Safety of intraarticular corticosteroid injection preceding hip and knee arthroplasty: a systematic review and meta-analysis amid resolving COVID-19 arthroplasty restrictions

ABSTRACT

Intraarticular corticosteroid injection (ICSI) is a widely practiced management for hip and knee osteoarthritis. Imposed delays to arthroplasty during coronavirus disease 2019 pandemic have led us to postulate that many patients have opted for recent ICSI. We compared the odds of prosthetic joint infection (PJI) in patients who were or were not administered ICSI within 12 months prior to hip or knee arthroplasty. A systematic search of PubMed, Embase, The Cochrane Library and Web of Science was performed in February 2021, with studies assessing the effect of ICS on PJI rates identified. All studies, which included patients that received ICSI in the 12 months prior to primary hip and knee arthroplasty, were included. In total 12 studies were included: four studies with 209 353 hips and eight studies with 438 440 knees. ICSI administered in the 12 months prior to hip arthroplasty increased the odds of PJI [odds ratio (OR) = 1.17, P = 0.04]. This was not the case for knees. Subgroup analysis showed significantly higher odds of PJI in both hip [OR = 1.45, P = 0.002] and knee arthroplasty [OR = 2.04; P = 0.04] when ICSI was within the preceding 3 months of surgery. A significantly higher odds of PJI were seen in patients receiving ICSI within the 12 months prior to hip arthroplasty. Subgroup analysis showed increased odds of PJI in both hip and knee arthroplasty, in patients receiving ICSI within 3 months prior to their arthroplasty. We recommend delaying knee arthroplasty for at least 3 months after ICSI and possibly longer for hip arthroplasty.

Level of Evidence

Level III - Systematic Review of Level II and III Studies.

INTRODUCTION

Prosthetic joint infection (PJI) affects between 0.76% and 1.24% of primary hips and knees in the Western world [1]. When PJI occurs, it has potentially devastating consequences, with associated morbidity and a 1-year mortality rate as high as 11% when arthroplasty is revised for PJI [2]. Treatment for PJI varies depending upon the patient profile and the severity of infection, which ranges from implant salvage procedures, such as liner exchange, to single or two-stage revision arthroplasties.

In recent decades, the demand for joint arthroplasty has increased and is projected to continue to rise further [3]. Recent studies project 3.5 million knee and 600 000 total hip arthroplasties will be performed in the USA by 2030 [4]. Accounting for the current incidence of PJI, we expect a disease burden of ∼50 000 PJIs annually. For all patients, arthroplasty is the best considered when non-operative measures have been exhausted. A recommended mode of symptom management in osteoarthritis is via intraarticular corticosteroid injections (ICSIs), often, as part of a multimodal pain management effort [5–9], aiming to achieve symptom control by immunosuppression [10]. Injection into a native joint carries the inherent risk of intraarticular inoculation of pathogens.

It may be theorized that ICSI performed in the months leading up to arthroplasty may risk PJI although the precise time window for this remains unclear. Previous published systematic reviews and meta-analyses on this topic have conflicting results. Two of these meta-analyses concluded an increased risk of subsequent PJI following ICSI [11, 12], while five other studies refuted this conclusion [13–17]. These studies have been criticized for their poor-quality study inclusion and high heterogeneity of their included studies. In this study, we provide an up-to-date systematic review and meta-analysis pertaining to the safe time interval between ICSI and arthroplasty. This is the first systematic review to investigate the temporal relationship between ICSI and odds of acquiring a PJI. Imposed delays to arthroplasty during coronavirus disease (COVID-19) pandemic and with many deferred patients reporting significant symptom progression [18], we postulate that many may have opted for recent ICSI. After pandemic elective arthroplasty restrictions are lifted, most patients will be eager to undergo arthroplasty at the earliest opportunity [19]. This may potentially place them at a higher risk of PJI if our premise is correct.

