Studies: Preop Injections Elevate Infection Risk!
Two major studies are now indicating that patients who receive injections in the months prior to total knee (TKR) or total hip replacement (THR) surgery may have an increased risk for infection and related complications. One study, “Preoperative Hip Injections Increase the Rate of Periprosthetic Infection after Total Hip Arthroplasty” was led by William Schairer, M.D., a third-year resident at Hospital for Special Surgery. This team of researchers reviewed data from 177, 762 patients in the Statewide Ambulatory Surgery and Inpatient Database, for Florida and California, from 2005 to 2012.
Dr. Schairer and his colleagues found that injections within three months of THR resulted in a 40% increased risk for post-operative infection. The infection rate after one year was 2.06% in patients who did not receive an injection, but that rate increased to 2.81% in patients who had an injection within three months prior to their procedures.
Dr. Schairer told OTW, “Infection after joint replacement is one of the most devastating complications. Injections are commonly performed before joint replacement, both to help the surgeon confirm that pain is coming from inside the joint, but also to deliver corticosteroids, which can provide the patient good relief for a few months. Steroids are used in other areas of medicine to intentionally suppress the immune system, such as after organ transplants or autoimmune diseases. Thus, we thought there may be a risk that injections may suppress the immune system inside the joint, which may increase the risk of infection if a joint replacement is performed too soon.”
“In talking with our colleagues, some have had a suspicion that injections before a joint replacement may raise the risk of infection, and they had already made it their practice not to perform the two close together. However, previous studies in the literature have had small numbers of patients, lacking statistical power to strongly confirm any association of injection and infection. This is one of the first large studies to confirm an association, and further to show that while injections may raise the risk if joint replacement is performed within three months of the injection, waiting until after three months for joint replacement appears to be safe—the same risk as if you had not had an injection.”
“Many surgeons may recommend a joint injection, which can be an important diagnostic and therapeutic tool to help treat patients. However, because of the increased risk of infection if a joint replacement is performed too soon, we would recommend that if a joint replacement may be performed in the future, surgeons and patients should discuss that after the injection, it would be a good idea to wait three months before any joint replacement is performed.”
“This study does not mean that a joint replacement should absolutely not be performed soon after an injection. There are some situations where it may not be reasonable to wait, such as if a patient has insurmountable hip pain or they have a hip fracture. Thus, although there may be an increased risk of infection, each patient’s situation warrants a discussion between them and the surgeon to weight the risks and benefits of the timing of their surgery.”
The second study was led by Nicholas Bedard, M.D., an orthopedic surgeon at the University of Iowa Hospitals and Clinics. In the second study, “Do injections Increase the Risk of Infection Following Total Knee Arthroplasty, ” Dr. Bedard and his team identified 83, 684 patients in the Humana, Inc. database who underwent TKR for the first time between 2007 and 2014. The researchers found that the rates of surgical site infection were significantly higher in patients with an injection prior to TKR than those without (4.4% versus 3.6%), as were the rates of infection requiring a return to the operating room (1.5% versus 1%).
Dr. Bedard told OTW, “The most surprising finding was that approximately 42% of injections occurred within three months prior to ipsilateral TKA (total knee arthroplasty).”
“I don’t believe this data necessarily creates a challenging situation, but in light of this project and other studies on the efficacy of injections for knee osteoarthritis symptoms, it will be important to incorporate this information into a shared decision making process between the patient and the surgeon regarding whether or not to undergo a knee injection and if, or when, to undergo subsequent TKA.”
Patients With Preop Malnutrition 2x as Likely to Develop Infection
New research from Rush University has found a serious situation…and a relatively easy solution. Craig Della Valle, M.D. and Daniel D. Bohl, M.D., M.P.H., collaborated to examine the records of nearly 50, 000 patients undergoing total joint replacement (hips and knees). Dr. Della Valle told OTW, “This work emanated from my experience with two patients I treated close together, both of whom developed infections. I started asking things like, ‘Was it the instrumentation? The technique?’ As it turned out, these morbidly obese patients had low albumin levels.”
“I then looked at my own data (500 patients) and found that individuals who had low albumin were indeed at a higher risk of having a chronically infected knee or hip replacement. At the same time, patients with low albumin were also at higher risk of having an infection after a revision replacement procedure. Then, one of our residents offered his experience with the enormous NSQIP (National Surgical Quality Improvement Program) database containing 50, 000 patients who had undergone primary hip or knee replacement. We confirmed our results—namely, that not only is low albumin predictive of infection, but it predicts the development of pneumonia. Also, those patients with low albumin had longer hospital stays and a greater risk for readmission following surgery.”
“Albumin is associated with nutrition and inflammation, but it is not a linear relationship. When we identify someone with low albumin, we can delay surgery and try to rectify the situation by having patients undergo basic nutritional counseling, which involves increasing protein and vegetables and staying away from sugars and processed foods. These patients typically respond well to these interventions and end up losing weight over time. Orthopedic surgeons should know that correcting the nutritional status of malnourished patients prior to surgery could potentially lead to improved outcomes.”
Patient-Perceived Physician Empathy Engenders Better Outcomes, Satisfaction
If a patient thinks his or her doctor is showing empathy, then a cascade of good things can happen, says new research from Massachusetts General Hospital (MGH). The researchers asked 112 new patients at the MGH Department of Orthopaedic Surgery to rate personal interaction with their hand surgeon. It turned out that a full 65% of patient satisfaction was attributed to physician empathy!
David Ring, M.D., Ph.D., now associate dean for Comprehensive Care Dell Medical School at The University of Texas at Austin, was formerly chair of the MGH Orthopedic Quality and Patient Safety Committee. Dr. Ring, principal investigator for the study, told OTW, “Empathy is the most important communication skill, but I think the most difficult thing to master is avoiding any type of adversarial interaction, the most common being a dispute between how things seem (patient intuition) and medical facts. An example would be a person that insists on antibiotics for a clear viral infection. The only effective strategy is empathy and respect. We need to convey the medical facts briefly and in a way that can be understood while optimizing hope. Trying to convince a patient that they don’t need antibiotics is a fruitless endeavor and damaging to the relationship. Wishing together with a patient how miserable it can be to have a cold and how nice it would be if we could get it to go away is a better approach. That is counterintuitive for doctors and all humans!”
Asked how he acquired such skills, Dr. Ring commented, “I took several courses and had a personal coach seeing patients with me. I used a personal communication skills manual that I assembled with my coach; this included important material that was created by John Tongue, M.D. I think the key is to get feedback from patients and coaches, cultivate self-awareness, and script and practice more effective words and behaviors.”
