Injections before Knee Replacements

Risk analysis of periprosthetic knee joint infection (PJI) in total knee arthroplasty after preoperative corticosteroid injection: a systematic review: A study performed by the Early-Osteoarthritis group of ESSKA-European Knee Associates section

M H Baums 1J Aquilina 2D Pérez-Prieto 3O Sleiman 4G Geropoulos 2T Totlis 5 6


Purpose: Intra-articular corticosteroid injection is widely used for symptomatic relief of knee osteoarthritis. However, if pain is not improved which consequences a total knee arthroplasty (TKA), there is a potential risk of post-operative periprosthetic joint infection (PJI). The aim of this study is to investigate whether the use of preoperative intra-articular corticosteroid injection increases the risk of PJI and to investigate a time frame in which the risk of subsequent infection is significantly increased.

Methods: A systematic search was performed in PubMed (Medline), Scopus, and the Cochrane Library. Inclusion criteria were original studies investigating the rate of PJI in patients receiving pre-operative intra-articular corticosteroid injection compared to controls.

Results: A total of 380 unique articles were screened. Six studies met the inclusion criteria with 255,627 patients in total. Overall, no statistical significance was observed in the intra-articular infection rate in corticosteroid compared to controls groups. However, intra-articular corticosteroid injections within 3 months prior to TKA were associated with a significantly increased risk of infection (OR: 1.52, 95% CI 1.37-1.67, p < 0.01); this was not observed in the 6 month period (OR: 1.05, 95% CI 0.80-1.39, p = 0.72).

Conclusions: Performing an intra-articular corticosteroid injection within 3 months prior to TKA is associated with a significantly increased risk of PJI. The current evidence supports the safe use of intra-articular corticosteroid injection more than 6 months before TKA. However, additional studies are needed to clarify the risk of PJI after TKA implantation between 3 and 6 months after the last corticoid injection.

Level of evidence: IV.

Keywords: Corticosteroids; Injection; PJI; Periprosthetic joint infection; TKA; Total knee arthroplasty.


  1. Bannuru RR, Osani MC, Vaysbrot EE et al (2019) OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage 27:1578–1589 – DOI
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What’s the Best Time of Day to Exercise? It Depends on Your Goals
Lou Schuler
June 20, 2022

For most of us, the “best” time of day to work out is simple: When we can.

Maybe that’s before or after work. Or when the gym offers free daycare. Or when our favorite instructor teaches our favorite class.

That’s why we call it a “routine.” And if the results are the same, it’s hard to imagine changing it up.

But what if the results aren’t the same?

They may not be, according to a new study from a research team at Skidmore College. The results of a 12-week exercise program were different for morning vs. evening workouts.

Women who worked out in the morning lost more fat, while those who trained in the evening gained more upper-body strength and power. As for men, the performance improvements were similar no matter when they exercised. But those who did so in the evening had a significant drop in blood pressure, among other benefits.

The study is part of a growing body of research showing different results for different times of day among different populations. As it turns out, when you exercise can ultimately have a big effect. And we’re not just talking strength and fat loss, but also heart health, mood, and quality of sleep.

An Accidental Discovery

The original goal of the Skidmore study was to test a unique fitness program with a group of healthy, fit, and extremely active adults in early middle age.

The program includes four workouts a week, each with a different focus: strength, steady-pace endurance, high-intensity intervals, and flexibility (traditional stretching combined with yoga and Pilates exercises).

But because the group was so large – 27 women and 20 men completed the 3-month program – they had to split them into morning and evening workout groups.

It wasn’t until researchers looked at the results that they saw the differences between morning and evening exercise, says lead author Paul Arciero, PhD.

Arciero stresses that participants in every group got leaner and stronger. But the women who worked out in the morning got much bigger reductions in body fat and body-fat percentage than the evening group. Meanwhile, women in the evening group got much bigger gains in upper-body strength, power, and muscular endurance than their morning counterparts.

Among the men, the evening group had significantly larger improvements in blood pressure, cholesterol levels, and the percentage of fat they burned for energy, along with a bigger drop in feelings of fatigue.

Strategic Timing for Powerful Results

Some of these findings are consistent with previous research. For example, a study published in 2021 showed that the ability to exert high effort and express strength and power peaks in the late afternoon, about the same time that your core body temperature is at its highest point.