MATERIALS AND METHODS

The systematic review was performed based on the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

Search strategy

We performed a systematic search of the literature across PubMed, Embase, The Cochrane Library and Web of Science from the date of inception of each database through to February 2021. No ‘grey literature’ search was performed. The population of interest was patients with primary hip or knee arthroplasty. Comparisons were made between patients who received ipsilateral ICSI to their native joint within the preceding 12 months of arthroplasty and those who did not. The outcome of interest was the diagnosis of PJI.

A literature search was performed using the following search terms and Boolean operators (‘arthroplasty’ OR ‘joint replacement’) AND (‘injection’ OR ‘steroid’ OR ‘corticosteroid’) AND (‘prosthetic joint infection’ OR ‘periprosthetic infection’ OR ‘infection’). The title and abstracts were then screened by two reviewers independently (T.C. and M.J.) for relevance and consideration into a provisional list. The provisional list was then assessed independently by the two reviewers after reading full text for their potential inclusion. The two reviewers had a consensus on the included articles.

All articles comparing the two comparators on the patient population of interest were included. Studies that included patients who received ipsilateral ICSI more than 12 months prior to arthroplasty with sufficient data in their analysis for us to isolate the patient population of interest were included. Papers that specifically looked into perioperative steroid injection as part of multimodal postoperative analgesia technique, hyaluronic acid injections only, conference abstracts that with insufficient data for extraction, and studies of revision hip or knee arthroplasty patients were excluded. There were no restrictions on included publications, whether based on date of publication, language, study quality or geography.

Data collection and assessment of risk of bias

Data extraction was performed by the first reviewer (T.C.) and validated by the second reviewer (M.J.). The individual study characteristics and outcomes of interest were assessed. Studies were grouped and assessed separately whether hip or knee arthroplasty. The methodological quality of studies included was assessed independently by both reviewers using the National Institute of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Publication bias was assessed using funnel plots.

Outcomes and statistical analysis

The outcome of interest was the number of PJI in each group. Further subgroup analysis was performed, where study data allowed, regarding the incidence of PJI where ICSI was in the preceding 3 months of arthroplasty. Subgroup analysis was compared against the wider cohort if no readily matched cohort was available. Continuous variables were expressed as mean ± standard error of the mean. Where values were not readily available, this was calculated from the data provided. Statistical analysis was performed using the Mantel–Haenszel method, utilizing either a fixed effect model if the heterogeneity is <50% or a random-effects model if the heterogeneity is >50%. Odds ratio (OR) was used to illustrate the effects of each treatment arm on Forest plots. The corresponding 95% confidence interval (95% CI) and heterogeneity of data (I2) are also illustrated in both Forest plots and full text. I2 is a scale from 0 to 100% where higher values are associated with greater heterogeneity [20]. The statistical software used in this study was RevMan 5.4 (The Cochrane Collaboration, 2020).

RESULTS Search results

Four hundred and seventy-two studies were identified with the initial search strategy. Fifty duplicate studies were removed. From the remainder, a further 392 studies were excluded by screening titles and abstracts. Twelve studies were included in the final analysis, of which four described PJI in hip arthroplasty [21–24], and the remaining eight described PJI in knee arthroplasty, [25–32] each following intra-articular injections into native joints. The results of our literature search are displayed in Fig. 1.

Fig. 1.

PRISMA flow diagram.

Fig. 1.

PRISMA flow diagram. Total hip arthroplasty

Four studies with a cumulative sample size of 209 353 hips described the odds of PJI in patients receiving ICSI within 12 months prior to ipsilateral hip arthroplasty [21–24], of which 9188 were in the ICSI group and 200 165 were in the control group. The baseline characteristics of the studies are outlined in Table I. There was no significant heterogeneity between the studies [I2 = 0%, P-value = 0.86], and hence, a fixed-effect model was used. There was a significant difference in rates of PJI between the two arms [OR = 1.17, 95% CI = 1.01–1.36, P-value = 0.04]. The Forest plots for this are shown in Fig. 2a.

Table I.

