Medical Malpractice Litigation Following Primary Total Joint Arthroplasty: A Comprehensive, Nationwide Analysis of the Past Decade

Medical Malpractice Litigation Following Hindfoot Arthrodesis

Given high patient expectations in the setting of complex surgeries, orthopedic surgeons are at risk of being subject to malpractice claims which can impose significant economic and psychological burden. This study investigates malpractice claims against orthopedic surgeons and podiatrists performing hindfoot arthrodesis and determine factors associated with plaintiff verdicts and settlements using the Westlaw legal database. The database was queried for all cases involving hindfoot arthrodesis using the terms "malpractice" and either "ankle fusion," "arthrodesis," "subtalar fusion," "tibiotalar fusion," "tibiotalocalcaneal fusion," "TTC fusion," or "tibiofibular fusion" from 1987 to 2023. Data regarding patient demographics, causes cited for litigation, case outcomes, and indemnity settlements were collected. Cases were excluded if the defendant was not an orthopedic surgeon or a podiatrist, the procedure involved was not a hindfoot arthrodesis, or if the patient was a minor. Forty-five cases of hindfoot arthrodesis met the inclusion criteria. The mean plaintiff age was 51.5 ± 13.8 years with 51.1% male. Thirty-three cases (73%) were in favor of the defendant, with an average inflation-adjusted payout of $853,863 (±456,179). The most alleged category of negligence was procedural/intraoperative error (75%) followed by postsurgical error (38%) and failure to inform (31%). The most common specific damages included functional/ROM limitation (49%), need for additional surgery (47%), continuing/worsened pain (27%), and nonunion/malunion (29%). Given the frequency of hindfoot arthrodesis performed, this study highlights the importance of effective communication with patients concerning potential postoperative complications, prognosis of their injury, and risks and benefits associated with each treatment modality.

The Anatomical Course of the Femoral Nerve with Regard to the Direct Anterior Approach for Total Hip Arthroplasty

BACKGROUND

Femoral nerve (FN) injury is noted as a serious neurological complication following total hip arthroplasty performed via a direct anterior approach (DAA). Therefore, we aimed to clarify the anatomical course of the FN around the acetabular rim and in relation to retractor placement during DAA.

METHODS

According to standard protocol, a DAA for total hip arthroplasty was performed on 69 hemipelves from formalin-preserved full-body donors. The surgery was halted after retractor placement at the anterior part of the acetabulum. Then dissection was performed to expose the FN and the iliopsoas muscle. Various measurements were taken using a reference line from the anterior superior iliac spine to the acetabulum's center. A total of 6 measurement points, one every 30° from 0° to 150° along the reference line were used to determine the association between the FN and the retractor tip (RT) and the anterior acetabular rim.

RESULTS

The mean distance from the RT to the FN was 22.5 millimeters (mm). The distance from the FN to the anterior acetabular rim decreased from 0 to 90°, where it was 18.8 mm, before increasing again to 27.3 mm at 150°.

CONCLUSIONS

In our cadaveric study, the FN was within 11 to 36 mm of the RT. Second, we found the FN to be closest to the anterior acetabular rim at 90° and 120°. Accordingly, special care should be taken during retractor placement, and if possible, placement at 90° and 120° avoided.

15-year survivorship of a unique dual-modular femoral stem in primary hip arthroplasty

BACKGROUND

Hip offset, version, and length are interdependent femoral variables which determine stability and leg length. Balancing these competing variables remains a core challenge in hip arthroplasty. The potential benefits of modular femoral stems have been overshadowed by higher rates of failure. The objective of this study was to assess the survivorship of a unique dual-modular femoral stem at an average 15-year follow-up period.

METHODS

The records of all patients with osteoarthritis who underwent primary total hip arthroplasty with this device between 2004-2009 were reviewed. There were no exclusions for BMI or other factors. We examined the data with Kaplan-Meier survival analysis. The primary endpoint for survival was mechanical failure of the modular neck-body junction.

RESULTS

The survivorship of this device in 172 subjects was 100% with none experiencing mechanical failure of the modular junction at an average of 15 years. 60 patients died of causes unrelated to their THA and 9 patients were lost to follow-up. There were three early (≤ 12 months) dislocations (1.7%), and seven total dislocations (4.1%). 16 patients underwent reoperations during the follow-up period, none for any complication of the modular junction. Radiographic results showed well-fixed femoral stems in all cases. There were no leg length discrepancies of greater than 10 mm, and 85% were within 5 mm.

CONCLUSION

There were no mechanical failures of the modular junction in any of the subjects over the average 15-year period, demonstrating that this dual-modular design is not associated with increased failure rates. We achieved a 1.7% early dislocation rate and a 4.1% total dislocation rate without any clinically significant leg length discrepancies.

Reasons for malpractice claims after primary total hip arthroplasty in France: Insurance data from 240 claims from 2014 to 2017

INTRODUCTION

Total hip arthroplasty (THA) is one of the most frequent orthopedic surgery procedures, and orthopedic surgeons are among the most frequently accused of malpractice by their patients. Identifying the main reasons for malpractice claims after THA is a prior condition to reducing their frequency. The quality of the preoperative risk information given to the patient by the surgeon is crucial for these purposes. Data specific to THA are sparse in France, and we therefore conducted a retrospective study (1) to determine whether the outcome of medico-legal expert appraisal correlated with the quality and traceability of preoperative information, and (2) to identify the most frequent grounds for complaint after primary THA.

HYPOTHESIS

The quality of patient information partly determines expert appraisal.

MATERIAL AND METHOD

A retrospective study was conducted based on data from the Branchet medical professional insurance agency for malpractice claims following THA over the period 2014-2017, with 240 complete files, for 125 women and 115 men. Data comprised: type of procedure, main grounds of complaint (complications), positive or negative expert appraisal, quality of preoperative patient information, amounts of compensation accorded and fees paid, and the practitioner's liability. We assessed correlations between information quality and liability.

RESULTS

Surgical site infection and neurologic deficit were the two main grounds for malpractice claims. In the 240 files, cases for 106 operations (44.2%) were submitted to arbitration, 95 (39.6%) were brought to court, and 39 (16.2%) were settled out of court. The practitioner was held at least partly liable in 40 files (16.7%). Information to the patient was deemed imperfect or poor for 119 files (49.6%) and good in 121 (50.4%). Mean compensation was €30,940 (range, €0 to €198,100). In 27 of the 40 cases of liability (67.5%), the information to the patient was deemed imperfect or poor. Twenty-six of the 40 cases (65%) were settled out of court. In case of poor information, there was a significant risk for the practitioner to be held liable: 7.5 vs. 25% (p=0.003).

