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Risk of Infection in Thumb Carpometacarpal Surgery After Corticosteroid Injection

      Purpose

      The purpose of this study was to determine whether patients who had an intra-articular corticosteroid injection into the thumb carpometacarpal (CMC) joint for the treatment of arthritis within the 3 months before CMC joint arthroplasty or arthrodesis were at increased risk for wound complication/infection and/or repeat surgery for wound complication/infection in comparison with patients who did not receive an injection within 6 months or who received an injection between 3 and 6 months before surgery.

      Methods

      We identified 5,046 patients in the Humana claims database who underwent surgery for CMC joint arthritis. The patients were stratified into 3 groups: (1) no thumb injection within 6 months of CMC joint surgery, (2) thumb injection between 3 and 6 months before CMC joint surgery, and (3) thumb injection within 3 months before CMC joint surgery. The primary outcome was wound complication/infection within 90 days after surgery. The secondary outcome was repeat surgery for wound complication/infection within 90 days after surgery. Multivariable logistic regression was performed to assess the associations between the timing of injection and wound complication/infection and repeat surgery for wound complication/infection.

      Results

      The rates of wound complication/infection within 90 days after surgery were similar among the 3 study groups. However, patients who received an intra-articular corticosteroid injection within 3 months before surgery had a 2.2 times greater likelihood of repeat surgery for a wound complication/infection compared with patients who did not have an injection within 6 months before surgery.

      Conclusions

      Patients who receive an intra-articular corticosteroid injection within the 3 months before surgery for CMC joint arthritis may be at increased risk of repeat surgery to treat a wound complication/infection in the 90-day postoperative period.

      Type of study/level of evidence

      Prognostic II.

      Key words

      The efficacy of repeated intra-articular injections for the treatment of painful thumb carpometacarpal (CMC) joint arthritis is controversial.
      • Joshi R.
      Intraarticular corticosteroid injection for first carpometacarpal osteoarthritis.
      • Spaans A.J.
      • van Minnen L.P.
      • Kon M.
      • Schuurman A.H.
      • Schreuders A.R.
      • Vermeulen G.M.
      Conservative treatment of thumb base osteoarthritis: a systematic review.
      • Trellu S.
      • Dadoun S.
      • Berenbaum F.
      • Fautrel B.
      • Gossec L.
      Intra-articular injections in thumb osteoarthritis: a systematic review and meta-analysis of randomized controlled trials.
      There is concern about septic arthritis following an intra-articular injection due to direct bacterial inoculation of the joint from a needle and concern about the possible immunosuppressive effect of corticosteroids.
      • Moran S.L.
      • Duymaz A.
      • Karabekmez F.E.
      The efficacy of hyaluronic acid in the treatment of osteoarthritis of the trapeziometacarpal joint.
      ,
      • Richardson S.S.
      • Schairer W.W.
      • Sculco T.P.
      • Sculco P.K.
      Comparison of infection risk with corticosteroid or hyaluronic acid injection prior to total knee arthroplasty.
      Giladi et al
      • Giladi A.M.
      • Rahgozar P.
      • Zhong L.
      • Chung K.C.
      Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery.
      reported a 20% increased risk of complications after CMC arthroplasty surgery, most notably infectious complications, in association with preoperative intra-articular CMC joint corticosteroid injections.
      Recent studies in hip and knee arthroplasty have found a time-dependence of injection with an increased risk of periprosthetic infection when a corticosteroid was injected into the joint within 3 months before surgery, but not when a corticosteroid was injected into the joint more than 3 months before surgery.
      • Richardson S.S.
      • Schairer W.W.
      • Sculco T.P.
      • Sculco P.K.
      Comparison of infection risk with corticosteroid or hyaluronic acid injection prior to total knee arthroplasty.
      ,
      • Bedard N.A.
      • Pugely A.J.
      • Elkins J.M.
      • et al.
      The John N. Insall Award: do intraarticular injections increase the risk of infection after TKA?.
      An increased risk for postoperative infection has also been found in association with localized corticosteroid injections administered within 3 months before trigger release surgery.
      • Matzon J.L.
      • Lebowitz C.
      • Graham J.G.
      • Lucenti L.
      • Lutsky K.F.
      • Beredjiklian P.K.
      Risk of infection in trigger finger release surgery following corticosteroid injection.
      We aimed to better define the relationship between the timing of an intra-articular corticosteroid injection and postoperative wound complications, including infection, in thumb CMC joint arthritis surgery.
      The purpose of this study was to determine whether patients who had an intra-articular corticosteroid injection for the treatment of arthritis of the thumb CMC joint within 3 months before CMC joint arthroplasty or arthrodesis were at increased risk for wound complication/infection and/or repeat surgery for wound complication/infection, in comparison to patients who did not receive an injection within 6 months before or between 3 and 6 months before surgery.

