Injections Prior to Arthroplasty
Limited evidence suggests intra-articular injection performed prior to total joint arthroplasty may have a time-dependent association for increased risk of PJI.

Rationale

One low strength study (Ravi et al. 2015) reported an association between intra-articular hip injection within 1 year prior to hip replacement and the development of periprosthetic hip infection). Another low strength study (Schairer et al. 2016) confirmed this association but only when the injection was within 3 months or less of the surgery. Kaspar et al (Kaspar 2005) also raise the concern for an increased risk for revision surgery due to infection in hips that had intra-articular steroid injections prior to replacement. A moderate strength study (Chambers et al. 2017) evaluated the effect of multiple steroid injections versus a single injection within the 12 months preceding hip replacement and found an increased risk for periprosthetic joint infection in the multiple injection cohort. The cohorts in this study were dissimilar in that the multi-injection cohort on average had injections closer to the time of hip replacement than the single cohort. Other low strength studies have shown no risk for infection when injections preceded hip arthroplasty (Meermans 2012, Sreekumar 2007, McIntosh 2006).

With respect to injections prior to knee arthroplasty, two low strength studies (Papavasiliou et al. 2006, Bedard et al. 2017) reported on an increased risk for deep infection if the patient had received an intra-articular steroid injection within 6 to 7 months (Bedard et al 2017) or within 12 months (Papavasiliou et al. 2006) prior to surgery. Other low strength studies have found no correlation between preoperative intra-articular injection and periprosthetic knee infection (Khanuja 2016, Amin 2016, Desai 2009). Looking at multiple preoperative injections in knee replacement patients, Kokubun et al (2017) conducted a low strength study that found no difference in infection risk between subjects with 4 or more injections versus those with 3 or less injections.

The studies on this topic are subject to the bias associated with retrospective design, numerous variables related to type and timing of injections, small sample size, and inconsistent definition of infection making firm conclusions difficult.

POSSIBLE HARMS OF IMPLEMENTATION
A possible harm to this recommendation is that patients could be inappropriately denied reconstruction of end stage joint disease if they had a prior intra-articular injection. It is important to note that the exact interval between an injection and surgery that may increase risk is not clear. Additionally, even though the risk was higher in injected patients in some studies, the overall event rate was still low.

FUTURE RESEARCH
With conflicting reports in the literature, a prospective and randomized study comparing injection versus no injection at a defined time interval and in a large patient cohort is needed. The ubiquitous nature of preoperative injections for symptomatic management of hip and knee arthritis deserves further investigation as to the possibility of an association with periprosthetic joint infection.
 


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