Baseline characteristics of hip arthroplasty studies

.  . Cases . Controls .  . Study . Study Design (LOE) . Number of Hips . Age . Injection Given . Mean Delay . Definition of PJI . Number of Hips . Age . Follow-up Period . McIntosh (2006) Retrospective matched cohort
(level III) 224 70 ± 9.8 years Type and amount of steroid given was left at the discretion of provider. 3.68 ± 2.66 months Not stated 224 69 ± 9.6 years 24–60 months Meermans (2012) Retrospective matched cohort (level III) 175 66.4 years 80 mg of methylprednisolone and between 1 and 3 mL levobupivacaine Not stated 

Sinus tract communicating with implant, OR

Identical pathogen isolated from two or more tissue samples, OR

Presence of purulence in joint

 175 66.6 years 12–131 months Schairer (2016) Retrospective cohort
(level III) 5421 66.9 Not stated Not stated Hospital readmission with a procedure for infection (irrigation and debridement, implant removal with placement of a cement spacer, or revision hip arthroplasty with a concurrent diagnosis of infection) 168 537 66.6 Up to 12 months Werner (2016) Retrospective cohort
(level III) 3368 Not stated Not stated Not stated Diagnosis of or procedure for either wound or deep infection 3 or 6 months after THA 31 229 Not stated Up to 6 months  .  . Cases . Controls .  . Study . Study Design (LOE) . Number of Hips . Age . Injection Given . Mean Delay . Definition of PJI . Number of Hips . Age . Follow-up Period . McIntosh (2006) Retrospective matched cohort
(level III) 224 70 ± 9.8 years Type and amount of steroid given was left at the discretion of provider. 3.68 ± 2.66 months Not stated 224 69 ± 9.6 years 24–60 months Meermans (2012) Retrospective matched cohort (level III) 175 66.4 years 80 mg of methylprednisolone and between 1 and 3 mL levobupivacaine Not stated 

Sinus tract communicating with implant, OR

Identical pathogen isolated from two or more tissue samples, OR

Presence of purulence in joint

 175 66.6 years 12–131 months Schairer (2016) Retrospective cohort
(level III) 5421 66.9 Not stated Not stated Hospital readmission with a procedure for infection (irrigation and debridement, implant removal with placement of a cement spacer, or revision hip arthroplasty with a concurrent diagnosis of infection) 168 537 66.6 Up to 12 months Werner (2016) Retrospective cohort
(level III) 3368 Not stated Not stated Not stated Diagnosis of or procedure for either wound or deep infection 3 or 6 months after THA 31 229 Not stated Up to 6 months Table I.

Baseline characteristics of hip arthroplasty studies

.  . Cases . Controls .  . Study . Study Design (LOE) . Number of Hips . Age . Injection Given . Mean Delay . Definition of PJI . Number of Hips . Age . Follow-up Period . McIntosh (2006) Retrospective matched cohort
(level III) 224 70 ± 9.8 years Type and amount of steroid given was left at the discretion of provider. 3.68 ± 2.66 months Not stated 224 69 ± 9.6 years 24–60 months Meermans (2012) Retrospective matched cohort (level III) 175 66.4 years 80 mg of methylprednisolone and between 1 and 3 mL levobupivacaine Not stated 

Sinus tract communicating with implant, OR

Identical pathogen isolated from two or more tissue samples, OR

Presence of purulence in joint

 175 66.6 years 12–131 months Schairer (2016) Retrospective cohort
(level III) 5421 66.9 Not stated Not stated Hospital readmission with a procedure for infection (irrigation and debridement, implant removal with placement of a cement spacer, or revision hip arthroplasty with a concurrent diagnosis of infection) 168 537 66.6 Up to 12 months Werner (2016) Retrospective cohort
(level III) 3368 Not stated Not stated Not stated Diagnosis of or procedure for either wound or deep infection 3 or 6 months after THA 31 229 Not stated Up to 6 months  .  . Cases . Controls .  . Study . Study Design (LOE) . Number of Hips . Age . Injection Given . Mean Delay . Definition of PJI . Number of Hips . Age . Follow-up Period . McIntosh (2006) Retrospective matched cohort
(level III) 224 70 ± 9.8 years Type and amount of steroid given was left at the discretion of provider. 3.68 ± 2.66 months Not stated 224 69 ± 9.6 years 24–60 months Meermans (2012) Retrospective matched cohort (level III) 175 66.4 years 80 mg of methylprednisolone and between 1 and 3 mL levobupivacaine Not stated 

