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Lean and Green Hand Surgery: Evaluating the Sterility of Corticosteroid Injection Preparations Using Next-Generation Sequencing
Harmon S Khela, BS
1, Bijan Dehghani, MD
2, Ana Sofia Rive, BS
3, Erin Hale, MD
2, Kurt Mohty, MD
2; Andrew D Sobel, MD
2(1)Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, (2)Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, (3)University of Connecticut School of Medicine, Farmington, CT
Introduction: Corticosteroid injections are among the most frequently performed procedures in outpatient orthopaedic and hand surgery clinics. Due to time constraints, many practitioners prepare injections in advance. Despite being prepared under aseptic conditions, unused syringes are discarded out of concern for potential contamination. This leads to significant avoidable waste of plastic materials and pharmaceuticals. To our knowledge, no studies have used high-sensitivity molecular diagnostics to evaluate the contamination risk of prepared corticosteroid injections over time. In this study, we conducted a controlled laboratory experiment simulating outpatient injection workflows to assess the sterility of corticosteroid-lidocaine injections stored under routine outpatient conditions using next-generation sequencing (NGS).
Materials & Methods: Sterile corticosteroid-lidocaine injections were prepared under aseptic outpatient conditions using sterile 3 mL Luer-lock syringes, 0.5 mL of 1% lidocaine, and 3 mg of triamcinolone acetonide (20 mg/mL), drawn with an 18-gauge needle and capped with a sterile 25-gauge needle. Investigators wore non-sterile gloves to reflect routine outpatient workflow. Syringes were labeled and stored at room temperature in a closed cabinet away from light and temperature fluctuation. The primary end point of this study was presence of bacterial DNA as identified by NGS. Samples were tested at 1 day, 3 days, 1 week, and 2 weeks post-preparation. At each time point, five fluid samples and five needle samples were sterilely collected and sent for NGS. Additionally, two positive-control fluid samples per time point were intentionally contaminated to confirm NGS assay sensitivity. All samples were analyzed using NGS to detect bacterial DNA contamination following the defined manufacturer protocol.
Results: A total of 40 experimental samples and 8 positive controls were analyzed. Of the experimental samples, 39 (97.5%) tested negative for bacterial DNA, including all 20 needle samples and 19 of 20 fluid samples. One fluid sample from the 1-week group tested positive for a
Streptococcus species. All positive controls from the 1-day, 3-day, and 1-week groups demonstrated polymicrobial contamination. Both 2-week control samples tested negative.
Conclusions: The results of our study challenge the belief that corticosteroid injections prepared under aseptic outpatient conditions become contaminated after 24 hours. These findings support extending the use of pre-drawn injections beyond same-day administration, offering a reliable and evidence-based strategy to reduce unnecessary waste, lower healthcare costs, and promote environmentally sustainability in orthopaedic care.
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