On the other hand, you’ll probably perform better in the morning when the activity requires a lot of skill and coordination or depends on strategic decision-making.

The findings apply to both men and women.

Performance aside, exercise timing might offer strong health benefits for men with type 2 diabetes, or at high risk for it.

A 2020 study showed that men who exercised between 3 and 6 p.m. saw dramatic improvements in blood sugar management and insulin sensitivity, compared to a group that worked out between 8 and 10 a.m.

They also lost more fat during the 12-week program, even though they were doing the exact same workouts.

Train Consistently, Sleep Well
When you exercise can affect your sleep quality in many ways, says McMaster University neuroscientist Jennifer Heisz, PhD, author of Move the Body, Heal the Mind: Overcome Anxiety, Depression, and Dementia and Improve Focus, Creativity, and Sleep.

First, she says, “exercise helps you fall asleep faster and sleep deeper at night.” (The only exception is if you exercise so intensely or so close to bedtime that your heart rate is still elevated.)

Second, “exercising at a consistent time every day helps regulate the body’s circadian rhythms.” It doesn’t matter if the exercise is in the morning, evening, or anywhere in between. As long as it’s predictable, it will help you fall asleep and wake up at the same times.

Outdoor exercise is even better, she says. The sun is the most powerful regulator of the circadian clock and works in tandem with physical activity.

Third, exercising at specific times can help you overcome jet lag or adjust to an earlier or later shift at work.

“Exercising at 7 a.m.

or between 1 and 4 p.m. helps your circadian clock to ‘fall back’ in time, making it easier to wake up earlier,” Heisz says. If you need to train your body to wake up later in the morning, try working out between 7 and 10 p.m.

All Exercise Is Good, but the Right Timing Can Make It Even Better
“The best time to exercise is when you can fit it in,” Arciero says. “You’ve got to choose the time that fits your lifestyle best.”

But context matters, he notes.

“For someone needing to achieve an improvement in their risk for cardiometabolic disease,” his study shows an advantage to working out later in the day, especially for men.

If you’re more focused on building upper-body strength and power, you’ll probably get better results from training in the afternoon or evening.

And for fat loss, the Skidmore study shows better results for women who did morning workouts.


And if you’re still not sure? Try sleeping on it – preferably after your workout.

Frontiers in Physiology: “Morning Exercise Reduces Abdominal Fat and Blood Pressure in Women; Evening Exercise Increases Muscular Performance in Women and Lowers Blood Pressure in Men.”

Paul Arciero, PhD, professor, Health and Human Physiological Sciences Department, Skidmore College.

BMJ Open Sport & Exercise Medicine: “Diurnal variations in the expression of core-clock genes correlate with resting muscle properties and predict fluctuations in exercise performance across the day.”

Physiological Reports: “Exercise training elicits superior metabolic effects when performed in the afternoon compared to morning in metabolically compromised humans.”

Jennifer Heisz, PhD, associate professor, Department of Kinesiology, McMaster University.

Many Patients with Persistent Pain 1 Year After TKA Report Improvement by 5 to 7 Years

Sellevold, Vibeke Bull RN, MSc1,2; Steindal, Simen A. RN, PhD1,3; Lindberg, Maren Falch RN, PhD4,5; Småstuen, Milada Cvancarova PhD2,6; Aamodt, Arild MD, PhD4; Lerdal, Anners RN, PhD6,7; Dihle, Alfhild RN, PhD2Author Information

doi: 10.1097/CORR.0000000000002183

Clinical Orthopaedics and Related Research: March 21, 2022 – Volume – Issue – 10.1097/CORR.0000000000002183



Knee Replacement Pain after surgery is common. Approximately 20% of patients report pain 12 months after TKA. No studies have investigated patients’ experiences of living with persistent postsurgical pain 5 to 7 years after TKA by combining a qualitative and quantitative methodology.


In a mixed methods study, we explored patients’ experiences of living with persistent pain up to 7 years after primary TKA. We asked: In a subgroup analysis of patients who reported persistent pain 1 year after TKA surgery, how do patients live with persistent pain at the 5- to 7-year postoperative timepoint?