DISCUSSION

The present study listed the main complications underlying malpractice claims after THA: infection, neurologic complications, and limb-length discrepancy. This should enable practitioners to improve patient information so as to reduce the rate of malpractice claims or at least decrease the practitioner's liability, as the study found a correlation between information quality and expert appraisal.

LEVEL OF EVIDENCE

IV; retrospective study.

Minimal pre-operative leg length discrepancy as a risk factor of post-operative leg length discrepancy after total hip arthroplasty: a retrospective study of patients with non-traumatic osteonecrosis of the femoral head

BACKGROUND

Leg length discrepancy (LLD) is one of the troublesome complications of total hip arthroplasty (THA). Previously, several risk factors have been suggested, but they were subjected to their inherent limitations. By controlling confounding variables, we hypothesized that known risk factors be re-evaluated and novel ones be discovered. This study aimed to analyze the independent risk factors for LLD after primary THA in patients with non-traumatic osteonecrosis of the femoral head (ONFH).

METHODS

We retrospectively reviewed patients with non-traumatic ONFH who underwent unilateral THA between 2014 and 2021. All patients were operated by one senior surgeon using a single implant. Demographic data, surgical parameters, and radiological findings (pre-operative LLD, Dorr classification, and femoral neck resection) were analyzed to identify the risk factors of ≥ 5 mm post-operative LLD based on radiological measurement and to calculate odds ratios by logistic regression analysis. Post hoc power analysis demonstrated that the number of analyzed patients was sufficient with 80% power.

RESULTS

One hundred and eighty-six patients were analyzed, including 96 females, with a mean age of 58.8 years at the time of initial THA. The average post-operative LLD was 1.2 ± 2.9 mm in the control group and 9.7 ± 3.2 mm in the LLD group, respectively. The LLD group tended to have minimal pre-operative LLD than the control group (-3.2 ± 5.1 mm vs. -7.9 ± 5.8 mm p = 2.38 × 10- 8). No significant difference was found between the groups in age, gender, body mass index, femoral cortical index, and implant size.

CONCLUSION

Mild pre-operative LLD is associated with an increased risk of post-operative LLD after primary THA in patients with ONFH. Thus, surgeons should recognize pre-operative LLD to achieve an optimal outcome and must inform patients about the risk of developing LLD.

Managing early complications in total hip arthroplasty: the safety of immediate revision

PURPOSE

Immediate revision refers to a reoperation that involves resetting, draping, and exchanging the implant, after wound closure in total hip arthroplasty. The purpose of this study is to investigate the impact of immediate revision after total hip arthroplasty on subsequent infection and complication rates.

METHODS

A total of 14,076 primary total hip arthroplasties performed between 2010 and 2020 were identified in our institutional database, of which 42 underwent immediate revision. Infection rates were determined 2 years after the index arthroplasty. The cause and type of revision, duration of primary and revision surgeries, National Nosocomial Infections Surveillance score, implant type, changes in implants, complications, and preoperative and intraoperative antibiotic prophylaxis were all determined.

RESULTS

No infections were observed within 2 years after the index arthroplasty. Leg length discrepancy (88%, n = 37) and dislocation (7.1%, n = 3) were the main causes of immediate revision. In most cases of discrepancy, the limb was clinically and radiologically longer before the immediate revision. The mean operative time was 48 ± 14 min for the primary procedure and 23.6 ± 9 min for the revision. The time between the first incision and last skin closure ranged from 1 to 3 h. None of the patients were extubated between the two procedures. Two patients had a National Nosocomial Infections Surveillance score of 2, 13 had a score of 1, and 27 had a score of 0.

CONCLUSION

Immediate revision is safe for correcting clinical and radiological abnormalities, and may not be associated with increased complication or infection rates.

STUDY DESIGN

Retrospective cohort study; level of evidence, 3.

Forgotten joint score is worse when the affected leg perceived longer than shorter after total hip arthroplasty

BACKGROUND

One of the causes of patient dissatisfaction after total hip arthroplasty (THA) is leg length discrepancy (LLD). Even when radiographic LLD (R-LLD) is within 5 mm, some people perceive the affected side to be longer, while others perceive it is shorter. The purpose of this study was to investigate the relationship between perceived LLD (P-LLD), R-LLD, and Forgotten Joint Score (FJS-12) after THA.

METHODS

A retrospective study of 164 patients with unilateral hip disease was conducted. Based on P-LLD after THA, they were classified into three categories: perceived short (PS 21 patients), no LLD (PN 121 patients), and perceived long (PL 22 patients). On the other hand, based on R-LLD after THA, they were divided into <  - 5 mm (RS 36 patients), - 5 mm ≤ x < 5 mm (RN 99 patients), and 5 mm ≥ (RL 29 patients), respectively. The proportion of P-LLD in the RN group was also evaluated. In each group, the relationship between P-LLD, R-LLD and FJS-12 was investigated.

RESULTS

After THA, the PL group had significantly worse FJS-12 (PS: 68.3 ± 26.2, PN: 75.0 ± 20.9, PL: 47.3 ± 25.2, P < .0001). In the R-LLD evaluation, there was no difference in FJS-12 among the three groups (RS: 73.7 ± 21.1, RN: 70.0 ± 24.5, RL: 67.7 ± 25.4, P < .53). The RN group perceived leg length to be longer (RN-PL) in 12.1% of cases, and the RN-PL groups had significantly worse FJS-12 (RN-PS: 65.4 ± 24.8, RN-PN: 73.8 ± 23.1, RN-PL: 41.8 ± 27.6, P < .0001).

CONCLUSION

One year after THA, patients with longer P-LLD had worse FJS-12, even if the R-LLD was less than 5 mm.

Critical Review of Oncologic Medical Malpractice Claims Against Orthopaedic Surgeons

INTRODUCTION

The purpose of this study was to determine the most common allegations for malpractice litigation brought against orthopaedic surgeons for oncologic matters and the resulting verdicts.

METHODS

The Westlaw Legal research database was queried for malpractice cases filed against orthopaedic surgeons for oncologic matters in the United States after 1980. Plaintiff demographics, state of filing, allegations, and outcomes of lawsuits were recorded and reported accordingly.

