Why are hip joint corticosteroid (Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)) injections avoided before joint replacement surgery?

From the Guidelines

Hip joint corticosteroid injections should be avoided for at least 3 months before joint replacement surgery due to the increased risk of post-surgical infection and impaired wound healing. This recommendation is based on the most recent and highest quality study available, which suggests that patients who receive corticosteroid injections within 3 months of surgery may have a higher risk of infection and other complications 1. The use of corticosteroid injections can temporarily suppress the local immune response in the joint, creating an environment where bacteria can thrive during surgery, and also mask inflammation signs, making it harder for surgeons to identify infection during the procedure. Additionally, the immunosuppressive effects of corticosteroids can impair wound healing after surgery. For pain management before surgery, oral medications like acetaminophen or appropriate NSAIDs may be used instead, along with physical therapy and activity modification. Some key points to consider when evaluating the use of corticosteroid injections before joint replacement surgery include:

• The potential increased risk of infection and other complications associated with corticosteroid injections
• The importance of informing the orthopedic surgeon about any injections received when planning for joint replacement
• The use of alternative pain management strategies, such as oral medications and physical therapy, before surgery
• The need for careful consideration of the benefits and risks of corticosteroid injections in the context of joint replacement surgery, as outlined in recent clinical practice guidelines 1. It is also worth noting that the evidence supporting the use of corticosteroid injections before joint replacement surgery is indirect and of low quality, and that the potential harms associated with delaying surgery for glucocorticoid injection treatment, particularly in patients with diabetes mellitus, should be carefully considered 1.

From the FDA Drug Label

Although this method of treatment will ameliorate symptoms, it is in no sense a cure and the hormone has no effect on the cause of the inflammation.

Suitable sites for intra-articular injection are the knee, ankle, wrist, elbow, shoulder, phalangeal, and hip joints. Since difficulty is not infrequently encountered in entering the hip joint, precautions should be taken to avoid any large blood vessels in the area

The FDA drug label does not answer the question.

From the Research

Reasons to Avoid Hip Joint Corticosteroid Injections Before Joint Replacement Surgery

• The primary concern is the potential increase in the risk of periprosthetic joint infection (PJI) after total joint arthroplasty, as suggested by studies such as 2 and 3.
• Research indicates that intra-articular corticosteroid injections within 3 months before arthroplasty may be associated with a higher risk of PJI, as found in 2 and 3.
• A dose-dependent relationship between corticosteroid injections and the risk of PJI has also been observed, with each subsequent injection increasing the odds of PJI, as reported in 4.
• The timing of the injection plays a crucial role, with injections administered within 3 months before hip arthroplasty appearing to be less safe than waiting a 3-month interval, as stated in 3.

Key Findings from Relevant Studies

• A meta-analysis published in 2 found that intra-articular corticosteroid injections within 3 months before arthroplasty were associated with an increased risk of PJI.
• A study published in 4 demonstrated a temporal and dose-dependent relationship between preoperative corticosteroid injections and the rate of postoperative infection following total hip arthroplasty.
• Another meta-analysis published in 3 found a significant association between PJI and corticosteroid injections for total hip arthroplasty, with a higher risk of PJI if injections were performed within 3 months preoperatively.

Contrasting Views and Older Studies

• An older study published in 5 found no evidence of associated risk of prosthetic infection or early revision of total hip arthroplasty after hip joint injection with corticosteroids, highlighting the importance of maintaining a strict aseptic protocol.
• A meta-analysis published in 6 found no significantly increased rate of infection among participants with steroid injection prior to total hip or knee arthroplasty, suggesting that the risk may not be as high as previously thought.