Prior hip or knee prosthetic joint infection in another joint increases risk three-fold of prosthetic joint infection after primary total knee arthroplasty: a matched control study.

AIMS: There is little information regarding the risk of a patient developing prosthetic joint infection (PJI) after primary total knee arthroplasty (TKA) when the patient has previously experienced PJI of a TKA or total hip arthroplasty (THA) in another joint. The goal of this study was to compare the risk of PJI of primary TKA in this patient population against matched controls. PATIENTS AND METHODS: We retrospectively reviewed 95 patients (102 primary TKAs) treated between 2000 and 2014 with a history of PJI in another TKA or THA. A total of 50 patients (53%) were female. Mean age was 69 years (45 to 88) with a mean body mass index (BMI) of 36 kg/m2 (22 to 59). In total, 27% of patients were on chronic antibiotic suppression. Mean follow-up was six years (2 to 16). We 1:3 matched these (for age, sex, BMI, and surgical year) to 306 primary TKAs performed in 306 patients with a THA or TKA of another joint without a subsequent PJI. Competing risk with death was used for statistical analysis. Multivariate analysis was followed to evaluate risk factors for PJI in the study cohort. RESULTS: The cumulative incidence of PJI in the study cohort (6.1%) was significantly higher than the matched cohort (2.6%) at ten years (hazard ratio (HR) 3.3; 95% confidence interval 1.18 to 8.97; p = 0.02). Host grade in the study group was not a significant risk factor for PJI. Patients on chronic suppression had a higher rate of PJI (HR 15; p = 0.002), with six of the seven patients developing PJI in the study group being on chronic suppression. The new infecting microorganism was the same as the previous in only two of seven patients. CONCLUSION: In this matched cohort study, patients undergoing a clean primary TKA with a history of TKA or THA PJI in another joint had a three-fold higher risk of PJI compared with matched controls with ten-year cumulative incidence of 6.1%. The risk of PJI was 15-fold higher in patients on chronic antibiotic suppression; further investigation into reasons for this and mitigation strategies are recommended. Cite this article: Bone Joint J 2019;101-B(7 Supple C):91-97.

Irrigation and debridement with chronic antibiotic suppression for the management of infected total knee arthroplasty: A Contemporary Analysis.

AIMS: The results of irrigation and debridement with component retention (IDCR) in the treatment of acutely infected total knee arthroplasties (TKAs) have been variable. The aim of this study was to assess the outcome after IDCR when combined with chronic antibiotic suppression. We also evaluated survivorship free from subsequent infection, removal of the components, and death, as well as the risk factors for failure. PATIENTS AND METHODS: This was a single-centre retrospective review of 134 infected primary TKAs that were treated with IDCR. Infections within four weeks of the procedure were defined as acute postoperative infections, and those occurring more than four weeks after the procedure with symptoms for less than three weeks were defined as acute haematogenous infections. Patients were treated with intravenous antibiotics for four to six weeks, followed by chronic oral antibiotic suppression. Estimates of survival were made using a competing risk analysis. The mean follow-up was five years (2.1 to 13). RESULTS: The infection was an acute postoperative infection in 23 TKAs and an acute haematogenous infection in 111 TKAs. The incidence of subsequent infection was 36% in those with an acute postoperative infection and 33% in those with a haematogenous infection, five years postoperatively (p = 0.40). Age < 60 years increased the risk of subsequent infection (hazard ratio (HR) 2.4; p = 0.009) and removal of the components (HR 2.8; p = 0.007). Infection with a staphylococcal species increased the risk of subsequent infection (HR 3.6; p < 0.001), and removal of the components (HR 3.2; p = 0.002). Musculoskeletal Infection Society host type and local extremity grade, body mass index (BMI), the duration of symptoms, gender, and the presence of a monoblock tibial component had no significant effect on the outcome. CONCLUSION: In a rigorously defined group of acute periprosthetic infections after TKA treated with IDCR and chronic antibiotic suppression, the infection-free survival at five years was 66%. The greatest risk factor for failure was an infection with a staphylococcal species, followed by age of < 60 years. Cite this article: Bone Joint J 2018;100-B:1471-76.

