Article

Litigation after hip and knee replacement in the National Health Service

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Abstract

The results of hip and knee replacement surgery are generally regarded as positive for patients. Nonetheless, they are both major operations and have recognised complications. We present a review of relevant claims made to the National Health Service Litigation Authority. Between 1995 and 2010 there were 1004 claims to a value of £41.5 million following hip replacement surgery and 523 claims to a value of £21 million for knee replacement. The most common complaint after hip surgery was related to residual neurological deficit, whereas after knee replacement it was related to infection. Vascular complications resulted in the highest costs per case in each group. Although there has been a large increase in the number of operations performed, there has not been a corresponding relative increase in litigation. The reasons for litigation have remained largely unchanged over time after hip replacement. In the case of knee replacement, although there has been a reduction in claims for infection, there has been an increase in claims for technical errors. There has also been a rise in claims for non-specified dissatisfaction. This information is of value to surgeons and can be used to minimise the potential mismatch between patient expectation, informed consent and outcome. Cite this article: Bone Joint J 2013;95-B:122–6.

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... In recent years, the number of total knee arthroplasty (TKA) operations has gradually increased [4]. However, another trend is that the TKA-related litigations have also been steadily on the rise with the increase in the volume of TKA [5]. According to a study by McWilliams et al. [5], the number of claims after TKA increased by 46% between 2002 and 2010. ...
... However, another trend is that the TKA-related litigations have also been steadily on the rise with the increase in the volume of TKA [5]. According to a study by McWilliams et al. [5], the number of claims after TKA increased by 46% between 2002 and 2010. According to the statistics, joint reconstruction surgeons are twice more likely to be sued for medical damage than other doctors, with nearly 80% of joint reconstruction surgeons having been sued at least once in their careers, and more than 50 percent of lawsuits taking place in the first 10 years of their practice [6][7][8]. ...
... In recent years, the litigations related to total knee arthroplasty have gradually increased with the increase in the amount of total knee arthroplasty [5]. Scott et al. [10] found that up to 20% of patients were not satisfied with the results after knee arthroplasty, and the dissatisfactions tend to lead to litigation. ...
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Background The medical damage litigations after knee arthroplasty are on the rise year by year. However, few studies examined the litigation after knee arthroplasty. This study analyzed the litigation of medical damage after knee replacement in the past ten years based on a Chinese database. It synthesized the focus of the dispute in these cases to provide a reference for doctors to reduce the risk of litigation. Methods Retrospectively analyzed were medical damage litigations after total knee arthroplasty in the past ten years (June 2011–June 2021) from the "Wolters Kluwer Legal Information Database". The data collected included the characteristics of patients, causes of litigation, the results of litigation and the amount of compensation. Results A total of 110 litigation cases were analyzed, including 40 male patients (36.3%) and 70 female patients (63.6%). The top cause of litigation was infection (43.6%). The most common factor leading to the doctor losing the case was "complications caused by operational error" ( P < 0.05). Complications, such as amputation, postoperative ischemic stroke and infection, were more likely to result in higher compensation. Conclusions The prevention of infection and the avoidance of operational errors are very important in avoiding medical litigations. Moreover, avoiding disabling complications or a protracted course of disease could significantly reduce the amount of compensation. In addition, full and reasonable communication, paying full attention to the reaction of patients, and timely diagnosis could also effectively minimize the risk of litigation and loss.
... Orthopedic surgery seems to be the speciality most at risk of litigation [6], both in the United States of America (USA) and Europe. THA could lead to a claim in 0.3% of cases in the Netherlands [7], and represent up to 11% of orthopedic claims in the United Kingdom [8]. Upadhyay et al. showed that the main reasons for THA complaints were, respectively, nerve injury, limb length discrepancy, and infection [9]. ...
... Upadhyay et al. showed that the main reasons for THA complaints were, respectively, nerve injury, limb length discrepancy, and infection [9]. Complaints following TKA are variable in Europe, ranging from 2.5% of complaints in Finland [10], to 7% in the UK [8]. The main reasons for complaining were: septic complications, technical errors or negligence in postoperative care [7][8][9][10]. ...
... Complaints following TKA are variable in Europe, ranging from 2.5% of complaints in Finland [10], to 7% in the UK [8]. The main reasons for complaining were: septic complications, technical errors or negligence in postoperative care [7][8][9][10]. ...
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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.
... In fact, more than 75% to 90% of arthroplasty surgeons were reported to have been the subject of a malpractice lawsuit [3,4,5]. Nerve palsy is the most common reason for medical litigation after THA [3,4,5,6,7]. Bokshan et al. reported litigation associated with hip and knee arthroplasty. ...
... In the cases of nerve palsy, 10.3% of cases ended in settlement and 53.9% ended in physician loss, and the doctor's win rate was low [3]. McWilliams et al. reported that the rate of physician's payment was 46% in cases of nerve palsy after THA [7]. In these two reports, the average payment for nerve injury was USD 1,089,825 and UKP 116,800 [3,7]. ...
... McWilliams et al. reported that the rate of physician's payment was 46% in cases of nerve palsy after THA [7]. In these two reports, the average payment for nerve injury was USD 1,089,825 and UKP 116,800 [3,7]. The incidence of peripheral nerve palsy following primary THA has been estimated to be from 0% to 4.0% [8,9,10]. ...
Article
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Nerve palsy following total hip arthroplasty (THA) can have a serious effect on a patient`s functional prognosis and on cost-effectiveness, and it is the leading cause of THA-associated medical litigation. However, only a few studies focus on femoral nerve palsy (FNP) following THA with the direct anterior approach (DAA). Moreover, several studies have reported that THA with DAA may result in higher complication rates, particularly during the so-called ‘learning-curve period’ for the surgeon. This study aimed to identify the incidence of FNP following primary THA with DAA, to determine presumed etiologies through a retrospective investigation of FNP clinical courses following primary THA with DAA and to identify any relationship between the occurrence of FNP following primary THA with DAA and the surgeon’s experience of DAA. Since August 2007, DAA for primary THA was introduced in our institution. All 273 consecutive primary THAs with DAA (42 bilateral and 189 unilateral cases) between August 2007 and February 2014 were included in this study. All patients’ charts and radiographs were reviewed to identify cases with palsy and to retrieve related factors. In this study, FNP was defined as weakness of the quadriceps femoris (manual muscle test <3) with or without sensory disturbance over the anteromedial aspect of the thigh. The incidence of FNP following primary THA with DAA was 1.1% (3/273 joints). In all 3 cases, the motor deficit recovered completely within a year. Suspected causes of the palsy in the 3 cases were believed to be improper positioning of the anterior acetabular retractor, excessive leg lengthening, or unknown etiology. There was no significant relationship between palsy and surgeon’s experience of DAA. In THA with DAA for patients requiring major leg lengthening, the likelihood of FNP must be considered. To prevent FNP, the anterior acetabular retractor must be placed properly.
