EDITOR’S CHOICE

Risk of Infection in Thumb

Carpometacarpal Surgery After
Corticosteroid Injection
Mia M. Qin, MD,* Charles D. Qin, MD,† Daniel J. Johnson, MD,* David M. Kalainov, MD, MBA*

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 treat-
ment 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 complica-
tion/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. (J Hand Surg Am.
2021;46(9):765e771. Copyright Ó 2021 by the American Society for Surgery of the Hand. All
rights reserved.)
Type of study/level of evidence Prognostic II.
Key words Corticosteroid injection, infection, thumb carpometacarpal arthritis, thumb carpo-
metacarpal surgery.

From the *Department of Orthopedic Surgery, Northwestern University; and the †Department Corresponding author: Mia M. Qin, MD, Department of Orthopedic Surgery, Northwestern
of Orthopedic Surgery, University of Chicago, Chicago, IL. University, 259 E. Erie St. 13th floor, Chicago, IL 60611E; e-mail: mia.helfrich@northwestern.
edu.
Received for publication April 16, 2020; accepted in revised form April 7, 2021.
0363-5023/21/4609-0005$36.00/0
No benefits in any form have been received or will be received related directly or indirectly https://doi.org/10.1016/j.jhsa.2021.04.010
to the subject of this article.

Ó 2021 ASSH r Published by Elsevier, Inc. All rights reserved. r 765

766 INFECTION IN CMC SURGERY AFTER INJECTION
T
HE EFFICACY OF REPEATED intra-articular in-
jections for the treatment of painful thumb
carpometacarpal (CMC) joint arthritis is
controversial.1e3 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.4,5 Giladi et al6 reported a
20% increased risk of complications after CMC
arthroplasty surgery, most notably infectious com-
plications, 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.5,7 An increased risk for postoperative
infection has also been found in association with
localized corticosteroid injections administered
within 3 months before trigger release surgery.8 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 in-
jection 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 compli-
cation/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.9
J Hand Surg Am.
From the group of qualifying ICD-9 codes, pa-
tients 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 sur-
gery was identified by filtering for CPT code 20600
(injection small joint fingers) in association with the
National Drug Codes for triamcinolone, betametha-
sone, 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 sur-
gical 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 pa-
tients). The time frame we chose to analyze cortico-
steroid joint injections (ie, administered within or
more than 3 months before surgery) was based on
previous studies.8,10e12 Patient demographics and
medical histories were tabulated in each case,
including age, sex, tobacco use, diabetes, and co-
morbidity status, using the Charlson comorbidity in-
dex (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.13
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 post-
operative infection (Table E1, available online on
the Journal’s website at www.jhandsurg.org). A
repeat surgical procedure was defined by an ICD-9
r Vol. 46, September 2021
 INFECTION IN CMC SURGERY AFTER INJECTION 767

TABLE 1. Patient Demographics

No Injection Injection Between Injection Within
Within 6 Months 3 and 6 Months 3 Months P
Patient Characteristics of Surgery (3,047) Before Surgery (1,313) Prior to Surgery (686) Value

Age (y) <.05

35e39 11 (0.36%) <10 (<1%) <10 (<1%)
40e44 24 (0.79%) <10 (<1%) <10 (<1%)
45e49 66 (2.17%) 26 (1.98%) 15 (2.19%)
50e 54 162 (5.32%) 72 (5.48%) 51 (7.43%)
55e59 283 (9.29%) 142 (10.81%) 65 (9.48%)
60e64 362 (11.88%) 174 (13.25%) 107 (15.60%)
65e69 866 (28.42%) 356 (27.11%) 195 (28.43%)
70e74 768 (25.21%) 368 (28.03%) 144 (21.0%)
75e79 408 (13.39%) 150 (11.42%) 77 (11.22%)
80e84 135 (4.43%) 56 (4.27%) 25 (3.64%)
85e89 23 (0.75%) <10 (<1%) <10 (<1%)
>90 15 (0.49%) <10 (<1%) <10 (<1%)
Female 2,228 (73.12%) 988 (75.25%) 527 (76.82%) .08
Diabetes 1,042 (34.2%) 455 (34.65%) 247 (36.0%) .66
Smoker 1,193 (39.15%) 518 (39.45%) 296 (43.15%) .15
Charlson comorbidity index* 1.7 (2.1) 1.8 (2.1) 1.7 (2.1) >.99
Carpectomy, 1 bone 295 (9.68%) 59 (4.49%) 31 (4.52%) <.05
Arthroplasty, interposition, 2,682 (88.02%) 1,228 (93.53%) 634 (92.42%)
intercarpal, or CMC joint
Arthrodesis, CMC joint, 70 (2.30%) 26 (1.98%) 21 (3.06%)
thumb, with or without
internal fixation

*Mean (SD).

