Systematic review: the safety of intra-articular corticosteroid injection prior to total knee arthroplasty

Background: Up to 30% of patients undergoing total knee arthroplasty (TKA) have received intra-articular corticosteroid injections prior to surgery. Debate exists as to whether such injections increase the rate of post-operative infection. Given that deep infection is a disastrous complication, a systematic review of the literature was undertaken to evaluate the safety of intra-articular corticosteroid injections given prior to TKA. Other features of corticosteroid use are also discussed including mechanism of action and optimal dosage.

Methods: Using PRISMA guidelines, EMBASE, CINAHL and MEDLINE databases were searched using the search terms 'total knee arthroplasty', 'replacement', 'corticosteroid', 'steroid', 'infection', 'safety', and relevant articles critically appraised. The Newcastle-Ottawa Scale was used to assess for bias.

Results: No level one or two studies were available for review. Two retrospective case control studies and two cohort studies (level three evidence) which specifically evaluated the risk of infected TKA in association with pre-operative steroid injection were reviewed: three showed that prior steroid injection was not associated with increased infection rates; one article showed that prior steroid injection was associated with a significantly increased risk of deep infection post-TKA.

Conclusion: Clinicians commonly administer steroid injections to patients who are candidates for TKA but may be unaware of the potential long term complications. The included studies were underpowered and at risk of selection bias and only one study demonstrated an increased risk of infection post-operatively. We recommend that further research is required to evaluate the safety of steroid injection prior to TKA.

Level of evidence: III.