RESULTS

A total of 36 cases met the inclusion and exclusion criteria and were subsequently included in the final analysis. The overall rate of cases filed remained consistent through the past four decades and was primarily related to a primary sarcoma diagnosis in adult women. The primary reason for litigation was failure to diagnose a primary malignant sarcoma (42%) followed by failure to diagnose unrelated carcinoma (19%). The most common states of filing were primarily located in the Northeast (47%), where a plaintiff verdict was also more commonly encountered as compared with other regions. Damages awarded averaged $1,672,500 with a range of $134, 231 to $6,250,000 and a median of $918,750.

CONCLUSION

Failure to diagnose primary malignant sarcoma and unrelated carcinoma was the most common reason for oncologic litigation brought against orthopaedic surgeons. Although most of the cases ruled in favor of the defendant surgeon, it is important for orthopaedic surgeons to be aware of the potential errors that not only prevent litigation but also improve patient care.

Litigation involving patients with slipped capital femoral epiphysis

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a hip disorder of late childhood and adolescence. Litigation involving SCFE may occur, as it is frequently diagnosed late, and/or may be temporally related to an injury. The purpose of this study was to review litigation cases involving SCFE in the US, focusing on the type of litigation (professional, premise, or product liability), the outcome of the litigation and indemnity payouts.

METHODS

Cases of litigation involving SCFE were identified using 5 legal databases and Google Scholar searching for the term "slipped capital femoral epiphysis". These databases originated as early as 1973. The data collected was the alleged complaint, type of defendant, outcome, state where filed, and amount of indemnity payout. Payout amounts were converted to 2020 US$. Statistical analyses were performed with SYSTAT® 10 software.

RESULTS

There were 135 unique cases identified which involved professional liability (103), premise liability (30), both premise and professional liability (1), and product liability (1). Complaints for professional liability cases were alleged failure in diagnosis (71), inappropriate treatment (14), both diagnosis and treatment (12), and others (7). The delay in those with an alleged late diagnosis (37 cases) was 5.8 months. The three most common specialties named as defendant(s) were primary care (31%), orthopaedic surgeons (29%), and radiologists (16%). The primary allegations against non-orthopaedic surgeons were failure in diagnosis (89%) as opposed to orthopaedic surgeons where the complaints of alleged failures in diagnosis and inappropriate treatment were equal (50%). The geographic region of the filed cases was the Northeast (44%), South (24%), Midwest (16%), and West (16%). There were no differences between premise and professional liability cases by geographic region. The overall outcome was favorable for the defendant(s) in 53% and the plaintiff in 47%; the defense prevailed in 60% of the professional liability but only 33% of the premise liability cases. The indemnity payout amount (for the 52 cases where known) averaged $1.28 million. Payout was higher in the complaints for professional compared to premise liability ($1.5 vs. $0.9 million). The average payout for those with and without avascular necrosis was $2.97 million vs. $1.02 million. For the professional liability claims, indemnity payout was most frequent in the Western US. It must be remembered that this study only represents law suits filed in the US court system. It does not include cases that might have been resolved prior to any legal action as those cases are not publicly available.

CONCLUSIONS

Reported litigation involving SCFE patients involved claims of professional liability in 77% and premise liability in 22% of located cases. Due to significant exposure, this study should serve as a reminder to all health care providers to include SCFE in the differential diagnosis of knee/thigh pain in adolescents.

Evidence-based informed consent form for total knee arthroplasty

INTRODUCTION

Informed consent documentation is often the first area of interest for lawyers and insurers when a medico-legal malpractice suit is concerned. However, there is a lack of uniformity and standard procedure about obtaining informed consent for total knee arthroplasty (TKA). We developed a solution for this need for a pre-designed, evidence-based informed consent form for patients undergoing TKA.

MATERIALS AND METHODS

We extensively reviewed the literature on the medico-legal aspects of TKA, medico-legal aspects of informed consent, and medico-legal aspects of informed consent in TKA. We then conducted semi-structured interviews with orthopaedic surgeons and patients who had undergone TKA in the previous year. Based on all of the above, we developed an evidence-based informed consent form. The form was then reviewed by a legal expert, and the final version was used for 1 year in actual TKA patients operated at our institution.

RESULTS

Legally sound, evidence-based Informed Consent Form for Total Knee Arthroplasty.

CONCLUSION

The use of legally sound, evidence-based informed consent for total knee arthroplasty would be beneficial to orthopaedic surgeons and patients alike. It would uphold the rights of the patient, promote open discussion and transparency. In the event of a lawsuit, it would be a vital document in the defence of the surgeon and withstand the scrutiny of lawyers and the judiciary.

Medical malpractice litigation after total shoulder arthroplasty: a comprehensive analysis based on the Westlaw legal database

INTRODUCTION

Orthopedic surgery is one of the most common subspecialties subject to medical malpractice claims. Although total shoulder arthroplasty (TSA) is associated with favorable patient outcomes and relatively low complication rates, surgeons performing this procedure may be subject to malpractice litigation leading to significant economic and psychological burden on the provider. The purpose of this study is to characterize and describe malpractice claims against orthopedic surgeons performing TSA using the Westlaw legal database.

METHODS

The Westlaw legal database was queried for all cases related to TSA using the terms "malpractice" AND "shoulder replacement" OR "shoulder arthroplasty." Cases were excluded if the defendant was not an orthopedic surgeon, the procedure involved was not a TSA, or if the patient was a minor. Patient demographics, causes cited for litigation, case outcomes, and indemnity payments were analyzed to determine common factors that lead plaintiffs to pursue legal action.

RESULTS

Thirty-five TSA cases were identified that met inclusion criteria. The mean plaintiff age was 55 years with 63.6% female. The most common category of negligence alleged was intraoperative error, which occurred in 25 claims (71%). The most common types of damages incurred were nerve injury (23%), functional limitation (20%), and infection (17%). Overall, 27 cases (77%) resulted in a defense verdict. Four cases (11%) resulted in settlements and 4 cases (11%) resulted in plaintiff verdicts. The average inflation-adjusted monetary award in these cases was $1,619,919 (standard deviation, $1,689,452).

DISCUSSION

This study provides a comprehensive summary of malpractice claims and associated outcomes in TSA. Given the rapidly increasing rate of TSA in the United States and the burden of associated malpractice claims, understanding potential legal implications of TSA is of great value to orthopedic surgeons. Intraoperative error was the category of negligence cited most commonly in TSA malpractice claims. Nerve injury, functional limitation, and infection were the most commonly cited specific damages. These findings highlight the need for orthopedic surgeons to educate patients regarding potential postoperative complications while continuing to focus on minimizing their occurrence.

