Patient injuries in primary total hip replacement

Patient injury claims for posterior cruciate ligament injury: a nationwide registry study in Finland

BACKGROUND AND PURPOSE

Posterior cruciate ligament (PCL) injuries usually occur in combination with other ligamentous knee injuries. The outcome varies and may be poor due to suboptimal treatment. We investigated claims following PCL injury treatment on a nationwide scale.

PATIENTS AND METHODS

All patient PCL injury claims filed in Finland from 1997 to 2015 were collected from the Patient Insurance Centre (PIC) register. We reviewed and analyzed all records to determine the causes of claims. General background data were obtained from the National Care Register for Social Welfare and Health Care (HILMO).

RESULTS

We found out from HILMO background data that, during the 19-year study period, 1,891 PCL and 1,380 multiligament reconstructions were performed in 99 different hospitals. The number of PCL injuries treated conservatively is unknown. During this same period, 49 claims arrived at the PIC, and 39/49 of these patients were operated on. 12/49 claims were compensated. Of these 12 claims, 6 were compensated for technical errors and 4 were compensated for diagnostic delays.

CONCLUSION

The number of patient injury claims was few, and compensated claims were even fewer. Technical errors and diagnostic delays were the most common reasons for reimbursement.

Patterns of malpractice claims and compensation after surgical procedures: a retrospective analysis of 8,901 claims from the Finnish patient insurance registry

BACKGROUND

Invasive surgical procedures carry risk of harm to patients. In addition to avoidable harm, disparities between patient expectations and the outcome of a procedure may lead to patient injury claims. The follow-up of claims and compensation is an important entity for patient safety. The number of claims should be related to the surgical volume, so that a healthcare provider can benchmark with similar organizations and see if its trends are developing favourably or deteriorating. Our objective was to find out the claims and compensation rates due to surgery in an insurance-based system.

METHODS

Data related to surgical claims and reference volume in the period 2011-2015 were collected from the claim register of the Finnish Patient Insurance Centre and benchmarking community register of Finnish operating departments. The data included age, gender, hospital, year of surgery, surgical code, and outcome of the claim.

RESULTS

There were 8,901 claims related to the corresponding reference group of 1,470,435 surgical procedures. The claims rate was 0.61% and compensation rate was 0.22%. Trends for claims and compensation rates decreased over the study period. In high volume procedures, a low compensation rate was detected for excision of tonsils and adenoids, Caesarean section and extracapsular cataract operations using the phacoemulsification technique. A high compensation rate was detected for primary prosthetic replacement of the hip and knee joints and decompression of spinal cord and nerve roots. Unreasonable injury (death or permanent deterioration of health) was compensated in 2.4 per 100,000 procedures.

CONCLUSIONS

Register data research in a no-fault patient insurance system revealed a claims rate of 6 per 1,000 procedures and compensation rate of 2 per 1,000 procedures. A decreasing trend in both rates over the study period was detected. Different surgical procedures exhibit varying claims and compensation rates.

Only 8% of major preventable adverse events after hip arthroplasty are filed as claims: a Swedish multi-center cohort study on 1,998 patients

Background and purpose - Hip arthroplasty is one of the most performed surgeries in Sweden, and the rate of adverse events (AEs) is fairly high. All patients in publicly financed healthcare in Sweden are insured by the Mutual Insurance Company of Swedish County Councils (Löf). We assessed the proportion of patients that sustained a major preventable AE and filed an AE claim to Löf.Patients and methods - We performed retrospective record review using the Global Trigger Tool to identify AEs in a Swedish multi-center cohort consisting of 1,998 patients with a total or hemi hip arthroplasty. We compared the major preventable AEs with all patient-reported claims to Löf from the same cohort and calculated the proportion of filed claims.Results - We found 1,066 major preventable AEs in 744 patients. Löf received 62 claims for these AEs, resulting in a claim proportion of 8%. 58 of the 62 claims were accepted by Löf and received compensation. The claim proportion was 13% for the elective patients and 0.3% for the acute patients. The most common AE for filing a claim was periprosthetic joint infection; of the 150 infections found 37 were claimed.Interpretation - The proportion of filed claims for major preventable AEs is very low, even for obvious and serious AEs such as periprosthetic joint infection.