Sinus tract communicating with implant, OR

Identical pathogen isolated from two or more tissue samples, OR

Presence of purulence in joint

 175 66.6 years 12–131 months Schairer (2016) Retrospective cohort
(level III) 5421 66.9 Not stated Not stated Hospital readmission with a procedure for infection (irrigation and debridement, implant removal with placement of a cement spacer, or revision hip arthroplasty with a concurrent diagnosis of infection) 168 537 66.6 Up to 12 months Werner (2016) Retrospective cohort
(level III) 3368 Not stated Not stated Not stated Diagnosis of or procedure for either wound or deep infection 3 or 6 months after THA 31 229 Not stated Up to 6 months 

Fig. 2.

(a) Overall odds of subsequent prosthetic hip joint (hip arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 12 months prior to replacement. (b) Overall odds of subsequent prosthetic hip joint (hip arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 3 months prior to replacement.

(a) Overall odds of subsequent prosthetic hip joint (hip arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 12 months prior to replacement. (b) Overall odds of subsequent prosthetic hip joint (hip arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 3 months prior to replacement.

Fig. 2.

(a) Overall odds of subsequent prosthetic hip joint (hip arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 12 months prior to replacement. (b) Overall odds of subsequent prosthetic hip joint (hip arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 3 months prior to replacement.

(a) Overall odds of subsequent prosthetic hip joint (hip arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 12 months prior to replacement. (b) Overall odds of subsequent prosthetic hip joint (hip arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 3 months prior to replacement.

Two studies [23, 24] with 202 758 hips, of which 2992 were in the ICSI group and 199 766 were in the control group, analyzed the effect of ICSI on the odds of PJI within the 3 months prior to ipsilateral hip arthroplasty. There was no heterogeneity between the studies [I2 = 0%, P-value = 0.67], and hence, a fixed-effect model was used. There was a significantly increased rate of PJI in patients who received an ICSI in 3 months preceding hip arthroplasty [OR = 1.45, 95% CI = 1.15–1.83, P-value = 0.002]. The results of the Forest plots are shown in Fig. 2b.

Total knee arthroplasty

Eight studies that enrolled a total of 438 440 cases described the rates of PJI of knee arthroplasty patients who received ICSI within 12 months prior to knee arthroplasty [25–32], of which 107 981 were in the ICSI group and 330 459 were in the control group. The baseline characteristics of these studies are outlined in Table II. There was significant heterogeneity [I2 = 99%, P-value < 0.00001] between studies, and hence, a random effect model was used. There was no significant difference in rates of PJI between those patients who had and those who had not received ICSI within 12 months prior to their knee arthroplasty [OR = 1.96, 95% CI = 0.97–3.96, P-value = 0.06]. The results of the Forest plots are shown in Fig. 3a.

Table II.

Baseline characteristics of knee arthroplasty series

.  . Cases . Controls .  . Study . Study Design (LOE) . Number of Knees . Age . Injection Given . Mean Delay . Definition of PJI . Number of Knees . Age . Follow-up Period . Amin (2016) Retrospective cohort (level III) 300 Not stated Not stated Not stated MSIS criteria as assessed by two senior surgeons 845 64.14 years Not stated Bedard (2016) Retrospective matched cohort (level III) 29 603 Not stated Not stated Not stated Patients identified to have undergone operative management related to Total Knee Arthroplasty (TKA) surgical site infection 54 081 Not stated 6 months Cancienne (2015) Retrospective matched cohort (level III) 22 240 Not stated Not stated Not stated Diagnosis or procedure for wound or deep infection within 3 or 6 months after Total Knee Arthroplasty (TKA) 13 650 Not stated 6 months Desai (2009) Prospective matched cohort (level II) 45 Not stated Depomedrone 40 mg + Chirocaine Not stated Cases with positive swab cultures or tissue biopsy from deep tissues and underwent washout/ debridement as a result, OR patients who underwent revision surgery for infection 180 72 years 12–72 months Khanuja (2016) Prospective cohort (level II) 280 Not stated Triamcinolone acetonide 1 mL + Xylocaine (4%) Not stated 