      Materials and Methods

      Using the PearlDiver analytic database (PearlDiver Technologies), a search of Humana claims data was completed to identify all patients 18 years or older with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis of osteoarthrosis of the hand (ICD-9 codes 715.14, 715.24, and 715.94) between January 1, 2007, and September 30, 2015. The Humana administrative claims data included medical, prescription, and laboratory data from 20.9 million privately insured and Medicare Advantage patients. A benefit of the PearlDiver Humana claims database over other large-volume national databases was the ability to identify the laterality of procedures, which was especially pertinent to CMC joint arthritis because this condition often manifests bilaterally.
      • Marshall M.
      • van der Windt D.
      • Nicholls E.
      • Myers H.
      • Dziedzic K.
      Radiographic thumb osteoarthritis: frequency, patterns and associations with pain and clinical assessment findings in a community-dwelling population.
      From the group of qualifying ICD-9 codes, patients who underwent surgery for CMC joint arthritis were identified by filtering for the Current Procedural Terminology (CPT) codes 25447 (arthroplasty, interposition, intercarpal, or CMC joints), 25210 (carpectomy, 1 bone), and 26841 (arthrodesis, CMC joint, thumb, with or without internal fixation). The search was further refined to include only patients with information in the database encompassing a minimum of 6 months before and 18 months after surgery. The 6-month preoperative time frame was chosen to capture a reasonable course of nonoperative management for CMC joint arthritis. The 18-month time frame after surgery was chosen to ensure adequate follow-up data.
      From the final surgical sample of 5,046 patients, an intra-articular corticosteroid injection before surgery was identified by filtering for CPT code 20600 (injection small joint fingers) in association with the National Drug Codes for triamcinolone, betamethasone, and methylprednisolone solutions. The CPT code modifiers identified in the database as FA (left thumb) and F5 (right thumb) were queried to ensure that the injection site was the same side as the surgical site. The CPT codes pertaining to other sites of injection, such as in the wrist, hand, and elsewhere in the body, were excluded.
      The operative patients were stratified into 3 groups: (1) no thumb injection within 6 months before CMC joint surgery (3,047 patients), (2) thumb injection between 3 and 6 months before CMC joint surgery (1,313 patients), and (3) thumb injection within 3 months before CMC joint surgery (686 patients). The time frame we chose to analyze corticosteroid joint injections (ie, administered within or more than 3 months before surgery) was based on previous studies.
      • Matzon J.L.
      • Lebowitz C.
      • Graham J.G.
      • Lucenti L.
      • Lutsky K.F.
      • Beredjiklian P.K.
      Risk of infection in trigger finger release surgery following corticosteroid injection.
      ,
      • Schairer W.W.
      • Nwachukwu B.U.
      • Mayman D.J.
      • Lyman S.
      • Jerabek S.A.
      Preoperative hip injections increase the rate of periprosthetic infection after total hip arthroplasty.
      • Cancienne J.M.
      • Werner B.C.
      • Luetkemeyer L.M.
      • Browne J.A.
      Does timing of previous intra-articular steroid injection affect the post-operative rate of infection in total knee arthroplasty?.
      • Werner B.C.
      • Cancienne J.M.
      • Browne J.A.
      The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk.
      Patient demographics and medical histories were tabulated in each case, including age, sex, tobacco use, diabetes, and comorbidity status, using the Charlson comorbidity index (Table 1). The Charlson comorbidity index ranks 12 comorbidities with various weights to reach a maximum score of 24, and it can be used to estimate the risk of readmission after hand surgery.