This follow-up study was part of a longitudinal study of pain, symptoms, and health-related quality of life in patients who underwent TKA for osteoarthritis. The present study targeted a subgroup of patients (22% [45 of 202]) identified in the longitudinal study who reported no improvement in pain interference with walking at 12 months after surgery. Inclusion criteria were: All 31 patients in this subgroup who attended their 5-year follow-up at the hospital and lived within a 2-hour drive from the hospital. Eight patients declined or were unable to participate due to illness or death. Hence, the final sample consisted of 23 patients (13 women and 10 men). The participants’ mean age at surgery was 66 ± 10 years. There were no differences in sociodemographic baseline data between the 23 included and the 22 excluded participants. A mixed-methods approach was employed, in which the quantitative data were followed up and investigated with qualitative interviews. Instruments used were the Brief Pain Inventory preoperatively, 12 months, and 5 years after surgery, as well as a semistructured interview guide. The individual interviews were conducted at one-time point 5 to 7 years post-surgery to capture how pain was experienced at that timepoint. The interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis. Meaning units were identified, condensed, and sorted into subthemes that were interpreted and abstracted into themes, guided by the research question. With a small sample, the quantitative analysis focused on descriptive statistics and nonparametric statistics when comparing demographics of included and non-included patients. In addition, two multivariate mixed models for repeated measures were employed to estimate within patient and between patients’ variations as well as to assess the effect of time on the pain outcomes.


Pain with walking decreased from 12 months to 5 years postoperatively (estimated mean scores 7 versus 4, difference of means -3 [95% CI -5 to -2]; p < 0.001). Pain with daily activity decreased from 12 months to 5 years postoperatively (estimated mean score 6 versus 3, difference of means -3 [95% CI -4 to -1]; p < 0.001). Pain intensity (average pain) decreased from 12 months to 5 years postoperatively (estimated mean score 5 versus 4, difference of means -1 [95% CI -3 to 0]; p = 0.03). The results are presented as point estimates rounded up to whole numbers. The qualitative data analysis yielded three themes: persistent limitations after TKA, regained wellness over time, and complexity in physical challenges. Intermittent pain with certain movements resulted in limitations with some activities in everyday life and seemed to persist beyond 5 years. Multiple painful body sites and presence of comorbidities seemed to interfere with regained wellness over time.


In this subgroup of patients experiencing postsurgical persistent pain 12 months after primary TKA, persistent postsurgical pain still limited certain activities for the participants, although pain seemed to be less influential in their everyday lives after 5 years to 7 years. Clinicians may use these findings to inform and guide patients with delayed improvements in pain into more realistic expectations for recovery, rehabilitation, and strategies for coping with pain, and impaired function. However, it is imperative to rule out other reasons for pain in patients reporting pain 12 months and longer after surgery and to be attentive of possible changes in pain over time.

Level of Evidence 

Level III, therapeutic study.

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Reliability of pain scores during a body weight support protocol in individuals with knee osteoarthritis

Rebecca Greenwood, Jennifer Ellison, Peggy Gleeson, Katy Mitchell

Disabil Rehabil. 2021 Dec 21 1-6 [Epub ahead of print]

PURPOSE To explore the reliability of percentage of Body Weight Support (BWS) needed for maximal pain relief and of pain scores across 12 walking conditions including pre and post-over-ground walking and an unweighting protocol from 0% to 40% BWS on a lower-body positive pressure (LBPP) treadmill for individuals with knee osteoarthritis (OA).

MATERIALS AND METHODS Twenty individuals (64 ± 9.44 years) with knee OA completed over-ground walking and an unweighting protocol on an LBPP treadmill. The amount of BWS started at 0% and increased by 5% increments until it reached 40%. Pain scores were recorded at the end of each increment.

RESULTS The reliability of pain scores was assessed using a Spearman’s rho. This study found moderate reliability of the percentage of BWS for maximal pain relief. Additionally, there was good reliability of pain scores with pre and post-over-ground walking and from 0% BWS to 30% BWS, but moderate reliability of pain scores was found at 35% and 40% BWS.

CONCLUSION This study supports the use of pain scores as a reliable measure during an unweighted walking session on an LBPP treadmill.