... Previous litigation analyses recognize that a review of radiographs and imaging by a senior clinician through trauma meetings can be a valuable tool in preserving patient safety, as well as providing ongoing education. 7 Common across both elective and trauma work was a high incidence of tissue damage from cast-related pressure sores, intraoperative burns, and the sequelae of poor application of tourniquets. This presents a key area of focus for improvement, and we hope that these unfortunate outcomes can be minimized if not eliminated through education, training, and systems. ...
... It is important to note that although the literature defines claims settled in favour of the claimant as closed claims where either damages or claimant legal costs have been paid, it does not necessarily follow that negligence has been proven. 7,8 Sometimes in these claims, a decision has been made to pay costs and damages either as a more cost-effective approach than fighting the claim or indeed as the NHS has admitted fault. There is no national record for admission of liability on the data provided by NHS Resolution. ...
... Of these, 100 claims were related to LLI. The mean pay-out per case was £84,000, and the highest was £595,000 [2]. Konyves et al. have reported a study in which the mean Oxford Hip Score in limb-lengthened patients was 27% worse than the rest of the population at three months and 18% worse after 12 months. ...
... This appears to be reported more frequently these days than in the past [15]. According to the NHS Litigation Authority report, from 1995 to 2010, litigation related to LLI comprised about 10% of all THA litigations [2]. Balancing the limb length without compromising hip stability remains one of the hardest intraoperative challenges [10,16]. ...
Article
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Limb length inequality (LLI) is a frequent and recurring issue after total hip arthroplasty (THA). It is often a source of patient dissatisfaction and litigation. This study reviewed the incidence of LLI in a UK District General Hospital in light of published evidence and identified the preoperative and intraoperative risk factors for LLI. Methods This was a retrospective study involving 380 consecutive unilateral primary total hip replacements over a period of 12 months. Patient demographics, clinical, radiological, and operative details were collected from the National Joint Registry (NJR) database and hospital records. The limb length was measured radiologically [OrthoView WorkstationTM (Materialise UK, Southampton, UK)], pre- and postoperatively, by two authors. They assessed the vertical distance between the intra-acetabular teardrop line and the medial apex of the lesser trochanters. After excluding complex primary, revision cases, tilted X-rays, and hip replacement for trauma patients, 338 cases were included in the final analysis. Results The mean postoperative LLI was 2.7 mm with a standard deviation (SD) of 6.56 mm. Only 5.3% of patients had LLI >15 mm. None of the studied variables showed a statistically significant correlation with LLI. Even with the apparent difference in the mean LLI between templating and not templating before surgery (2.19 vs. 3.53), the p-value was 0.06, which was below the level of statistical significance. There was a weakly positive Pearson correlation between body mass index (BMI) and the incidence of lengthening of the limb. Conclusion The cause of LLI after THA is multifactorial. No single factor can be singled out as the most significant contributor to this complication.
... Moreover, LLD is one of the leading causes of post-THA litigation [4,5]. ...
... Postoperative differences in leg length have been reported to affect gait and postoperative pain, adjacent knees and hips, and patient satisfaction, and have been reported to be one of the main causes of a post-THA lawsuits [4,5]. Conversely, there are reports that the objective LLD does not affect clinical performance and patient satisfaction [9][10][11] and that an objective LLD of 1-20 mm does not correlate with the motor function [23]. ...
Article
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PurposeLeg length discrepancy (LLD) after total hip arthroplasty (THA) prevents functional recovery and reduces patient satisfaction. We investigated impact of changes in patient-perceived LLD on patient satisfaction and walking ability.Methodsone hundred and forty-nine patients with unilateral hip osteoarthritis undergoing THA from 2014 to 2017, (125 women, 24 men; average age, 68.5 years) with an objective LLD < 1 cm were included. Outcome measures included the patient-perceived LLD, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, 10-m walking speed, and affected leg loading rate, assessed preoperatively and at 3 weeks, 3 months, and 1 year postoperatively.ResultsThe absolute patient-perceived LLD (mean ± SD) (the number of patients with perceived LLD > 5 mm) were 6.4 ± 9.6 mm [88 patients (59%)] preoperatively; and 2.2 ± 4.0 mm [48 (32%); p < 0.001], 0.7 ± 2.3 mm [17 (11%); p < 0.001], and 0.4 ± 1.6 mm [10 (7%); p = 0.095] at 3 weeks, 3 months, and 1 year postoperatively, respectively. All outcome measures improved over time. One year postoperatively, a weak positive correlation between the patient-perceived LLD and WOMAC or 10-m walking speed (r = 0.24, 0.23, respectively) was found. The risk of patient-perceived LLD persisting > 1 year postoperatively was 5.5-fold higher in patients who exhibited it at 3 months and those with a WOMAC score > 10 at 3 months postoperatively, using multivariate logistic regression.Conclusion Achieving a post-THA objective LLD < 1 cm significantly reduced the patient-perceived LLD up to 3 months postoperatively. The residual patient-perceived LLD at 1 year postoperatively was predicted from the WOMAC score or the presence of patient-perceived LLD at 3 months after THA.Level of evidenceTherapeutic level IV.
... Despite being a rare cause for lawsuit and malpractice claim (1.9%), the highest indemnity payments have been made after vascular injuries, particularly the ones that lead to amputation [7]. Likewise, in a report on litigation after hip and knee replacements settled in England, data of the National Health Service Litigation Authority (NHSLA) revealed that vascular injuries accounted for 4.2% of claims but generated the highest mean cost [8]. In this study, the cases with vascular-associated claims that resulted in payments of more than the mean figure involved compartment syndrome and amputation [8]. ...