      • Voskuijl T.
      • Hageman M.
      • Ring D.
      Higher Charlson comorbidity index scores are associated with readmission after orthopaedic surgery.
      Table 1Patient Demographics
      Patient CharacteristicsNo Injection Within 6 Months of Surgery (3,047)Injection Between 3 and 6 Months Before Surgery (1,313)Injection Within 3 Months Prior to Surgery (686)P Value
      Age (y)<.05
       35–3911 (0.36%)<10 (<1%)<10 (<1%)
       40–4424 (0.79%)<10 (<1%)<10 (<1%)
       45–4966 (2.17%)26 (1.98%)15 (2.19%)
       50– 54162 (5.32%)72 (5.48%)51 (7.43%)
       55–59283 (9.29%)142 (10.81%)65 (9.48%)
       60–64362 (11.88%)174 (13.25%)107 (15.60%)
       65–69866 (28.42%)356 (27.11%)195 (28.43%)
       70–74768 (25.21%)368 (28.03%)144 (21.0%)
       75–79408 (13.39%)150 (11.42%)77 (11.22%)
       80–84135 (4.43%)56 (4.27%)25 (3.64%)
       85–8923 (0.75%)<10 (<1%)<10 (<1%)
       >9015 (0.49%)<10 (<1%)<10 (<1%)
      Female2,228 (73.12%)988 (75.25%)527 (76.82%).08
      Diabetes1,042 (34.2%)455 (34.65%)247 (36.0%).66
      Smoker1,193 (39.15%)518 (39.45%)296 (43.15%).15
      Charlson comorbidity index
      Mean (SD).
      1.7 (2.1)1.8 (2.1)1.7 (2.1)>.99
      Carpectomy, 1 bone295 (9.68%)59 (4.49%)31 (4.52%)<.05
      Arthroplasty, interposition, intercarpal, or CMC joint2,682 (88.02%)1,228 (93.53%)634 (92.42%)
      Arthrodesis, CMC joint, thumb, with or without internal fixation70 (2.30%)26 (1.98%)21 (3.06%)
      Mean (SD).
      The primary outcome was wound complication/infection within 90 days after surgery. The secondary outcome was repeat surgery for wound complication/infection within 90 days after surgery. Wound complication/infection was defined by a range of ICD-9 codes covering wound dehiscence and postoperative infection (Table E1, available online on the Journal’s website at www.jhandsurg.org). A repeat surgical procedure was defined by an ICD-9 code(s) covering wound complication/infection and a CPT code encompassing incision and drainage, debridement, and/or arthrotomy with the National Correct Coding Initiative 78 modifier (Table E2, available online on the Journal’s website at www.jhandsurg.org). The 90-day cutoff after surgery was based on the senior author’s experience in diagnosing and managing such complications, and it was a time period 1 month longer than that used in a related report.
      • Giladi A.M.
      • Rahgozar P.
      • Zhong L.
      • Chung K.C.
      Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery.
      The χ
      • Spaans A.J.
      • van Minnen L.P.
      • Kon M.
      • Schuurman A.H.
      • Schreuders A.R.
      • Vermeulen G.M.
      Conservative treatment of thumb base osteoarthritis: a systematic review.
      test was used for the bivariate analysis of categorical variables, and analysis of variance was used for the analysis of continuous variables. Logistic regression testing was performed to assess for relationships between the timing of injection and postoperative wound complication/infection and/or repeat surgery for wound complication/infection, after adjusting for age, sex, tobacco use, diabetes, and comorbidity burden. The χ
      • Spaans A.J.
      • van Minnen L.P.
      • Kon M.
      • Schuurman A.H.
      • Schreuders A.R.
      • Vermeulen G.M.
      Conservative treatment of thumb base osteoarthritis: a systematic review.
      and logistic regression subanalyses of interposition arthroplasty cases alone (CPT code 25447) were also completed. The CPT code 25447, which included all interposition procedures whether with tendon, allograft, or artificial material, was the most common procedure queried, and it was analyzed as a separate group because of its adequate sample size. Statistical significance was determined for a P value of <.05. A post hoc power analysis was performed. With a beta of 0.8 and the given sample size, the study was powered to detect a 1.42% difference in wound complication/infection rates between different groups.

