Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery

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.

The Effect of Thumb Carpometacarpal Joint Corticosteroid Injections on Outcomes Following Arthroplasty

BACKGROUND

Prior studies suggest steroid injections may affect infection rates following thumb carpometacarpal joint (CMCJ) arthroplasty. However, it is unclear whether injections prior to CMCJ arthroplasty affect functional outcomes, primarily Quick Disabilities of the Arm, Shoulder, and Hand (qDASH).

METHODS

We retrospectively identified patients who underwent thumb CMCJ arthroplasty from 2015 to 2019. Patients who had qDASH scores reported preoperatively, and at 5 and 11 months postoperatively were included. Charts were reviewed for the presence or absence of prior corticosteroid injection to the CMCJ and complications. Delta qDASH was calculated by subtracting the patients' postoperative qDASH scores from the preoperative qDASH scores.

RESULTS

In all, 350 CMCJ arthroplasty patients were identified, 177 who had received at least 1 steroid injection and 173 who were steroid-naïve. No significant differences existed in delta qDASH scores postoperatively between the injection and naïve groups at 5 months (28.5 vs 28.6) or 11 months (31.2 vs 31.9). Whereas there were no significant differences in rates of major complications between the 2 groups, minor complications were higher in the injection group (16.4% vs 9.2%). Patients who received more than 3 injections did not have worse 5-month or 11-month delta qDASH scores or complication rates than those with fewer than 3.

CONCLUSIONS

Preoperative CMCJ steroid injection status does not affect major complication rates or functional outcomes following CMCJ arthroplasty. However, injections increase the rate of minor complications. The qDASH and complication rates following CMCJ arthroplasty are not affected by receiving greater than 3 injections preoperatively.

A 15-Year Review of Clinical Practice Patterns and Evidence-Based Medicine in Carpometacarpal Joint Arthroplasty

BACKGROUND

The purpose of this study was to help understand national practice patterns in carpometacarpal (CMC) arthroplasty and how they have evolved with evidence-based recommendations over the past 15 years.

METHODS

The American Board of Plastic Surgery (ABPS) started collecting practice data on primary CMC joint arthroplasty in 2006 as a portion of its continuous certification (CC) process. Data on primary CMC arthroplasty from May 2006 through December 2013 were reviewed and compared to those from January 2014 to March 2020. National practice trends observed in these data were evaluated. Comprehensive evidence-based medicine reviews published in 2008, 2011, 2013, and 2017 were reviewed alongside the CC data.

RESULTS

In all, 570 primary CMC joint arthroplasty cases were included from May 2006 to March 2020. The average age at the time of repair was 62 years and the patient population was predominantly female (79%). Most cases were done under general anesthesia (69%), and there was an increase in the use of regional anesthesia with nerve block when our 2 cohorts were compared (27% vs 37%; P = .020). A trapezium excision with flexor carpi radialis tendon ligament reconstruction was the most popular technique (72%) and an increase in the use of simple trapeziectomy was observed (6% vs 14%; P = .001). One-third of patients did not receive any form of deep vein thrombosis prophylaxis.

CONCLUSIONS

The ABPS CC data provide a databank that allows for direct observation of national practice trends and sheds light on potential avenues for improvement in patient care.

Long-Term Oral Steroid Use: A Unique Risk Factor in 4-Corner Fusion Compared With Other Wrist Salvage Operations

INTRODUCTION

Salvage procedures such as proximal row carpectomy, 4-corner fusion, total wrist arthroplasty, and total wrist arthrodesis are commonly used at the end stages of wrist arthritis. These operations have high complication rates, and significant controversy exists regarding the selection of procedure. Long-term oral glucocorticoid therapy has previously been identified as a risk factor for complications in multiple orthopedic procedures. The purpose of this study is to investigate the effect long-term oral preoperative corticosteroid use has on complications after different salvage operations for wrist arthritis.

METHODS

The National Surgical Quality Improvement Program database was queried to identify patients who underwent proximal row carpectomy, 4-corner fusion, total wrist arthroplasty, or total wrist fusion between 2005 and 2020. Patients were classified by steroid use. Univariate analysis and multivariate logistic regression were used to assess the risk of complications.

