Association of intra-articular injection and knee arthroscopy prior to primary knee replacement with the timing and outcomes of surgery: retrospective cohort study using data from the clinical practice research datalink GOLD database

Background Patients with symptomatic knee osteoarthritis may undergo non-surgical interventions such as intra-articular steroid injections and knee arthroscopy. This study aimed to investigate their association with the timing and outcomes of subsequent primary knee replacement.

Methods and findings Observational retrospective analysis of linked Clinical Practice Research Datalink, Hospital Episode Statistics, Patient Reported Outcome Measures (CPRD GOLD-HES-PROMS) data of 38,494 patients undergoing primary knee replacements in England. Prior use of intra-articular steroid injections and knee arthroscopy were identified. Hazard ratios (HRs) with 95% CIs were estimated for primary outcomes of revision and reoperation using Cox regression. Secondary outcomes included time from first diagnosis of ipsilateral knee osteoarthritis to knee replacement, 6-month post-operative Oxford Knee Scores (OKS), mortality (90-days and 3-months), and post-operative surgical site infection (SSI) (3-months) using linear and logistic regression. Prior steroid injections were associated with an increased risk of revision (HR = 1.25 95%CI (1.06 to 1.49)), re-operation (HR = 1.18 95%CI (1.05 to 1.32)), and SSI (HR = 3.10 95%CI (1.14 to 8.46). Timing from diagnosis of knee osteoarthritis to knee replacement was 6 months longer in patients receiving steroid injections. Knee arthroscopy was associated with an increased risk of revision (HR = 3.14 95%CI (2.64 to 3.73)), re-operation (HR = 3.25 95%CI (2.89 to 3.66)), lower post-operative OKS -1.63 95%CI (-2.31 to -0.95). Both interventions were associated with a lower risk of mortality.

Conclusions Steroid injection and knee arthroscopy prior to primary knee replacement are each associated with worse outcomes. The observed association of lower mortality risk is suggestive of confounding by indication. The observed associations in this study could be used to inform shared decision making with patients on the treatment pathway for knee osteoarthritis.