      Results

      The rates of wound complication/infection within 90 days after surgery were similar among the 3 study groups: no intra-articular corticosteroid injection within 6 months before surgery (3.0%), intra-articular corticosteroid injection between 3 and 6 months before surgery (2.8%), and intra-articular corticosteroid injection within 3 months before surgery (4.2%, P = .35) (Table 2). In contrast, the incidence of repeat surgery within 90 days after surgery for wound complication/infection was significantly greater in the patient group treated with an intra-articular corticosteroid injection within 3 months before surgery compared with the other 2 groups (2.2% vs 1.1% and 0.9%, P < .05) (Table 2).
      Table 2Bivariate Analysis
      OutcomeNo Injection Within 6 Months of Surgery (3,047)Injection Between 3 and 6 Months Before Surgery (1,313)Injection Within 3 Months Prior to Surgery (686)P Value
      Wound complication/infection90 (3.0%)37 (2.8%)29 (4.2%).35
       Repeat surgery32 (1.1%)12 (0.9%)15 (2.2%)<.05
      In the subanalysis of interposition arthroplasty cases, the incidences of wound complication/infection within 90 days after surgery were similar among the 3 study groups: no intra-articular corticosteroid injection within 6 months before surgery (3.0%), intra-articular corticosteroid injection between 3 and 6 months before surgery (2.7%), and intra-articular corticosteroid injection within 3 months before surgery (4.3%) (P = .45). In contrast, the rate of repeat surgery within 90 days after surgery for wound complication/infection was significantly greater in the patient group treated with an intra-articular corticosteroid injection within 3 months before surgery in comparison to the other 2 groups (2.4% vs 0.9% and 0.8%, P < .05) (Table 3).
      Table 3Subanalysis Bivariate Analysis
      OutcomeNo Injection Within 6 Months of Surgery (2,683)Injection Between 3 and 6 Months Before Surgery (1,231)Injection Within 3 Months Prior to Surgery (634)P Value
      Wound complication/infection80 (3.0%)33 (2.7%)27 (4.3%).45
      Repeat surgery24 (0.9%)10 (0.8%)15 (2.4%)<.05
      On regression analysis, neither the group of patients who had an intra-articular corticosteroid injection within 3 months before CMC joint surgery nor the group of patients who had an injection more than 3 months before surgery was found to have an increased likelihood of postoperative wound complication/infection within 90 days after surgery (P > .17). However, patients who received an intra-articular corticosteroid injection within 3 months before surgery had an increased likelihood of repeat surgery within 90 days for wound complication/infection in comparison to patients who did not have an injection within 6 months before surgery (odds ratio 2.2, 95% confidence interval 1.0–4.1, P < .05) (Table 4).
      Table 4Logistic Regression Analysis
      OutcomeInjection Between 3 and 6 Months Before Surgery OR (95% CI)P ValueInjection Within 3 Months Prior to Surgery OR (95% CI)P Value
      Wound complication/infection
      Reference group is no injection.
      0.7 (0.5–1.1).191.3 (0.9–1.9).17
      Repeat surgery
      Reference group is no injection.
      0.9 (0.4–1.7).662.2 (1.0–4.1)<.05
      CI, confidence interval; OR, odds ratio.
      Reference group is no injection.
      The same relationship was found on regression analysis of the interposition arthroplasty cases alone. Patients who received an intra-articular corticosteroid injection within 3 months before surgery had an increased likelihood of repeat surgery for wound complication/infection within 90 days after surgery in comparison to patients who did not receive an injection within 6 months before surgery (odds ratio 2.8, 95% confidence interval 1.5–5.3, P < .05) (Table 5).
      Table 5Subanalysis Logistic Regression Analysis
      OutcomeInjection Between 3 and 6 Months Before Surgery OR (95% CI)P ValueInjection Within 3 Months Prior to Surgery OR (95% CI)P Value
      Wound complication/infection
      Reference group is no injection.
      0.8 (0.5–1.2).321.5 (0.8–2.2).12
      Repeat surgery
      Reference group is no injection.
      0.9 (0.4–1.8).792.8 (1.5–5.3)<.05
      Reference group is no injection.

