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Reply to the Letter to the Editor: Not the Last Word: Safety Alert: One in 200 Knee Replacement Patients Die Within 90 Days of Surgery

Bernstein, Joseph MD1,a

Clinical Orthopaedics and Related Research®: April 2017 - Volume 475 - Issue 4 - p 1277–1277
doi: 10.1007/s11999-017-5248-2
Reply to the Letter to the Editor

1Department of Orthopaedic Surgery, University of Pennsylvania, 424 Stemmler Hall, 19104, Philadelphia, PA, USA


Received January 11, 2017/Accepted January 13, 2017; previously published online January 24, 2017

(RE: Bernstein J. Not the Last Word: Safety Alert: One in 200 Knee Replacement Patients Die Within 90 Days of Surgery. Clin Orthop Relat Res. 2017;475:318-323).

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

To the Editor,

I thank Drs. Berstock and Whitehouse for their interest in the column and for providing additional information about the mortality risks following knee replacement.

There is certainly room for us to debate. We can start with the fact that Hunt and colleagues [1], the large study Drs. Berstock and Whitehouse cited in their letter, reported on 45-day mortality, not 90-day mortality; the study also included unicompartmental surgery. That is to say, the methods used by Hunt and colleagues [1] skew the result downward, perhaps to the point of irrelevance regarding the question at hand.

But let's focus on what is not debatable: The risk of death following knee replacement is at least one in 1000, and a risk of that magnitude, when life is on the line, is material and consequential.

I trust that Drs. Berstock and Whitehouse would also agree that more research is needed. If my calculations can be termed “back-of-the-envelope meta-analysis,” then this discussion is “back-of-the-journal-meta-meta-analysis.” Our patients deserve better. The true risk of patient-specific mortality should be easily available, and this information should be shared broadly.

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1. Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, Tobias JH, Vernon K, Blom AW. 45-day mortality after 467,779 knee replacements for osteoarthritis from the National Joint Registry for England and Wales: An observational study. Lancet. 2014;384:1429-1436 10.1016/S0140-6736(14)60540-7.
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