Health Policy Views and Political Advocacy of Arthroplasty Surgeons: A Survey of the American Association of Hip and Knee Surgeons Members

BACKGROUND

The American Association of Hip and Knee Surgeons (AAHKS) is the largest specialty society for arthroplasty surgeons in the United States and is dedicated to education, research, and advocacy. The purpose of this study was to identify the health policy views of AAHKS members and better characterize their advocacy participation.

METHODS

A 22 question survey was electronically distributed multiple times via email link to all 3,638 United States members of AAHKS who were in practice or training in 2022. Study results were analyzed using descriptive statistics.

RESULTS

There were 311 responses (9%), with 18% of respondents being within 5 years of practice and 38% having more than 20 years of practice. Respondents identified as Republicans (40%), Independents (37%), and Democrats (21%). Top policy issues included preserving physician reimbursement and equitable fee schedule representation (95%), the burden of prior authorization (53%), the impact of Center of Medicare and Medicaid Services regulations (39%), and medical liability and tort reform (39%). Members ranked maintaining appropriate physician reimbursement (44%) and advocating for patients (37%) as the top benefits to participation in advocacy. A majority of respondents (81%) stated that they spend more time on presurgery optimization now than 10 years ago. The most common barrier to advocacy participation was a lack of time (77%).

CONCLUSION

Responding AAHKS members are well-informed, politically engaged, patient-oriented, and eager for a voice in policy decisions that affect the professional future of arthroplasty surgeons. These results can be used to help direct strategic efforts of the AAHKS Advocacy Committee to further increase advocacy efforts.

Legally Sound, Evidence-Based Informed Consent Form for Total Hip Arthroplasty

Introduction

Informed consent documentation is often the first area of interest for lawyers and insurers when a medico-legal malpractice suit is concerned. However, there is a lack of uniformity and standard procedure for obtaining informed consent for total hip arthroplasty (THA). We aimed to develop a solution for this need for a pre-designed, evidence-based informed consent form for THA cases.

Materials and Methods

We extensively reviewed the literature on the medico-legal aspects of THA, medico-legal aspects of informed consent, and medico-legal aspects of informed consent in THA. We then conducted semi-structured interviews with orthopaedic surgeons and patients who had previously undergone THA in the previous year. Based on all of the above, we developed an informed consent form that was evidence-based. We then had the form reviewed by a legal expert. The final form was utilised for THA cases at our institution for 1 year.

Results

Legally sound, evidence-based Informed Consent Form for Total Hip Arthroplasty is given in Form A.

Conclusion

The use of legally sound, evidence-based informed consent for total hip arthroplasty cases would be beneficial to orthopaedic surgeons and patients alike. It would uphold the rights of the patient, and promote open discussion and transparency. In the event of a lawsuit, it would be a vital document in the defence of the surgeon and withstand the scrutiny of lawyers and the judiciary.

Routine Pathologic Examination of the Femoral Head in Total Hip Arthroplasty: A Survey Study of the American Association of Hip and Knee Surgeons

Background

Current literature does not provide conclusive evidence on whether routine pathologic examination of femoral heads from total hip arthroplasty is indicated or cost-effective. As a result, there is substantial variation in opinion among surgeons related to this issue. Our study aim was to determine factors that impact surgeon propensity to order pathologic examination of femoral heads.

Methods

A 12-question survey was created to evaluate surgeon practices, indications, and patient care implications surrounding routine pathologic examination of femoral heads. The email survey was distributed to all members of the American Association of Hip and Knee Surgeons (n = 2598).

Results

There were 572 survey respondents. Out of all respondents, 28.4% always send femoral heads to pathology, and 27.6% reported an institutional requirement to do so. Of the 572 surgeons, 73.6% report femoral head pathology has never resulted in a change in patient disease course. Factors that increase the likelihood of surgeons ordering femoral head pathologic examination include institutional requirements, medicolegal concern, and prior experience with femoral head pathologic examination changing patients' disease course (P < .001). Cost concern decreases the likelihood of surgeons ordering femoral head pathologic examination (P = .0012).

Conclusions

A minority of surgeons routinely send femoral heads from total hip arthroplasty for pathologic examination, mostly because of institutional requirement. The majority of surgeons feel that femoral head pathologic examination never changes patient management, although others have infrequently detected malignancy and infection. Institutional policy, concern for litigation, and prior experience with discordant pathologic diagnoses increase femoral head pathologic examinations, while cost concern decreases them.

Hip & Knee Are the Most Litigated Orthopaedic Cases: A Nationwide 5-Year Analysis of Medical Malpractice Claims

BACKGROUND

Approximately 80% of hip and knee surgeons will face malpractice litigation. Understanding contemporary reasons for litigation and legal outcomes in our field may help surgeons deliver more effective and satisfying care, while limiting their legal exposure. This study aimed to determine: 1) which orthopaedic subspecialties were most frequently litigated; 2) malpractice damages and negligence claimed; 3) the proportion of different case outcomes; and 4) factors associated with defense verdicts.

METHODS

A nationwide database was queried for all orthopaedic medical malpractice claims (2015 to 2020), obtaining 164 claims from 17 states. Variables included were as follows: case outcome, indemnity payment, damages, negligence claimed, treatment, and patient characteristics. A binary logistic regression determined if any collected variable increased the likelihood of a defense verdict.

RESULTS

Hip and knee cases were the highest-represented (n = 49, 29.9%; knee: n = 26, 15.9%; hip: n = 23, 14.0%), followed by the spine (n = 36; 22.0%), trauma (n = 29;17.7%), hand and wrist (n = 16; 9.8%), sports (n = 16; 9.1%), foot and ankle (n = 7; 4.3%), pediatric (n = 6; 3.7%), and shoulder (n = 6; 3.7%). Within hip and knee surgery, defense verdicts occurred in 38 cases (77.6%), while 9 (18.4%) resulted in plaintiff verdicts (mean payment: $4,866,929) and 2 (4.1%) resulted in settlements (mean settlement: $1,550,000). Nonreversible damages (eg, paralysis, amputation, and death; P < .001) were associated with a decreased likelihood of a defense outcome.

CONCLUSION

Hip and knee cases were the highest-represented in orthopaedic malpractice litigation. Surgeons were more frequently found negligent when nonreversible damages occurred. Orthopaedic surgeons should be cognizant of litigation patterns while ensuring patient-centered high-quality care.

