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Intra-Articular Injections Prior to Total Knee Arthroplasty Do Not Increase the Risk of Periprosthetic Joint Infection: A Prospective Cohort Study.

ABSTRACT: Periprosthetic joint infections (PJI) occur in 0.5 to 2.8% of total knee arthroplasties (TKA) and expose them to an increase of morbidity and mortality. TKA are mainly performed after failure of non-surgical management of knee osteoarthritis, which frequently includes intra-articular injections of corticosteroids or hyaluronic acid. Concerning the potential impact of intra-articular injections on TKA infection, literature provides a low level of evidence because of the retrospective design of the studies and their contradictory results. In this prospective cohort study, we included patients after a total knee arthroplasty, at the time of their admission in a rehabilitation center, and we excluded patients with any prior knee surgery. 304 patients were included. Mean follow-up was 24.9 months, and incidence proportion of PJI was 2.6%. After multivariate logistic regression, male was the only significant risk factor of PJI (OR = 19.6; p = 0.006). The incidence of PJI did not differ between patients who received prior intra-articular injections and others, especially regarding injections in the last 6 months before surgery. The use of intra-articular injection remains a valid therapeutic option in the management of knee osteoarthritis, and a TKA could still be discussed.

SUBMITTER: Grondin J

PROVIDER: S-EPMC8004162 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Objective: The current review was designed to assess the impact of prior intra-articular injections on the risk of prosthetic joint infection (PJI) in patients undergoing total joint arthroplasty (TJA) with a focus on the timing of injection before surgery. Methods: The databases of PubMed, Embase and Google Scholar were searched up to 15th June 2021. All studies comparing the incidence of PJI with and without prior intra-articular injections were included. Risk ratios (RR) with 95% confidence intervals were calculated for PJI. Results: Nineteen studies were included. Both corticosteroids and hyaluronic acid injections were used before TJA in the included studies. Overall, comparing 127,163 patients with prior intra-articular injections and 394,104 patients without any injections, we noted a statistically significant increased risk of PJI in the injection group (RR 1.24 95% CI: 1.11, 1.38 I2 = 48% p = 0.002). On subgroup analysis, there was a statistically significant increased risk of PJI in the injection group in studies where intra-articular injections were administered <12 months before surgery (RR 1.18 95% CI: 1.10, 1.27 I2 = 7% p < 0.00001). Furthermore, on meta-analysis, we noted non-significant but increased risk of PJI when injections were administered 1 month (RR 1.47 95% CI: 0.88, 2.46 I2 = 77% p = 0.14), 0-3 months (RR 1.22 95% CI: 0.96, 1.56 I2 = 84% p = 0.11), and 3-6 months (RR 1.16 95% CI: 0.99, 1.35 I2 = 49% p = 0.06) before surgery. Conclusion: Our results indicate that patients with prior intra-articular injections have a small but statistically significant increased risk of PJI after TJA. Considering that PJI is a catastrophic complication with huge financial burden, morbidity and mortality; the clinical significance of this small risk cannot be dismissed. The question of the timing of injections and the risk of PJI still remains and can have a significant impact on the decision making. Systematic Review Registration: PROSPERO: CRD42021258297.

Project description:A growing number of recent investigations on the human genome, gut microbiome, and proteomics suggests that the loss of mucosal barrier function, particularly in the gastrointestinal tract, may substantially affect antigen trafficking, ultimately influencing the close bidirectional interaction between the gut microbiome and the immune system. This cross-talk is highly influential in shaping the host immune system function and ultimately affecting the outcome of interventions. We hypothesized that the loss of mucosal barrier in the gut may be associatedto acute and chronic periprosthetic joint infections (PJI). Zonulin, soluble CD14 (sCD14), and lipopolysaccharide (LPS) were tested in plasma as part of a prospective cohort study of patients undergoing primary arthroplasty or revision arthroplasty because of an aseptic failure or PJI (as defined by the 2018 criteria). All blood samples were collected before antibiotic administration. Samples were tested using commercially available enzyme-linked immunosorbent assays as markers for gut permeability. A total of 134 patients were included in the study of which 44 patients had PJI (30 chronic and 14 acute), and the remaining 90 patients were categorized as non-infected that included 64 patients revised for aseptic failure, and 26 patients undergoing primary total joint arthroplasty. Both Zonulin (7.642 ± 6.077 ng/mL vs 4.560 ± 3.833 ng/mL; p < 0.001) and sCD14 levels (555.721 ± 216.659 ng/mL vs 396.872 ± 247.920 ng/mL; p = 0.003) were significantly elevated in the PJI group compared to non-infected cases. Higher levels of Zonulin were found in acute infections compared to chronic PJI (11.595 ± 6.722 ng/mL vs. 5.798 ± 4.841 ng/mL; p = 0.005). This prospective study reveals a possible link between gut permeability and the 'gut-immune-joint axis' in PJI. If this association continues to be borne out with a larger cohort and more in-depth analysis, it will have a clinically significant implication in managing patients with PJI. It may be that in addition to the administration of antimicrobials, patients with PJI and other orthopaedic infections may benefit from administration of gastrointestinal modulators such as pro and prebiotics.

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Intra-Articular Injections Prior to Total Knee Arthroplasty Do Not Increase the Risk of Periprosthetic Joint Infection: A Prospective Cohort Study.

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