... Likewise, in a report on litigation after hip and knee replacements settled in England, data of the National Health Service Litigation Authority (NHSLA) revealed that vascular injuries accounted for 4.2% of claims but generated the highest mean cost [8]. In this study, the cases with vascular-associated claims that resulted in payments of more than the mean figure involved compartment syndrome and amputation [8]. ...
Article
Purpose Peri-operative major arterial haemorrhage after revision total hip arthroplasty (RTHA) is an odd but limb- and life-threatening complication. In this retrospective analysis, we sought to determine the prevalence of such injuries requiring selective catheter embolization or bypass after RTHA and to evaluate the associated mortality rate. Methods Between 1995 and 2016, 2524 RTHAs were performed at a high-volume centre (1031 one-stage revisions, 1370 two-stage revisions and 123 resection arthroplasties). Throughout this period, nine patients presented with signs of persistent bleeding unaddressed during index surgery (9/2524; 0.35%), causing haemodynamic instability. All patients underwent angiographic exploration within the first 24 post-operative hours. Angiography evidenced four cases of bleeding pseudoaneurysms (three of them related to the common femoral artery and one to the medial circumflex femoral artery) and five cases of direct lacerations (one case in the inferior epigastric artery, one in the hypogastric artery, one in the external iliac artery, one in the popliteal artery and another in the superior gluteal artery). Results Six cases underwent selective percutaneous angiographic embolization with gelatin microspheres, obtaining immediate haemodynamic stabilization; whereas three cases required a further bypass surgery with synthetic graft. Of the former group, four patients had an uneventful evolution, while two died at a mean of 49 days after surgery due to multi-organ failure (MOF). Two cases of the bypass group died because of MOF at a mean of 22 days. Overall mortality rate was 44%. Conclusions The overall risk of arterial injury associated with RTHA was low. However, recognition of such a complication is imperative since it was associated with a high mortality rate.
... In other published experiences, a tendency for malpractice claims to focus on the lower limbs was noted for the elective surgery subgroup [13], which may be a more lower-limb-focused branch than the more ubiquitous post-traumatic surgery. Claims focusing on iatrogenic complications of hip and knee replacement surgeries strongly show this trend, with sciatic nerve injury the crucial adverse event for hip replacement surgeries, and postoperative prosthesis infection the crucial adverse event for knee replacement surgeries [25]. Claims about knee replacement surgery failures often relate to the implantation of an oversized prosthesis, and it is believed that the strict use of complete preoperative checklists could dramatically limit such claims [26]. ...
... According to our results, claims concerning nosocomial infections (14% of all claims) related mainly to elective prosthetic procedures on hips or knees. Litigation after knee replacement surgery has already been associated with an epidemic of perioperative infections [25]. It also seems that infections from post-traumatic surgery are less likely to trigger claims, possibly because such patients reason that the infection is linked to the original trauma rather than to the therapeutic surgery. ...
Article
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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.
... 22 An analysis of nearly 22,500 claims handled by the National Health Service Litigation Authority in England found that 17% of lawsuits involved total hip and knee arthroplasties. 23 Similarly, in the Netherlands, from 2000 to 2012, 0.14% to 0.3% of primary total hip arthroplasty procedures led to litigation, with nerve palsy being the most frequent reason for these lawsuits (19.6%), followed by poor communication, the need for revision surgery, and discrepancies in limb length. 24 In the United States, a review of 213 lawsuits from 1988 to 2015 related to hip and knee arthroplasty found that 15.0% of cases resulted in settlements, whereas 29.6% ended in plaintiff verdicts. ...
Article
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Surgical complications remain an unfortunate inevitability of surgical practice. When adverse events arise, orthopaedic surgeons must be prepared to navigate the complex medical, ethical, and legal dimensions through a multifaceted response. Prompt communication and collaboration with the risk management team, along with proper documentation, are essential. The art of disclosure must be guided by compassionate yet candid discussions that focus on transparency and accountability. The effects of complications transcend the confines of the operating room, affecting not only patients and their families but also orthopaedic surgeons. Without adequate support, the emotional consequences experienced by surgeons involved in the adverse event can lead to devastating cascading effects, which negatively affect job performance and patient care due to maladaptive coping mechanisms. To ameliorate these issues, programs have been developed to improve the psychological and personal well-being of healthcare providers after adverse events, shifting toward a nonpunitive culture that emphasizes improvement rather than blame. In light of the absence of a roadmap for orthopaedic surgeons facing complications, this review is dedicated to presenting a comprehensive guide for navigating such events when they arise, while also highlighting the effect of these challenges on surgeons and potential avenues for their support and improvement.
... Between 1996 and 2000, orthopaedic surgery was the most commonly litigated specialty in Italy 6 . Elective procedures are also prone to litigation, with a UK-based study demonstrating that 17% of litigated cases in the National Health Service (NHS) were related to joint arthroplasty 10 . ...
Article
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Background: Total hip arthroplasty (THA) is commonly performed procedure internationally, and patientsmay expect an excellent prognosis. Risks associated with the procedure may lead to patient dissatisfactionand litigation. International data suggests orthopaedic surgery is particularly prone to high litigation rates,third to only obstetrics and general surgery in this regard. In Australia, there is currently no body whichaccurately collates litigation data following surgery.Methods: We performed a systematic search of several Australian legal databases to find cases of litigationfollowing THA, and supplemented this with data provided by the Health Care Complaints Commission,National Joint Replacement Registry and medical indemnity insurers. We also performed a review of thecurrent literature in the field.Conclusions: 11 cases were found and analysed. 28% of cases were successfully litigated. Approximately1/3 of litigation was for leg length discrepancy. Other causes for litigation included infection, nerve injuryand dislocation. Remuneration following successful litigation varied between 25,000and25, 000 and 265, 000,corrected for inflation. The Australian data is in keeping with that of similar studies from USA and UK. Thedissemination and accessibility of this data is important for surgeons in improving the informed consentprocess for their patients.
... While THA is widely viewed as one of modern medicine's most successful surgical procedures, it is not perfect [5,19,20]. LLD after THA remains a significant problem. Our study results showed that RPA and DAA THA were equally effective in minimizing LLD. ...