      Discussion

      In a large United States health insurance administrative database, the incidences of wound complication/infection within 90 days after surgery for CMC joint arthritis were similar between patients who did and did not receive a preoperative CMC joint corticosteroid injection, regardless of whether the injection was administered before or within a 3-month period ahead of surgery. We suspect that our findings differ from the conclusions drawn in large joint arthroplasty studies because of the absence of prosthetic implantation in the majority of CMC arthritis surgeries.
      In contrast, patients who received an intra-articular corticosteroid injection within 3 months before surgery were at an increased risk of repeat surgery within 90 days postoperatively to treat a wound complication/infection. This may be a spurious association or related to wound breakdown and/or infection. There are recognized adverse effects of steroid injections on collagen production and degradation.
      • Wei A.S.
      • Callaci J.J.
      • Juknelis D.
      • et al.
      The effect of corticosteroid on collagen expression in injured rotator cuff tendon.
      The exact mechanisms by which a corticosteroid joint injection may increase the risk of infection and the time frame for developing an infection are not clear. Direct inoculation and/or immunosuppression caused by the steroid product are conceivable risk factors.
      • Dahl J.
      • Hammert W.C.
      Overview of injectable corticosteroids.
      Injectable steroids alter the action of cytokines involved in inflammation and block the production of prostaglandins and leukotrienes, which are primary inflammatory mediators.
      • Dahl J.
      • Hammert W.C.
      Overview of injectable corticosteroids.
      • D'Acquisto F.
      • Paschalidis N.
      • Raza K.
      • Buckley C.D.
      • Flower R.J.
      • Perretti M.
      Glucocorticoid treatment inhibits annexin-1 expression in rheumatoid arthritis CD4+ T cells.
      • Barnes P.J.
      Anti-inflammatory actions of glucocorticoids: molecular mechanisms.
      The incidences of a wound complication/infection (2.8%–4.2%) and the rates of returning to surgery for the treatment of a wound complication/infection (0.9%–2.2%) in our study groups were greater than 2 previous CMC joint arthroplasty reports. Menendez et al
      • Menendez M.E.
      • Lu N.
      • Unizony S.
      • Choi H.K.
      • Ring D.
      Surgical site infection in hand surgery.
      found a 0.49% infection rate, and Shah et al
      • Shah K.N.
      • Defroda S.F.
      • Wang B.
      • Weiss A.C.
      Risk factors for 30-day complications after thumb CMC joint arthroplasty: an American College of Surgeons National Surgery Quality Improvement Program Study.
      found a 0.66% wound complication rate and a 0.15% return-to-surgery incidence after CMC joint arthroplasty. Conversely, Giladi et al
      • Giladi A.M.
      • Rahgozar P.
      • Zhong L.
      • Chung K.C.
      Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery.
      found a 5% infection complication rate after CMC joint arthroplasty or fusion in an administrative database study of 16,268 surgical cases. The odds of any complication, most notably infectious, were increased by 20% by 1 preoperative corticosteroid injection. Our methodology, which included more than 2 dozen ICD-9 codes to identify complications after CMC joint surgery, was most similar to that of Giladi et al
      • Giladi A.M.
      • Rahgozar P.
      • Zhong L.
      • Chung K.C.
      Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery.
      and different from that of Menendez et al
      • Menendez M.E.
      • Lu N.
      • Unizony S.
      • Choi H.K.
      • Ring D.
      Surgical site infection in hand surgery.
      and Shah et al,
      • Shah K.N.
      • Defroda S.F.
      • Wang B.
      • Weiss A.C.
      Risk factors for 30-day complications after thumb CMC joint arthroplasty: an American College of Surgeons National Surgery Quality Improvement Program Study.
      which we believe played a role in the differences in reported infection rates.
      A higher risk of postoperative infection in patients who had an intra-articular corticosteroid injection within 3 months before surgery has been reported after trigger release surgery. Matzon et al
      • Matzon J.L.
      • Lebowitz C.
      • Graham J.G.
      • Lucenti L.
      • Lutsky K.F.
      • Beredjiklian P.K.
      Risk of infection in trigger finger release surgery following corticosteroid injection.
      found an increased risk of deep infection requiring surgical irrigation and debridement, but not superficial infection, after trigger release surgery when a corticosteroid injection was administered within 3 months (ie, between 31 and 90 days) prior to surgery, but not when an injection was administered more than 90 days before surgery. The patients in our study who were categorized as not having received a CMC joint injection within 6 months before surgery could still have received an injection(s) before that time interval (ie, before the start of data collection).
      • Gershkovich G.E.
      • Boyadjian H.
      • Conti Mica M.
      The effect of image-guided corticosteroid injections on thumb carpometacarpal arthritis.
