Medical Malpractice Following Carpal Tunnel Surgery

Ultrasound-guided percutaneous release procedures in the transverse carpal ligament by acupotomy: A cadaveric study

Objective

This study aimed to determine the safety and accuracy of ultrasound-guided acupotomy percutaneous loosening of the transverse carpal ligament.

Methods

The 100 upper limb specimens were equally divided into the ultrasound-guided acupotomy group (U) and the nonultrasound-guided acupotomy group (N). For the U group, we simulated ultrasound-guided acupotomy loosening of the transverse carpal ligament in a human specimen, and for the N group, we performed the loosening of the transverse carpal ligament through the same approach under nonultrasound-guided conditions. The safety and accuracy of the two methods were compared through measurement.

Results

In the ultrasound-guided group, the injury rate of nerves, blood vessels and tendons caused by needle-knife release was 0%. In the non-ultrasound-guided group, the rate of nerve, blood vessel and tendon damage was 6 percent, 12 percent and 20 percent, respectively. χ ² test (Fisher exact test) was performed for the nerve and blood vessel damage rates in the two groups (P_N  > 0.05, P_A  < 0.05), the difference in nerve damage rates was not statistically significant, but the difference in blood vessel damage rates was statistically significant. Pearson's χ ² test was performed on the tendon injury rates of the two groups (P_F  < 0.05), and the difference was statistically significant. In the ultrasound-guided group, the proportion of acupotomy marks greater than or equal to half of the width of the transverse carpal ligament was 86%, and the non-ultrasound-guided group was 36%. The accuracy of the two surgical methods was tested by Pearson's χ ² test (P_L  < 0.05), and the difference was statistically significant. According to the measurement, the ultrasound-guided acupotomy technology had high safety and accuracy.

Conclusion

In this study, we designed a new method for cutting the transverse carpal ligament under ultrasound guidance, which is different from surgery. These results indicate that this is a safe and accurate method of interventional treatment of carpal tunnel syndrome.

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.

A Comparison of Histologic and Intraoperative Visual Assessments of Transverse Carpal Ligament During Revision Carpal Tunnel Release

PURPOSE

We sought to determine surgeon-pathologist agreement with respect to distinguishing between a previously undivided transverse carpal ligament (TCL) and scar during revision carpal tunnel release (CTR). Additionally, we aimed to describe the histologic findings of the TCL and flexor tenosynovium during revision CTR.

METHODS

All patients undergoing revision CTR for persistent or recurrent CTS by a single surgeon between 2013 and 2019 were included. An intraoperative assessment was made as to the presence of scar versus a previously undivided TCL by the surgeon. Two pathology specimens (1 consisting of flexor retinaculum and 1 consisting of tenosynovium) were sent for histopathological analysis with hematoxylin-eosin staining. The pathologist's assessment of the flexor retinaculum specimen was categorized as either "ligamentous" if a previously undivided TCL was identified or "nonligamentous" if scar or any other tissue was identified. The surgeon's intraoperative assessment served as the reference standard when comparing the histologic assessment.

RESULTS

A total of 40 patients underwent 46 revision CTRs. The histologic assessment agreed with the surgeon's intraoperative assessment of a previously undivided TCL versus a scar in 30 of 46 (65%) cases. In 12 of 46 (26%) revision cases, the surgeon determined that there was a previously undivided TCL. In these 12 cases, the pathologist identified a ligament 17% of the time.

CONCLUSIONS

Surgeon-pathologist agreement is low with respect to determining previously undivided TCLs versus nonligamentous tissue in the setting of revision CTR. The results of this investigation suggest that pathologists (with limited clinical information) have difficulty confirming the clinical diagnosis of persistent CTS with previously unreleased TCL when using routine hematoxylin-eosin staining. Routine biopsy of the TCL during revision CTR may be of limited clinical utility, as it does not alter the diagnosis or management in these cases.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Medical Malpractice Trends in Foot and Ankle Surgery

Medical malpractice lawsuits can place significant economic and psychologic burden on a provider. Orthopedic surgery is one of the most common subspecialties involved in malpractice claims. There is currently no study examining malpractice lawsuits within foot and ankle surgery. Accordingly, the purpose of this work is to examine trends in malpractice claims in foot and ankle surgery. The Westlaw legal database was queried for lawsuits pertaining to foot and ankle surgery from 2008 to 2018. Only cases involving medical malpractice were included for analysis. All available details pertaining to the cases were collected. This included plaintiff demographic and geographic data. Details regarding the cases were also collected such as anatomical location, pathology, complications, and case outcomes. Forty-nine malpractice lawsuits pertaining to foot and ankle were identified. Most plaintiffs in these cases were adult females, and the majority of cases occurred in the northeast (53.1%). The most common anatomical region involved in claims involved the forefoot (29%). The majority of these claims involved surgery (65%). Infection was the most common complication seen in claims (22%). The jury ruled in favor of the defendant surgeon in most cases (73%). This is the first study to examine trends in medical malpractice within foot and ankle surgery. Infection was the most frequent complication seen in claims and forefoot surgery was the most common anatomic location. A large portion of claims resulted after nonoperative treatment. A better understanding of the trends within malpractice claims is crucial to developing strategies for prevention.

Malpractice trends in shoulder and elbow surgery

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Fatores de insucesso do tratamento cirúrgico da síndrome do túnel do carpo: Quando e como revisar a cirurgia de descompressão do túnel do carpo

Despite being a procedure widely used all over the world with high rates of symptom remission, surgical treatment of carpal tunnel syndrome may present unsatisfactory outcomes. Such outcomes may be manifested clinically by non-remission of symptoms, remission of symptoms with recurrence a time after surgery or appearance of different symptoms after surgery. Different factors are related to this unsuccessful surgical treatment of carpal tunnel syndrome. Prevention can be achieved through a thorough preoperative clinical evaluation of the patient. As such, the surgeon will be able to make differential or concomitant diagnoses, as well as determine factors related to patient dissatisfaction. Perioperative factors include the correct identification of anatomical structures for complete median nerve decompression. Numerous procedures have been described for managing postoperative factors. Among them, the most common is adhesion around the median nerve, which has been treated with relative success using different vascularized flaps or autologous or homologous tissue coverage. The approach to cases with unsuccessful surgical treatment of carpal tunnel syndrome is discussed in more detail in the text.

Evaluation and Management of Unsuccessful Carpal Tunnel Release

Carpal tunnel release (CTR) is a routine and effective surgical treatment for carpal tunnel syndrome. Dissatisfied patients after CTR are uncommon but present diagnostic and therapeutic challenges. This article discusses the most common reasons for unsuccessful CTR, the appropriate ensuing workup, and current evidence regarding revision surgery. The authors' preferred treatment algorithm for the surgical management of the unsuccessful CTR is presented.