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.6
The c2 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 re-
lationships between the timing of injection and
postoperative wound complication/infection and/or
repeat surgery for wound complication/infection, af-
ter adjusting for age, sex, tobacco use, diabetes, and
comorbidity burden. The c2 and logistic regression
subanalyses of interposition arthroplasty cases alone
(CPT code 25447) were also completed. The CPT
code 25447, which included all interposition pro-
cedures 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

J Hand Surg Am. r Vol. 46, September 2021

768 INFECTION IN CMC SURGERY AFTER INJECTION
TABLE 2. Bivariate Analysis
No Injection Within
6 Months of
Outcome Surgery (3,047)
Wound complication/infection 90 (3.0%)
Repeat surgery 32 (1.1%)
corticosteroid injection within 3 months before sur-
gery (4.2%, P ¼ .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).
In the subanalysis of interposition arthroplasty
cases, the incidences of wound complication/infec-
tion 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 sur-
gery (4.3%) (P ¼ .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 cortico-
steroid 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).
On regression analysis, neither the group of pa-
tients who had an intra-articular corticosteroid injec-
tion 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 1.0e4.1, P < .05)
(Table 4).
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
J Hand Surg Am.
Injection Between Injection Within
3 and 6 Months 3 Months Prior to
Before Surgery (1,313) Surgery (686) P Value
37 (2.8%) 29 (4.2%) .35
12 (0.9%) 15 (2.2%) <.05
complication/infection within 90 days after surgery in
comparison to patients who did not receive an in-
jection within 6 months before surgery (odds ratio
2.8, 95% confidence interval 1.5e5.3, P < .05)
(Table 5).
DISCUSSION
In a large United States health insurance administra-
tive 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 corticoste-
roid 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 implan-
tation in the majority of CMC arthritis surgeries.
In contrast, patients who received an intra-articular
corticosteroid injection within 3 months before sur-
gery were at an increased risk of repeat surgery
within 90 days postoperatively to treat a wound
complication/infection. This may be a spurious as-
sociation or related to wound breakdown and/or
infection. There are recognized adverse effects of
steroid injections on collagen production and degra-
dation.14 The exact mechanisms by which a cortico-
steroid 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.15 Injectable steroids alter the
action of cytokines involved in inflammation and
block the production of prostaglandins and leukotri-
enes, which are primary inflammatory
mediators.15e17
The incidences of a wound complication/infection
(2.8%e4.2%) and the rates of returning to surgery for
the treatment of a wound complication/infection
(0.9%e2.2%) in our study groups were greater than 2
previous CMC joint arthroplasty reports. Menendez
et al18 found a 0.49% infection rate, and Shah et al19
r Vol. 46, September 2021
 INFECTION IN CMC SURGERY AFTER INJECTION 769

TABLE 3. Subanalysis Bivariate Analysis

No Injection Within Injection Between Injection Within
6 Months of 3 and 6 Months 3 Months Prior
Outcome Surgery (2,683) Before Surgery (1,231) to Surgery (634) P Value

Wound complication/infection 80 (3.0%) 33 (2.7%) 27 (4.3%) .45

Repeat surgery 24 (0.9%) 10 (0.8%) 15 (2.4%) <.05

TABLE 4. Logistic Regression Analysis

Injection Between Injection Within
3 and 6 Months Before 3 Months Prior
Outcome Surgery OR (95% CI) P Value to Surgery OR (95% CI) P Value

Wound complication/infection* 0.7 (0.5e1.1) .19 1.3 (0.9e1.9) .17

Repeat surgery* 0.9 (0.4e1.7) .66 2.2 (1.0e4.1) <.05

CI, confidence interval; OR, odds ratio.

*Reference group is no injection.