Alcohol's impact on man's activities. Its role in unnatural death.

The association of alcohol with unnatural death, especially automobile accidents, is widely accepted. Unfortunately, national statistics often do not include information from medical examiners, which can be a significant contribution. This report summarizes the experience of the New Mexico Office of the Medical Investigator during the period 1974-76. Thirty-nine per cent of automobile drivers involved in fatal motor vehicle accidents and 40% of pedestrians killed by motor vehicles had some blood alcohol present. The relationship of alcohol and other violent crimes is summarized, indicating the involvement of alcohol in 39% to 74% of the several types of crimes presented. The expense of alcohol-related accidents is presented. The psychological autopsy was used to prepare profiles of drivers involved in a variety of vehicular accidents. Drivers were grouped into five categories according to behavioral characteristics that were likely to have contributed to their accidents. Twenty-eight per cent of drivers involved in serious and fatal accidents in this study were judged to have had behavioral disorders in which alcohol often played a role.

The autopsy. Past, present, and future.

The autopsy appears to be on the way to assuming an increasingly important role in patient care, continuing education, education of medical students and house staff, research in environmental pathology, and more fundamental aspects of disease. This trend needs to be nurtured. Not only pathologists but all physicians need to plan carefully to utilize autopsies to the fullest possible extent. Interest will continue to grow only if autopsies are performed or are closely supervised by highly motivated and experienced pathologists asking critical questions of current medical, scientific, and social concern. New, imaginative approaches are needed to develop the data necessary to address these questions.

A five-year study of mortality in a busy ski population.

A 5-year study of a busy ski population in Utah revealed a total at-risk period of approximately 3.5 million skier-days. While the morbidity (fractures, strains, sprains, and occasionally more severe injuries) associated with skiing is well recognized and considered by most physicians concerned to be distributed somewhat unevenly within the various skills of skiing, the authors have identified an exceedingly low mortality among the same population. Six individuals died as a result of injuries directly attributable to skiing. Three of these were considered to be advanced skiers and three were of intermediate skill. In three instances the environment was considered to play a role in the accident. Two of these victims were skiing out of control, one as a result of ice-covered snow and one as a result of speed in combination with a small jump. The third victim was crushed in an avalanche. One accident was completely unexplained, the skier having skied without apparent attempt at checking or change of course into a nonrecreational area. The two remaining skiers of intermediate skill both suffered injuries incident to falling forward with considerable force onto a relatively flat, hard snow surface. Notwithstanding the intense and sometimes prolonged exertion at relatively high altitudes (9,400 to 11,000 ft or 2.9 to 3.3 km), only one skier with a previous history of atherosclerotic heart disease died while skiing. One additional middle-aged skier with similar history died at the conclusion of the day.(ABSTRACT TRUNCATED AT 250 WORDS)

The medicolegal investigation of operating room associated deaths.

For those medicolegal investigative systems charged by statute with the responsibility of investigating and examining known or suspected iatrogenic deaths--whether in a perioperative or operative situation, or in some other relationship to medical intervention--there is usually little doubt that these types of investigations constitute the most difficult, often perplexing, and far-reaching investigation, examination, and reporting problems of any of the types of cases referred. Much of this difficulty derives from the changing attitude of the public at large, including the medical and the legal community. In the United States, as recently as 15 years ago, the loss of life or injury subsequent to a therapeutic or operative procedure, with rare exception, was accepted virtually as an act of God.

Several unusual cases of child abuse.

All childhood deaths which occurred in New Mexico during 1974 and 1975 were reviewed. Nine fatal instances of abuse were identified representing the entire spectrum of physical abuse: neglect, abuse in a single episode of injury, repetitive abuse, or sexual abuse. Several cases are summarized. These are unusual either in the distribution of pathologic findings or in the problems encountered in court presentation.