Steroids Before Hip Arthroplasty Increase Infection Risk

Patients should not receive intra-articular steroid injections in the hip in the 3 months before total hip arthroplasty because it could put them at higher risk for postoperative infection, new research shows.

“I’ve spoken with surgeons who have been reluctant to perform hip injections before surgery because of the theoretical risk of infection due to immunosuppression,” said William Schairer, MD, from the Hospital for Special Surgery in New York City.

“Now that we have established this association, surgeons can have more serious discussions about implications with their patients,” he told Medscape Medical News.

Dr Schairer presented the study results here at the American Academy of Orthopaedic Surgeons 2016 Annual Meeting.

He and his colleagues assessed the effect of a preoperative intra-articular steroid injection on the risk for periprosthetic joint infection after total hip arthroplasty, using data from the Statewide Ambulatory Surgery and Inpatient Database for Florida and California from 2005 to 2012.

Of the 177,762 patients who underwent total hip arthroplasty, 5527 (3.1%) had received a hip injection in the year before surgery. Intra-articular steroid injections are a common diagnostic and therapeutic procedure for patients with hip pain. They can confirm the source of pain and provide pain relief that could help delay surgery.

Of the 5527 injections, 1416 (0.8%) were administered 6 to 12 months before surgery, 1899 (1.1%) were administered 3 to 6 months before surgery, and 2212 (1.2%) were administered 0 to 3 months before surgery.

In the 6-month period after surgery and in the 12-month period, the rate of periprosthetic joint infection was highest in patients who received injections in the 3 months before surgery.

Table. Postoperative Infection Rates

Time From Injection to Surgery	6-Month Infection Rate (%)	12-Month Infection Rate (%)
0 to 3 months	1.76	2.04
3 to 6 months	1.13	1.35
6 to 12 months	1.58	1.72
No hip injection	1.21	1.47

 

Joint infection is the worst complication you can get, said Dr Schairer. “If it’s severe enough and you have to take the hip out, that buys you a couple more surgeries,” he told Medscape Medical News.

Despite the fact that many doctors already believed this to be the case, it has only been possible to study this type of information in the last 5 years, he explained. “Until big data, it was difficult to look at more than a couple of hundred patients at a time from single institutions.”

These results are in line with those from a recent study conducted by researchers at the University of Virginia Health System who evaluated the risk for infection in nearly 35,000 arthroplasty patients, more than 3000 of whom received a steroid injection before surgery (J Arthroplasty. Published online September 1, 2015). They found an infection rate of 3.74% in the 6-month period after surgery in patients who received an injection 3 months before surgery.

“We’ve always suspected that injections within 3 months increase infection risk, and now there are even more data to support this,” said Raymond Kim, MD, from Colorado Joint Replacement in Denver.

Dr Kim said he encourages nonoperative treatments, such as anti-inflammatory medications, gait aids, and the avoidance of high-impact activities, before injections.

“We’ll only resort to injections if the patient doesn’t want surgery or wants temporary relief. For example, if the arthritic pain is really bad, an injection could help them get through a vacation where they’ll be walking a lot,” he told Medscape Medical News.

With the new bundled payment system coming down the pike, surgeons will have to work harder to minimize modifiable risks, such as making sure blood sugar is in check and that the patient is not smoking, he added. “We want to decrease risks of complications after surgery.”

American Academy of Orthopaedic Surgeons (AAOS) 2016 Annual Meeting: Abstract 916. Presented March 2, 2016.