Original Research

Preoperative Corticosteroid Use for Medical Conditions is Associated with Increased Postoperative Infectious Complications and Readmissions After Total Hip Arthroplasty: A Propensity-Matched Study

Publish date: December 10, 2018

References

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Corticosteroids are powerful anti-inflammatory steroid hormones that have many indications in the treatment of medical diseases, including advanced or poorly controlled asthma, chronic obstructive pulmonary disease (COPD), inflammatory bowel disease, allergic conditions, among other indications.^1-4 In orthopedics and rheumatology, systemic steroids are, at times, used in patients with rheumatoid arthritis, systemic lupus erythematosus, and vasculitides.^5-7 Overman and colleagues,⁸ using data from the National Health and Nutrition Examination Survey between 1999 and 2008 identified both a 1.2% prevalence of chronic corticosteroid usage in the United States across all age groups and a positive correlation between steroid use prevalence and increasing age. In that study, nearly two-thirds of survey respondents reported using corticosteroids chronically for >90 days. Another observational study in the United Kingdom found that long-term steroid prescriptions increased between 1989 to 2008 and that 13.6% of patients with rheumatoid arthritis and 66.5% of patients with polymyalgia rheumatica or giant cell arteritis used long-term steroids.⁹

Enterally- or parenterally-administered corticosteroids have numerous systemic effects that are of particular relevance to orthopedic surgeons. Corticosteroids induce osteoporosis by preferentially inducing osteoclastic activity while inhibiting the differentiation of osteoblasts, ultimately leading to decreased bone quality and mass.¹⁰ As a consequence, patients who have previously used corticosteroids are more than twice as likely to have a hip fracture.¹¹ Steroids also increase the risk of both osteonecrosis and myopathy, among other musculoskeletal effects.¹² In addition to orthopedic complications, steroids have broad inhibitory effects on both acquired and innate immunity, which significantly increases the risk of infections.¹³ This increased risk of infection is dose-dependent¹⁴ and synergistic with other immunosuppressive drugs.¹⁵

Patients with hip pain may receive localized corticosteroid hip joint injections during the nonoperative management of various hip pathologies, including arthritis, bursitis, and labral tears.^16,17 Outcomes of patients who received intra-articular corticosteroid injections before total hip arthroplasty (THA) were evaluated in a systematic review of 9 studies by Pereira and colleagues.¹⁷ These authors found that the infection rate (both superficial and deep surgical site infections [SSI]) after THA in patients who received local steroid injection into the hip before surgery was between 0% and 30%.¹⁷ However, similar studies assessing the impact that systemic steroids have on outcomes after THA are lacking. Patients who undergo THA for conditions associated with higher lifetime steroid usage have worse outcomes than those who do not. For instance, in patients undergoing THA for rheumatoid arthritis, the rates of both postoperative periprosthetic joint infection and hip dislocation are higher, when compared with osteoarthritis.^18,19 However, it is unclear how much of this difference in outcomes is due to the underlying disease, adverse effects of steroids, or both. Given the high prevalence of chronic systemic steroid use, it is essential to elucidate more clearly the impact that these medications have on perioperative outcomes after THA.

Therefore, the purpose of this study was to characterize short-term perioperative outcomes, including complication and readmission rates in patients undergoing THA while taking chronic preoperative corticosteroids. We also sought to identify the most common reasons for hospital readmission in patients who did and did not use long-term steroids.

MATERIALS AND METHODS

STUDY DESIGN AND SETTING

This investigation was a retrospective cohort study that utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry.²⁰ The ACS-NSQIP is a prospectively collected, multi-institutional database that collects demographical information, operative variables, and both postoperative complications and hospital readmission data. Data is collected for up to 30 days after the index procedure, and patients are contacted by telephone if they are discharged before 30 days. Patient data is entered by specially trained surgical clinical reviewers and is routinely audited by the ACS-NSQIP, leading to more accurate data when compared with administrative research databases.^21,22 The ACS-NSQIP has been used in orthopedic surgery outcomes-based studies.^23-25

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