Anterior cruciate ligament reconstruction-related patient injuries: a nationwide registry study in Finland

Background and purpose - Treatment outcomes of anterior cruciate ligament (ACL) injuries are generally good, but complications after ACL reconstruction (ACLR) can result in long-lasting problems. Patient injury claims usually fall on the more severe end of the complication spectrum. They are important to investigate because they may reveal the root causes of adverse events, which are often similar regardless of the complication's severity. Therefore, we analyzed ACL-related patient injuries in Finland, the reasons for these claims, causes of complications, and grounds for compensation.Patients and methods - We analyzed all claims filed at the Patient Insurance Centre (PIC) between 2005 and 2013 in which the suspected patient injury occurred between 2005 and 2010. This study also reviewed all original patient records and available imaging studies. General background data were obtained from the National Care Register for Social Welfare and Health Care (HILMO).Results - There were 248 patient injury claims, and 100 of these were compensated. Compensated claims were divided into 4 main categories: skill-based errors (n = 46), infections (n = 34), knowledge-based errors (n = 6), and others (n = 14). Of the compensated skill-based errors, 34 involved graft malposition, 26 of them involved the femoral-side tunnel. All compensated infections were deep surgical site infections (DSSI).Interpretation - This is the first nationwide study of patient injuries concerning ACLRs in Finland. The most common reasons for compensation were DSSI and malposition of the drill tunnel. Therefore, it would be possible to decrease the number of serious complications by concentrating on infection prevention and optimal surgical technique.

The Outcome of Cemented Acetabular Components in Total Hip Arthroplasty for Osteoarthritis Defines a Proficiency Threshold: Results of 22,956 Cases From the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

The declining popularity of cemented acetabular components is incongruous, given the published results of prostheses implanted using contemporary techniques. The outcome of arthroplasty has previously been demonstrated to correlate with surgeon experience and volume of practice. We aim to explore if surgeon volume alters outcomes of cemented acetabular components based on survivorship data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR).

METHODS

An observational study was undertaken using a cohort of 22,956 patients with a primary diagnosis of osteoarthritis in the period 2003-2016 in whom cemented acetabular components were implanted. The cohort was stratified by age (greater than or less than 65 years) and annualized surgical volume of ≤10, >10-≤25, and >25 cases.

RESULTS

Stratified by age and volume, there was a protective benefit against revision conveyed at volume thresholds of 10 cases per annum and 25 cases per annum for patients ≥65 years of age and <65 years of age, respectively.

CONCLUSION

Cemented total hip arthroplasty has excellent survivorship out to 15 years based on AOANJRR data. This survivorship is further improved if surgeons perform a higher volume of cases, with >25 cases conferring the greatest benefit. The AOANJRR data set is used to define best practice; surgeons who choose to utilize cemented acetabular fixation should be encouraged to perform this technique in adequate volumes to minimize revision risk and ensure the preservation of this important surgical skill set.

Geographical variations in patient-reported outcomes after total hip arthroplasty between 2008 - 2012

BACKGROUND

Health care on equal terms is a cornerstone of the Swedish health care system. Total hip arthroplasty (THA) is considered a success story in Sweden with low frequency of reoperations and restored health-related quality of life (HRQoL). Administratively, health care in Sweden is locally self-governed by 21 counties. In this longitudinal nation-wide observational study we assessed the possible geographical variations in 1-year follow-up patient-reported outcomes (PROs): EQ-5D index, EQ VAS, Pain VAS and Satisfaction VAS.

METHODS

Study population consisted of 36,235 Swedish THA patients, operated during 2008 to 2012 due to hip osteoarthritis. Individual data came from Swedish Hip Arthroplasty Register, Statistics Sweden and National Board of Health and Welfare. We used descriptive statistics together with multivariable regression analysis to analyse the data.

RESULTS

We observed county level differences in both preoperative and postoperative PROs. The results showed that the differences observed in preoperative PROs could not fully explain the differences observed in postoperative PROs, even after adjustment for patient demographics (age, sex, BMI, Elixhauser comorbidity index, marital status, educational level and disposable income). This indicates that other factors might influence the outcome after THA.

CONCLUSION

Likely, structural and process differences such as indication for surgery have an influence on PROs after surgery. Standardization of care at hospital levels may decrease geographical variations in postoperative HRQoL. Remaining differences will then possibly be associated to patient demographics.

The Impact of Patient and Surgical Factors on the Rate of Postoperative Infection After Total Hip Arthroplasty-A New Zealand Joint Registry Study

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty (THA). The potential to define and modify risk factors for infection represents an important opportunity to reduce the incidence of PJI. This study uses New Zealand Joint Registry data to identify independent risk factors associated with PJI after primary THA.

METHODS

Data on 91,585 THAs performed between 2000 and 2014 were analyzed. Factors associated with revision for PJI within 12 months were identified using univariate and multivariate analyses.

RESULTS

Revision rates for PJI were 0.15% and 0.21% at 6 and 12 months, respectively. Multivariate analysis showed significant associations with the American Society of Anesthesiologists grade (odds ratio [OR] 6.13, 95% confidence interval [CI] 1.28-29.39), severe or morbid obesity (OR 2.15, CI 1.01-4.60 and OR 3.73, CI 1.49-9.39), laminar flow ventilation (OR 1.98, CI 1.38-2.85), consultant-supervised trainee operations (OR 1.94, CI 1.22-3.08), male gender (OR 1.68, CI 1.23-2.30) and anterolateral approach (OR 1.62, CI 1.11-2.37). Procedures performed in the private sector were protective for revision for infection (OR 0.68, CI 0.48-0.96).

