Electronic Letters to:

Knee: A. V. Papavasiliou, D. L. Isaac, R. Marimuthu, A. Skyrme, and A. Armitage Infection in knee replacements after previous injection of intra-articular steroid J Bone Joint Surg Br 2006; 88-B: 321-323 [Abstract] [Full text] [PDF]

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Steroid injections and infection in knee replacements

Gintautas Tucinskas, Ramankutty Sreekumar, Lower Limb Arthroplasty Fellow   (27 October 2006)

Infection following total knee arthroplasty. Is previous steroid injection the sole cause?

Oguz Cebesoy   (15 June 2006)

Author's reply:

ATHANASIOS PAPAVASILIOU   (6 June 2006)

Author's reply:

ATHANASIOS PAPAVASILIOU   (6 June 2006)

Author's reply:

ATHANASIOS PAPAVASILIOU   (5 June 2006)

Infections in knee replacements after previous injection of intra-articular steroid

Jeremy A Read, Neil Ferguson, David M Ricketts   (5 June 2006)

Infection in knee replacements after previous injection of intra-articular steroid

Nick J Little, Alex Chipperfield, David M Ricketts   (20 April 2006)

Infection in knee replacements after previous injection of intra-articular steroid

Laurence E Dodd   (22 March 2006)

Infection in knee replacements after previous injection of intra-articular steroid

Girish Vashista   (21 March 2006)