Article
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Background: Advocates of robot-assisted technique argue that robots could improve leg length restoration in total hip replacement. However, there were few studies to compare the robot-assisted posterior approach (RPA) with conventional posterior approach (PA) THA and direct anterior approach (DAA) THA in LLD. This study aimed to determine whether robot-assisted techniques could significantly reduce LLD compared to manual DAA and manual PA. Methods: We retrospectively reviewed the cohort of consecutive ONFH patients who underwent THA robot-assisted posterior, manual posterior, and manual DAA from January 2018 to December 2020 in one institution. One experienced surgeon performed all procedures. We calculated the propensity score to match similar patients in different groups by multivariate logistic regression analysis for each patient. We included confounders consisting of age at the time of surgery, sex, body mass index (BMI), and preoperative LLD. Postoperative LLD and Harris hip scores (HHS) at two years after surgery of different cohorts were compared. Result: We analyzed 267 ONFH patients treated with RPA, DAA, or PA (73 RPA patients, 99 DAA patients, and 95 PA patients). After propensity score matching, we generated cohorts of 40 patients in DAA and RPA groups. And we found no significant difference in postoperative LLD between RPA and DAA cohorts (4.10 ± 3.50 mm vs 4.60 ± 4.14 mm, p = 0.577) in this study. The HHS at 2 years postoperatively were 87.04 ± 7.06 vs 85.33 ± 8.34 p = 0.202. After propensity score matching, we generated cohorts of 58 patients in manual PA and RPA groups. And there were significant differences in postoperative LLD between the RPA and PA cohorts. (3.98 ± 3.27 mm vs 5.38 ± 3.68 mm, p = 0.031). The HHS at 2 years postoperatively were 89.38 ± 6.81 vs 85.33 ± 8.81 p = 0.019. After propensity score matching, we generated cohorts of 75 patients in manual DAA and PA groups. And there were significant differences in postoperative LLD between the DAA and PA cohorts. (4.03 ± 3.93 mm vs 5.39 ± 3.83 mm, p = 0.031) The HHS at 2 years postoperatively were 89.71 ± 6.18 vs 86.91 ± 7.20 p = 0.012. Conclusion: This study found no significant difference in postoperative LLD between RPA and DAA, but we found a significant difference between RPA and manual PA, DAA and manual PA in ONFH patients. We found a significant advantage in leg length restoration in primary total hip arthroplasty with robot-assisted surgery.
... McGrory et al. [10] also reported that nerve injury was the most common cause of complaints (64 out of 490 cases) in their study. McWilliams et al. [12] found that nerve injury was the most common subject of a lawsuit with 13.9% in their large series study. Zengerink et al. [13] evaluated a total of 516 cases from the Netherlands and reported that the most common cause of complaint after THA was sciatic nerve lesion (19.6%). ...
Article
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Objectives: In this study, we aimed to identify the most frequently reported claims after total hip arthroplasty (THA) and the reasons put forward by the plaintiffs. Patients and methods: Between January 2011 and December 2020, data of a total of 74 cases (21 males, 53 females; mean age: 53.7±12.8 years; range, 29 to 83 years) obtained from the Turkish Forensic Medicine Institute were retrospectively analyzed. Claims for litigation, demographic data, data regarding the identity of the accused and the hospital setting were recorded. Results: The most common reason for lawsuits was death (n=15; 20.3%), followed by nerve injury (n=13; 17.6%), and eight patients had more than one complaint. According to the forensic medicine reports, malpractice was detected in 10 (12.5%) of the cases. Among the hospital types, only nerve injury made a significant difference among all complaint sources in different hospital settings (p=0.003). Conclusion: In our study, death was the most common reason for lawsuits regarding malpractice accusations after THA, which is different from medical malpractice allegations throughout the world.
... LL inequality after THA is a major cause of patient dissatisfaction due to unsatisfactory outcomes, such as limping, knee and back pain, early prosthesis loosening and revision surgery, and litigation. [1][2][3][4][5][6][7][8] Furthermore, improper OS adjustment also causes issues such as hip joint instability, decreased range of motion, and gait alteration. [7][8][9][10][11] To obtain appropriate LL and OS, preoperative planning is necessary to determine the extent to which LL and OS will change before and after surgery, and it is desirable to be able to confirm these changes intraoperatively. ...
Article
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Objective: During total hip arthroplasty (THA), both pelvic and femur positions affect leg length (LL) and offset (OS) measurements because LL and OS calipers depend on the fixed reference points on the pelvis and femur, respectively. However, LL and OS measurement errors because of pelvic positional changes have not been described. This study aimed to clarify the effects of pelvic positional changes on LL and OS measurements in relation to the pelvic reference using a THA simulator. Methods: We developed an experimental THA simulator using Sawbones models of the hemipelvis and femur that facilitated modification of the obliquity, tilt, and rotation of the pelvis. Using an LL and OS caliper, LL and OS measurement errors due to pelvic positional changes were determined with the femoral position fixed. Measurements were performed from two pelvic reference positions: the iliac tubercle (P1) and the top of the iliac crest intersecting the line of the femoral long axis (P2). Results: Concerning pelvic obliquity, the total error of LL was 25.0 mm in P1 and 26.5 mm in P2, while the total error of OS was 13.0 mm in P1 and 10.9 mm in P2. For pelvic tilt, the total error of LL was 9.0 mm in P1 and 3.8 mm in P2, while the total error of OS was 0.5 mm in P1 and 1.0 mm in P2. Regarding pelvic rotation, the total error of LL was 13.8 mm in P1 and 3.2 mm in P2, while the total error of OS was 3.8 mm in P1 and 4.0 mm in P2. Conclusions: Pelvic positional changes alter LL and OS measurements. The acceptable range (error <2 mm) on LL and OS measurement errors of pelvic obliquity was only 2°, regardless of the pelvic reference position. The pelvic reference position should be at the top of the iliac crest intersecting the line of the long axis of the femur because of a small LL measurement error with pelvic tilt and rotation.
... Within the orthopaedic discipline, the incidence of litigation is rapidly rising 35 . For knee replacement surgery, vascular injuries represent 4.2% of claims, and are the most expensive cause of claims with a mean cost per claim of £232,900 36 , representing a significant annual cost to the NHS. Additionally, failure to warn patients about inherent risks represents a substantial proportion of claims 37 , and may represent the most straightforward method of reducing them. ...
