The incidence of late prosthetic joint infections A registry-based study of 112,708 primary hip and knee replacements

Background and purpose - Late prosthetic joint infections (PJIs) are a growing medical challenge as more and more joint replacements are being performed and the expected lifespan of patients is increasing. We analyzed the incidence rate of late PJI and its temporal trends in a nationwide population. Patients and methods - 112,708 primary hip and knee replacements performed due to primary osteoarthritis (OA) between 1998 and 2009 were followed for a median time of 5 (1-13) years, using data from nationwide Finnish health registries. Late PJI was detected > 2 years postoperatively, and very late PJI was detected > 5 years postoperatively. Results - During the follow-up, involving 619,299 prosthesis-years, 1,345 PJIs were registered: cumulative incidence 1.20% (95% CI: 1.13-1.26) (for knees, 1.41%; for hips, 0.92%). The incidence rate of late PJI was 0.069% per prosthesis-year (CI: 0.061-0.078), and it was greater after knee replacement than after hip replacement (0.080% vs. 0.057%, p = 0.006). The incidence rate of very late PJI was 0.051% per prosthesis-year (CI: 0.042-0.063), 0.058% for knees and 0.044% for hips (p = 0.2). The incidence rate of late PJI varied between 0.041% and 0.107% during the years of observation without any temporal trend (incidence rate ratio (IRR) = 0.98, 95% CI: 0.93-1.03). Very late PJI increased from 0.026% in 2004 to 0.056% in 2010 (IRR = 1.11, 95% CI: 1.02-1.20). Interpretation - In our nationwide study, the incidence rate of late PJI after hip or knee arthroplasty was approximately 0.07% per prosthesis-year. The incidence of very late PJI appeared to increase.Peer reviewe

Advising and limiting medical treatment during phone consultation : a prospective multicentre study in HEMS settings

Background We investigated paramedic-initiated consultation calls and advice given via telephone by Helicopter Emergency Medical Service (HEMS) physicians focusing on limitations of medical treatment (LOMT). Methods A prospective multicentre study was conducted on four physician-staffed HEMS bases in Finland during a 6-month period. Results Of all 6115 (mean 8.4/base/day) paramedic-initiated consultation calls, 478 (7.8%) consultation calls involving LOMTs were included: 268 (4.4%) cases with a pre-existing LOMT, 165 (2.7%) cases where the HEMS physician issued a new LOMT and 45 (0.7%) cases where the patient already had an LOMT and the physician further issued another LOMT. The most common new limitation was a do-not-attempt cardiopulmonary resuscitation (DNACPR) order (n = 122/210, 58%) and/or 'not eligible for intensive care' (n = 96/210, 46%). In 49 (23%) calls involving a new LOMT, termination of an initiated resuscitation attempt was the only newly issued LOMT. The most frequent reasons for issuing an LOMT during consultations were futility of the overall situation (71%), poor baseline functional status (56%), multiple/severe comorbidities (56%) and old age (49%). In the majority of cases (65%) in which the HEMS physician issued a new LOMT for a patient without any pre-existing LOMT, the physician felt that the patient should have already had an LOMT. The patient was in a health care facility or a nursing home in half (49%) of the calls that involved issuing a new LOMT. Access to medical records was reported in 29% of the calls in which a new LOMT was issued by an HEMS physician. Conclusion Consultation calls with HEMS physicians involving patients with LOMT decisions were common. HEMS physicians considered end-of-life questions on the phone and issued a new LOMT in 3.4% of consultations calls. These decisions mainly concerned termination of resuscitation, DNACPR, intubation and initiation of intensive care.Peer reviewe