Steroid injections and infection in knee replacements 27 October 2006
Gintautas Tucinskas, Clinical Research Fellow Wrightington Hospital, Wigan, Ramankutty Sreekumar, Lower Limb Arthroplasty Fellow Send letter to journal: Re: Steroid injections and infection in knee replacements gtucinskas{at}yahoo.com Gintautas Tucinskas, et al.	Sir, We read this article with interest and although we agree with the authors that the role of steroid injections in osteoarthritis is limited to short term relief, we would question their argument that it leads to raised infection in subsequent knee replacements. The authors do not mention their technique of knee injections but do quote a reference that injections are done in many centres with 'token aseptic precautions'. We would suggest that all intra-articular injections have to be carried out with strict aseptic precautions in order to prevent infection in the injected joint. The authors themselves suggest that a prospective study will help to confirm this issue. In the meantime, to suggest that intra-articular injections cause infection in subsequent total knee replacements appears to be too strong a conclusion. G. Tucinskas, Clinical Research Fellow, R. Sreekumar, Lower Limb Arthroplasty Fellow, Wrightington Hospital, Wigan, UK.
Infection following total knee arthroplasty. Is previous steroid injection the sole cause? 15 June 2006
Oguz Cebesoy, MD,Orthopedic and Traumatology specialist gaziantep university faculty of medicine Send letter to journal: Re: Infection following total knee arthroplasty. Is previous steroid injection the sole cause? ocebesoy{at}gmail.com Oguz Cebesoy	Sir, We read with interest this article by Papavasiliou et al and would like to comment on it. In the authors' study, the steroid-injected patients had total knee replacement surgery (TKR) approximately one year after the injections. This interval is so short that it makes us think the patients may already have been unsuitable for injection. Based on the literature, as well as our clinical experience, the reported risk factors in the text are not enough to blame steroids for infections. Post-operative wound discharge, persistent haematoma, obesity, poor nutritional status and a poor metabolic state are also responsible. Intra-articular steroids can still be used in appropriate cases with the advantages of being cheap and easy to administer, with few side effects. In advanced-stage osteoarthritis patients, if the patient is likely to have a TKR soon, neither steroids nor any other agents should be used as they will unnecessarily delay the operation and increase the risk of infection. O. Cebesoy, MD, Orthopaedic and Traumatology Specialist, Faculty of Medicine, Gaziantep University, Gaziantep,Turkey. K.C. Kose, MD, Assistant Professor, Faculty of Medicine, Afyon Kocatepe University, Afyon, Turkey.
Author's reply: 6 June 2006
ATHANASIOS PAPAVASILIOU Eastbourne District General Hospital, East Sussex Hospitals NHS Trust Send letter to journal: Re: Author's reply: PpvslA{at}aol.com ATHANASIOS PAPAVASILIOU	Sir, We thank Mr Vashista for his comments. 1. The length of time between injection of steroids into the knee and subsequent increased risk of post-operative infection lead us to speculate that some of the steroid crystals do not fully dissolve within the knee joint but remain within the surrounding soft tissues or cystic areas of degeneration within the knee. Jones et al1 in a contrast radiography study, reported that one third of injections into the knee are actually extra-articular and within the surrounding soft tissues. At the time of the operation the steroid crystals may be released (reactivated) from the soft tissues finding their way within the operating field. 2. I am not aware of such a practice. I do know that US surgeons inject a cocktail of drugs into their knee joint replacements but for analgesia and haemostasis purposes. A.V. PAPAVASILIOU, BSc, MD, PhD, Research Registrar in Orthopaedics, Eastbourne District General Hospital, East Sussex, UK. 1. Jones A, Regan M, Ledingham J, et al. Importance of placement of intra-articular steroid injections. BMJ 1993;307:1329-30.
Author's reply: 6 June 2006
ATHANASIOS PAPAVASILIOU Eastbourne District General Hospital, East Sussex Hospitals NHS Trust Send letter to journal: Re: Author's reply: PpvslA{at}aol.com ATHANASIOS PAPAVASILIOU	Sir, We thank Mr Dodd for his letter in response to our article. Infections in total knee arthroplasty (TKA) are rare and depend on many factors, and one would need a very large study to demonstrate conclusively the connection between steroids and an increased risk post-TKA infection. Our study though, demonstrates sufficient concern and concludes that the decision to administer intra-articular (I/A) steroids to a patient who may be a candidate for knee replacement surgery should not be taken lightly. Many centres should review their results retrospectively and report them. The variable time and number between steroid injection and time to surgery is one of the inherent limitations of any retrospective study. The important fact is that there seems to be an increased infection risk period of 11 months between the last injection and surgery. This is of increased importance since the waiting list for a joint replacement in the UK is currently about six months. I believe that there is enough published data1-6 to show that I/A steroid injections show a positive effect that is only short-lived (1 to 4 weeks) and confounded by a powerful response to placebo, and as such are of