma, stem cells, infliximab, interferon-? and botulinum toxin, based on the published randomized controlled trials on PubMed database. The limited published literature revealed the short-term symptomatic benefits of corticosteroids in interphalangeal OA while long-term data are lacking. Most of the short-term studies showed no significant difference between corticosteroids and hyaluronic acid in thumb-base OA, usually with a faster onset of pain relief in the corticosteroid group and a slower but greater (statistically insignificant) pain improvement in the HA group. The majority of studies in investigational agents were limited by small sample size, short-term follow-up, and presence of serious side effects. In addition, we reported higher accuracy rates of drug administrations under imaging guidance than landmark guidance (blind method), and then briefly describe challenges for the long-term efficacy and prospects of IA therapeutics.

Indications for Ligament Reconstruction and Suspensionplasty in Carpometacarpal Arthroplasty

The trapeziometacarpal joint is the site that most commonly develops arthritis in the hand. Although optimal treatment requires careful consideration of history, physical examination, radiographs, and functional goals, many patients ultimately undergo surgical intervention. Several described techniques and approaches are highlighted in this article, especially pertaining to carpometacarpal arthroplasty with ligament reconstruction and tendon interposition. The rationale, benefit, and evidence for each approach are discussed and the author's preferred technique is described.