CONCLUSIONS

The PJI risk profile for patients undergoing THA is constituted of a complex of patient and surgical factors. Several patient factors had strong independent associations with revision rates for PJI. Although surgical factors were less important, these may be more readily modifiable in practice.

Public Perceptions About Nerve Injury From Hip Replacement Surgery

BACKGROUND

Nerve injury is a distressing complication for patients and surgeons that is difficult and frustrating to understand and treat. Whether the standard of care has been met when this complication occurs is a common question for both patients and surgeons but there is no information about how the public feels about nerve injury.

METHODS

The author surveyed 1409 individuals insured in a senior products health program using a 22-item questionnaire about nerve injury during hip replacement. Participants were given written descriptions of total hip arthroplasty, nerve injury, and the standard of care.

RESULTS

Seventeen percent of participants indicated that a direct nerve laceration is a standard of care violation. Respectively, 98%, 100%, 94%, and 97% of participants responded that the standard of care requires the surgeon to promptly identify the nerve injury, completely inform the patient about the nature and prognosis of the injury, and present options for treating the nerve injury. Eleven percent indicated that they lack trust in health care. Participants with distrust were more likely to find a standard of care violation than other participants. Women and non-white participants responded more commonly that a standard of care violation occurred with the nerve injury. Income level, age, prior surgery, and educational background were not differentiating factors as to whether participants found that a violation of the standard of care had occurred.

CONCLUSION

Most participants would accept the possibility of nerve injury during hip replacement but they would expect to be informed in advance that this complication is possible.

Patient injury claims involving fractures of the distal radius

Background and purpose - Optimal treatment for distal radius fractures remains controversial, with a significant number of fractures resulting in complications and long-term morbidity. We investigated patient injury claims related to distal radius fractures to detect the critical steps in the treatment leading to avoidable adverse events Patients and methods - We analyzed all compensated patient injury claims in Finland between 2007 and 2011. Claims were collected from the Patient Insurance Center's (PIC) nationwide claim register. Patients of all ages were included. Each claim decision, original patient records, and radiographs related to treatment were reviewed. Results - During the study period, the PIC received 584 claims regarding distal radius fractures, of which 208 (36%) were compensated. Pain and impaired wrist function were the most common subjective reasons to file claims among compensated patients. In 66/208 patients, more than 1 adverse event leading to patient injury was detected. The detected adverse events could be divided into 3 main groups: diagnostic errors (36%, n = 103), decision/planning errors (30%, n = 87), and insufficient technical execution (32%, n = 91). Issues related to malalignment were the main concerns in each group. Diagnostic errors were often related to incorrect assessment of the fracture (re)displacement (75%, n = 78). All of the decision-making errors concerned physicians' decisions to accept unsatisfactory fracture alignment. The most common technical error was insufficient reduction (29%, n = 26). Interpretation - We identified avoidable adverse events behind patient injuries related to distal radius fracture treatment. This study will help physicians to recognize the critical steps in the treatment of this common fracture and enhance patient safety.

Outcome of surgery for nerve injury following total hip arthroplasty

PURPOSE

During hip replacement, nerves in the operative field can be injured accidently. Additional surgical procedures can help restore function and reduce pain if there has been no recovery.

METHODS

One-hundred sixty-two patients presented with nerve injuries, and 113 were candidates for surgical treatment. The author performed 91 procedures on the injured limb (80 patients; 11 had 2 procedures) consisting of shortening, sympathectomy, tendon transfer, neurolysis or nerve repair/graft and 30 spinal and three fibular-neck decompressions. A meaningful recovery was defined as an increase of >1 level in strength or a reduction of >2 points on the visual analogue (VAS) pain scale.

RESULTS

Of 21 shortening procedures, 15 improved; of 12 nerve repair/grafting procedures, four improved. No patient >55 years of age made a meaningful recovery from a nerve repair/graft. One obturator nerve was resected and did not improve, and two were buried in muscle and had less pain. Of seven sympathectomies, six had less dysesthetic pain. Of 28 nerves treated with neurolysis, 24 made a meaningful recovery, with 13 making a near complete recovery. Of three fibular decompressions, two recovered completely. Of 20 tendon transfers, 18 made a meaningful recovery. Of 30 spinal decompressions, 25 made a meaningful recovery. There were six (5.3%) surgical complications (2 worsening pain, 2 infections, 2 deformities from tendon transfer).

CONCLUSIONS

If a sciatic, femoral or obturator nerve injury due to hip replacement does not recover spontaneously, additional surgical procedures can be of benefit.