limited benefit in the long-term management of osteoarthritis (OA) of the knee. I agree that clinical experience shows that few patients achieve a significant and sustained response. The problem is that it is not possible to predict which patients will actually respond.7 Osteoarthritis is increasingly viewed as a phasic condition in which organ damage occurs intermittently. The ability to detect these phases of increased disease activity perhaps could in the future lead to a more rational approach to the use of intra-articular steroids in OA. In our unit we avoid intra-articular steroids in patients that are to be placed on the waiting list for TKA. If a patient is not a candidate for TKA and has had a good and lasting response to I/A steroid treatment in the past then the injection is repeated. A.V. PAPAVASILIOU BSc, MD, PhD, Research Registrar in Orthopaedics, Eastbourne District General Hospital, East Sussex, UK. 1. Gossec L, Dougados M. Intra-articular treatments in osteoarthritis: from the symptomatic to the structure modifying. Ann Rheum Dis 2004;63:478-82. 2. Ayral X. Injections in the treatment of osteoarthritis. Best Pract Res Clin Rheumatol 2001;15:609-26. 3. Kirwan JR, ,Rankin E. Intra-articular therapy in osteoarthritis. Baillieres Clin Rheumatol 1997;11:769-94. 4. Creamer P. Intra-articular corticosteroid treatment in osteoarthritis. Curr Opin Rheumatol 1999;11:417-21. 5. Friedman DM, Moore ME. The efficacy of intraarticular steroids in osteoarthritis: a double-blind study. J Rheumatol 1980;7:850-6. 6. Dieppe PA, Sathapatayavongs B, Jones HE, Bacon PA, Ring EF. Intra-articular steroids in osteoarthritis. Rheumatol Rehabil 1980;19:212-7. 7. Jones A, Doherty M. Intra-articular corticosteroids are effective in osteoarthritis but there are no clinical predictors of response. Ann Rheum Dis 1996;55:829-32.
Author's reply: 5 June 2006
ATHANASIOS PAPAVASILIOU Eastbourne District General Hospital, East Sussex Hospitals NHS Trust Send letter to journal: Re: Author's reply: PpvslA{at}aol.com ATHANASIOS PAPAVASILIOU	Sir, We thank Mr Little et al for raising some points that require further clarification. During the period of time studied (February 2002 to October 2004), three types of total knee replacement (TKR) were routinely used in our department, namely AGC, IBII and Scorpio. We chose to study the AGC prosthesis for the simple reason that it represented the largest group (231 out of 420 patients). By reviewing one type of prosthesis we minimised the variables depending on the type of TKR used, and also reduced the number of surgeons involved. Patient number 6 (Table I) had no evidence in his record of being treated with an intra-articular (I/A) steroid injection prior to surgery (seen in Table I as N/A - not applicable). This patient was excluded from our final study since he did not meet our set strict inclusion criteria. A.V. PAPAVASILIOU, BSc, MD, PhD, Research Registrar in Orthopaedics, Eastbourne District General Hospital, East Sussex, UK.
Infections in knee replacements after previous injection of intra-articular steroid 5 June 2006
Jeremy A Read, Specialist Registrar Princess Royal Hospital, Haywards Heath, Neil Ferguson, David M Ricketts Send letter to journal: Re: Infections in knee replacements after previous injection of intra-articular steroid jezafr{at}aol.com Jeremy A Read, et al.	Sir, The article by Papavasiliou et al is of great interest. This is an important area of study, as many patients are initially treated with steroid injections either in general practice, or in hospital prior to further intervention. We would like to make the following point. The authors establish a link between deep knee infection and intra-articular steroid injection. A small number of cases were studied. Previous surgery was defined as one of their exclusion criteria, however, arthroscopy was not included in this definition. Arthroscopy is a violation of the joint space and produces some soft tissue trauma; it may lead to an increased infection risk.1 No information is presented as to the number of patients who had undergone a previous arthroscopy nor their distribution between groups I and II. It is therefore difficult to determine whether steroids or previous joint violation may be affecting these results. Are the authors able to determine from their data what proportion of their patients with deep infection had had a previous knee arthroscopy? J.A. Read, Specialist Registrar, N. Ferguson, D.M. Ricketts, The Princess Royal Hospital, Haywards Heath, West Sussex, UK. 1. Babcock HM, Matava MJ, Fraser V. Postarthroscopy surgical site infections: review of the literature. Clin Infect Dis. 2002;34:65-71.
Infection in knee replacements after previous injection of intra-articular steroid 20 April 2006
