Review of successful litigation against english health trusts in the treatment of adults with orthopaedic pathology: clinical governance lessons learned

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.

Does-dual mobility still offer improved stability in smaller cup sizes? A computer modelling comparison of stability with 22-mm versus 28-mm inner heads in dual-mobility versus single-bearing constructs

PURPOSE

Dislocation remains 1 of the leading causes of revision after primary total hip arthroplasty (THA) and there is clear evidence the dual-mobility (DM) is used more frequently to minimise this. But in smaller cups, whether the use of DM with smaller 22-mm heads imparts any increased stability compared to standard bearing is unknown; especially when those smaller cups now allow for large single-bearing (SB) heads.

METHODS

3 primary cup sizes (48 mm, 50 mm, 52 mm) were chosen a priori for modelling. Head sizes trialled for the standard bearing (SB) constructs group were 28-0 mm, 32-0 mm and 36-0 mm against neutral polyethylene liners. In the modular sub-hemispheric DM constructs the inner head sizes for the DM constructs were altered where appropriate (22-0 mm vs. 28-0 mm). Cup position, stem offset, and stem size were standardised.

RESULTS

Both DM constructs outperformed all SB constructs because of a statistically significant jump distance increase (p < 0.001). However, there was no difference in range of motion (ROM) or jump distances between the 22-mm and 28-mm DM inner heads.The ROM angle before impingement between the DM (with 22-mm or 28-mm heads) and SB (with different head sizes where appropriate) showed no statistically significant difference. However, DM constructs presented significantly larger jump distances than SB constructs for both provocative dislocation tests across all 3 cup sizes.Of interest, for 50-mm and 52-mm cup sizes (for which this particular DM construct design can accommodate both 22-mm and 28-mm inner heads), there were no differences in ROM or jump distance between 22-mm versus 28-mm inner heads.

CONCLUSIONS

In this computer-modelling study, DM constructs are advantageous over SB constructs for improving jump distances in clinically provocative positions, but not range of motion angles. Inner head diameter of DM has no effect on stability.

Medical errors, affected sites, and adverse consequences among patients in the orthopaedic department: Does age matter?

Background

Orthopaedics have become the focus of research on patient safety due to the high incidence of medical errors. Previous studies were based on all orthopaedic patients and rarely conducted empirical analyses from the perspective of age. This study aimed to fill the academic gap in the age variable by comparing medical errors, affected sites, and adverse consequences in orthopaedic patients.

Methods

This retrospective study included 329 litigation claims against orthopaedists using data from China Judgments Online. First, we performed computer crawling and screened 5,237 litigation documents using keywords, including medical errors. Second, 2,536 samples were retained through systematic random sampling, and 549 irrelevant cases were deleted after manual reading. Finally, three clinicians from different medical departments selected 329 incidents related to orthopaedics for further analysis, according to the description of the lawsuits. Three other professional orthopaedists evaluated the patients' ages, affected sites of medical errors, and adverse consequences.

Results

The greatest number of medical errors was observed in the joints (30.43%) for all orthopaedic patients. However, adult patients (aged 18-60 years) were most susceptible to errors in the extremities (30.42%). A higher rate of complications was associated with a higher rate of morbidity/mortality for the corresponding patients. Medical errors correlated with complications occurred in the following sites: joints (15.38%), extremities (12.50%), spine (16.95%), multiple sites (15.38%), and hands and feet (14.81%). In addition to surgical errors, over 10% of all orthopaedic patients experienced missed diagnoses. The incidence of insufficient adherence to informed consent obligations was 13.5% among adult patients and was much higher in paediatric and older adults patients. When orthopaedic patients suffered from medical technical errors, iatrogenic mortality/morbidity would decrease by 0.3% for one unit increase in age.

Conclusion

Dividing patients into different ages demonstrated diverse results in terms of medical errors and affected sites. Negligence in diagnosis and examination can be fatal factors that endanger safety, and complications may cause morbidity/mortality. When patients suffered from technical errors, age is inversely proportional to mortality/morbidity. Special attention needs to be paid to technical errors in the younger older adults population (60-64 years old), which has inspired implications in promoting aging and public health.

UK robotic arthroplasty clinical and cost effectiveness randomised controlled trial for hips (RACER-Hip): a study protocol

INTRODUCTION

The number of robotic-assisted hip replacement procedures has expanded globally with the intended aim of improving outcomes. Intraoperative robotic-arm systems add additional costs to total hip replacement (THR) surgery but may improve surgical precision and could contribute to diminished pain and improved function. Additionally, these systems may reduce the need for expensive revision surgery. Surgery with conventional instruments may be just as successful, quick and affordable. There is timely demand for a robust evaluation of this technology.

METHODS AND ANALYSIS

The Robotic Arthroplasty Clinical and cost Effectiveness Randomised controlled trial for Hips (RACER-Hip) is a multicentre (minimum of six UK sites), participant-assessor blinded, randomised controlled trial. 378 participants with hip osteoarthritis requiring THR will be randomised (1:1) to receive robotic-assisted THR, or THR using conventional surgical instruments. The primary outcome is the Forgotten Joint Score at 12 months post-randomisation; a patient-reported outcome measure assessing participants' awareness of their joint when undertaking daily activities. Secondary outcomes will be collected post-operatively (pain, blood loss and opioid usage) and at 3, 6, 12, 24 months, then 5 and 10 years postrandomisation (including function, pain, health-related quality of life, reoperations and satisfaction). Allocation concealment will be accomplished using a computer-based randomisation procedure on the day of surgery. Blinding methods include the use of sham incisions for marker clusters and blinded operation notes. The primary analysis will adhere to the intention-to-treat principle. Results will adhere to Consolidated Standards of Reporting Trials statements.

ETHICS AND DISSEMINATION

The trial was approved by an ethics committee (Solihull Research Ethics Committee, 30 June 2021, IRAS: 295831). Participants will provide informed consent before agreeing to participate. Results will be disseminated using peer-reviewed journal publications, presentations at international conferences and through the use of social media. We will develop plans to disseminate to patients and public with our patient partners.

TRIAL REGISTRATION NUMBER

ISRCTN13374625.

Epidemiology of the causes of complaints after discectomy collected from a French insurance company

INTRODUCTION

Lumbar discectomy is a frequent procedure performed by surgeons from specialties at risk of patient complaints. The objective of the study was to analyze the causes of litigations following lumbar discectomy to be able to reduce their frequency.

MATERIAL AND METHODS

This observational, retrospective study was carried out at a French insurance company (Branchet). All files opened between the 1st of January 2003 and the 31st of December 2020, following lumbar discectomy without instrumentation and without any other associated code, undertaken by a surgeon insured by Branchet, were analyzed. The data was extracted from the database by a consultant from the insurance company and analyzed by an orthopedic surgeon.

RESULTS

One hundred and forty-four records met all inclusion criteria and were complete and available for analysis. Infection was the leading cause of litigation, responsible for 27% of complaints. Residual postoperative pain was the second cause of complaint with 26% of cases, of which 93% had persistent pain. Neurological deficits were the third cause of complaint with 25% of cases among which 76% were related to the appearance of a deficit and 20% related to the persistence of an existing deficit. Early recurrence of herniated disc also appeared as a cause of complaint, accounting for 7% of cases.

