Septic arthritis following intra-articular steroid injection of the knee ? a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee

Abstract

Septic arthritis is a potential catastrophic complication of intra-articular steroid injection. There is lack of evidence regarding the precautions that should be taken to avoid such a complication, as well as how often it is encountered. The aim of this study was to evaluate the antiseptic precautions taken during intra-articular steroid injection of the knee in the United Kingdom (UK), and estimate how often septic arthritis is encountered by health professionals in the UK following steroid injection of the knee. A questionnaire was posted to 100 orthopaedic surgeons, 100 rheumatologists and 50 general practitioners (GPs), asking them about the cases of septic arthritis following intra-articular steroid injection of the knee that they encountered during their practice and the precautions they take when injecting knees. The response rate was 76.4%; 57.6% of the respondents used alcohol swabs to clean the skin, and the remaining 42.4% used chlorhexidine or Betadine. Only 16.3% used sterile towels to isolate the injection site. There were 32.5% of respondents who routinely used sterile gloves when injecting, and a total of 46.6% used either sterile or non-sterile gloves. Also, 91.1% changed needles between drawing the steroid and injecting it into the joint. Only 24 respondents (12.6%) had encountered septic arthritis after steroid injection of the knee (18 once, 3 twice, 2 three times, 1 several times). We concluded that septic arthritis post intra-articular steroid injection of the knee is probably rare. There is a wide variation in the precautions taken to avoid such a complication. However, the trend seems to be towards minimal use of antiseptic techniques. Further large prospective studies are needed to determine how frequently septic arthritis of the knee is encountered post steroid injection, and the exact precautions that should be taken to avoid it.

Does the Use of Ultrasound Affect Contamination of Musculoskeletal Injections Sites?

“…Our findings should be considered in the context of our protocol that required the use of sterile gloves during specimen collection. This is important to consider as the individual performing the injection is a potential source of bacterial contamination, and among practitioners there is marked inconsistency in precautions against contamination [6]. The reason for this variability is unknown but is likely attributable to training, resources, perceived risk, and experience.…”

“…The reason for this variability is unknown but is likely attributable to training, resources, perceived risk, and experience. There is also wide variability in the perceived risk of postinjection joint sepsis among practitioners [3,6]. In a survey distributed to providers who performed intraarticular injections, 5.4% perceived this risk as negligible, 36.5% believed infection rates were one or fewer per 1000 injections, 39.2% reported a perceived rate of one or fewer per 100, and none perceived the risk as five or greater per 100 injections.…”

“…In a survey distributed to providers who performed intraarticular injections, 5.4% perceived this risk as negligible, 36.5% believed infection rates were one or fewer per 1000 injections, 39.2% reported a perceived rate of one or fewer per 100, and none perceived the risk as five or greater per 100 injections. Of those surveyed, 12.6%, reported having seen patients with a septic joint after intraarticular injection [6]. In a separate survey of 853 orthopaedists, 50% reported a perceived infection risk of one per 1000, and those who performed injections recalled 68 cases of postinjection infection [10].…”

“…Isopropyl alcohol swabs are the most common injection site preparatory agents used for the purposes of in-office intraarticular injections [6]. Cawley and Morris investigated colonization of needles used for intraarticular injections immediately after withdrawal from the joint using either isopropyl alcohol or chlorhexadine preparations of the overlying skin [5].…”

“…It is not uncommon for many of these practitioners to perform several hundred injections per year [6]. Therefore, considering the frequency of musculoskeletal injections in the context of an estimated incidence of postinjection infection of 4.6 per 100,000 injections, the effect of this complication should not be underestimated [12,21].…”