Measurement Techniques for Leg Length Discrepancy in Total Hip Arthroplasty: A Systematic Review of Reliability and Validity

BACKGROUND

Total hip arthroplasty (THA) carries a substantial litigative burden. THA may introduce leg length discrepancy (LLD), necessitating a valid and reliable technique for LLD measurement. This study investigates the reliability and validity of techniques quantitively measuring LLD in both pre- and post-THA.

METHODS

Embase and MEDLINE databases were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for articles assessing either the validity or reliability of LLD measurement techniques. Data was pooled using random effects meta-analysis to derive reliability estimates. Study quality was assessed using the Brink and Louw checklist.

RESULTS

Forty-two articles with 2059 participants were included. Thirty-three investigated reliability and 25 validity. Reliability displayed high heterogeneity. Poor to excellent intra-rater reliability was reported for antero-posterior pelvis radiographs, moderate to excellent for computed tomography scanograms, and good to excellent for clinical methods and teleradiography, and excellent for bi-planar radiography (BPR). Poor to excellent inter-rater reliability was reported for antero-posterior pelvis radiographs and clinical methods, moderate to excellent for teleradiography, good to excellent for computed tomography scanogram and excellent for BPR. The tape measure method is a valid clinical measure of LLD whilst markerless motion analysis and the block method are not. Imaging techniques are appropriately cross-validated with the exception of BPR.

CONCLUSION

The reported intra- and inter-rater reliability for most measurement techniques vary widely. The tape measure method is a valid clinical measurement of LLD. Imaging techniques have been appropriately cross-validated, with the exception of BPR, although they lack validation against a common reference technique.

Litigation after primary total hip and knee arthroplasties in France: review of legal actions over the past 30 years

INTRODUCTION

Since the law of March 4, 2002, several modifications have impacted medical practices and their medico-legal implications. In case of an infectious complication not related to a fault of the practitioners (surgeons, anesthetists), the patient has the right to compensation assumed by the care structures. Moreover, the lack of preoperative information is no longer just a failing of the ethical standards but a breach of medical and legal obligations. Then, aims of this study were: (1) to describe the reasons for a lawsuit in France following total primary hip (THA) and total knee (TKA) arthroplasties and (2) to compare litigation characteristics of private and public practices.

MATERIALS AND METHODS

Civil (private practice) and administrative (public practice) court decisions in France between 1990 and 2020 were collected using the two main legal data sources (Legifrance, Doctrine).

RESULTS

Eighty-three TKA and 173 THA cases were identified. Reasons for complaint in primary THA were mainly infection (29%), prosthetic failures (18%), nerves injuries (17%), and leg length discrepancies (11%). The main grounds for complaint in favor of the plaintiff were diagnostic or indication mistakes (100%), infections (80%), especially if a lack of information was recognized (88%). Reasons for complaint following primary TKA were mainly infections (65%) and persistent pain or stiffness (12%). Whatever the reason, the verdict was in favor of the plaintiff in about 2/3 of the cases. THAs were more at risk of appeal in administrative procedures than in civil (p = 0.008). There were more cases of implant failure in civil proceedings (p = 0.008). Indemnities after primary THA was higher in public activity litigation (p = 0.04). There were no differences in verdicts, grounds for complaints, and compensation between public and private practices for primary TKA.

CONCLUSION

The main complaint about all the arthroplasties in France was a septic complication. The lack of information could be an added pejorative element for the final verdict.

Malpractice against shoulder surgeons: what the data say

BACKGROUND

Thousands of orthopedic surgeons in the United State face medical malpractice claims annually; however, little is known regarding the common causes for litigation against shoulder surgeons. In addition, the current analysis does not take into consideration how surgical frequency affects the litigation likelihood. The purpose of our investigation was to identify the most common causes of litigation against shoulder surgeons in the United States adjusting for surgical frequency.

METHODS

The VerdictSearch database was used using the search terms "medical malpractice," "shoulder," and "NOT cancer." Results were queried, and all studies pertaining to orthopedic shoulder surgery included. Data gathered included cause of lawsuit, indemnity paid, type of surgery performed, results of the cases, verdict or settlement, and, if applicable, technical error. A query of a multisurgeon institutional database was conducted to determine how frequently surgeries were performed. Then the frequency of litigation was adjusted by the procedure frequency to determine which surgery has the greatest likelihood to be litigated relative to rotator cuff surgery.

RESULTS

Forty-five cases were included in our study. After adjusting for the procedure frequency, the most likely procedure to be litigated, relative to rotator cuff repair, was manipulation under anesthesia (MUA), 251 times more likely to be litigated, and washout/lavage procedures, 17 times more likely to be litigated. Injection and total shoulder arthroplasty were 23 and 14 times less likely to be litigated relative to rotator cuff repair, respectively. In addition, the average age of the patients was 47 years, and 53% of the cases involved a male plaintiff. The most commonly litigated procedures were rotator cuff repair (42%), MUA (13%), and humeral open reduction and internal fixation (9%). The most commonly cited symptoms for litigation against shoulder surgeons were pain (60%) and loss of range of motion (40%). Of the 45 cases, 44% ended in physician loss, with the average indemnity paid via verdict being $1,118,714 vs. $416,875 for settlement.

CONCLUSIONS

This study identifies that MUA and lavage/washout procedures are much more likely to be litigated relative to rotator cuff repair. Rotator cuff repair is actually one of the least likely procedures to be litigated. Furthermore, settlement may represent a method of decreasing the indemnity paid for malpractice cases for which surgeons are implicated.

Characterizing the Magnitude of and Risk Factors for Functional Limb Lengthening in Patients Undergoing Primary Total Knee Arthroplasty

Background: There is little data on the magnitude and factors for functional leg lengthening after primary total knee arthroplasty (TKA). Questions/Purpose: We sought to determine the incidence of and risk factors for functional leg lengthening after primary TKA. Methods: We retrospectively reviewed consecutive unilateral primary TKAs at a single institution from 2015 to 2018. Of the 782 TKAs included, 430 (55%) were performed in women; the mean age was 66 years, and the mean body mass index was 29 kg/m². Preoperatively, 541 (69%) knees were varus deformities and 223 (29%) were valgus deformities. Hip to ankle biplanar radiographs were obtained preoperatively and 6 weeks postoperatively for all patients. Two independent researchers measured leg length, coronal plane deformity, lateral knee flexion angle, and overall mechanical alignment on all preoperative and postoperative radiographs. Results: The mean overall ipsilateral functional leg lengthening was 7.0 mm. Seven hundred knees (90%) were overall functionally lengthened, including 462 (59%) knees lengthened >5 mm and 250 (31%) knees lengthened 10 mm or more. A valgus deformity and coronal plane deformity of 10° or more were significant risk factors for increased functional lengthening. Patients with severe valgus deformities (>10°) had the largest amount of functional lengthening, at a mean of 13.5 mm. Conclusion: After primary TKA, 90% of limbs are functionally lengthened, including roughly one-third over a centimeter. Valgus knee deformities and severe deformities (>10°) were significant risk factors for increased limb lengthening.