CONCLUSION

Surgical site infection, persistence of pain, and the appearance or persistence of neurological disorders are the primary causes of complaints leading to investigation in the aftermath of lumbar discectomy. It seems essential to us that this information be brought to the attention of surgeons to enable them to better adapt their explanations in the delivery of preoperative information.

LEVEL OF EVIDENCE

IV.

A randomized controlled trial of patient recall after detailed written consent versus standard verbal consent in adults with routine orthopaedic trauma

Patient decision aids have previously demonstrated an improvement in the quality of the informed consent process. This study assessed the effectiveness of detailed written patient information, compared to standard verbal consent, in improving postoperative recall in adult orthopaedic trauma patients. This randomized controlled feasibility trial was conducted at two teaching hospitals within the South Eastern Sydney Local Health District. Adult patients (age ≥ 18 years) pending orthopaedic trauma surgery between March 2021 and September 2021 were recruited and randomized to detailed or standard methods of informed consent using a random sequence concealed in sealed, opaque envelopes. The detailed group received procedure-specific written information in addition to the standard verbal consent. The primary outcome was total recall, using a seven-point interview-administered recall questionnaire at 72 hours postoperatively. Points were awarded if the participant correctly recalled details of potential complications (maximum three points), implants used (maximum three points), and postoperative instructions (maximum one point). Secondary outcomes included the anxiety subscale of the Hospital and Anxiety Depression Scale (HADS-A) and visual analogue scale (VAS) for pain collected at 24 hours preoperatively and 72 hours postoperatively. Additionally, the Patient Satisfaction Questionnaire Short Form (PSQ-18) measured satisfaction at 72 hours postoperatively. A total of 60 patients were randomized, 32 to the standard group and 28 to the detailed group. Patients in the detailed group had significantly higher total recall score compared to the standard group (mean difference 1.29 points (95% confidence interval (CI) 0.51 to 2.08); p = 0.002). There were no differences in HADS-A (mean difference 0.39 (95% CI -2.11 to 2.88); p = 0.757), VAS pain (mean difference 5.71 (95% CI -22.25 to 11.11); p = 0.499), or PSQ-18 (mean difference 0.499; 95% CI -1.6 to 3.42; p = 0.392). Detailed written tools are useful in improving postoperative recall in adult orthopaedic trauma patients.

Investigation of litigation in trauma orthopaedic surgery

BACKGROUND

It has been said that the number of orthopaedic claims has increased in the last few years. Investigation through the most prevalent cause would help to prevent further cases.

AIM

To review the cases of medical complaints in orthopedic patients who had been involved in a traumatic accident.

METHODS

A retrospective multi-center review of trauma orthopaedic-related malpractice lawsuits from 2010 to 2021 was conducted utilizing the regional medicolegal database. Defendant and plaintiff characteristics along with fracture location, allegations, and litigation outcomes were investigated.

RESULTS

A total of 228 claims referred to trauma-related conditions with a mean age of 31.29 ± 12.56 were enrolled. The most common injuries were at hand, thigh, elbow, and forearm, respectively. Likewise, the most common alleged complication was related to malunion or nonunion. In 47% of the cases, the main problem that led to the complaint was the inappropriate or insufficient explanation to the patient, and in 53%, there was a problem in the surgery. Eventually, 76% of the complaints resulted in a defense verdict, and 24% resulted in a plaintiff verdict.

CONCLUSION

Surgical treatment of hand injuries and surgery in non-educational hospitals received the most complaints. The majority of litigation outcomes were caused by a physician’s failure to fully explain and educate the traumatic orthopedic patients and technological errors.

Litigations in orthopedics and trauma surgery: reasons, dynamics, and profiles

BACKGROUND

In recent literature, the increasing number of medical litigations, both in terms of the number of cases being filed and the substantive costs associated with lawsuits, has been described. This study aims to provide an overview of the profile of litigation for orthopedic and trauma surgery to describe the differences and the development of the number of cases over time.

PATIENTS AND MATERIALS

A retrospective review of all litigations between 2000 and 2017 was conducted using the institutional legal database. The causes of litigation were documented and classified into seven major categories. In addition to plaintiff characteristics, the litigation outcomes and the differences between emergency and elective surgery were analyzed.

RESULTS

A total of 230 cases were evaluated. The mean age of the plaintiffs was 44.6 ± 20.1 years, and 56.8% were female. The main reasons for litigation were claimed inappropriate management (46.1%), misdiagnosis (22.6), and poor nursing care (8.3%). Significantly more litigations were filed against surgeons of the orthopedic subspecialty compared with trauma surgeons (78%; p ≤ 0.0001). There were significantly fewer litigations per 1000 cases filed overall in 2009-2017 (65% less; p = 0.003) than in 2000-2008.

CONCLUSION

Our results could not confirm the often-stated trend of having more litigations against orthopedic and trauma surgeons. Although the absolute numbers increased, the number of litigations per 1000 patients treated declined. Patients who underwent elective surgery were more likely to file complaints than emergency patients.

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 Litigation in Hand Surgery: A Comprehensive Nationwide Analysis

BACKGROUND

The circumstances surrounding claims against hand surgeons have not been elucidated in the literature. The purpose of this study was to analyze trends in malpractice litigation regarding hand surgery through a nationwide legal database.

METHODS

The Westlaw legal research database was queried for verdicts and settlements between 1985 and 2017 for hand surgery-related malpractice cases. Cases were included if the hand surgeon was sued for malpractice. Procedure type and complications and/or adverse events that resulted in litigation were recorded. Patient characteristics, state, date of case, case outcomes, and indemnity payment were also noted. All dollar amounts were adjusted to 2017 values using the Consumer Price Index.

RESULTS

In all, 171 cases (35 states) were included. The most frequently litigated surgeries were carpal tunnel releases followed by fracture treatment. Nerve injury was the predominant cause of litigation. The median nerve was predominantly injured, followed by the ulnar and radial nerves. In fracture surgery, malunion was the predominant cause, followed by weakness, nerve injury, and infection. In total, 72.5% of cases yielded verdicts in favor of the defense, 21.6% favored the plaintiff, and 5.9% were settled. Indemnity varied between $7800 and $8.99 million, averaging $570,397 for cases when the jury ruled in favor of the plaintiffs. Settled cases averaged $1,140,527.

CONCLUSIONS

Malpractice litigation has substantial financial implications on surgeons and the health care system. Litigation arises most commonly from routine procedures (carpal tunnel release and fracture fixation) rather than complex surgical cases, potentially due to the high variability in operating surgeon subspecialization, with discrepant training.

Patient Complaints in Orthopedic Surgery: An Analysis Utilizing a Large National Database

INTRODUCTION

Unsolicited patient complaints (UPCs) about surgeons correlate with surgical complications and malpractice claims. Analysis of UPCs in orthopedics is limited.

METHODS

Patient complaint reports recorded at 36 medical centers between January 1, 2015 and December 31, 2018 were coded using a previously validated coding algorithm Patient Advocacy Reporting System.