TABLE 5. Subanalysis Logistic Regression Analysis

Injection Between Injection Within
3 and 6 Months Before 3 Months Prior
Outcome Surgery OR (95% CI) P Value to Surgery OR (95% CI) P Value

Wound complication/infection* 0.8 (0.5e1.2) .32 1.5 (0.8e2.2) .12

Repeat surgery* 0.9 (0.4e1.8) .79 2.8 (1.5e5.3) <.05

*Reference group is no injection.

found a 0.66% wound complication rate and a 0.15%
return-to-surgery incidence after CMC joint arthro-
plasty. Conversely, Giladi et al6 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 methodol-
ogy, which included more than 2 dozen ICD-9 codes
to identify complications after CMC joint surgery,
was most similar to that of Giladi et al6 and different
from that of Menendez et al18 and Shah et al,19 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 al8 found an
increased risk of deep infection requiring surgical
irrigation and debridement, but not superficial
infection, after trigger release surgery when a corti-
costeroid 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).20
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) admin-
istered 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 com-
mon billing code for treatment of CMC arthritis. This
procedural code included all interposition procedures,

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770 INFECTION IN CMC SURGERY AFTER INJECTION
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 in-
jection 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 al6 found that each cortico-
steroid 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 pre-
operative corticosteroid injections influences the risk
of postoperative infection.5,21
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 be-
tween 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 treat-
ment of a postoperative wound complication/infec-
tion (designated by a CPT code encompassing
incision and drainage, debridement, and/or arthrot-
omy) would reflect a serious wound complication/
deep infection rather than a minor wound complica-
tion/superficial infection.8 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
J Hand Surg Am.
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 corti-
costeroid 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/infec-
tion. 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.22
Patients who receive an intra-articular corticoste-
roid 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.
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771.e1 INFECTION IN CMC SURGERY AFTER INJECTION

TABLE E1. ICD-9 Codes to Identify Postoperative Wound Complication/Infection

ICD-9 Codes Descriptors

Wound complication 998.3 Codes all related to disruption of operative wound

998.3
998.31
998.32
998.83 Non-healing surgical wound
882.0 Open wound of hand (except fingers alone)
882.1 Open wound of hand (except fingers alone), complicated
882.2 Open wound of hand (except fingers alone), with tendon involvement
Infection 998.59 Post-operative wound infection
682.4 Cellulitis and abscess of hand (except fingers and thumb)
682.8 Cellulitis and abscess of other site
682.9 Cellulitis and abscess of unspecified site
681.0 Cellulitis and abscess of finger
681.00 Cellulitis and abscess of finger, unspecified
681.9 Cellulitis and abscess of unspecified digit
686.8 Other specified local infections of skin and subcutaneous tissue
686.9 Unspecified local infection of skin and subcutaneous tissue
998.5 Post-operative infection, not elsewhere classified
998.59 Other post-operative infection
996.60 Infection and inflammatory reaction due to unspecified device, implant, and graft
996.69 Infection and inflammatory reaction due to internal prosthetic device, implant,
and graft
996.79 Other complications due to other internal prosthetic device, implant, and graft
996.67 Infection and inflammatory reaction due to other internal orthopedic device,
implant, and graft

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 INFECTION IN CMC SURGERY AFTER INJECTION 771.e2

TABLE E2. CPT Codes for Repeat Surgery Due to Wound Complication/Infection
CPT codes Descriptors

11040 Debridement of skin, partial thickness

11041 Debridement of skin, full thickness
11042 Debridement of skin and subcutaneous tissue
11043 Debridement of skin, subcutaneous tissue, and muscle
11044 Debridement of skin, subcutaneous tissue, muscle, and bone
10140 Incision and drainage of hematoma, seroma, or fluid collection
10180 Incision and drainage, complex, postoperative wound infection
20000 Drainage of abscess or fluid collection
20005 Incision of soft tissue abscess, deep or complicated
25028 Incision and drainage, forearm and/or wrist, deep abscess or hematoma
25035 Incision, deep, with opening of bone cortex forearm and/or wrist
25040 Arthrotomy, radiocarpal or mediocarpal joint, with exploration, drainage, or removal of foreign body
26034 Incision, deep, with opening of bone cortex, hand or finger
26070 Arthrotomy, for infection, with exploration, drainage, or removal of foreign body, carpometacarpal joint
10060 Incision and drainage of abscess, simple or single
10061 Incision and drainage of abscess, complex or multiple
10120 Incision and removal of foreign body, subcutaneous tissue, simple
10121 Incision and removal of foreign body, subcutaneous tissue, complicated
12020 Treatment of superficial wound dehiscence, simple closure
12021 Treatment of superficial wound dehiscence, with packing
16020 Dressings and/or debridement, without anesthesia, small
16025 Dressings and/or debridement, without anesthesia, medium
16030 Dressings and/or debridement, without anesthesia, large

J Hand Surg Am. r Vol. 46, September 2021