Nerve Injuries Following Total Hip Arthroplasty: The Influence of Surgical Approach

Nerve injuries following total hip arthroplasty are rare but devastating complications. The most important modifiable risk factor remains the choice of hip approach and surgical technique applied. The risk of nerve injuries is related to technical complexity of the procedure and anatomic variability of the nerves. Surgeons should remain cognizant of inherent risk factors, variations in the course and branching patterns of different nerves, and technical considerations of the surgical approach to mitigate risks. This article reviews the literature on postsurgical nerve injuries following total hip arthroplasty and characterizes the influence of surgical approach on the risk of this complication.

A Cadaveric Study Measuring Femoral Nerve Tension During Anterior Total Hip Arthroplasty Approach

Femoral nerve palsy is a rare but devastating complication of anterior total hip arthroplasty. Its etiology is still unknown, but several studies have suggested that anterior acetabular retractors may place the femoral nerve at increased risk. This study hypothesized that hip extension and traction places tension on the femoral nerve, offering an additional explanation for the development of femoral nerve palsy. A spring device was secured across 6 transected femoral nerves from 5 lower extremity cadavers and the hip was extended and pulled into traction with and without retractor placement. The change in spring length was used to determine femoral nerve tension. The average spring length changed +8.83 mm with hip extension, +3.73 mm with traction, -0.7 mm with traction and placement of the anterior acetabular retractor, and -1.15 mm with extension and placement of the femoral retractor. Femoral nerve tension was greatest with hip extension followed by traction. Acetabular and femoral retractor placement decreased average femoral nerve tension in both traction and hip extension. This may be due to medialization of the femoral nerve by the retractors, reducing the overall distance traveled, and thereby reducing tension. Previous studies have found femoral nerve pressure to be greatest during anterior acetabular retractor placement. It is likely that both pressure and tension contribute to femoral nerve palsy. Careful retractor placement, staying safely on anterior acetabular bone, and efficient femoral preparation to decrease time under hip extension and traction may help to minimize the risk of femoral nerve palsy.

Current Trends and Predictors of Case Outcomes for Malpractice in Colonoscopy in the United States

BACKGROUND

Over 14 million colonoscopies are performed annually, and this procedure remains the largest contributor to malpractice claims against gastroenterologists. The aim of this study was to evaluate reasons for litigation and predictors of case outcomes.

MATERIALS AND METHODS

Cases related to colonoscopy were reviewed within the Westlaw legal database. Patient demographics, reasons for litigation, case payouts, and verdicts were assessed. Multivariate regression was used to determine predictors of defendant verdicts.

RESULTS

A total of 305 cases were included from years 1980 to 2017. Average patient age was 54.9 years (range, 4 to 93) and 52.8% of patients were female. Juries returned defendant and plaintiff verdicts in 51.8% and 25.2% of cases, respectively, and median payout was $995,000. Top reasons for litigation included delay in treatment (65.9%) and diagnosis (65.6%), procedural error (44.3%), and failure to refer (25.6%). Gastroenterologists were defendants in 71% of cases, followed by primary care (32.2%) and surgeons (14.8%). Cases citing informed consent predicted defendant verdict (odds ratio, 4.05; 95% confidence interval, 1.90-9.45) while medication error predicted plaintiff verdict (odds ratio, 0.18; 95% confidence interval, 0.04-0.59). Delay in diagnosis (P=0.060) and failure to refer (P=0.074) trended toward plaintiff verdict but did not reach significance. Most represented states were New York (21.0%), California (13.4%), Pennsylvania (13.1%), Massachusetts (12.5%).

CONCLUSIONS

Malpractice related to colonoscopy remains a significant and has geographic variability. Errors related to sedation predicted plaintiff verdict and may represent a target to reduce litigation. Primary care physicians and surgeons were frequently cited codefendants, underscoring the significance of interdisciplinary care for colonoscopy.

Malpractice trends in shoulder and elbow surgery

BACKGROUND

Medical malpractice is a very common occurrence that many medical providers will have to face; approximately 17,000 medical malpractice cases are filed in the United States each year, and more than 99% of all surgeons are faced with at least 1 instance of malpractice litigation throughout their careers. Malpractice litigation also carries a major economic weight, with medical malpractice spending resulting in an aggregate expenditure of nearly $60 billion annually in the United States. Orthopedic surgery is one of the most common subspecialties involved in malpractice claims. Currently, there are no comprehensive studies examining malpractice lawsuits within shoulder and elbow surgery. Therefore, the purpose of this work is to examine trends in malpractice claims in shoulder and elbow surgery.

METHODS

The Westlaw online legal database was queried in order to identify state and federal jury verdicts and settlements pertaining to shoulder and elbow surgery from 2010-2020. Only cases involving medical malpractice in which an orthopedic shoulder and elbow surgeon was a named defendant were included for analysis. All available details pertaining to the cases were collected. This included plaintiff demographic and geographic data. Details regarding the cases were also collected, such as anatomic location, pathology, complications, and case outcomes.

RESULTS

Twenty-five malpractice lawsuits pertaining to orthopedic shoulder and elbow surgery were identified. Most plaintiffs in these cases were adult men, and the majority of cases were filed in the Southwest (28%) and Midwest (28%) regions of the United States. The most common anatomic region involved in claims was the rotator cuff (32%), followed by the glenohumeral joint (20%). The majority of these claims involved surgery (56%). Pain of mechanical nature was the most common complication seen in claims (56%). The jury ruled in favor of the defendant surgeon in most cases (80%).

DISCUSSION

This is the first study that comprehensively examines the full scope of orthopedic shoulder and elbow malpractice claims across the United States. The most common complaint that plaintiffs reported at the time of litigation was residual pain after treatment due to a mechanical etiology, followed by complaints of nerve damage. A large portion of claims resulted after nonoperative treatment. A better understanding of the trends within malpractice claims is crucial to developing strategies for prevention.