RESULTS

A total of 33,174 physicians had 4 consecutive years of data across the 36 participating medical centers and met other inclusion criteria.

CONCLUSIONS

Orthopedists with high numbers of UPCs may benefit from being made aware of their elevated risk status in ways that invite reflection on underlying causes.

Malpractice lawsuits in orthopedic trauma surgery: a meta-analysis of the literature

Introduction

The objectives for this study were to identify whether diagnostic or procedural errors more commonly resulted in lawsuit, as well as to elucidate how specific variables affected mean indemnity.

Methods

Systematic review of English-language articles in the PubMed and Google Scholar databases (through 2020) using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analysis was performed to estimate measures of proportions and differences in mean indemnity.

Results

The estimated probability of lawsuits related to orthopedic trauma in overall studies was 23.3%. There were no significant rate differences between main causes of claims (diagnostic vs procedural errors) and areas of injury (upper vs lower). There was no significant difference of mean indemnity between the probabilities of trauma-related claims, diagnostic error, and procedural error.

Conclusion

Non-trauma cases were more likely to result in lawsuit than trauma cases. Procedural errors accounted for most malpractice claims. The average indemnity increased according to the higher diagnostic errors, while the indemnity was lower with a relatively higher proportion of procedural errors. The most common cause of litigation varied between studies; however, among the most cited reasons were missed diagnosis/error in diagnosis, improper/substandard surgical performance, and, though not specifically studied in this analysis, errors of informed consent.

Level of Evidence

Economic and Decision Analyses Level VI.

National trends and cost of litigation in UK National Health Service (NHS): a specialty-specific analysis from the past decade

BACKGROUND AND AIMS

Medical litigation claim and costs in UK are rising. This study aims to analyse the 10-year trend in litigation costs for individual clinical specialties in the UK from 2009/10 to 2018/19.

METHODS

Data were procured from National Health Service (NHS) Resolution. Number of claims, total litigation costs and cost per claim were ascertained for each financial year. The data collected also includes the number of claims and average amount per claim per speciality during the years 2009-2019 (2009/2010 to 2018/2019 financial years).

RESULTS

The total annual cost of NHS litigation is currently £3.6 billion(2018/2019). Damages make up the greatest proportion of costs(£1.5 billion). Surgical specialties have the greatest number of claims annually(2847) but Obstetrics has the greatest total litigation(£1.9 billion) and cost per claim(£2.6 million). Number of claims, total costs and cost per claim are significantly greater in 2018/2019 than in 2009/2010.

CONCLUSIONS

Addressing the issue of litigations is complex. Medically there are speciality specific issues that require attention, whilst some general measures are common to all: effective communication, setting realistic targets and maintaining a motivated, adequately staffed workforce. These, alongside legal reforms, may reduce the financial burden of increasing litigation on the NHS.

Assessing the quality of consent in elective hip and knee arthroplasty: Do modern orthopaedic surgeons make the cut?

INTRODUCTION

Improper consent is a failure of clinical care and also a major cause of litigation within health care authorities. 4% of surgical negligence claims are attributed to improper consenting in the NHS, with an average settlement fee of approximately £40,000 per claim. Improving quality of consenting therefore not only improves patient care but could also reduce healthcare cost.

METHOD

A retrospective analysis of 100 elective hip and knee arthroplasties at a district general hospital in the South of England. Clinic letters and consent forms were reviewed, using the British Orthopaedic Association (BOA) consent proforma as a comparison standard. Quality of consent was reviewed based upon inclusion of BOA suggested risks.

RESULTS

40% of hip arthroplasty clinic letters and 20% of knee arthroplasty clinic letters did not include a risk discussion. Common risks on consent forms when compared to BOA standards were 84.8% compliant in knees and 88.8% in hips. Less common risks on consent forms were 100% compliant in knees and 96% in hips. Rare risks on consent forms were 74.8% compliant in knees and 57.7% in hips. Notably blood clots and infection were consented for in almost all patients. Risk of death meanwhile, was only consented for 62% of the time, across both procedures.

CONCLUSION

Standard of consenting in this audit falls short of BOA standards. Improvement is needed to improve patient care and avoid medical litigation. An integrated electronic form linking consent process of both outpatient and pre-operative review could be a beneficial intervention.

Cost Analysis of Screening Programmes for Developmental Dysplasia of the Hip: A Systematic Review

AIMS

The aim of this study was to assess screening costs in developmental dysplasia of the hip (DDH), to provide any clarity on the cost-effectiveness of various hip screening programmes internationally.

METHODS

A PROSPERO-registered systematic review was performed by examining cost analysis studies of various DDH screening programmes, including those based around clinical examination, selective ultrasound and universal ultrasound. Costs were analysed using narrative synthesis.

RESULTS

There were 14 studies included in this review. Two studies found that clinical hip screening is advantageous over no screening at all, both in terms of overall cost and favourable outcomes. When considering selective ultrasound imaging versus clinical screening, two studies found it to be more expensive, one found it cheaper and three studies calculated the overall programme costs to be similar. With universal ultrasound, four studies calculated this to be cheaper than clinical or selective ultrasound screening due to a reduced late detection and surgery rate. However, a comparable number of studies concluded that the increased financial costs of universal ultrasound were greater than the reduction in surgical costs. No studies included any long-term data.

CONCLUSION

There is a dearth of information on DDH screening costs, with significant heterogeneity amongst the existing literature. Future research should include the cost analysis of long-term complications of DDH, including the social and psychological impact of early onset arthritis, as well as gender specific ultrasound screening programmes.

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.

Litigation in arthroscopic surgery: a 20-year analysis of legal actions in France

PURPOSE

The main objective of this study was to identify the epidemiological characteristics of litigation following arthroscopic procedures, performed in private practice and public hospitals in France. The secondary objective was to establish a risk profile for medical malpractice lawsuits after arthroscopic surgery.

METHODS

All court decisions related to arthroscopic surgery between 1994 and 2020 were collected and reviewed cases from the two main French legal databases (Legifrance and Doctrine). Data were retrospectively collected and included: gender, joint and defendant's specialty involved, reason behind the lawsuit, initial indication and the type of arthroscopic procedure performed. The final verdicts as well as the indemnity awarded to the plaintiff (if any) were recorded.

RESULTS

One-hundred eighty cases met the inclusion criteria of the study and were analyzed: 58 cases were before administrative courts and 122 were before civil courts. An orthopaedic surgeon was involved alone or in solidum in 45.6% of cases (82/180), followed by anesthesiologists in 5.6% (10/180). The private surgery center or public hospital were implicated in 63.9% (115/180) of cases. The 2 most common joints involved in litigation following arthroscopic surgery were the knee (82.2%, n = 148) and the shoulder (11.1%, n = 20). The main reasons behind the lawsuit were related to postoperative infection in 78/180 cases and to a musculoskeletal complication in 45/180 cases (25%). A failure to inform was also reported in 34/180 cases (18.9%). Of the 180 cases, 122 cases (67.8%) resulted in a verdict for the plaintiff. The average indemnity award for the plaintiff was 77.984 euros [2.282-1.117.667]. A verdict for the plaintiff was significantly associated with postoperative infection or a wrong-side surgery, while technical error and musculoskeletal complications were more significantly likely to result in a verdict in favor of the defendant (p = 0.003).

