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Intra-articular injection receipt within 3 months prior to primary total knee arthroplasty is associated with increased periprosthetic joint infection risk



This systematic review and meta-analysis analyzed the influence of pre-operative intra-articular injections (IAI) on periprosthetic joint infection (PJI) rates after primary total knee arthroplasty (TKA).


Studies published between January 1st, 2000 and May 1st, 2021 evaluating PJI rates among TKA patients with and without IAI were identified from PubMed, Cochrane Library, MEDLINE, EBSCO Host, and Google Scholar. The pooled effect of IAI on PJI risk was calculated utilizing Mantel–Haenszel (M–H) models. Sub-analysis comparisons were conducted based on the interval from IAI to TKA: 0–3 months; > 3–6 months; > 6–12 months. The Methodological Index for Non-Randomized Studies (MINORS) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool were utilized to evaluate the quality of each included study.


The present analysis included 12 studies reporting on 349,605 TKAs (IAI: n = 115,122; No IAI: n = 234,483). Patients receiving an IAI at any point prior to TKA (2850/115,122; 2.48%) had statistically significant increased risk of infection compared to patients not receiving IAIs (4479/234,483; 1.91%; OR: 1.14, 95% CI: 1.08–1.20; p < 0.0001). However, this finding was not demonstrated across sensitivity analyses. Receiving injections within 3 months prior to TKA was associated with increased infection risk (OR: 1.23, 95% CI: 1.14–1.31; p < 0.0001). There were no differences in infection rates when injections were given between > 3 and 6 months (OR: 0.82, 95% CI: 0.47–1.43; p = 0.49) and > 6–12 months prior to TKA (OR: 1.26, 95% CI: 0.89–1.78; p = 0.18).


Based on the current literature, the findings of this analysis suggest that patients receiving IAI should wait at least 3 months before undergoing TKA to mitigate infection risk. Orthopaedic surgeons and patients can utilize this information when undergoing shared decision-making regarding osteoarthritis management options and timing.

Level of evidence

Level III.

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Correspondence to Atul F. Kamath.

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A.F.K. reports the following disclosures: research support (Signature Orthopaedics), paid presenter or speaker (DePuy Synthes and Zimmer Biomet), paid consultant (DePuy Synthes and Zimmer Biomet), stock or stock options (Zimmer Biomet, Johnson & Johnson, and Procter & Gamble), IP royalties (Innomed), and board or committee member (AAOS, AAHKS, and Anterior Hip Foundation). The remaining authors have nothing to disclose.

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Avila, A., Acuña, A.J., Do, M.T. et al. Intra-articular injection receipt within 3 months prior to primary total knee arthroplasty is associated with increased periprosthetic joint infection risk. Knee Surg Sports Traumatol Arthrosc 30, 4088–4097 (2022).

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  • Total knee arthroplasty (TKA)
  • Periprosthetic joint infection (PJI)
  • Intra-articular injections (IAIs)
  • Systematic review
  • Meta-analysis
  • 3-Month waiting period
  • Increased infection risk