Hospital for Special Surgery, New York, NY.
J Bone Joint Surg Am. 2019 Jan 16;101(2):112-118. doi: 10.2106/JBJS.18.00454.
Recent studies have shown that intra-articular injections ≤3 months before total knee arthroplasty increase the risk of periprosthetic joint infection. We are aware of no previous study that has differentiated the risk of periprosthetic joint infection on the basis of the type of medication injected. In addition, we are aware of no prior study that has evaluated whether hyaluronic acid injections increase the risk of infection after total knee arthroplasty. In this study, we utilized pharmaceutical data to compare patients who received preoperative corticosteroid or hyaluronic acid injections and to determine whether a specific injection type increased the risk of periprosthetic joint infection.
Patients undergoing unilateral primary total knee arthroplasty were selected from a nationwide private insurer database. Ipsilateral preoperative injections were identified and were grouped by medication codes for corticosteroid or hyaluronic acid. Patients who had received both types of injections ≤1 year before total knee arthroplasty were excluded. The outcome of interest was periprosthetic joint infection that occurred ≤6 months following the total knee arthroplasty. The risk of periprosthetic joint infection was compared between groups (no injection, corticosteroid, hyaluronic acid) and between patients who received single or multiple injections. Statistical comparisons were performed using logistic regression controlling for age, sex, and comorbidities.
A total of 58,337 patients underwent total knee arthroplasty during the study period; 3,249 patients (5.6%) received hyaluronic acid and 16,656 patients (28.6%) received corticosteroid ≤1 year before total knee arthroplasty. The overall infection rate was 2.74% in the no-injection group. Multivariable logistic regression showed independent periprosthetic joint infection risk for both corticosteroid (odds ratio [OR], 1.21; p = 0.014) and hyaluronic acid (OR, 1.55; p = 0.029) given ≤3 months before total knee arthroplasty. There was no increased risk with injections >3 months prior to total knee arthroplasty. Direct comparison of corticosteroid and hyaluronic acid showed no significant difference (p > 0.05) between medications or between single and multiple injections.
Preoperative corticosteroid or hyaluronic acid injection ≤3 months before total knee arthroplasty increased the risk of periprosthetic joint infection. There was no difference in infection risk between medications or between multiple and single injections. On the basis of these data, we recommend avoiding both injection types in the 3 months prior to total knee arthroplasty.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
最近的研究表明，全膝关节置换术前 3 个月内进行关节内注射会增加假体周围关节感染的风险。我们不知道之前有任何研究根据注射药物的类型来区分假体周围关节感染的风险。此外，我们不知道之前是否有研究评估过透明质酸注射是否会增加全膝关节置换术后感染的风险。在这项研究中，我们利用药物数据比较了接受术前皮质类固醇或透明质酸注射的患者，并确定了特定的注射类型是否会增加假体周围关节感染的风险。
从一家全国性私人保险公司的数据库中选择了接受单侧初次全膝关节置换术的患者。确定了同侧术前注射，并按皮质类固醇或透明质酸的药物代码进行分组。排除了在全膝关节置换术前 1 年内接受过这两种类型注射的患者。感兴趣的结果是全膝关节置换术后 6 个月内发生的假体周围关节感染。通过逻辑回归比较了无注射、皮质类固醇、透明质酸组之间的感染风险，以及接受单次或多次注射的患者之间的风险。统计比较在控制年龄、性别和合并症的情况下进行。
在研究期间，共有 58337 名患者接受了全膝关节置换术；3249 名患者（5.6%）在全膝关节置换术前 1 年内接受了透明质酸注射，16656 名患者（28.6%）接受了皮质类固醇注射。无注射组的总体感染率为 2.74%。多变量逻辑回归显示，皮质类固醇（比值比[OR]，1.21；p = 0.014）和透明质酸（OR，1.55；p = 0.029）在全膝关节置换术前 3 个月内使用与假体周围关节感染风险独立相关。在全膝关节置换术前 3 个月以上使用则没有增加感染风险。皮质类固醇和透明质酸的直接比较显示，药物之间或单次和多次注射之间没有显著差异（p > 0.05）。
全膝关节置换术前 3 个月内皮质类固醇或透明质酸注射增加了假体周围关节感染的风险。两种药物之间或多次和单次注射之间的感染风险没有差异。基于这些数据，我们建议在全膝关节置换术前 3 个月内避免使用这两种注射类型。
治疗性 III 级。请参阅作者说明，以获取完整的证据水平描述。