CONCLUSION

This study evaluated and mapped lawsuits following after arthroscopic surgery in France over a period of more than 20 years. The main joint involved in lawsuits was knee. The main causes of lawsuits following arthroscopic surgery were related to postoperative infection, musculoskeletal complications and failure to inform.

LEVEL OF EVIDENCE

Level IV.

A mixed-methods survey to explore issues with virtual consultations for musculoskeletal care during the COVID-19 pandemic

OBJECTIVE

To explore orthopaedic and musculoskeletal clinicians' views and experiences of legal, safety, safeguarding and security issues regarding the use of virtual consultations (VC) during the COVID-19 pandemic. A secondary objective was to suggest ways to overcome these issues.

METHODS

A mixed method cross-sectional survey was conducted, seeking the views and experiences of orthopaedic and musculoskeletal medically qualified and Allied Health Professionals in the United Kingdom. Descriptive statistical analysis was employed for quantitative data and a qualitative content analysis undertaken for qualitative data. Findings were presented in accordance with the four key issues.

RESULTS

Two hundred and ninety professionals (206 physiotherapists, 78 medically qualified professionals, 6 'other' therapists) participated in the survey. Of the 290 participants, 260 (90%) were not using VC prior to the COVID-19 pandemic, 248 respondents (86%) were unsure whether their professional indemnity insurance covered VC, 136 (47%) had considered how they would handle an issue of safeguarding whilst the remainder had not, 126 (43%) had considered what they would do if, during a virtual consultation, a patient suffered an injury (e.g. bang on their head) or a fall (e.g. mechanical or a medical event like syncope) and 158 (54%) reported they felt the current technological solutions are secure in terms of patient data. Qualitative data provided additional context to support the quantitative findings such as validity of indemnification, accuracy of diagnosis and consent using VC, safeguarding issues; and security and sharing of data. Potential changes to practice have been proposed to address these issues.

CONCLUSIONS

VC have been rapidly deployed since the onset of the COVID-19 pandemic often without clear guidance or consensus on many important issues. This study identified legal, safeguarding, safety and security issues. There is an urgent need to address these and develop local and national guidance and frameworks to facilitate ongoing safe virtual orthopaedic practice beyond the COVID-19 pandemic.

Institutional differences in management of compartment syndrome at academic and community-based trauma centers: A survey of Orthopaedic Trauma Association (OTA) members

OBJECTIVES

The purpose of this study was to compare management of compartment syndrome at academic and community trauma centers and to identify any institutional variables that influence the number of adverse events reported to the hospital's peer review process.

DESIGN

Web-based survey.

SETTING

N/A.

PARTICIPANTS

Orthopedic Trauma Association (OTA) members.

METHODS

A link to a 9-item web-based questionnaire was sent to members of the OTA.

RESULTS

Two hundred twenty-four (21%) of 1031 OTA members completed the survey. Respondents indicated that residents were primarily responsible for checking compartments at academic trauma centers (91%), while community trauma centers reported higher utilization rates of ortho attendings (81%), trauma attendings (26%), and nurses (27%). Seventy-five percent of respondents at academic trauma centers relied on intra-compartmental pressure monitoring to make the diagnosis in intubated/obtunded patients as opposed to just 56% of respondents at community centers. Seventy percent of all respondents utilizing prophylactic fasciotomies practiced at community trauma centers. Forty-four percent indicated that they had submitted cases involving management of compartment syndrome to their hospital peer review process. While most submitted only 1 or 2 cases (75% of positive replies), 5% had submitted 5 or more cases for peer review. Use of a pressure monitor and orthopaedic surgeons performing all fasciotomies were associated with a lower number of cases submitted to peer review (P < .02 and P < .04, respectively).

CONCLUSION

Academic and community trauma centers differ in their utilization of in-house staff for early assessment, in the diagnostic modalities employed in obtunded patients, and in their threshold for fasciotomy. Adverse events are regularly reported for peer review at both academic and community trauma centers. As there is great variability between institutions in terms of clinical practice as demonstrated by the responses to this survey, it is recommended that institutions devise their own written protocol based on the resources they have available to reduce adverse events.

LEVEL OF EVIDENCE

Therapeutic Level V.

No-Fault Compensation From the Patient Compensation Association in Denmark After Primary Total Hip Replacement in Danish Hospitals 2005-2017

BACKGROUND

There is an annually rising number of performed total hip arthroplasty (THA) surgeries in Denmark and this is expected to become even more common. However, there are still risks of adverse events, which become the basis for compensation claims. In Denmark, there are no studies available concerning filed claims after THA. The aims of this study are to determine the incidence of claims related to THAs in Denmark, the reasons to claim, which claims lead to compensation, the amount of compensation, and trends over time.

METHODS

In this observational study, we analyzed all closed claims between 2005 and 2017 from the Danish Patient Compensation Association (DPCA). With the intention to contribute to prevention, we have identified the number and outcome of claims.

RESULTS

There were 2924 cases (ie, 2.5% of all THAs performed in this period). The approval rate was 54%. The number of claims filed was stagnant over time, except for a spike of metal-on-metal (MoM) prosthesis cases. The total payout was USD 29,591,045, and 87% of this was due to nerve damage (USD 9,106,118), infection (USD 6,046,948), MoM prosthesis (USD 4,624,353), insufficient or incorrect treatment (USD 472,500), and fracture (USD 2,088,110).

CONCLUSION

In total, 2.5% of all THAs performed between 2005 and 2017 lead to a claim submission at the DPCA. One of 2 claims were approved. The majority of payouts were due to nerve damage, infection, MoM prosthesis, insufficient or incorrect treatment, and fracture. Although DPCA manages claims for patients, the data can also provide beneficial feedback to arthroplasty surgeons with the aim of improving patient care.

Reasons for Litigation in Arthroplasty Infections and Lessons Learned

BACKGROUND

Infections complicate a minority of orthopaedic arthroplasties but are the leading cause of malpractice claims. The basis for the claims is unclear. The objective of this study was to identify the main deviations from current recommendations by reviewing patient files recorded by a major French medical liability-specialized insurance company for private practitioners (MACSF [Mutuelle d'Assurance du Corps de Santé Français]) and to analyze legal claims and outcomes of litigation.

METHODS

All claims data for periprosthetic joint infections were analyzed retrospectively from 2010 to 2014. Treatment strategies were compared with therapeutic guidelines published by medical societies.

RESULTS

Forty-five claims for periprosthetic joint infection were recorded; 82% of patients were men and the mean patient age was 63 years. Twenty-one patients (47%) had a knee arthroplasty, 21 had a hip arthroplasty, 2 had a shoulder arthroplasty, and 1 had an ankle arthroplasty. Twenty-three infections (51%) occurred within 1 month postoperatively. Staphylococcus aureus was isolated from intraoperative samples in 36% of the cases (including 25% of these with methicillin-resistant strains), and coagulase-negative staphylococci were isolated in 51% (44% methicillin-resistant strains) of the cases. Treatment lasted for a median of 9.5 months (range, 1.5 to 96 months), with a median of 6 months (range, 1.5 to 20 months) of antibiotics and 3 surgical procedures (range, 0 to 7 surgical procedures). A total of 18% of patients had antibiotic-related side effects, 2% of patients died, and 76% of patients had persistent sequelae. An infectious disease specialist's advice was required for 56% of the patients. Discordances with therapeutic guidelines were found in 76% of the patient files, including delay in diagnosis (44%) and inadequate medical treatment (18%) or medico-surgical treatment (13%).

