Donor knee cartilage linked to post-op death?

Other two Minnesota cases unexplained

The Centers for Disease Control and Prevention (CDC) is investigating whether donated cartilage tissue was linked to the death of one of three patients who mysteriously died following knee surgery in west-central Minnesota last November.

Minnesota Department of Health investigators say they haven’t found anything that would connect the mid-November deaths of three elective knee surgery patients. The bacteria Clostridium sordellii — which rarely causes disease in humans, but is known to produce a potent toxin — was found in one of the three patients. No pathogens were identified in laboratory specimens for the other two patients.

The 23-year-old patient who tested positive for C. sordellii received a cartilage graft, using tissue from a donor. The other two patients did not receive allograft tissue, according to a health department spokesman. The CDC recently reported four other patients who acquired post-surgical septic arthritis linked to contaminated bone-tendon-bone allografts used in anterior cruciate ligament (ACL) knee injuries.1

In those cases, which occurred in Florida and Louisiana in 2000, investigators suspect contaminated allografts. In addition, a tissue bank linked to those cases had supplied allografts from a common donor that were released inadvertently before standard terminal sterilization procedures were conducted, the CDC reported. Few clues have emerged in the other two Minnesota deaths, both of which occurred in patients undergoing knee replacements. In all, the three patients were:

  1. Nov. 7 — the aforementioned 23-year-old, who had a cartilage graft at St. Cloud (MN) Hospital;
  2. Nov. 9 — a 78-year-old man who had a knee replacement at the same facility;
  3. Nov. 13 — a 60-year-old man who had a knee replacement at Douglas County Hospital in Alexandria, MN.

The first two patients died on Nov. 11, and the third on Nov. 16. Separate surgical teams in three different operating rooms did the three knee procedures at the two hospitals. Investigators have been intensively examining the various products used during the course of these surgeries, including surgical instruments and supplies, antiseptic products, and drugs. Thus far, no common thread has been identified.

"We took a very close look at these two facilities in the course of doing our investigation," says Harry Hull, MD, Minnesota state epidemiologist. "They cooperated fully with the investigation, and we found nothing to suggest any problem from their end. There is absolutely no reason why patients who receive care or have surgery in these hospitals should have any special concerns."

While a contaminated allograft may eventually explain only one of the cases, the CDC is calling for several improvements in the way tissues are handled in light of the other cases in 2000. Those recommendations include:

  • standard practices for screening, disinfecting, sterilizing, or discarding potentially contaminated allografts;
  • mechanisms for certification and oversight of tissue banks and adherence to quality standards; a system for reporting and investigating infections (bacterial, viral, or fungal) potentially transmitted through human tissues;
  • the development of safe and effective sterilization methods for musculoskeletal tissue.

Reference

1. Centers for Disease Control and Prevention. Septic arthritis following anterior cruciate ligament reconstruction using tendon allografts — Florida and Louisiana, 2000. MMWR 2001; 50:281-283.