Sinus tract to prosthesis

Pathogen isolated by culture from two or more deep samples

Four of the following: raised ESR or CRP; raised synovial leukocyte count; raised synovial neutrophil percentage; purulence from joint; pathogen isolated from single deep specimen; more than 5 neutrophils per HPF

 302 65 21–66 months Kurtz (2021) Retrospective cohort (level III) 38 803 Not stated Either corticosteroid injection or corticosteroid mixed with hyaluronic acid Not stated Patients identified using diagnostic code for infection as well as concurrent procedural code for either revision arthroplasty, arthrotomy, or spacer insertion 222 879 Not stated 24 months Papavasiliou (2006) Retrospective cohort (level III) 54 Not stated Not stated Not stated 

Purulent drainage from depths of incision

Positive culture from aseptically aspirated fluid or deep tissue biopsy, or pus cells on microscopy

Deep incision that has spontaneously dehisced or opened by a surgeon when the patient was febrile

An abscess or evidence of infection involving deep tissues seen during reoperation

Diagnosis by attending clinician

 90 Not stated Not stated Richardson (2019) Retrospective cohort (level III) 16 656 Not stated Not stated Not stated Diagnosis or procedure for wound or deep infection within 6 months after Total Knee Arthroplasty (TKA) 38 432 Not stated 6 months  .  . Cases . Controls .  . Study . Study Design (LOE) . Number of Knees . Age . Injection Given . Mean Delay . Definition of PJI . Number of Knees . Age . Follow-up Period . Amin (2016) Retrospective cohort (level III) 300 Not stated Not stated Not stated MSIS criteria as assessed by two senior surgeons 845 64.14 years Not stated Bedard (2016) Retrospective matched cohort (level III) 29 603 Not stated Not stated Not stated Patients identified to have undergone operative management related to Total Knee Arthroplasty (TKA) surgical site infection 54 081 Not stated 6 months Cancienne (2015) Retrospective matched cohort (level III) 22 240 Not stated Not stated Not stated Diagnosis or procedure for wound or deep infection within 3 or 6 months after Total Knee Arthroplasty (TKA) 13 650 Not stated 6 months Desai (2009) Prospective matched cohort (level II) 45 Not stated Depomedrone 40 mg + Chirocaine Not stated Cases with positive swab cultures or tissue biopsy from deep tissues and underwent washout/ debridement as a result, OR patients who underwent revision surgery for infection 180 72 years 12–72 months Khanuja (2016) Prospective cohort (level II) 280 Not stated Triamcinolone acetonide 1 mL + Xylocaine (4%) Not stated 

Sinus tract to prosthesis

Pathogen isolated by culture from two or more deep samples

Four of the following: raised ESR or CRP; raised synovial leukocyte count; raised synovial neutrophil percentage; purulence from joint; pathogen isolated from single deep specimen; more than 5 neutrophils per HPF

 302 65 21–66 months Kurtz (2021) Retrospective cohort (level III) 38 803 Not stated Either corticosteroid injection or corticosteroid mixed with hyaluronic acid Not stated Patients identified using diagnostic code for infection as well as concurrent procedural code for either revision arthroplasty, arthrotomy, or spacer insertion 222 879 Not stated 24 months Papavasiliou (2006) Retrospective cohort (level III) 54 Not stated Not stated Not stated 

Purulent drainage from depths of incision

Positive culture from aseptically aspirated fluid or deep tissue biopsy, or pus cells on microscopy

Deep incision that has spontaneously dehisced or opened by a surgeon when the patient was febrile

An abscess or evidence of infection involving deep tissues seen during reoperation

Diagnosis by attending clinician

 90 Not stated Not stated Richardson (2019) Retrospective cohort (level III) 16 656 Not stated Not stated Not stated Diagnosis or procedure for wound or deep infection within 6 months after Total Knee Arthroplasty (TKA) 38 432 Not stated 6 months Table II.