CONCLUSIONS

Late diagnosis of early postoperative infections appears to be the major cause of inappropriate management and malpractice litigation. Discordance with current guidelines was identified. Early consultation with an infectious disease specialist may help to reduce malpractice claims.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does using anatomical models improve patient satisfaction in orthopaedic consenting? Single-blinded randomised controlled trial

BACKGROUND

Patient satisfaction in consenting is a major pillar of clinical governance and healthcare quality assessment. The purpose was to observe the effect of using 3D anatomical models of knee and shoulder joints on patient satisfaction during informed consent in the largest single-blinded randomised controlled trial in this field.

METHODS

52 patients undergoing elective knee or shoulder surgery were randomised into two groups when being consented. The intervention group (n = 26) was shown an anatomical model of the knee/shoulder joint while the control group (n = 26) was given only a verbal explanation without a model. Patients rated their satisfaction on the validated Medical Interview Satisfaction Scale (MISS-26) questionnaire. Semi-structured interviews were analysed for specific themes to determine key factors that influenced patient satisfaction. The mean score ±SD were calculated with significance set at p < 0.05.

RESULTS

There was a significant difference in the overall satisfaction between the control and intervention cohorts (MISS-26 score 4.33 [86.6%] ± 0.646 vs 4.70 [94.0%] ± 0.335 respectively, 7.4% improvement, 8.5% difference, p = 0.01). Behavioural criteria showed a 13% increase in satisfaction (p = 0.02). Semi-structured interviews determined that the factors influencing satisfaction included the surgeon's interpersonal manner, the use of the visual aid and seeing the consultant surgeon in clinic. All patients in the intervention cohort identified factors contributing to their satisfaction, whereas a fifth of the control cohort claimed nothing at all made them feel satisfied.

CONCLUSION

Anatomical models as visual aids significantly increased patient satisfaction during the consenting process and played an integral part of the surgeon's explanation. Patients exposed to anatomical models also claimed to be more satisfied with the surgeon's inter-personal skills. This study recommends the use of anatomical models, which are both cost-effective and easily implementable, during explanation and consent for orthopaedic procedures.

An assessment of the quality of clinical records in elective orthopaedics using the STAR score

BACKGROUND

Litigation claims related to surgery have increased significantly in recent years. Despite the medico-legal importance of clinical records, there have been few published studies describing the quality of medical records in orthopaedic surgery. This study aimed to evaluate the quality of clinical note taking in an elective orthopaedic setting over a 10-year period by comparing medical records from 2003 and 2013.

METHODS

We used the previously validated Surgical Tool for Auditing Records (STAR) on a sample of 20 medical records from each year. We performed statistical analysis to determine if significant differences existed between 2003 and 2013.

RESULTS

There was an overall improvement in the quality of medical records from 76.7% (range 68-82%) in 2003, to 81% (range 72-88%) in 2013 (P value < 0.05). There were significant improvements in the subsequent entry score, from 5.15 to 6.3 (P value < 0.05) and discharge summary score, 6.65 to 7.95 (P value < 0.05). The score for the operative record section decreased from 8.45 to 8.0 (P value < 0.05).

CONCLUSION

The overall standard of medical records in both 2003 and 2013 was high and comparable to other surgical specialties. There was no possible correlation observed between standards of medical records and increasing litigation claims in surgery. Widespread implementation of Electronic Medical Records (EMRs) is likely to have a significant impact on the quality of medical records. Further research is required to determine how the design of EMRs influences how healthcare professionals record data.

Universal versus selective ultrasound screening for developmental dysplasia of the hip: a single-centre retrospective cohort study

A total of 28 068 infants were studied to investigate whether universal ultrasound screening for developmental dysplasia of the hip results in fewer delayed presentations than selective screening, and whether the screening protocol affects subsequent treatment. The rate of delayed presentation was not lower with selective screening compared with universal screening but all cases of delayed presentation in this cohort were administrative errors. There were no sonographic errors (false-negatives). The treatment rate was significantly higher with universal screening but infants were treated earlier and were significantly less likely to require any surgical intervention. Those requiring surgery were less likely to require open reduction or pelvic osteotomy.

Alleged malpractice in orthopaedics. Analysis of a series of medmal insurance claims

Background

Medical malpractice is an important topic worldwide, and orthopedics is a clinical branch that is considered to be at a high risk for claims. The analysis of a series of medmal insurance claims allows forensic pathologists, clinicians, and insurance companies to probe the risk of a specific clinical branch for medical malpractice claims and highlights areas where care may be improved. We investigated the main features of a major Italian insurance broker’s archive in order to identify recurrent pitfalls in this field.

Materials and methods

A retrospective study was carried out on orthopedics claims. The archive covered claims from 2002 to 2013 that targeted 1980 orthopedists.

Results

635 claims were found and analyzed with a focus on the clinical activity invocked in the claim, the presence of alleged team malpractice, the clinical outcome of the case, and the final forensic decision regarding the claim. 299 orthopedists had at least one malpractice claim made against them during the available period; 146 orthopedists were subject to more than one malpractice claim. Most of the claims regarded perioperative and operative cases, usually originating from civil litigation. The anatomical sites most commonly involved were the hip or knees, and sciatic nerve lesions were the main contributor.

Conclusions

Orthopedics is a medical specialty with a high risk for malpractice claims. In our study, medical malpractice was observed in nearly 50% of the cases—typically in surgery-linked cases resulting in permanent impairment of the patient. Death from orthopedics malpractice seemed to be rare.

Level of Evidence

IV.

A comparison of complication rates between locking and non-locking plates in distal fibular fractures

BACKGROUND

Locking compression plates have become increasingly popular in orthopaedic surgery. However, the gold standard of treatment for distal fibular fractures remains fixation with a non-locking one-third tubular plate. It has been reported that locking plates in distal fibular fractures are associated with an increased complication rate.

HYPOTHESIS

The objective of this study is to assess the complication rates of locking versus non-locking plates in patients who underwent surgical fixation of distal fibular fractures.

MATERIALS & METHODS

A retrospective analysis of closed distal fibular fractures that underwent surgical repair over a 2-year period with either a locking or non-locking plate was undertaken, analysing the groups for both wound and overall postoperative complications.

RESULTS

A total of 160 patients were treated over 2 years, of which 129 and 31 patients were treated with non-locking and locking plates respectively. There was no significant difference between the non-locking and locking plates overall complication rates (13.5% versus 15.4%, p=0.76) or wound complication rates (3.97% versus 3.85%, p=1.00).

DISCUSSION

Distal fibular fractures managed with locking plates do not have a higher complication rate in comparison to those managed with non-locking plates.