Article
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Introduction: Total knee arthroplasty (TKA) is a common operation and is becoming more common due to population aging and increasing BMI. TKA provides excellent improvement in quality of life but carries risk of arterial complications in the perioperative period. This systematic review aims to provide a greater understanding of the incidence of such complications, and time taken to diagnose arterial injury. Materials and methods: PubMed, Medline, Ovid SP and EMBASE databases were searched with the following MeSH keywords: 'complication', 'vascular injury', 'ischaemia', 'spasm', 'thrombosis', 'pseudoaneurysm', 'transection', 'pulse', 'ABPI OR ABI', 'Doppler', 'amputation'. All arterial vascular events in the perioperative state of the total knee replacement were included. Records were independently screened by two reviewers, and data was extracted according to a pre-determined proforma. Overall incidence and time to diagnosis was calculated for complications. Systematic review registration PROSPERO: CRD42018086643. No funding was received. Results: Twelve studies were selected for inclusion. A total of 3325 cases of arterial complications were recorded across all studies, and were divided into three categories, pseudoaneurysms (0.06%); ischaemia and thrombosis (0.17%); haemorrhage and arterial transections (0.07%). Time taken to reach the diagnosis for each complication was longest in the ischaemia and thrombosis group (6.8 days), followed by pseudoaneurysm (3.5 days) and haemorrhage and transections (3.0 days). Conclusion: TKA post-operative vascular complications are rare, but when they do occur they lead to limb and life threatening complications. This should be discussed with patients during the consent process. Current times to diagnosis represent missed opportunities to recognise arterial injury and facilitate rapid treatment of the complication. A very low threshold for seeking specialist input should be adopted, and any concern for vascular injury, such as unexplained perioperative bleeding, absent lower limb pulses in the post-operative period or unexplained severe pain should warrant immediate review by a vascular surgeon, and in centres where this is not possible, immediate blue-light transfer to the closest vascular centre.
... When symptomatic, LLD can be associated with patient dissatisfaction, the need to wear a permanent shoe lift and, if not compensated by the patient, the need for revision surgery. Additionally, LLD can compromise doctor-patient relationship and it is one of the most common causes of litigation following THR [7][8][9][10][11][12][13]. ...
... 5 It is important to note that although the literature defines claims settled in favour of the claimant as closed claims where either damages or claimant legal costs have been paid, it does not necessarily follow that negligence has been proven and the NHS still pays its defence costs when a claim is successfully defended. 6,7 Sometimes, in claims settled in favour of the claimant, a decision has been made to pay costs and damages either as a more cost-effective approach than fighting the claim due to a lack of defence evidence, or indeed, as the NHS has admitted fault. There is no national record for admission of liability on the data provided by NHS Resolution. ...
Article
Introduction Litigation against the NHS in England is rising. The aim of this study was to determine the incidence and characteristics of hospital dentistry clinical negligence claims in England.Methods A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to hospital dentistry between April 2015 and April 2020. Analysis was performed using the information for cause, patient injury and claim cost.Results A total of 492 claims were identified, with an estimated potential cost of £14 million. The most frequent causes for clinical negligence claims included failure/delay in treatment (n = 175; £3.9 million), inappropriate treatment (n = 56; £1.8 million) and failure to warn/obtain informed consent (n = 37; £1.5 million). Wrong site surgery was cited in 33 claims. The most frequent injury reported was dental damage (n = 197; £4.3 million), unnecessary pain (n = 125; £2.3 million) and nerve damage (n = 52; £2.4 million).Conclusion Clinical negligence claims in hospital dentistry are related to several different aspects of patient management and are not limited to treatment complications alone. Human ergonomics and patient perception of dentistry cannot be controlled but a focus on patient safety measures and effective communication can serve as tools to combat these factors.
... While hip and knee arthroplasty is known to have excellent outcomes in terms of improvement in patients' quality of life, there are known complications, which can result in varying degrees of morbidity. A study from 2013 on litigation following hip and knee arthroplasty in the National Health Service (NHS) in the United Kingdom (UK) shows that claims to a value of £62.5 million were made associated with hip and knee replacement [1]. Harrison et al. [2] have shown that 4% of claims of surgical negligence are related to consent and average about £40,000 per claim. ...
Article
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Introduction The process of informed consent is vital, not only to good clinical practice and patient care, but also to avoid negligence and malpractice claims. Elective hip and knee arthroplasty numbers are increasing globally, and the British Orthopaedic Association (BOA) has endorsed standards for obtaining written consent for these procedures. Many centres in the United Kingdom and globally, use handwritten consent forms to document informed consent, leaving open the potential for missing out important procedure and risk-related information. Our study aimed to assess whether information on handwritten consent forms was compliant with BOA standards for elective arthroplasty of the hip and knee. Methods We retrospectively reviewed 70 handwritten consent forms, across theatre lists of 12 arthroplasty consultants at our elective arthroplasty centre. These included 35 forms each for hip and knee arthroplasty respectively. We compared the information on these forms to the standards prescribed by the BOA. We assessed compliance of the forms with common, less common and rare risks of hip and knee replacement, as described by the BOA. We also noted the designation of the person filling out the form (consultant, registrar or nurse practitioner) and whether this affected information on the form. We assessed the forms for legibility issues, and whether the setting (clinic/pre-operative ward) affected information on the form. Results None of the 70 forms reviewed achieved full compliance with BOA standards. When assessed for common risks of hip and knee arthroplasty, the number of compliant forms was 25.7% and 42.8%, respectively. None of the forms mentioned all rare risks of either hip or knee arthroplasty. We identified legibility issues in 12 of 70 (17.1%) forms. There was no significant difference in information written on forms filled out by consultants, registrars or nurse practitioners, or between forms filled out in the clinic versus those on the pre-operative ward. Conclusion Handwritten forms lack compliance with prescribed standards for written informed consent in elective hip and knee arthroplasty. Ideally, a pre-written consent form should be used, but with the option of adding information individually tailored to the patients’ background. This ensures that good clinical practice is optimally followed, and reduces the potential risk of any litigation.
... Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed surgeries worldwide. The number of joint replacement surgeries being performed has increased considerably over the past two decades, but it has also seen an increase in litigation associated with it [1]. In fact orthopaedic adult reconstruction subspecialists are sued for alleged medical malpractice at a rate over twice that of the physician population as a whole [2]. ...
