Key takeaways:
- Patients had an increased risk for complications with each additional corticosteroid injection before TSA.
- Five or more corticosteroid injections had higher rates of revision and postoperative stiffness.
Published results showed patients who received a higher number of corticosteroid injections before total shoulder arthroplasty experienced a higher rate of postoperative complications.
“We should apply some caution to the use of corticosteroid injections in patients that we know have a higher likelihood to undergo shoulder replacement in the future,” Ron Gilat, MD, of Tel Aviv Sourasky University Medical Center, told Healio. “It is something for us to think about and to discuss with our patients before doing these injections, especially if these are recurrent injections.”
Utilizing data from the PearlDiver database from 2010 to 2022, Gilat and colleagues categorized 124,144 patients who underwent TSA based on the number of corticosteroid injections they received before surgery. Researchers matched patients by baseline demographics and compared patients who had at least one corticosteroid injection in the preceding 5 years (n = 33,925) with patients who had no history of corticosteroid injection.
Researchers considered 5-year surgical complications as the primary endpoint, while medical complications within 90 days and surgical complications within 90 days and 1 year served as the secondary endpoints.
Results showed an association between increased corticosteroid injections with higher rates of surgical complications. At 1 year postoperatively, researchers found a stepwise increase in complications for rates of revision, postoperative stiffness, cuff disease and nerve injury with each additional corticosteroid injection administered. Compared with matched patients who did not receive corticosteroid injections, patients who received five or more corticosteroid injections before TSA had higher rates of revision at 5 years and postoperative stiffness at 1 year and 5 years, according to researchers.
Within 5 years, patients in the unmatched cohort had a statistically significant compounding 2.03% increased risk for revision surgery. Researchers also found patients in the matched cohort had a statistically significant compounding 2.67% increased risk for new onset rotator cuff disease within 5 years.
“This is an interesting study because it is something we see daily in clinic. Some patients get recurrent injections because they do not want to have surgery at the time,” Gilat said. “There is a role for corticosteroid injections in these types of patients, but our study helps delineate maybe we should be more cautious with those recurrent injections. If there is a patient who we know is likely going to undergo shoulder replacement, we should advise and have a meaningful discussion about the risks and benefits of another injection right now, and then make a decision together whether or not we are going to do another injection.”
For more information:
Ron Gilat, MD, can be contacted at rongi@tlvmc.gov.il.
Perspective
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The recent article by Ron Gilat, MD, and colleagues describes a dose-dependent risk for postoperative complications following shoulder arthroplasty related to preoperative corticosteroid injections. For years, physicians have utilized these injections to manage arthritis and rotator cuff disease. However, with the advent of mega-database analytics, their cumulative impact has become increasingly apparent.
Using the PearlDiver database during a nearly 13-year period encompassing more than 120,000 shoulder arthroplasty cases, a dose-dependent and concerningly negative impact of corticosteroid injections was identified — including higher rates of revision surgery, prosthetic loosening, postoperative stiffness, rotator cuff disease and nerve injury. Corticosteroid injections are seemingly attractive, as they typically provide rapid relief of shoulder pain. Reluctant to consider surgery, patients often request repeat injections, longing for another period of pain relief. In some cases, patients end up receiving injections every 4 to 6 weeks. This article sheds light onto the concerning risks related to repeat corticosteroid injections, which are not without consequence.
While temporary benefits of pain relief are appealing, it must be weighed against the negative impact these injections may have on the ultimate surgical procedure — shoulder arthroplasty. This article is eye-opening for many surgeons and provides evidence to support a cautious approach to repeat corticosteroid injections in patients who are candidates for shoulder arthroplasty.
Jonathan C. Levy, MD
Disclosures: Levy reports no relevant financial disclosures.
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