LEVEL OF EVIDENCE

III (case control study).

A practical 'safe zone' technique for lag screw fixation of the fibula

Introduction During ankle fracture fixation, iatrogenic trauma to retro fibula structures can result in morbidity and reoperation. We describe a safe zone for lag screw insertion. Materials and methods This study was completed in three sections. We identified the average entry and exit points for the lag screw using 45 Weber B ankle fractures identified from our trauma database. We then analysed 26 sequentially presented ankle magnetic resonance images, concentrating on axial sections at 4, 8, 12 and 16 mm above the ankle joint. Finally, we used 63 sequentially performed magnetic resonance scans to confirm the safe zone from these consistent structures. Results The typical lag screw exit point was 14.2 mm above the ankle joint (95% confidence Interval 11.3-17.1 mm). A safe zone trajectory occurred between 31 and 45 degrees taken from the anterior aspect of the flat fibular surface at this level. The obvious palpable landmark to direct screw trajectory and avoid 'at risk' structures was found to be the medial edge of the Achilles tendon. Our final dataset confirmed in 63 scans, the medial aspect of the Achilles tendon to be a consistent safe zone with a minimum distance of at risk structures of 4 mm. Conclusion This simple method of directing the fibula lag screw towards the palpable medial edge of the Achilles tendon is practical, easy to teach and directs the screw on a safe trajectory away from the most commonly injured structures around the back of the fibula.

Litigation in orthopedic surgery: What can we do to prevent it? Systematic analysis of 126 legal actions involving four university hospitals in France

INTRODUCTION

Orthopedic surgery produces 20% of medical malpractice claims. However only a few studies have examined the reasons for and consequences of these disputes, and they have usually been limited to a single hospital. This led us to perform a retrospective analysis of the claims at four teaching hospitals in northwestern France. The goals were (1) to describe the circumstances that led to these claims and recommend ways to prevent them, and (2) to describe the conduct of the proceedings and their financial and social outcomes.

HYPOTHESIS

A systematic analysis of litigation cases will provide accurate information on the circumstances leading to these claims.

METHODS

The study included 126 disputes settled between 2000 and 2010 and related to orthopedic or trauma care given at one of four teaching hospitals in northwestern France. The method of recourse, grounds of the complaint, type of surgical procedure, expert findings and amount of the award were systematically analyzed.

RESULTS

Of these 126 cases, 54 (43%) of them were submitted to the French CRCI (regional conciliation and compensation commission), 48 (39%) to the French administrative courts and 51 (41%) were settled amicably. Multiple methods of recourse were used in 21% of cases (n=27/126). The average length of administrative court proceedings was 36.7±27 months [4-102], which was significantly longer than the CRCI proceedings (22.7±17.9 months [3-80]) or out-of-court settlement (23.7±21.5 months [0-52]) (p<0.0001). Damages were sought for medical error or treatment-related risk in 67.5% of the complaints (n=85/126), and for failure to inform in 15.8% of cases (n=20/126). There was a suspected surgical site infection in 79.3% of cases (n=100/126). There were multiple grounds for complaint in 68.3% of cases (n=86/126). Poor communication between the physician and patient was identified in 26.2% of cases (n=33/126). Damages were awarded in 25% of cases (n=31/126), with an average award of €58,303±€91,601 [0-357,970].

CONCLUSION

The primary grounds for legal action are infection-related complications combined with a deterioration in the doctor-patient relationship. Disputes could be prevented by continuing efforts to combat hospital-acquired infections and providing better communications training.

LEVEL OF PROOF

IV (retrospective study).

Epidemiology of malpractice claims in the orthopedic and trauma surgery department of a French teaching hospital: A 10-year retrospective study

INTRODUCTION

Orthopedic and trauma surgery is the specialty for which claims for compensation are most often filed. Little data exists on the subject in France, especially in a teaching hospital. We conducted a retrospective study aimed at (1) identifying the epidemiological characteristics of patients filing claims against the orthopedic surgery and traumatology department of a teaching hospital in France, (2) analyzing the surgical procedures involved, the type of legal proceedings, and the financial consequences.

HYPOTHESIS

The epidemiological profile of proceedings seeking damages in France is consistent with the data from European and American studies.

MATERIALS AND METHODS

An observational, retrospective, single-center study of all claims for damages between 2007 and 2016 involving the orthopedic and trauma surgery department of a teaching hospital was carried out. Patients' epidemiological data, the surgical procedure, type of legal proceeding, and financial consequences were analyzed.

RESULTS

Of the 51,582 surgical procedures performed, 71 claims (0.0014%) were analyzed (i.e., 1/726 procedures). A significant increase in the number of cases (p=0.040) was found over a 10-year period. Of these, 36/71 (53.7%) were submitted to the French regional conciliation and compensation commission (CRCI), 23/71 (32.8%) were filed with the administrative court, and 12/71 (13.4%) were submitted for an amicable settlement. The most common reason for which patients filed claims was hospital-acquired infections, with 36/71 (50.7%) cases. Twenty-nine complaints (40.8%) resulted in monetary damages being awarded to the patient, with an average award of € 28,301 (€ 2,400-299,508). Damage awards were significantly higher (p<0.05) for cases involving surgery on a lower limb than those involving an upper limb.

CONCLUSION

Claims against orthopedic surgeons have been increasing significantly over the last 10 years. Although rare, they represent a significant cost to society. Hospital-acquired infections are the main reason for disputes in our specialization.

LEVEL OF EVIDENCE

IV, retrospective study.

Lawsuits After Primary and Revision Total Knee Arthroplasty: A Malpractice Claims Analysis

INTRODUCTION

As the number of total knee arthroplasties (TKAs) increases, the number of associated complications will also increase. Our goal with this study was to identify common causes of and financial trends relating to malpractice claims filed after TKA.

METHODS

We analyzed malpractice claims filed for alleged neglectful primary and revision TKA surgeries performed between 1982 and 2012 by orthopaedic surgeons insured by a large New York state malpractice carrier.

RESULTS

We identified 69 primary and 8 revision TKAs in the malpractice carrier's database. All cases were performed between 1982 and 2012; all claims were closed between 1989-2015. The most frequent factor leading to lawsuits for primary TKA was chronic pain or dissatisfaction in 12 cases, followed by nerve palsy in 8, postoperative in-hospital falls in 5, and deep vein thrombosis or pulmonary embolism in 3. Medical complications included acute respiratory distress syndrome, cardiac arrest, and decubitus ulcers. Contracture was most common after revision TKA (three of eight cases). Mean indemnity was $325,369, and the largest single settlement was $2.42 million. The average expense relating to the defense of these cases was $66,365.

CONCLUSIONS

Orthopaedic surgeons should continue to focus attention on prevention of complications and on preoperative patient education. Preoperative counseling regarding the risks of incomplete pain relief could reduce substantially the number of suits relating to primary TKAs.

Lawsuits After Primary and Revision Total Hip Arthroplasties: A Malpractice Claims Analysis

BACKGROUND

As the prevalence of total hip arthroplasty (THA) expands, so too will complications and patient dissatisfaction. The goal of this study was to identify the common etiologies of malpractice suits and costs of claims after primary and revision THAs.