Baseline characteristics of knee arthroplasty series

.  . Cases . Controls .  . Study . Study Design (LOE) . Number of Knees . Age . Injection Given . Mean Delay . Definition of PJI . Number of Knees . Age . Follow-up Period . Amin (2016) Retrospective cohort (level III) 300 Not stated Not stated Not stated MSIS criteria as assessed by two senior surgeons 845 64.14 years Not stated Bedard (2016) Retrospective matched cohort (level III) 29 603 Not stated Not stated Not stated Patients identified to have undergone operative management related to Total Knee Arthroplasty (TKA) surgical site infection 54 081 Not stated 6 months Cancienne (2015) Retrospective matched cohort (level III) 22 240 Not stated Not stated Not stated Diagnosis or procedure for wound or deep infection within 3 or 6 months after Total Knee Arthroplasty (TKA) 13 650 Not stated 6 months Desai (2009) Prospective matched cohort (level II) 45 Not stated Depomedrone 40 mg + Chirocaine Not stated Cases with positive swab cultures or tissue biopsy from deep tissues and underwent washout/ debridement as a result, OR patients who underwent revision surgery for infection 180 72 years 12–72 months Khanuja (2016) Prospective cohort (level II) 280 Not stated Triamcinolone acetonide 1 mL + Xylocaine (4%) Not stated 

Sinus tract to prosthesis

Pathogen isolated by culture from two or more deep samples

Four of the following: raised ESR or CRP; raised synovial leukocyte count; raised synovial neutrophil percentage; purulence from joint; pathogen isolated from single deep specimen; more than 5 neutrophils per HPF

 302 65 21–66 months Kurtz (2021) Retrospective cohort (level III) 38 803 Not stated Either corticosteroid injection or corticosteroid mixed with hyaluronic acid Not stated Patients identified using diagnostic code for infection as well as concurrent procedural code for either revision arthroplasty, arthrotomy, or spacer insertion 222 879 Not stated 24 months Papavasiliou (2006) Retrospective cohort (level III) 54 Not stated Not stated Not stated 

Purulent drainage from depths of incision

Positive culture from aseptically aspirated fluid or deep tissue biopsy, or pus cells on microscopy

Deep incision that has spontaneously dehisced or opened by a surgeon when the patient was febrile

An abscess or evidence of infection involving deep tissues seen during reoperation

Diagnosis by attending clinician

 90 Not stated Not stated Richardson (2019) Retrospective cohort (level III) 16 656 Not stated Not stated Not stated Diagnosis or procedure for wound or deep infection within 6 months after Total Knee Arthroplasty (TKA) 38 432 Not stated 6 months  .  . Cases . Controls .  . Study . Study Design (LOE) . Number of Knees . Age . Injection Given . Mean Delay . Definition of PJI . Number of Knees . Age . Follow-up Period . Amin (2016) Retrospective cohort (level III) 300 Not stated Not stated Not stated MSIS criteria as assessed by two senior surgeons 845 64.14 years Not stated Bedard (2016) Retrospective matched cohort (level III) 29 603 Not stated Not stated Not stated Patients identified to have undergone operative management related to Total Knee Arthroplasty (TKA) surgical site infection 54 081 Not stated 6 months Cancienne (2015) Retrospective matched cohort (level III) 22 240 Not stated Not stated Not stated Diagnosis or procedure for wound or deep infection within 3 or 6 months after Total Knee Arthroplasty (TKA) 13 650 Not stated 6 months Desai (2009) Prospective matched cohort (level II) 45 Not stated Depomedrone 40 mg + Chirocaine Not stated Cases with positive swab cultures or tissue biopsy from deep tissues and underwent washout/ debridement as a result, OR patients who underwent revision surgery for infection 180 72 years 12–72 months Khanuja (2016) Prospective cohort (level II) 280 Not stated Triamcinolone acetonide 1 mL + Xylocaine (4%) Not stated 

