What are the contraindications to interarticular joint injections?

Contraindications to Intra-articular Joint Injections

Intra-articular joint injections are contraindicated in cases of active joint infection, overlying skin infection, bacteremia, and should be avoided in prosthetic joints except when performed by orthopedic surgeons after careful screening for prosthetic infection. 1

Absolute Contraindications

• Active joint infection/septic arthritis: Injecting into an infected joint can worsen the infection and spread it systemically
• Overlying skin infection: Risk of introducing cutaneous bacteria into the joint space
• Bacteremia: Risk of seeding the joint with bacteria from the bloodstream
• Known hypersensitivity to the injectable agent: Prevents allergic reactions

Relative Contraindications and Special Considerations

Timing Around Joint Replacement Surgery

• Pre-operative considerations:

  • Injections should be performed at least 3 months prior to planned joint replacement surgery 1
  • Injections within 4 weeks of total knee arthroplasty significantly increase the risk of prosthetic joint infection 2
  • The infection risk decreases when injections are performed more than 4 weeks before surgery 2

• Post-operative considerations:

  • Injections into prosthetic joints should generally be avoided in routine practice 1
  • If necessary, should only be performed by orthopedic surgeons after strict screening for prosthetic infection 1
  • Consultation with the surgical team is required before injecting a prosthetic joint 3

Diabetes Management

• Not a contraindication, but requires special precautions:
  • Patients with diabetes, especially those with suboptimal control, should be informed about the risk of transient hyperglycemia following glucocorticoid injections 1
  • Blood glucose monitoring is recommended from the first to third day post-injection 1
  • No severe adverse events such as hyperosmolar hyperglycemic state or ketoacidosis have been reported 1

Frequency Limitations

• While not a contraindication, excessive frequency of injections should be avoided:
  • Generally accepted guideline: limit to 3-4 glucocorticoid injections per joint per year 1, 3
  • Injections should be spaced at least 7 days apart 3
  • Consider benefits from previous injections when deciding on repeat injections 1

Important Clinical Considerations

Bleeding Risk

• Caution in patients on anticoagulation therapy
• Consider INR levels and bleeding risk before proceeding

Joint Overuse

• Patients should avoid overuse of injected joints for 24 hours following injection 1, 3
• Complete immobilization is not recommended and may be counterproductive 1

Steroid Flare

• Patients should be warned about potential post-injection flare of pain
• Usually self-limiting within 24-48 hours

Common Pitfalls to Avoid

1. Injecting too close to planned joint replacement surgery: Maintain at least 3-4 months between injection and surgery to minimize infection risk 1

2. Excessive frequency of injections: Adhering to the 3-4 injections per year guideline helps prevent cartilage damage and systemic effects 1, 3

3. Failure to recognize active infection: Always examine the joint and overlying skin for signs of infection before proceeding

4. Inadequate aseptic technique: Proper skin preparation with alcohol, iodine disinfectant or chlorhexidine is essential to prevent infection 1

5. Ignoring diabetes management: Failure to advise diabetic patients about the need for glucose monitoring can lead to uncontrolled hyperglycemia 1