METHODS

Analysis of 115 malpractice claims filed for alleged neglectful primary and revision THA surgeries by orthopedic surgeons insured by a large New York state malpractice carrier between 1983 and 2011.

RESULTS

The incidence of malpractice claims filed for negligent THA procedures is only 0.15% per year in our population. In primary cases, nerve injury ("foot drop") was the most frequent allegation with 27 claims. Negligent surgery causing dislocation was alleged in 18 and leg length discrepancy in 14. Medical complications were also reported, including 3 thromboembolic events and 6 deaths. In revision cases, dislocation and infection were the most common source of suits. The average indemnity payment was $386,153 and the largest single settlement was $4.1 million for an arterial injury resulting in amputation after a primary hip replacement. The average litigation cost to the insurer was $61,833.

CONCLUSION

Nerve injury, dislocation, and leg length discrepancy are the most common reason for malpractice after primary THA. Orthopedic surgeons should continue to focus on minimizing the occurrence of these complications while adequately incorporating details about the risks and limitations of surgery into their preoperative education.

Legal and psychological considerations for obtaining informed consent for reverse total shoulder arthroplasty

This paper seeks to outline recent legal developments and requirements pertinent to obtaining informed consent. We argue that this is of particular relevance to patients considering a reverse total shoulder arthroplasty, due to the high complication rate associated with this procedure. By examining the cognitive processes involved in decision-making, and other clinician-related factors such as delivery of information, gender bias and conflict of interest, we explore some of the barriers that can undermine the processes of shared decision-making and obtaining genuine informed consent. We argue that these issues highlight the importance for surgeons in understanding the cognitive processes and other influential factors involved in patients' comprehension and decision-making. We recommend, based on strong evidence, that decision aids could prove useful in overcoming such challenges and could provide one way of mitigating the ethical, professional and legal consequences of failing to obtain proper informed consent. They are not widely used in orthopaedics at present, although it would be in the interests of both the surgeon and patient for such measures to be explored.

Negligence claims following non-union and malunion of long bone fractures: An analysis of 15 years of data

INTRODUCTION

Non-unions and malunions are recognised to be complications of the treatment of long bone fractures. No previous work has looked at the implications of these complications from a medicolegal perspective.

METHODS

A complete database of litigation claims in Trauma and Orthopaedic Surgery was obtained from the NHS Litigation Authority. Two separate modalities of the treatment of long bone fractures were examined i) non-union and ii) acquired deformity. The type of complaint, whether defended or not, and costs were analysed.

RESULTS

There were claims of which 97 related to non-union and 32 related to postoperative limb deformity. The total cost was £8.2 million over a 15-year period in England and Wales. Femoral and tibial non-unions were more expensive particularly if they resulted in amputation. Rotational deformity cost nearly twice as much as angulation deformities.

CONCLUSIONS

The cosmetic appearances of rotational malalignment and amputation results in higher compensation; this reinforces an outward perception of outcome as being more important than harmful effects. Notwithstanding the limitations of this database, there are clinical lessons to be gained from these litigation claims.

Controversies and Trends in United Kingdom Bunion Surgery

Current practice and controversies in UK bunion surgery are discussed. Patients tend to be offered a distally based metatarsal osteotomy, such as a chevron or scarf osteotomy, for mild to moderate symptomatic bunions. Greater deformities are managed with a more extreme scarf, supplemented with a proximal phalangeal osteotomy. A proximal fusion in the form of the Lapidus-type procedure is still reserved for the most severe, hypermobile, or arthritic cases. Minimally invasive techniques for bunions have failed to disseminate into common UK practice. The trends in the United Kingdom regarding litigation, venous thromboembolism, and osteodesis for bunion surgery are also discussed.

Learning from lawsuits: Ten-years of NHS litigation authority claims against 11 surgical specialities in England

INTRODUCTION

Medico-legal claims are a drain on NHS resources and promote defencive practice. The litigious burden of surgery in England has not been previously described. This paper describes trends over ten years of claims made against the NHS across 11 surgical specialities.

MATERIALS AND METHODS

Data were requested for all claims received by the NHS Litigation Authority (NHSLA) from 2004 to 2014. Surgical specialities included cardiothoracic, general, neurosurgery, obstetric, oral and maxillofacial (OMFS), orthopaedic, otorhinolaryngology, paediatric, plastic, urology and vascular surgery. A literature review of peer-reviewed publications was performed with search terms 'NHSLA' and 'Surgery'.

RESULTS

The NHS paid out approximately £1.5 billion across 11 surgical specialities from 2004 to 2014. Orthopaedic, obstetric and general surgery received the largest number of claims per year, and paediatric surgery the least. The mean time from registration of claim with the NHSLA to settlement was 25.5 months (range 17.8 months-35 months). Neurosurgery was responsible for the highest average amount paid per claim, and OMFS the lowest. Failure/delay in treatment and/or diagnosis and failure to warn/adequately consent were the three leading types of claim. 806 never events were successfully claimed for during the ten-year period.

DISCUSSION AND CONCLUSION

Sharing information and good practice should be a priority for surgical professionals. Lessons learnt from medico-legal claims are transferrable in strategic planning. This pan-speciality report has demonstrated considerable burden on the NHS and should promote improvement in practice on an individual level in addition to providing systems based recommendations to NHS and international organisations.

[Clinical safety and professional liability claims in Orthopaedic Surgery and Traumatology]

The specialist in orthopaedic and traumatological surgery, like any other doctor, is subject to the current legal provisions while exercising their profession. Mandatory training in the medical-legal aspects of health care is essential. Claims against doctors are a reality, and orthopaedic and traumatological surgery holds first place in terms of frequency of claims according to the data from the General Council of Official Colleges of Doctors of Catalonia. Professionals must be aware of the fundamental aspects of medical professional liability, as well as specific aspects, such as defensive medicine and clinical safety. The understanding of these medical-legal aspects in the routine clinical practice can help to pave the way towards a satisfactory and safe professional career. The aim of this review is to contribute to this training, for the benefit of professionals and patients.

Litigation costs of wrong-site surgery and other non-technical errors in orthopaedic operating theatres

INTRODUCTION

This study reviews the litigation costs of avoidable errors in orthopaedic operating theatres (OOTs) in England and Wales from 1995 to 2010 using the National Health Service Litigation Authority Database.

MATERIALS AND METHODS

Litigation specifically against non-technical errors (NTEs) in OOTs and issues regarding obtaining adequate consent was identified and analysed for the year of incident, compensation fee, cost of legal defence, and likelihood of compensation.

RESULTS

There were 550 claims relating to consent and NTEs in OOTs. Negligence was related to consent (n=126), wrong-site surgery (104), injuries in the OOT (54), foreign body left in situ (54), diathermy and skin-preparation burns (54), operator error (40), incorrect equipment (25), medication errors (15) and tourniquet injuries (10). Mean cost per claim was £40,322. Cumulative cost for all cases was £20 million. Wrong-site surgery was error that elicited the most successful litigation (89% of cases). Litigation relating to implantation of an incorrect prosthesis (eg right-sided prosthesis in a left knee) cost £2.9 million. Prevalence of litigation against NTEs has declined since 2007.