Compensation claims after hip arthroplasty surgery in Norway 2008-2018

Background and purpose - Orthopedic surgery is one of the specialties with most compensation claims, therefore we assessed the most common reasons for complaints following total hip arthroplasty (THA) reported to the Norwegian System of Patient Injury Compensation (NPE) and viewed these complaints in light of the data from the Norwegian Arthroplasty Register (NAR).Patients and methods - We collected data from NPE and NAR for the study period (2008-2018), including age, sex, and type of complaint, and reason for accepted claims from NPE, and the number of arthroplasty surgeries from NAR. The institutions were grouped by quartiles into quarters according to annual procedure volume, and the effect of hospital procedure volume on the risk for accepted claim was estimated.Results - 70,327 THAs were reported to NAR. NPE handled 1,350 claims, corresponding to 1.9% of all reported THAs. 595 (44%) claims were accepted, representing 0.8% of all THAs. Hospital-acquired infection was the most common reason for accepted claims (34%), followed by wrong implant position in 11% of patients. Low annual volume institutions (less than 93 THAs per year) had a statistically significant 1.6 times higher proportion of accepted claims compared with higher volume institutions.Interpretation - The 0.8% risk of accepted claims following THAs is 1.6 times higher for patients treated in low-volume institutions, which should consider increasing the volume of THAs or referring these patients to higher volume institutions.

Characteristics of the medical malpractice cases against orthopedists in China between 2016 and 2017

Background

This study aimed to identify the most frequent reasons for orthopedic medical malpractice, gain insight into the related patient demographics and clinical characteristics, and identify the independent factors associated with it.

Methods

We collected and analyzed the demographic and injury characteristics, hospital levels and treatments, medical errors, and orthopedist’s degree of responsibility for the patients who were subject to orthopedic medical malpractice at our institution. Univariate and multivariate analyses were performed to identify the factors associated with the orthopedist’s degree of responsibility in the medical malpractice cases.

Results

We included 1922 cases of medical malpractice in the final analysis. There were 1195 and 727 men and women, respectively (62.2% and 37.8%, respectively). Of the total patients, 1810, 1038, 1558, 1441, and 414 patients (94.2%, 54.0%, 81.1%, 75.0%, and 21.5%, respectively) were inpatients, had closed injuries, underwent surgery, were trauma cases, and had preoperative comorbidities, respectively. Most medical malpractice cases were in patients with fractures and spinal degenerative disease (1229 and 253 cases; 63.9% and 13.2%, respectively), and occurred in city-level hospitals (1006 cases, 52.3%), which were located in the eastern part of china (1001, 52.1%), including Jiangsu and Zhejiang (279 and 233 cases, 14.52% and 52.1%, respectively). Between 2016 and 2017, the orthopedist’s degree of responsibility in medical malpractice claims were deemed as full, primary, equal, secondary, and minor in 135, 654, 77, 716, and 340 orthopedists (7.0%, 34.0%, 4.0%, 37.3%, and 17.7%). Most medical errors made by orthopedists in cases of medical malpractice were related to failure to supervise or monitor cases, improper performance of procedures, and failure to instruct or communicate with the patient (736, 716, and 423 cases; 38.3%, 37.3%, and 22.0%, respectively). The multivariate analysis found that patients with preoperative comorbidities, who sustained humerus injuries, who were aged ≥65 years, who were treated by doctors who failed to supervise or monitor them, and who were treated at the provincial and city level hospitals were more likely to claim that the orthopedist bore a serious degree of responsibility in the medical malpractice case.

Conclusions

Our results provide detailed information on the plaintiff demographics, clinical characteristics, and factors associated with medical malpractice. Medical malpractice is related to poor treatment outcomes. The first preventative measure that is required is a comprehensive improvement in the medical staff quality, mainly through medical ethics cultivation, and professional ability and technique training. Additionally, failure to supervise or monitor cases was the leading cause of medical malpractice and one of the factors that led to orthopedists bearing an equal and higher responsibility for medical malpractice. Orthopedists should improve patient supervision, especially when treating older patients and those with preoperative comorbidities and humerus injuries.

Medico-Legal Issues Related to Hip and Knee Arthroplasty: A Literature Review Including the Indian Scenario

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed surgeries worldwide. The number of joint replacement surgeries being performed has increased considerably over the past two decades, but it has also seen an increase in litigation associated with it. The purpose of our study was to review and consolidate literature regarding medico-legal issues pertaining to THA and TKA cases. We looked at the causes of litigation, medico legal aspects of pre-operative requirements, optimisation of medical condition, indications and contraindications for arthroplasty, informed consent, implants, mixing of components from different manufacturers and post-operative rehabilitation. We also wanted to analyse available literature and legal proceedings regarding these cases in India specifically.

The Anatomical Course of the Superior Gluteal Nerve With Regard to the Direct Anterior Approach for Primary and Revision Total Hip Arthroplasty

BACKGROUND

During primary and revision total hip arthroplasty (THA) lesions of the superior gluteal nerve (SGN) can substantially compromise patient outcome. For the primary direct anterior approach (DAA) and its proximal approach extensions, especially the muscular branch entering the tensor fasciae latae (TFL) muscle is at risk. SGN lesions can result in fatty atrophy and functional loss of the TFL. Therefore, the course and branching pattern of the SGN were examined and related to the DAA and its proximal approach extension. The aim of the study is to describe safe and danger zones for the SGN with regard to the DAA and its proximal extensions.

METHODS

Twenty-five formalin-fixed cadavers with 48 hemipelves were dissected. The course, distribution, and branching pattern of the SGN and its muscular branch inserting into the TFL muscle were investigated with regard to the DAA with the help of anatomical landmarks like the greater trochanter and the iliac tubercle.

RESULTS

In 72.9% of the specimens the SGN passed the greater sciatic foramen superior to the piriformis muscle with one main trunk. The muscular branch of the SGN supplying the TFL divided from the main branch in 89.6% of the specimens at the level of the greater sciatic foramen. Before entering the TFL muscle the muscular branch showed a variable branching pattern in the interval between the gluteus medius and minimus. A danger zone for the SGN with regard to the DAA was found in the proximal fourth of the skin incision.

CONCLUSION

Special care in proximal instrument placement should be taken during the DAA. When extending the DAA proximally manipulations in the proximal, caudal surgical window should be performed with the utmost care.