Sinus tract to prosthesis

Pathogen isolated by culture from two or more deep samples

Four of the following: raised ESR or CRP; raised synovial leukocyte count; raised synovial neutrophil percentage; purulence from joint; pathogen isolated from single deep specimen; more than 5 neutrophils per HPF

 302 65 21–66 months Kurtz (2021) Retrospective cohort (level III) 38 803 Not stated Either corticosteroid injection or corticosteroid mixed with hyaluronic acid Not stated Patients identified using diagnostic code for infection as well as concurrent procedural code for either revision arthroplasty, arthrotomy, or spacer insertion 222 879 Not stated 24 months Papavasiliou (2006) Retrospective cohort (level III) 54 Not stated Not stated Not stated 

Purulent drainage from depths of incision

Positive culture from aseptically aspirated fluid or deep tissue biopsy, or pus cells on microscopy

Deep incision that has spontaneously dehisced or opened by a surgeon when the patient was febrile

An abscess or evidence of infection involving deep tissues seen during reoperation

Diagnosis by attending clinician

 90 Not stated Not stated Richardson (2019) Retrospective cohort (level III) 16 656 Not stated Not stated Not stated Diagnosis or procedure for wound or deep infection within 6 months after Total Knee Arthroplasty (TKA) 38 432 Not stated 6 months 

Fig. 3.

(a) Overall odds of prosthetic knee joint (knee arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 12 months prior to replacement. (b) Overall odds of prosthetic knee joint (knee arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 3 months prior to replacement.

(a) Overall odds of prosthetic knee joint (knee arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 12 months prior to replacement. (b) Overall odds of prosthetic knee joint (knee arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 3 months prior to replacement.

Fig. 3.

(a) Overall odds of prosthetic knee joint (knee arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 12 months prior to replacement. (b) Overall odds of prosthetic knee joint (knee arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 3 months prior to replacement.

(a) Overall odds of prosthetic knee joint (knee arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 12 months prior to replacement. (b) Overall odds of prosthetic knee joint (knee arthroplasty) infection in patients receiving intra-articular steroid injection to ipsilateral native joint within 3 months prior to replacement.

Six of those eight studies with a total of 309 283 knees, of which 35 600 were in the ICSI group and 273 683 were in the control group, described the rates of PJI in patients who received ICSI within 3 months prior to arthroplasty [25–27, 29, 30, 32]. There was significant heterogeneity [I2 = 97%, P-value < 0.00001] between studies, and hence, a random effect model was used. There was a significantly increased odds of PJI in those who had received ICSI within 3 months prior to arthroplasty, compared to those who had not [OR = 2.04, 95% CI = 1.05–3.97, P-value = 0.04]. The Forest plots are shown in Fig. 3b.

Risk of bias analysis

Risk of bias in individual studies was analyzed using the National Institute of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The results are displayed in Table III. No studies provided any justification for sample size or the number of ICSI. Concerningly, a study by Amin et al. categorized patients into one of three groups: no injection, steroid injection or viscosupplementation injection. However, the group classification was based upon which injection the patient last had, which may have led to significant bias in the results [25]. It was unclear from all studies whether outcome assessors were blinded to the exposure status of the participants.

Table III.

Risk of bias analysis using the National Institute of Health assessment tool for observational cohort and cross-sectional studies

. McIntosh . Meermans . Schairer . Werner . Amin . Bedard . Cancienne . Desai . Khanuja . Kurtz . Papavasiliou . Richardson .  . (2006) . (2012) . (2016) . (2016) . (2016) . (2016) . (2015) . (2009) . (2016) . (2021) . (2006) . (2019) . Was the research question or objective in this paper clearly stated? Y Y Y Y Y Y Y Y Y Y Y Y Was the study population clearly specified and defined? Y Y Y Y Y Y Y Y Y Y Y Y Was the particip

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