RESULTS

A total of 1298 patients were identified. Overall, steroid use was found to be independently associated with a higher complication rate. On multivariate analysis of patients who underwent 4-corner fusion, steroid use was found to be associated with higher complication rate and surgical site infection rate. Steroid use was not associated with increased complications in patients who underwent proximal row carpectomy, total wrist arthroplasty, or total wrist fusion when examined individually.

CONCLUSION

Long-term oral corticosteroid therapy was associated with an increased risk of postoperative infections in patients who underwent 4-corner fusion, which was not found in other wrist salvage operations.

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.

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.

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.

New Trends in Injection-Based Therapy for Thumb-Base Osteoarthritis: Where Are We and where Are We Going?

Thumb-base osteoarthritis (TBOA) is a common condition, mostly affecting post-menopausal women, often inducing a significant impact on quality of life and hand functionality. Despite its high prevalence and disability, the therapeutic options in TBOA are still limited and few have been investigated. Among the pharmacological strategies for TBOA management, it would be worthwhile to mention the injection-based therapy. Unfortunately, its efficacy is still the subject of debate. Indeed, the 2018 update of the European League Against Rheumatism (EULAR) recommendations for the management of hand osteoarthritis (OA) stated that intra-articular (IA) injections of glucocorticoids should not generally be used, but may be considered in patients with painful interphalangeal joints, without any specific mention to the TBOA localization and to other widely used injections agents, such as hyaluronic acid (HA) and platelet-rich plasma (PRP). Even American College of Rheumatology (ACR) experts conditionally recommended against IA HA injections in patients with TBOA, while they conditionally encouraged IA glucocorticoids. However, the recommendations from international scientific societies don’t often reflect the clinical practice of physicians who routinely take care of TBOA patients; indeed, corticosteroid injections are a mainstay of therapy in OA, especially for patients with pain refractory to oral treatments and HA is considered as a safe and effective treatment. The discrepancy with the literature data is due to the great heterogeneity of the clinical trials published in this field: indeed, the studies differ for methodology and protocol design, outcome measures, treatment (different formulations of HA, steroids, PRP, and schedules) and times of follow-up. For these reasons, the current review will provide deep insight into the injection-based therapy for TBOA, with particular attention to the different employed agents, the variety of the schedule treatments, the most common injection techniques, and the obtained results in terms of efficacy and safety. In depth, we will discuss the available literature on corticosteroids and HA injections for TBOA and the emerging role of PRP and other injection agents for this condition. We will consider in our analysis not only randomized controlled trials (RCTs) but also recent pilot or retrospective studies trying to step forward to identify satisfactory management strategies for TBOA.

Low rate of subsequent surgery and serious complications following intra-articular steroid injection for base of thumb osteoarthritis: national cohort analysis

Objectives

Intra-articular steroid injection is commonly used to treat base of thumb osteoarthritis (BTOA), despite a lack of large-scale data on safety and effectiveness. We estimate the incidence of serious complications and further procedures following BTOA injection, including the risk of post-operative serious surgical site infection for subsequent operative intervention.

Methods

Hospital Episode Statistics data linked to mortality records from 1 April 1998 to 31 March 2017 were used to identify all BTOA injections undertaken in adults in the National Health Service secondary care in England. Patients were followed up longitudinally until death or 31 March 2017. A multivariable regression with a Fine and Gray model adjusting for the competing risk of mortality in addition to age, sex and socioeconomic deprivation was used to identify factors associated with progression to further procedure. Secondary outcomes included serious complications after injection and subsequent surgical site infection.

Results

A total of 19 120 primary injections were performed during the 19-year period in 18 356 patients. Of these 76.5% were female; mean age 62 years (s.d. 10.6); 50.48% underwent further procedure; 22.40% underwent surgery. Median time to further intervention was 412 days (IQR 110–1945). Female sex was associated with increased risk of proceeding to surgery. Serious complication rate following injection was 0.04% (0.01–0.08) within 90 days. Of those proceeding to surgery 0.16% (0.06–0.34) presented with a wound infection within 30 days and 90 days, compared with an overall post-operative wound infection rate of 0.03% (0.02–0.05).

Conclusions

Very low rates of serious complications were identified following BTOA injections performed in secondary care; only one in five patients proceeded to subsequent surgery.

Clinical trial registration

clinicaltrials.gov, https://www.clinicaltrials.gov, NCT03573765