Limb Lengthening after Primary Total Knee Arthroplasty: Customized Patient-Specific Instrumentation Does Not Affect Expected Limb Lengthening

Introduction

Expectations for limb length differences after TKA are important for patient perception and outcomes. Limb length discrepancies may occur due to postoperative leg length increases, which can lead to decreased patient functionality and satisfaction and even possible litigation. The purpose of this study is to examine the frequency and extent of limb lengthening among various preoperative deformities and between two different implant systems.

Methods

Preoperative and postoperative full-length standing radiographs were obtained between August 2018 and August 2019 to measure mechanical axis and limb length of operative limbs. Demographic information such as age, sex, and BMI was also collected. Patients were grouped into categories for pre- and postoperative subgroup analysis: valgus, varus, customized implant, and conventional implant. Regression analysis was performed to evaluate significant relationships.

Results

Of the 121 primary TKAs analyzed, 62% of the knees showed an increase in limb length after TKA, with an average lengthening of 5.32 mm. Preoperative varus alignment was associated with a mean lengthening of 3.14 mm, while preoperative valgus alignment was associated with a mean lengthening of 16.2 mm. Overall, there were no statistically significant differences in limb lengths pre- and postoperatively (p = 0.23) and no significant changes in limb length for any subgroup. Further, no variables were associated with limb length changes (p = 0.49), including the use of customized implants (p = 0.2).

Conclusions

Limb lengthening after TKA is common and, on average, occurs more significantly in valgus knees. No significant difference in limb lengthening could be demonstrated using customized over conventional implants. Preoperative counseling is important to manage patient expectations.

Does total hip arthroplasty via the direct anterior approach using dual mobility increase leg length discrepancy compared with single mobility?

Background

Total hip arthroplasty (THA) via the direct anterior approach (DAA) using dual mobility cup (DMC) is considered to effectively prevent postoperative dislocation. However, the dislocation and reduction procedure using a trial implant during the surgery is difficult because of high soft tissue tension. Thereby, leg length discrepancy (LLD) is difficult to assess when using DM via the DAA.

Purpose

To compare the LLD between cases using conventional SM and those using DMC in THA via the DAA with fluoroscopy.

Patients and methods

We retrospectively investigated 34 hips treated with DMC (DMC-DAA group) and 31 hips treated with SM (SM-DAA group). The LLD was defined as the difference in the distance from the teardrop to the medial-most point of the lesser trochanter between the operative and nonoperative sides at immediate postoperative X-ray.

Results

The mean LLD in the DMC-DAA group and SM-DAA group was 0.68 ± 7.7 mm and 0.80 ± 5.5, respectively, with no significant difference. The absolute value of the LLD in the DMC-DAA group and SM-DAA group was 6.3 ± 4.4 mm and 5.9 ± 5.5, respectively, with no significant difference.

Conclusion

Despite the difficulty in assessment of the LLD during THA via the DAA using DMC, this technique does not increase the LLD compared with the use of SM.

Level of evidence

III, matched case-control study.

Retrospective analysis of medical malpractice claims in tertiary hospitals of China: the view from patient safety

OBJECTIVES

The study analysed medical malpractice claims to assess patient safety in hospitals. The information derived from malpractice claims reflects potential risks and could help lead to reducing medical errors and improving patient safety.

DESIGN, SETTING

We analysed 4380 medical malpractice claims from 351 grade-A tertiary hospitals in China for 2008-2017. We examined the characteristics of medical errors and patient safety, including the types of medical errors, proportionate liabilities and payments for medical malpractice in different clinical specialties.

MAIN OUTCOME MEASURES

We assessed claim characteristics, payment amounts and liability.

RESULTS

Our data analysis demonstrated that 72.5% of the claims involved medical errors, with average payments of US$31 430. The hospital's errors in medical malpractice resulted in 41.4% average liability in patient injury payments. Most medical malpractice cases occurred in Shanghai (817 claims, 18.7%) and Beijing (468 claims, 10.7%). The highest risks for medical error and malpractice claims were related to orthopaedics (11.3% of all claims, 72.8% with medical errors) and obstetrics and gynaecology (10.0% of all claims, 76.0% with medical errors). The highest rates related to proportionate liabilities were observed in otolaryngology (51.9%) and endocrinology (47.7%). Respiratory medicine had the highest proportion of claims in death rates (77.3%). Medical technology errors accounted for 91.8% of the claims and medical ethics errors for 5.8%. The highest average payment was found in cardiovascular surgery (US$41 733) and the lowest in stomatology (US$8822).

CONCLUSIONS

A previous study found that grade-A tertiary hospitals in China have similar medical error rates to general Chinese hospitals. ³⁶Different specialties had different risk characteristics regarding medical errors, payments and proportionate liabilities. Orthopaedics had the highest number of malpractices claims and higher proportionate liability but lower death rates.

A low-volume surgeon is an independent risk factor for leg length discrepancy after primary total hip arthroplasty: a case-control study

PURPOSE

Leg length discrepancy (LLD) is one of the bothersome complications that reduce patient satisfaction after total hip arthroplasty (THA). This study aimed to investigate the independent risk factors of LLD after primary THA.

METHODS

This is a case-control study of 163 THAs for 163 patients at our institution between April 2015 and March 2018. The relevant data about the general characteristics of the patients (age, sex, body mass index, and diagnosis), surgery (surgical approach, type of femoral stem fixation, and surgeon volume), and radiological findings (Dorr classification and pre-operative LLD) were reviewed to identify the risk factors of ≥ 5 mm post-operative LLD according to radiological measurement and to calculate odds ratios (OR) via logistic regression analysis.

RESULTS

The median (interquartile) absolute value of post-operative LLD was 3.9 (2.3-7.4) mm, and 57 (35.0%) patients had LLD of ≥ 5 mm. After controlling for possible confounders, a low-volume surgeon was considered the only independent risk factor of post-operative LLD (adjusted OR: 8.26; 95% confidence interval: 3.48, 19.60; P < 0.001). Among the 103 patients performed by high-volume surgeons, 82 (79.6%) had LLD of < 5 mm, whereas among the 60 patients performed by low-volume surgeons, only 24 (40.0%) achieved LLD of < 5 mm (P < 0.001).

CONCLUSION

A low-volume surgeon is associated with an increased risk of a post-operative LLD after primary THA, and the importance of measurements should be recognized to prevent post-operative LLD and achieve optimal outcomes. Moreover, surgeons must inform patients about the risk of developing LLD pre-operatively.