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Notice to Readers: Unexplained Deaths Following Knee Surgery --- Minnesota, November 2001

The Minnesota Department of Health (MDOH) has received reports of three previously healthy persons who died unexpectedly following uncomplicated knee surgery; two had total knee replacements and one had a cartilage graft implantation. The surgeries were performed at two local hospitals. Two patients died on November 11, 2001, and one died on November 16, approximately 36--82 hours following surgery. CDC is assisting MDOH in the investigation of these events.

All three patients became ill 1--4 days following surgery. Symptoms included severe abdominal pain and a sudden decline in blood pressure followed by a fulminant course with death within 24 hours of symptom onset. The clinical course was consistent with septic or cardiogenic shock. After 5 days of incubation, a blood culture taken from one of the patients yielded Clostridium sordellii. The source of infection in the one patient and the cause of death in all patients remain unknown.

In response to these deaths, MDOH is recommending that all elective knee surgery in Minnesota be suspended pending findings of the investigation. To identify possible cases in other areas, CDC is seeking reports of patients who have had orthopedic surgery since October 1, 2001, involving the knee or other large joint, and within 7 days following surgery who have 1) had hypotension and other clinical findings of cardiogenic or septic shock or abdominal pain; 2) had no other identified cause; and 3) required intensive care or have died. Clinicians should report such patients to their state health department or CDC's Division of Healthcare Quality Promotion, telephone 800-893-0485.

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