      However, without an increase in risk of a wound complication/infection or additional surgery to treat a wound complication/infection, we can infer that a CMC joint corticosteroid injection(s) administered more than 6 months before surgery had no adverse effect on wound healing or surgical site infection.
      The CPT code 25447 (arthroplasty, interposition, intercarpal or carpometacarpal) was the most common billing code for treatment of CMC arthritis. This procedural code included all interposition procedures, whether with tendon, allograft, or artificial material. While the implication for infection risk of other procedures (such as implant arthroplasty) may be of greater interest, we did not complete subanalyses of other CPT codes due to inadequate sample sizes. Like our entire study sample, the patients designated by CPT code 25447 who received a corticosteroid injection within 3 months before CMC arthroplasty surgery had an increased likelihood of returning to surgery for treatment of a wound complication/infection.
      There are several limitations of our study. With a beta of 0.8 and the given sample size, the study is powered to detect a 1.42% difference in wound complication/infection rates between groups. To our knowledge, the percentage difference that denotes a clinically meaningful difference has not been defined. The Humana claims database does not provide detailed information on suture anchors, plates, screws, wires, or allografts. These implants may conceivably influence the risk of a thumb CMC joint wound complication/infection. We did not assess the number of preoperative corticosteroid injections into the basal joint of the thumb because these data were not available. Giladi et al
      • Giladi A.M.
      • Rahgozar P.
      • Zhong L.
      • Chung K.C.
      Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery.
      found that each corticosteroid injection after the first injection increased the odds of a complication after thumb CMC arthritis surgery by 10%. In hip and knee arthroplasty, reports vary based on whether the absolute number of preoperative corticosteroid injections influences the risk of postoperative infection.
      • Richardson S.S.
      • Schairer W.W.
      • Sculco T.P.
      • Sculco P.K.
      Comparison of infection risk with corticosteroid or hyaluronic acid injection prior to total knee arthroplasty.
      ,
      • Chambers A.W.
      • Lacy K.W.
      • Liow M.H.L.
      • Manalo J.P.M.
      • Freiberg A.A.
      • Kwon Y.M.
      Multiple hip intra-articular steroid injections increase risk of periprosthetic joint infection compared with single injections.
      The imprecision of ICD-9 coding may have also have had an impact on our study findings. The ICD-9 classification system that was in use in the United States through September 2015 did not specify between thumb and finger CMC joints or the severity of CMC arthritis when coding for osteoarthritis in the hand. Consequently, some operations in our analyses may have involved the finger rather than the thumb CMC joints. The ICD-9 coding system also did not classify the severity of a wound complication or distinguish between superficial and deep infections. Intuitively, a return to the operating room for treatment of a postoperative wound complication/infection (designated by a CPT code encompassing incision and drainage, debridement, and/or arthrotomy) would reflect a serious wound complication/deep infection rather than a minor wound complication/superficial infection.
      • Matzon J.L.
      • Lebowitz C.
      • Graham J.G.
      • Lucenti L.
      • Lutsky K.F.
      • Beredjiklian P.K.
      Risk of infection in trigger finger release surgery following corticosteroid injection.
      However, an individual surgeon’s rationale for returning a patient to the operating room cannot be discerned from the claims database and may have influenced our findings. Moreover, the relative risk estimates in our analyses include wide confidence intervals, making it difficult to determine the true relative risk of steroid injection on repeat surgery.
      Surgeon variations in operative and injection techniques and differences in administrative CPT coding may have also affected our results. We did not assess for potential differences between the 3 corticosteroid solutions (triamcinolone, betamethasone, and methylprednisolone) regarding any association with postoperative wound complication/infection or repeat surgery for a wound complication/infection. In addition, the CPT codes pertaining to other sites of injection in the wrist and hand were excluded. Consequently, we did not assess the potential adverse effects of nearby steroid injections on the risk of a postoperative CMC joint wound complication/infection. Finally, an evaluation of repeat surgery for the treatment of the first metacarpal instability and/or hardware failure is not included in our study design; the management of such complications has been previously reported.
      • Mattila S.
      • Waris E.
      Revision of trapeziometacarpal arthroplasty: risk factors, procedures and outcomes.
      Patients who receive an intra-articular corticosteroid injection within 3 months before surgery for CMC joint arthritis of the thumb may be at increased risk in the first 90 days postoperatively for additional surgery to treat a wound complication/infection. Although further studies are needed to draw definitive conclusions, intra-articular injections may be a modifiable risk factor for infection in the 3 months before surgery to treat thumb CMC joint arthritis.