Article
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed surgeries worldwide. The number of joint replacement surgeries being performed has increased considerably over the past two decades, but it has also seen an increase in litigation associated with it. The purpose of our study was to review and consolidate literature regarding medico-legal issues pertaining to THA and TKA cases. We looked at the causes of litigation, medico legal aspects of pre-operative requirements, optimisation of medical condition, indications and contraindications for arthroplasty, informed consent, implants, mixing of components from different manufacturers and post-operative rehabilitation. We also wanted to analyse available literature and legal proceedings regarding these cases in India specifically.
... In order to achieve an optimal functional result after THA, it is desirable to properly adjust leg length (LL) and restore offset (OS) within the hip. LL inequality after THA can cause limping, pain in the knee or back, abnormal force transmission across the hip, revision surgery, and even litigation [1][2][3][4][5][6][7]. Inadequate OS restoration can also cause hipjoint instability, increased polyethylene wear, and decreased range of motion [8,9]. ...
Article
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Background Leg length (LL) and offset (OS) are important factors in total hip arthroplasty (THA). Because most LL and OS callipers used in THA depend on fixed points on the pelvis and the femur, limb position could affect measurement error. This study was conducted on a THA simulator to clarify the effects of lower limb position and iliac pin position on LL and OS errors and to determine the permissible range of limb position for accurate LL and OS measurement. Methods An LL and OS measurement instrument was used. Two pin positions were tested: the iliac tubercle and the top of the iliac crest intersecting with the extension of the femoral axis. First, the limb was moved in one direction (flexion-extension, abduction-adduction, or internal-external rotation), and LL and OS were measured for each pin position. Next, the limb was moved in combinations of the three directions. Then, the permissible range of combined limb position, which resulted in LL and OS measurement error within ±2 mm, was determined for each pin position. Results Only 4° of abduction/adduction caused 5–7 mm error in LL and 2–4 mm error in OS, irrespective of pin position. The effects of flexion–extension and internal–external rotation on LL error were smaller for the top of the iliac crest than for the iliac tubercle, though OS error was similar for both pin positions. For LL, the permissible range of the combined limb position was wider for the top of the iliac crest than for the iliac tubercle. Conclusion To minimize LL and OS measurement errors in THA, adduction–abduction must be maintained. The iliac pin position in the top of the iliac crest is preferred because it provides less LL measurement error and a wider permissible range of combined limb position for accurate LL measurement.
... 15,16 A consequential rise in failed TKAs is inevitable, and they present a significant financial and health-related burden to patients and healthcare systems. 17,18 However, the distribution and frequencies of failure modes vary according to type of study, registries, nationality and cohort. ...
Article
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Objective The aim of this narrative review was to provide an overview of failure modes after total knee arthroplasty in different parts of the world based on data from worldwide representative studies and National Joint Registries. Methods A review of the available literature was performed using the keyword terms “total knee arthroplasty”, “revision”, “failure”, “reasons”, “causes”, “complications”, “epidemiology”, “etiology”; “assessment”, “painful knee”, “registry” and “national” in several combinations. The following databases were assessed: Pubmed (https://pubmed.ncbi.nlm.nih.gov), Cochrane Reviews (https://www.cochrane.org), Google Scholar (https://scholar.google.com). In addition, registry data were obtained directly from national registry archives. Due to the heterogeneity of available data it was decided to present the review in a narrative manner. Results Current literature report that infection has become the primary acute cause of TKA failure, while aseptic loosening and instability remain the overall most frequent reasons for revisions. Based on national registries certain tendencies can be deducted. The predominant overall failure mode of aseptic loosening is particularly found in Japan, United Kingdom, New Zealand and Switzerland. Leading early TKA failure mode represents infection with percentages of 20–30% in Sweden, Australia, New Zealand, Japan and the United States. Higher numbers could only be found in clinical studies on the Asian continent such as Korea (38%), China (53%), Iran (44%) and India (87%). Conclusion Although there are regional differences in TKA failure modes, TKA fails worldwide especially due to infections and aseptic loosening. It is important to diagnose these in good time and reliably using appropriate, standardized diagnostics in order to recommend the best possible therapy to the patient.
... Of 100 malpractice cases after primary THA, LLD (14/100) was the third most common malpractice claim after sciatic nerve injury (27/100) and joint instability (18/100) [24]. McWil-liams [25] showed that neurological deficit is the most common cause for malpractice claims after hip surgery in England (14 %), where 8.7 % of these claims were made on account of LLD. ...
Method
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Preoperative planning of total hip arthroplasty (THA) is important to achieve accurate reconstruction and an- ticipate intraoperative difficulties and obstacles. The method we describe here is one of many techniques for planning a THA. Our approach allows the surgeon to plan a THA independent of the available software tools, which integrates leg length, femoral offset as well as other biomechanical or anatomical parameters with the aim that the analysis with early recognition of possible intraoperative difficulties can be anticipated.
... In the UK setting, most research into NHS litigation cases has focused on the cause of litigation within particular specialties [7][8][9] or patient groups [10]. Previous studies have identified various potential causes for clinical litigation [9,[11][12][13]. ...
Article
Objective Identify organizational factors associated with high clinical litigation rates among acute National Health Service (NHS) trusts in England. Design Cross-sectional analysis using routine data. Setting NHS trusts in England. Participants A total of 235 NHS trusts used the NHS Clinical Negligence Scheme in 2016–17. Ninety-seven trusts (41.3%) with no maternity services, 2 (0.9%) providing specialized services and 3 (1.2%) without clinical negligence claims were excluded. Hence, the remaining 133 trusts (56.6%) were included. Intervention(s) None. Main Outcome Measures Rate of clinical litigation by trust per 100 000 occupied bed days. Results The mean rate of clinical litigation was 25.4 per 100 000 occupied bed days. In univariable analyses, higher values of summary hospital-level mortality indictor, staff sickness, written complaints, patient safety incidents and being in the North of England led to increased clinical litigation rates. Conversely, higher patient admissions, NHS Staff Survey overall engagement score and occupied bed days led to decreased clinical litigation rates. In the multivariable model, factors associated with increased clinical litigation rates were as follows: summary mortality hospital-level indicator (SHMI) (0.9 increase in litigation rate per 0.05 increase in SHMI; P = 0.012); new written complaints (0.62 increase per 50 complaints higher; P < 0.001); located in the North of England compared to London (5.22 higher; P < 0.001). Conversely, a higher number of occupied bed days (−0.64 change per 50 000 days higher; P = 0.007) was associated with lower clinical litigation rates. Conclusions This study identified organizational factors associated with clinical litigation, which will be of interest to clinicians and the NHS. This research also highlights areas for further investigation.