IMPLICATIONS FOR REHABILITATION Both the OARSI and ACR recommend exercise in the treatment of individuals with knee OA but acknowledge that pain during exercise and exercise preference/accessibility are important when considering the type of exercise for an individual.LBPP treadmills decrease pain in individuals with knee OA during walking. Pain scores during unweighted walking show moderate to good reliability for individuals with knee OA. This study provides an unweighting protocol to use clinically to determine the Body Weight Support needed to decrease pain.

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Compression Stocking Help Reduce Blood Volumes in Leg Veins



This study was designed to explore venous deformation of the lower extremities and the changes in venous hemodynamics in supine position before and after wearing graduated elastic stockings in patients awaiting total knee arthroplasty (TKA).


The leg veins of 21 elderly patients awaiting TKA were imaged in the supine position with and without knee-length graduated compression stockings (GCS) according to a fixed protocol. Measured parameters including the lateromedial (LM) diameter, anteroposterior (AP) diameter, and cross-sectional area (CSA) of the great saphenous vein (GSV), gastrocnemius vein (GV), soleus vein (SV), posterior tibial vein (PTV), fibular vein (FV), and anterior tibial vein (ATV). In addition, the mean and maximum velocities of the popliteal vein (PV) and superficial femoral vein (FSV) were measured.


GCS-related compression was observed for all the measured veins. Maximal reduction was observed for the GV and SV, whereas the GSV exhibited the lowest degree of GCS-related compression. The mean cross-sectional area reduction values associated with GCS were 33.1 ± 41.2 % for the GSV, 94.8 ± 11.1 % for the GV, and 85.6 ± 20.3 % for the SV, while the mean reduction of anteroposterior diameter was 18.1 ± 34.5 % for the GSV, 89.0 ± 22.5 % for the GV, and 72.9 ± 35.1 % for the SV, and the mean reduction of the lateromedial diameter was 25.9 ± 36.4 % for the GSV, 89.6 ± 19.6 % for the GV, 78.2 ± 28.3 % for the SV. No significant GCS-related changes in blood velocity in the superficial femoral veins or popliteal veins were detected.


For elderly patients awaiting TKA, knee-length GCS can significantly reduce calf vein dilation while at rest in the supine position, with the greatest reductions being observed for the soleus and gastrocnemius veins. These data might help provide a theoretical basis for the GCS in reducing incidence of deep vein thrombosis in patients undergoing TKA.Keywords: Graduated compression stockings, Vein diameter, Blood velocity, Venous thrombosis, Thromboprophylaxis

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The impact of tourniquet on tibial bone cement penetration in different zones in primary total knee arthroplasty: a meta-analysis

Abstract: Background:Cement mantle penetration and the cement–bone interface strength were critical to a successfulprimary total knee arthroplasty (TKA). It remained unclear whether decreased blood and fat in the cancellous boneachieved with the use of a tourniquet increases tibial cement mantle penetration in different zones on AP andlateral view in TKA according to criteria defined by the Knee Society Scoring System (KSS). The purpose of thisstudy was to determine whether tourniquet use influences tibial cement mantle penetration in different zones onAP and lateral view in TKA according to KSS.

Methods: We conducted a meta-analysis to identify studies involving the impact of tourniquet use and no tourniquet use on tibial bone cement penetration in primary TKA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, VIP, Wanfang database, up to January 2021. Finally, we identified 1231 patients (1231 knees) assessed in twelve studies.

Conclusion: The application of a tourniquet increases the thickness of the tibial bone cement penetration—the increase in the thickness of bone cement penetration mainly located in zone 3 on the anteroposterior (AP) view.

Results: Tourniquet use increases the cumulative cement mantle penetration (P< 0.00001), mean cement mantle penetration (P= 0.004), and cement mantle in zone 3(P< 0.0001) on AP view. However, there were no significant differences in cement mantle in zone 1(P= 0.5), zone 2(P=0 .54), zone 4(P= 0.07) on AP view, and zone 1(P=0.32), zone 2(P= 0.38) on lateral view between two groups. There were also no significant differences in length of surgery(P= 0.7), change in hemoglobin(P= 0.4), transfusion rates(P= 0.47), and complications such as muscular calfvein thrombosis(P= 0.21), superficial infection (P= 0.72), and deep vein thrombosis (P= 0.66) between two groups.