      Appendix A

      Table E1ICD-9 Codes to Identify Postoperative Wound Complication/Infection
      ICD-9 CodesDescriptors
      Wound complication998.3Codes all related to disruption of operative wound
      998.3
      998.31
      998.32
      998.83Non-healing surgical wound
      882.0Open wound of hand (except fingers alone)
      882.1Open wound of hand (except fingers alone), complicated
      882.2Open wound of hand (except fingers alone), with tendon involvement
      Infection998.59Post-operative wound infection
      682.4Cellulitis and abscess of hand (except fingers and thumb)
      682.8Cellulitis and abscess of other site
      682.9Cellulitis and abscess of unspecified site
      681.0Cellulitis and abscess of finger
      681.00Cellulitis and abscess of finger, unspecified
      681.9Cellulitis and abscess of unspecified digit
      686.8Other specified local infections of skin and subcutaneous tissue
      686.9Unspecified local infection of skin and subcutaneous tissue
      998.5Post-operative infection, not elsewhere classified
      998.59Other post-operative infection
      996.60Infection and inflammatory reaction due to unspecified device, implant, and graft
      996.69Infection and inflammatory reaction due to internal prosthetic device, implant, and graft
      996.79Other complications due to other internal prosthetic device, implant, and graft
      996.67Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft
      Table E2CPT Codes for Repeat Surgery Due to Wound Complication/Infection
      CPT codesDescriptors
      11040Debridement of skin, partial thickness
      11041Debridement of skin, full thickness
      11042Debridement of skin and subcutaneous tissue
      11043Debridement of skin, subcutaneous tissue, and muscle
      11044Debridement of skin, subcutaneous tissue, muscle, and bone
      10140Incision and drainage of hematoma, seroma, or fluid collection
      10180Incision and drainage, complex, postoperative wound infection
      20000Drainage of abscess or fluid collection
      20005Incision of soft tissue abscess, deep or complicated
      25028Incision and drainage, forearm and/or wrist, deep abscess or hematoma
      25035Incision, deep, with opening of bone cortex forearm and/or wrist
      25040Arthrotomy, radiocarpal or mediocarpal joint, with exploration, drainage, or removal of foreign body
      26034Incision, deep, with opening of bone cortex, hand or finger
      26070Arthrotomy, for infection, with exploration, drainage, or removal of foreign body, carpometacarpal joint
      10060Incision and drainage of abscess, simple or single
      10061Incision and drainage of abscess, complex or multiple
      10120Incision and removal of foreign body, subcutaneous tissue, simple
      10121Incision and removal of foreign body, subcutaneous tissue, complicated
      12020Treatment of superficial wound dehiscence, simple closure
      12021Treatment of superficial wound dehiscence, with packing
      16020Dressings and/or debridement, without anesthesia, small
      16025Dressings and/or debridement, without anesthesia, medium
      16030Dressings and/or debridement, without anesthesia, large

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