CONCLUSIONS

Improved patient-safety strategies such as the World Health Organization Surgical Checklist may be responsible for the recent reduction in prevalence of litigation for NTEs. However, addition of a specific feature in orthopaedic surgery, an 'implant time-out' could translate into a cost benefit for National Health Service hospital trusts and improve patient safety.

The cost of adverse events from knee surgery in the United Kingdom: an in-depth review of the National Health Service Litigation Authority database

BACKGROUND

There has been a significant rise in the number and value of claims against the National Health Service (NHS), with limited studies on litigation in orthopaedic surgery and none in knee surgery alone. We aimed to examine claims against the NHS involving all aspects of knee surgery with respect to costs and trends.

CLINICAL RELEVANCE

To raise awareness of the reasons for litigation in knee surgery, thus potentially improve patient care and reduce future claims.

METHODS

We analysed the NHS litigation authority (NHSLA) database for all orthopaedic surgery claims reported to the NHSLA between 2005 and 2010, with calculation of litigation success rates and odds ratios for those relating to knee surgery.

RESULTS

There were 515 cases identified from the 4609 orthopaedic cases in the NHSLA database (11.2%): 298 (58%) involving total knee replacements (TKRs), 11 (2%) involving unicondylar knee replacements, and 90 cases (30%) remaining open. The total pay out for closed cases was £10.45 million and amputation following TKR resulted in the highest single pay out. Litigation success rates for claimants were highest for retained drains (100%), incorrect prosthesis/prosthesis size (78%), renal failure (75%), poor outcome requiring further surgery (74%) and malalignment (71%). There were also 60 cases of delayed diagnosis which resulted in pay outs totalling £2.90 million. Based on these data, projected future pay out costs for the open TKR cases were estimated to be £2.71 million.

CONCLUSION

Litigation success rates for TKR were highest following technical errors such as malalignment compared to events less under the surgeon's control, such as infection. The number of claims involving incorrect prosthesis/size continues to be of concern. Despite the increased availability of imaging modalities, missed diagnosis also resulted in substantial pay outs.

Internet based patient education improves informed consent for elective orthopaedic surgery: a randomized controlled trial

Background

Obtaining informed consent is an essential step in the surgical pathway. Providing adequate patient education to enable informed decision making is a continued challenge of contemporary surgical practice. This study investigates whether the use of a patient information website, to augment patient education and informed consent for elective orthopaedic procedures is an effective measure.

Methods

A randomised controlled trial was conducted comparing the quality of informed consent provided by a standard discussion with the treating surgeon compared to augmentation of this discussion with an online education resource (www.orthoanswer.org). Participants were recruited from orthopaedic outpatient clinics. Patients undergoing five common orthopaedic procedures were eligible to participate in the trial. The primary outcome measure was knowledge about their operation. Satisfaction with their informed consent and anxiety relating to their operation were the secondary outcome measures.

Results

There was a statistically significant increase in patient knowledge for the intervention arm as compared to the control arm (p < 0.01). Patients in the intervention arm, had an average score of 69.25% (SD 14.91) correct answers as compared to 47.38% (SD 17.77) in the control arm. Satisfaction was also improved in the intervention arm (p = 0.043). There was no statistically significant difference between the control and intervention arm relating to their anxiety scores (p = 0.195).

Conclusions

The use of a patient education website as an augment to informed consent improves patient knowledge about their planned operation as well as satisfaction with the consent process whilst not increasing their anxiety levels. We recommend that all patients be directed to web based education tools to augment their consent.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614001058662.

Clinical negligence in foot and ankle surgery

We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012.

A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed.

During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million.

There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement.

Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice.

Cite this article: Bone Joint J 2014;96-B:1510–14.

Understanding risks and complications in the management of ankle fractures

Ankle fracture (AF) is a common injury with potentially significant morbidity associated with it. The most common age groups affected are young active patients, sustaining high energy trauma and elderly patients with comorbidities. Both these groups pose unique challenges for appropriate management of these injuries. Young patients are at risk of developing posttraumatic osteoarthritis, with a significant impact on quality of life due to pain and impaired function. Elderly patients, especially with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection and failure of fixation. In the most severe cases, this can lead to amputation and mortality. Therefore, individualized approach to the management of AF is vital. This article highlights commonly encountered complications and discusses the measures needed to minimize them when dealing with these injuries.

Sarcoma excision and pattern of complicating sensory neuropathy

A potential complication of sarcoma excision surgery is a sensory neurological dysfunction around the surgical scar. This study utilised both objective and subjective sensation assessment modalities, to evaluate 22 patients after sarcoma surgery, for a sensory deficit. 93% had an objective sensory deficit. Light touch is less likely to be damaged than pinprick sensation, and two-point discrimination is significantly reduced around the scar. Results also show that an increased scar size leads to an increased light touch and pinprick deficit and that two-point discriminatory ability around the scar improves as time after surgery elapses. 91% had a subjective deficit, most likely tingling or pain, and numbness was most probable with lower limb sarcomas. Results also demonstrated that there were no significant relationships between any specific subjective and objective deficits. In conclusion, sensory disturbance after sarcoma surgery is common and debilitating. Efforts to minimize scar length are paramount in the prevention of sensory deficit. Sensation may also recover to an extent; thus, sensory reeducation techniques must become an integral aspect of management plans. Finally to obtain a comprehensive assessment of sensory function, both objective and subjective assessment techniques must be utilised.

Malpractice in distal radius fracture management: an analysis of closed claims

PURPOSE

Distal radius fractures comprise the majority of hand- and wrist-related malpractice claims. We hypothesized that a majority of lawsuits would be for malunions resulting from nonsurgical treatment. Additional goals of this study were to quantify costs associated with claims, determine independent risk factors for making an indemnity payment, and illustrate trends over time.

METHODS

Seventy closed malpractice claims filed for alleged negligent treatment of distal radius fractures by orthopedic surgeons insured by the largest medical professional liability insurer in New York State (NYS) from 1981 to 2005 were reviewed. We separately reviewed defendants' personal closed malpractice claim histories from 1975 to 2011. Overall incidence of malpractice claims among distal radius fractures treated in NYS was calculated using the NYS Statewide Planning and Research Cooperative System database and the 2008 American Academy of Orthopedic Surgeons census data.

RESULTS

The overall incidence of malpractice claims for distal radius fracture management was low. Malunion was the most common complaint across claims regardless of treatment type. Claims for surgically treated fractures increased over time. A majority of claims documented poor doctor-patient relationships. Male plaintiffs in this group were significantly older than males treated for distal radius fractures in NYS. Most defendants had a history of multiple malpractice suits, all were male, and only a small percentage were fellowship-trained in hand surgery. Defendants lacking American Board of Orthopedic Surgery certification were significantly more likely to make indemnity payments. Thirty-eight of 70 cases resulted in an indemnity payment.

CONCLUSIONS

Malunion and poor doctor-patient relationships are the major features of malpractice litigation involving distal radius fracture management. Older defendant age and lack of American Board of Orthopedic Surgery certification increase the likelihood of making an indemnity payment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and decision analyses II.