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Vitamin D Supplementation

High-Dose Vitamin D Supplementation May Have Beneficial Effect on Bone Microarchitecture in Seniors

By Danny Kucharsky

MONTREAL — October 3, 2018 — Long-term, high-dose vitamin-D supplementation of 2,000 IU daily may have a slight beneficial effect on bone microarchitecture in seniors, according to results of a double-blind study presented at the 2018 Annual Meeting of the American Society for Bone and Mineral Research (ASBMR).

The trial evaluated the effect of 2-year long supplementation of 800 IU versus 2,000 IU daily of vitamin D on bone microarchitecture in patients aged 60 years or greater using high-resolution peripheral quantitative computed tomography (HR-pQCT).

HR-pQCT, a non-invasive imaging method, allows for in vivo 3-dimensional characterisation of human bone microstructure. Most trials use the 2-dimensional dual-energy x-ray absorptiometry (DXA) to assess bone outcomes, but DXA cannot resolve bone microstructure, explained lead author Ursina Meyer, PhD, Centre on Aging and Mobility, University Hospital Zurich, Zurich Switzerland, speaking here on September 28.

Dr. Meyer and colleagues recruited 273 patients undergoing unilateral total-knee replacement due to severe knee osteoarthritis. The team randomised patients to receive daily doses of either 2,000 IU vitamin D or the standard-dose of 800 IU vitamin D. All patients received 500 mg of calcium supplements daily.

After 2 years, the group receiving 2,000 IU vitamin D daily had higher 25(OH)D levels compared with the group receiving 800 IU vitamin D (35.7±6.8 vs 28.8±6.1 ng/ml; P≤ .001).

DXA showed similar small increases in mean areal bone mineral density (aBMD) at 2 years, but when investigators used HR-pQCT to assess bone outcomes at the tibia, there was a significant increase in trabecular number (TbN) (beta = 0.05mm-1 [95% confidence interval: 0.004 to 0.09]) at the tibia in the 2,000 IU group compared to the 800 IU vitamin D group. The increase in TbN was accompanied by a statistically trending lower rate of TbN bone loss in the 2,000 IU group.

The investigators observed no other statistically significant differences in other microstructural parameters of the tibia and radius.

In a preliminary subanalysis, a higher 2-year dose of vitamin D did not translate into increases in bone strength as represented by changes in stiffness or failure load compared with the 800 IU vitamin D group.

[Presentation title: Effect of High-Dose Vitamin D on Bone Microarchitecture assessed via High Resolution Peripheral Quantitative Computed Tomography (HR-pQCT): a Double-Blind RCT. Abstract FRI-0827]

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Large Knee Swelling may be a Reason to Operate

Association of Changes in Effusion‐Synovitis and Progression of Cartilage Damage Over 18 Months in Patients with Osteoarthritis and Meniscal Tear

Cover image

First published: 22 August 2018

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/art.40660



Synovitis is a feature of knee osteoarthritis (OA) and meniscal tear and has been associated with articular cartilage damage. Our study examined the associations between baseline and changes in effusion‐synovitis and changes in cartilage damage in a cohort with OA and meniscal tear.


We analyzed data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of surgery vs. physical therapy for treatment of meniscal tear. We performed semiquantitative grading of effusion‐synovitis and cartilage damage on magnetic resonance imaging (MRI), and dichotomized effusion‐synovitis as none/small (‘minimal’) and medium/large (‘extensive’). We assessed the association between baseline and changes in effusion‐synovitis on changes in cartilage damage size and depth over 18 months, using Poisson regression models. Analyses were adjusted for demographics, treatment, and baseline cartilage damage.


We analyzed 221 participants. Over 18 months, effusion‐synovitis was persistently minimal in 45.3% and persistently extensive in 21.3%. The remaining 33.5% had minimal synovitis on one occasion and extensive on the other. In adjusted analyses, extensive effusion‐synovitis at baseline was associated with a relative risk (RR) of 1.7 (95% CI 1.1, 2.6) for progression of cartilage damage depth. Compared to those with persistently minimal effusion‐synovitis, persistently extensive effusion‐synovitis had a statistically significant increased risk of progression of cartilage damage depth (RR 2.0 95% CI 1.1, 3.4).


The presence of extensive effusion‐synovitis is associated with subsequent progression of cartilage damage over 18 months. Persistence of extensive effusion‐synovitis over time was associated with the greatest risk of concurrent cartilage damage progression.

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