... [7][8][9] Conversely, patients are more likely to litigate and be dissatisfied with care when surgery does not meet their expectations. 10 One strategy to set realistic expectations is to address common patient misconceptions. For example, since 80% of Mohs micrographic surgery (MMS) patients expect scars to be less than half of their actual final length, 11 surgeons can realign expectations by emphasizing the anticipated length of scar before surgery. ...
Article
Background: The natural evolution of facial scars has not been well described. Identifying factors that correlate with optimal scar healing may help patients and physicians during the perioperative period. Methods: A retrospective study of 108 facial skin cancer patient scars was performed. The Patient and Observer Scar Assessment Scale (POSAS) was used to grade scars at two time points (1 week and 3 months postoperatively). Paired two-tailed t-tests identified differences in scar ratings between the time points. Analysis of variance (ANOVA) explored whether POSAS scores differed by anatomic site or reconstruction type. Receiver operating characteristic analysis was performed to identify if 1-week scar appearance correlated with scar appearance at 3 months. Results: Between 1 week and 3 months the total POSAS score improved by 36.3% and overall opinion of the scar improved by 38.6% (p < 0.001). Facial cosmetic units differed in their 1-week and 3-month scores and all anatomic sites demonstrated significant improvement between time points. Differential scoring occurred among reconstruction types. Scar appearance at 1 week was able to predict overall scar appearance at the 3-month visit (area under the curve = 0.7732). Conclusions: Early scar appearance predicts later scar appearance, and scars will improve by nearly 40% 3 months after surgery. These data can be used to assist with perioperative counseling and expectation management.
... However, those likely to result in payout of a malpractice claim were operator error (82%), nonoperative site injury (70%), and postoperative care (69%). McWilliams et al [16] reviewed litigation after hip arthroplasty in the National Health Service and found that the commonest reason for litigation was neurological deficit. Zengerink et al [17] showed the top 4 reasons to claim in the Netherlands to be nerve damage, lack of sufficient communication and informed consent, reoperation, and leg length discrepancy. ...
Article
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 were to determine: 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 2005-2017 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 2,924 cases (i.e. 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), metal on metal (MoM) prosthesis (USD 4,624,353), insufficient or incorrect treatment (USD 472,500), and fracture (USD 2,088,110). Conclusion 2.5% of all THAs performed between 2005-2017 lead to a claim submission at the DPCA. 1 out 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.
... The most common cause of complaint from knee arthroplasties was related to infection. [4]. ...
Article
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Background Total hip and knee arthroplasties are generally very successful surgical procedures; however, if there is a complication or if the patient is dissatisfied with the outcome, the patient may initiate a legal suit against the surgeon. Methods and Results We evaluated the reasons for instigating a legal suit after hip or knee arthroplasty surgery in the State of California between 1981 and 2018. Using a verified database and the keywords hip, knee, replacement, arthroplasty, we identified 12 legal suits filed and adjudicated on during this time period. Of the 12 cases, the major complaints were pain (seven cases), foot drop (three cases) numbness (two cases), foreign item left in the body of the patient (one case), general physical problems (one case), and wrongful death (one case). In some cases, more than one reason was listed (note: the total is greater than 12 because some cases had more than one reason listed). Conclusion In reviewing these cases and the literature on this subject, we conclude that in order to avoid legal suits, doctors should be communicative, honest, and compassionate with patients, be highly competent in their specialty, and maintain meticulous medical record documentation.
... 37 These complications, have a significant financial impact as they are associated with large monitory payouts by National Health Service Litigation Authorities or health institutions every year. 38 The assessment of suspected LLD following THA is pragmatic. In our practice, radiologically identified LLD which are asymptomatic are managed expectantly. ...
... While maximizing improvements in patient-related outcomes is key to success in orthopedic procedures, post-operative LLDs have other substantial impacts, include economic. Orthopedic surgery trails only obstetrics and general surgery as the most high-malpractice risk surgical speciality, typically due to the risk of these post-surgical complications [18]. For orthopedic surgeons, post-operative leg length inequalities rank among the most common causes of litigation, with a recent statistic indicating that the average insurer payout after complications following primary or revision THA was, per claim, approximately $73,457 per surgeon [19]. ...
Article
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One of the primary challenges of total hip arthroplasty (THA) is equalizing the limb lengths to re-establishing normal hip biomechanics. Post-operative leg length discrepancies (LLD) lead to patient dissatisfaction and are a main source of orthopedic malpractice cases. The aim of this case series was to document three cases of substantial LLD that were corrected during THA with the assistance of an imageless computer navigation system. Medical records were reviewed for history and radiographs were consulted. All patients in this series presented with complaints related to hip fractures and reported a significant lengthening of leg length following THA. No surgical complications of adverse events were reported. In these cases, imageless navigation provided intraoperative measurements of leg length which allowed for enhanced accuracy of component placement and improved outcomes following surgery.
... Other prior studies in the orthopaedic literature looked at malpractice risk in pediatric populations, [3] specific fracture types, [4,5] as well as particular surgical procedures. [6] Some of these studies have identified specific underlying or contributing causes to litigation that include diagnostic errors, issues with care, technical errors, and the development of complications. [5] Unlike other orthopaedic specialties, orthopaedic trauma does not have the luxury of patient selection, preoperative workup, or patient optimization. ...