Nick J Little, Specialist Registrar Princess Royal Hospital, Haywards Heath, Alex Chipperfield, David M Ricketts Send letter to journal: Re: Infection in knee replacements after previous injection of intra-articular steroid njlittle{at}gmail.com Nick J Little, et al.	Sir, We read with interest the March 2006 paper by Papavasiliou et al1 entitled "Infection in knee replacements after previous injection of intra-articular steroid", and note the authors' hypothesis that "intra-articular steroid injection is associated with a higher incidence of post-operative deep wound infection in total knee replacement." We would like to make the following points: 1. The authors’ diagnostic criteria are not supported by a reference to the evidence base in the literature. The criteria given for both superficial and deep surgical sites of infection appear to be closely related, but not identical, to the National Nosocomial Infection Surveillance (NNIS) guidelines.2,3 In the authors’ methods, there is no distinction between deep and organ /space-based infections. In the NNIS criteria intra-articular infection following knee replacement falls into the organ / space-based infection category. The NNIS guidelines make no reference to diagnosis via "pus cells present on microscopy" for deep surgical site infection. Pus cells are present in many inflammatory processes and their presence may not always indicate infection. Of interest, both the authors’ and the NNIS guidelines state that both superficial and deep surgical site infections can be diagnosed by an attending clinician alone. This subjective criterion could lead to considerable variation in the diagnosis of infection. 2. Following the pilot study, the authors decided to retrospectively examine the AGC prosthesis. There was no reason stated as to why the AGC prosthesis was chosen. We note that four of the six deep infections (Table I) were found with this prosthesis. Was the AGC prosthesis chosen due to the high, deep infection rate and therefore increased probability of producing a significant difference in deep infection between the two study groups? 3. Table I lists four patients with AGC prostheses that had evidence of deep infection. It was stated in the results that there were only three recorded deep infections, all within Group I. There is no mention of the last patient (case 6, Table I) in the results, nor whether she had received a previous intra-articular steroid injection. N.J. LITTLE, Specialist Registrar, A. CHIPPERFIELD, Specialist Registrar, D.M. RICKETTS, Consultant, Orthopaedics and Trauma, Princess Royal Hospital, Haywards Heath, UK. 1. Papavasiliou AV, Isaac DL, Marimuthu R, Skyrme A, Armitage A. Infection in knee replacements after previous injection of intra-articular steroid. J Bone Joint Surg [Br] 2006;88-B:321-3. 2. Centers for Disease Control (U.S.). NNIS manual: NNIS, National Nosocomial Infections Surveillance System. Atlanta, Georgia, USA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, 1999. 3. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606-8.
Infection in knee replacements after previous injection of intra-articular steroid 22 March 2006
Laurence E Dodd, Senior House Officer Royal College Surgeons England Send letter to journal: Re: Infection in knee replacements after previous injection of intra-articular steroid docdodd{at}doctors.org.uk Laurence E Dodd	Sir, I read with interest the paper by Pavasiliou et al1 in the March 2006 issue entitled "Infection in knee replacements after previous injection of intra-articular steroid." The authors suggest that there is a significant increase in the incidence of post-operative deep infection with the prior use of intra-articular steroid. However, there are a number of points that detract from the power of this study that I would like to highlight. In the first instance the numbers shown are very small, and statistically significant differences based on three outcomes are questionable. Furthermore there were a number of variables that may be subject to bias, namely a different operating surgeon in each case, variable time between injection and surgery, and variable numbers of injections prior to surgery. The authors also comment on the evidence, or rather the lack of it, that steroids do not provide lasting beneficial value in osteoarthritis (OA). I think most would agree but that does not detract from the fact that they can provide good symptom control in the short term, perhaps delaying surgery until a more appropriate time. I appreciate, as do the authors, the inherent weaknesses in a retrospective study such as this, and agree that a prospective study with more defined variables would lend weight to their argument. Finally, I wonder whether the practice of the authors has changed in light of their results. Have they abandoned the use of intra-articular steroids? L.E. DODD, MRCS, Senior House Officer, Plastic Surgery, Queen Victoria Hospital, East Grinstead, UK.
Infection in knee replacements after previous injection of intra-articular steroid 21 March 2006
Girish Vashista, Specialist Registrar Barnsley District General Hospital Send letter to journal: Re: Infection in knee replacements after previous injection of intra-articular steroid girishnvashista{at}yahoo.com Girish Vashista	Sir, I read with interest the paper by Pavasiliou et al1 in the March 2006 issue entitled "Infection in knee replacements after previous injection of intra-articular steroid." Many surgeons anecdotally feel that injecting knees with steroid prior to total knee replacement (TKR) is not advisable. It was interesting to note that the authors did not find any relationship between the number or timing of injections to post-operative deep infection. I would like to raise the following queries with the authors: 1. It has been mentioned that the steroid is 'reactivated' in the knee several months after injection. What exactly do they mean by that? 2. From personal experience, I know that many surgeons in North America inject a cocktail of drugs into wounds after total hip and knee arthroplasties, often containing, among others, a long-lasting steroid. The authors quote no increase in post-operative infection rates. G.N. VASHISTA, MRCS, Specialist Registrar, Barnsley District General Hospital, Barnsley, South Yorkshire, UK.