Risk Analysis of Perioperative Injections in Arthroscopic Reconstruction of the Rotator Cuff of the Shoulder – A Systematic Review

Abstract

Background The present study used a systematic review to analyse the risk of perioperative injections during arthroscopic reconstruction of the rotator cuff of the shoulder. The questions of interest were whether perioperative local injection increases the infection risk and whether the number of postoperative revisions is increased.

Material and Methods A systematic review of the U. S. National Library of Medicine/National Institutes of Health (PubMed) database and the Cochrane Library was performed using the PRISMA checklist. The keywords used were “shoulder” and “arthroscopy” and “injection” and “risk”. In the course of the study, work that was not also primarily concerned with the reconstruction of the rotator cuff was excluded. English original articles and case series were included that contained at least some arthroscopic reconstructions of the rotator cuff. The risk of bias was determined using the Newcastle-Ottawa Scale. The content of the articles relevant to the research questions was analysed.

Results 48 hits were primarily generated. 9 articles corresponded to the inclusion criteria and were analysed. In the 6 studies with details on the injected substances, cortisone was used in 98 – 100% of the cases. The reported infection and revision rates based on insurance data were higher with injection than without. The risk of bias in the studies analysed here was rather low based on the Newcastle-Ottawa Score. The risk of infection after a cortisone injection before, during or after surgery was increased. Injection was associated with infection in up to 8% of cases with injections within two weeks of surgery. The risk of infection was increased by up to 11 times with injections within 4 weeks after the operation. Likewise, the risk of revision surgery after injection was increased, with the time intervals between injection and surgery sometimes differing between studies.

Discussion Local infections and to a lesser extent revision surgery are associated with perioperative injections (with cortisone) within 3 months preoperatively and 4 weeks postoperatively. However, there were only database studies of insurance data with several studies from a few centres. Thus, no causal relationships could be proven. Currently, however, the following can be recommended using a cautious approach: The interval between injection with cortisone before surgery should be at least 2 weeks, better 3 months. No cortisone injections should be applied intraoperatively. Postoperatively, cortisone should not be injected for at least 4 weeks. If, in exceptional cases, deviations from these time limits are required, patients should be informed about an increased risk of complications.

Key words

shoulder - rotator cuff reconstruction - injection - risk - infection

Publikationsverlauf

Artikel online veröffentlicht:
29. März 2021

• References/Literatur

• 1 Agarwalla A, Puzzitiello RN, Mascarenhas R. et al. Preoperative injections may be an iatrogenic cause of reoperation after arthroscopic rotator cuff repair. Arthroscopy 2019; 35: 325-331
• 2 Kew ME, Cancienne JM, Christensen JE. et al. The timing of corticosteroid injections after arthroscopic shoulder procedures affects postoperative infection risk. Am J Sports Med 2019; 47: 915-921
• 3 Werner BC, Cancienne JM, Burrus MT. et al. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. J Shoulder Elbow Surg 2016; 25: 390-397
• 4 Cancienne JM, Brockmeier SF, Carson EW. et al. Risk factors for infection after shoulder arthroscopy in a large medicare population. Am J Sports Med 2018; 46: 809-814
• 5 Weber AE, Trasolini NA, Mayer EN. et al. Injections prior to rotator cuff repair are associated with increased rotator cuff revision rates. Arthroscopy 2019; 35: 717-724
• 6 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6: e1000100
• 7 von Knoch M, Frosch S, Lehmann W. Arthroscopic Reconstruction of Intratendinous Lesions of the Supraspinatus Tendon – a Systematic Review. Z Orthop Unfall 2018; 156: 547-553
• 8 Wells G, Shea B, OʼConnell D. et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa, ON: Ottawa Hospital Research Institute 2019. Im Internet (Stand: 15.02.2020): http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
• 9 Bhattacharjee S, Lee W, Lee MJ. et al. Preoperative corticosteroid joint injections within 2 weeks of shoulder arthroscopies increase postoperative infection risk. J Shoulder Elbow Surg 2019; 28: 2098-2102
• 10 Forsythe B, Agarwalla A, Puzzitiello RN. et al. The timing of injections prior to arthroscopic rotator cuff repair impacts the risk of surgical site infection. J Bone Joint Surg Am 2019; 101: 682-687
• 11 Traven SA, Brinton D, Simpson KN. et al. Preoperative shoulder injections are associated with increased risk of revision rotator cuff repair. Arthroscopy 2019; 35: 706-713
• 12 Desai VS, Camp CL, Boddapati V. et al. Increasing numbers of shoulder corticosteroid injections within a year preoperatively may be associated with a higher rate of subsequent revision rotator cuff surgery. Arthroscopy 2019; 35: 45-50