Joint Injection or Aspiration before Total Knee Arthroplasty: Does It Increase the Risk of Periprosthetic Joint Infection?

Abstract

Injections are a common preoperative treatment for patients who eventually undergo total knee arthroplasty (TKA). However, recent studies have shown a relationship between preoperative injections and adverse outcomes following surgery. The purpose of this study was to characterize the type of intra-articular procedure patients receive in the acute period prior to surgery and determine their association with postoperative periprosthetic joint infection (PJI).

An observational cohort study was conducted using the Merative MarketScan databases. Patients who underwent primary TKA between April 1, 2019, and July 4, 2021, were included in the study. Patients were grouped according to the type of intra-articular procedure they received within the 90-day period prior to TKA: (i) intra-articular hyaluronic acid (IA-HA), (ii) intra-articular corticosteroid (IA-CS), (iii) aspiration, and (iv) no drug injections or aspirations. The primary outcome was the postoperative 180-day PJI rate.

A total of 43,219 patients were included in the study. About 11.8% of patients were found to have received at least one injection or aspiration in the 90 days prior to their TKA. The most common injection performed was IA-CS (78.3%), followed by aspiration (13.0%) and IA-HA (8.7%). No image guidance was performed for 92.3% of injections, with most being administered between 61 and 90 days before surgery (93.6%). Rates of PJI at 180 days were similar between patients with and without injections (OR = 1.11, p = 0.569). Neither drug type nor image guidance had an effect on the overall postoperative PJI rate.

Injections performed prior to TKA do not increase the risk of developing postoperative PJI.

Keywords

intra-articular injections - total knee arthroplasty - outcomes - infection

• References

• 1 Nin DZ, Chen YW, Talmo CT. et al. Costs of nonoperative procedures for knee osteoarthritis in the year prior to primary total knee arthroplasty. J Bone Joint Surg Am 2022; 104 (19) 1697-1702
• 2 Bedard NA, Pugely AJ, Elkins JM. et al. The John N. Insall award: do intraarticular injections increase the risk of infection after TKA?. Clin Orthop Relat Res 2017; 475 (01) 45-52
• 3 Kokubun BA, Manista GC, Courtney PM, Kearns SM, Levine BR. Intra-articular knee injections before total knee arthroplasty: outcomes and complication rates. J Arthroplasty 2017; 32 (06) 1798-1802
• 4 Horne G, Devane P, Davidson A, Adams K, Purdie G. The influence of steroid injections on the incidence of infection following total knee arthroplasty. N Z Med J 2008; 121 (1268): U2896
• 5 Cancienne JM, Werner BC, Luetkemeyer LM, Browne JA. Does timing of previous intra-articular steroid injection affect the post-operative rate of infection in total knee arthroplasty?. J Arthroplasty 2015; 30 (11) 1879-1882
• 6 Premkumar A, Kolin DA, Farley KX. et al. Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. J Arthroplasty 2021; 36 (05) 1484-1489.e3
• 7 Merative. Merative MarketScan Research Databases. Accessed July 25, 2024 at: https://www.merative.com/documents/brief/marketscan-explainer-general
• 8 Amin NH, Omiyi D, Kuczynski B, Cushner FD, Scuderi GR. The risk of a deep infection associated with intraarticular injections before a total knee arthroplasty. J Arthroplasty 2016; 31 (01) 240-244
• 9 Grondin J, Menu P, Métayer B, Crenn V, Dauty M, Fouasson-Chailloux A. Intra-articular injections prior to total knee arthroplasty do not increase the risk of periprosthetic joint infection: a prospective cohort study. Antibiotics (Basel) 2021; 10 (03) 330
• 10 Papavasiliou AV, Isaac DL, Marimuthu R, Skyrme A, Armitage A. Infection in knee replacements after previous injection of intra-articular steroid. J Bone Joint Surg Br 2006; 88 (03) 321-323
• 11 Lee YT, Shao HJ, Wang JH, Liu HC, Hou SM, Young TH. Hyaluronic acid modulates gene expression of connective tissue growth factor (CTGF), transforming growth factor-beta1 (TGF-beta1), and vascular endothelial growth factor (VEGF) in human fibroblast-like synovial cells from advanced-stage osteoarthritis in vitro. J Orthop Res 2010; 28 (04) 492-496
• 12 Moreland LW. Intra-articular hyaluronan (hyaluronic acid) and hylans for the treatment of osteoarthritis: mechanisms of action. Arthritis Res Ther 2003; 5 (02) 54-67
• 13 Ross KM, Mehr JS, Carothers BL. et al. Bacterial septic arthritis infections associated with intra-articular injection practices for osteoarthritis knee pain-New Jersey, 2017. Infect Control Hosp Epidemiol 2019; 40 (09) 1013-1018
• 14 Charalambous CP, Tryfonidis M, Sadiq S, Hirst P, Paul A. Septic arthritis following intra-articular steroid injection of the knee—a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clin Rheumatol 2003; 22 (06) 386-390
• 15 Mather III RC, Hug KT, Orlando LA. et al. Economic evaluation of access to musculoskeletal care: the case of waiting for total knee arthroplasty. BMC Musculoskelet Disord 2014; 15: 22
• 16 Bhattacharjee S, Wallace S, Luu HH, Shi LL, Lee MJ, Chen AF. Do we need to wait 3 months after corticosteroid injections to reduce the risk of infection after total knee arthroplasty?. J Am Acad Orthop Surg 2021; 29 (14) e714-e721
• 17 Bains SS, Chen Z, Sax OC, Naziri Q, Nace J, Delanois RE. Delaying total knee arthroplasty more than 4 weeks after intra-articular knee injection does not further decrease risk of septic revision. J Knee Surg 2022; 35 (14) 1511-1517
• 18 Lundstrom ZT, Sytsma TT, Greenlund LS. Rethinking viscosupplementation: ultrasound- versus landmark-guided injection for knee osteoarthritis. j ultrasound med 2020; 39 (01) 113-117
• 19 Berkoff DJ, Miller LE, Block JE. Clinical utility of ultrasound guidance for intra-articular knee injections: a review. Clin Interv Aging 2012; 7: 89-95