Article
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Objectives:. To analyze a series of claims from a large national malpractice insurer associated with fracture care to understand what parameters are associated with claims, defense costs, and paid indemnity. Design:. Review of claims in fracture care settings from a national database; case series. Setting:. Database draws from insured pool of 400,000 medical malpractice cases from 400 healthcare entities across the country, representing 165,000 physicians; both academic and private. Patients/Participants:. Fracture care patients bringing legal suit. Main Outcome Measurements:. Cost of legal proceedings and indemnity, ICD-9 codes, and contributing causes toward claims. Results:. A total of 756 fracture claims were asserted between 2005 and 2014 regarding fracture care within the database; 70% were brought for inaccurate, missed, or delayed diagnosis, while 22% addressed medical treatment and 8% were for surgical management. Orthopaedics was the primary service in 22%. Total cost (expenses and indemnity) to orthopaedic providers totaled $13.1MM (million). The most common claim against orthopaedics was for fractures of the tibia and fibula (11.4%). Impact factor (IF) analysis (as described by Matsen) of indemnity in these cases reveals 3 fracture regions of highest indemnity burden: fractures of the tibia and fibula (IF: 1.86, 11.4%), pelvis (IF: 1.77, 6.6%), and spine (IF 1.33, 6.6%). Analysis of contributing factors identifies the category of clinical judgement as the most common category (62%). Other common factors include patient noncompliance (31%), communication (28%), technical skill (17%), clinical systems (11%), and documentation (10%). The single most common specific cause of a claim in orthopaedic fracture care was misinterpretation of diagnostic imaging (25%). Conclusion:. This study is the first of its kind to identify fractures of the tibia and fibula as high risk for litigation against orthopaedic providers and provides general counseling of legal pitfalls in fracture care. Finally, we are able to identify the act of patient assessment as a key issue in over half of all fracture-related claims against orthopaedic providers. Providers in general and specialty settings can use this information to help guide their treatment and care ownership decisions in the care of patients with fractures. Level of Evidence:. Economic - Level III.
Article
Background & Objectives Neurosurgery has one of the highest risks for medical malpractice claims. We reviewed the factors associated with neurosurgical malpractice claims and litigation in the United States of America (USA) and reported the outcomes through a systematic review of the literature. Methods We conducted a systematic review of the literature according to the PRISMA guidelines using the Medline, Embase, Cochrane, PubMed, and Google Scholar databases. We sought to identify pertinent studies containing information about medical malpractice claims and outcomes involving neurosurgeons in the USA. Results We identified 15 retrospective studies spanning from 2002 to 2023 that reviewed over 7,890 malpractice claims involving practicing neurosurgeons in the USA. Disparities were evident in neurosurgical litigation, with 474 cases linked to brain-related surgeries and a larger proportion, 1926 cases, tied to spine surgeries. The most commonly filed claims were intra-procedural errors (37.4%), delayed diagnoses (32.1%), and failure to treat (28.8 %). Less frequently filed claims included misdiagnosis or choice of incorrect procedure (18.4%), occurrence of death (17.3%), test misinterpretation (14.4%), failure to appropriately refer patients for evaluation/treatment (14.3%), unnecessary surgical procedures (13.3 %), and lack of informed consent (8.3%). The defendant was favored in 44.3% of claims, while 31.3% of lawsuits, 17.7% of verdicts favored the plaintiff, and 16.6% reached an out-of-court settlement. Only 3.5% of lawsuits found both parties liable. Conclusion Neurosurgery is a high-risk specialty with one of the highest rates of malpractice claims. Spine claims had a significantly higher rate of filed malpractice claims, while cranial malpractice claims were associated with higher litigation compensation. Predictably, spinal cord injuries play a crucial role in predicting litigation. Importantly, nonsurgical treatments are also a common source of liability in neurosurgical practice
Article
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Introducción: Existen más de 20 técnicas diferentes para corregir la discrepancia de miembros inferiores. El método que aquí se evalúa se basa en una clavija fija posicionada en el ala ilíaca asociada a un “calibre” móvil, con otra clavija con la que se marca la referencia en el trocánter mayor. Objetivo: Evaluar la confiabilidad de este dispositivo de medición usado durante la artroplastia total de cadera para restaurar la longitud del miembro inferior y el offset femoral. Materiales y Métodos: Se formaron dos grupos: grupo A con pacientes en quienes no se había usado el dispositivo y grupo B con pacientes en quienes sí se había usado el dispositivo. Se realizaron las mediciones en la radiografía panorámica de pelvis obtenida con el paciente de pie, antes de la cirugía y 3 meses después. Resultados: Se obtuvo una muestra de 80 pacientes (40 por grupo). Se logró corregir la discrepancia de lalongitud de los miembros, pero no se hallaron diferencias estadísticamente significativas en la corrección promedio, entre ambos grupos (p = 0,07). Sin embargo, al analizar la varianza en la corrección de la discrepancia de la longitud de cada grupo se obtuvo una diferencia estadísticamente significativa (p <0,001). Conclusiones: Este dispositivo que permite una medición cuantificable más objetiva no asegura una corrección de la discrepancia de la longitud exacta a 0 mm, pero sí permite trabajar dentro de unrango más confiable y seguro.
Article
Informed consent is the process by which a medical provider explains the benefits, risks, and alternatives to a proposed medical intervention. It is a crucial part of maintaining patient autonomy and is particularly important in the context of elective surgical procedures, such as joint arthroplasty. The goal of this article is to review the topic of informed consent in the context of total joint arthroplasty. In this review, we discuss informed consent in general, considerations for informed consent in general arthroplasty procedures, and special twelve considerations for both hip and knee arthroplasty.
Article
Background: The objective of this study was to measure bone mineral density (BMD) of the cancellous bone in both femoral condyles and to compare the results according to the hip-knee-ankle (HKA) angle in patients with knee osteoarthritis. Hypothesis: BMD of cancellous bone in the medial condyle is markedly lower in valgus knees compared to that in the lateral condyle in varus knees. Methods: Consecutive patients with computed tomography (CT) of the knee and long-leg radiographs obtained in preparation for total knee arthroplasty were included. The 189 knees were divided into five groups based on whether the hip-knee-ankle angle was <170° (major varus deformity), 171°-177° (varus deformity), 178°-182° (normal alignment), 183°-189° (valgus deformity), and >190° (major valgus deformity). A protocol for CT measurement of BMD values at the femoral condyles was developed. Correlations between the HKA angle and BMD were assessed using the ratio of medial-to-lateral condyle BMD values (M/L). Results: M/L was lower for knees with valgus deformity than for normally aligned knees (0.7 vs. 1, p<0.001). This difference was larger in the group with major valgus deformity, with a mean M/L value of 0.5 (p<0.001). M/L was higher for knees with major varus (mean, 1.2; p=0.035). The correlation coefficients showed excellent intra-observer and inter-observer agreement for the BMD measurements. Conclusion: The BMD values of the femoral condyles correlate with the HKA angle. BMD is lower at the medial femoral condyle of valgus knees, particularly when the deformity exceeds 10°. This finding may deserve consideration when planning total knee arthroplasty. Level of evidence: IV; retrospective study.
Article
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Background Restoration of limb length is important in total hip arthroplasty. Clinical evaluation and preoperative templating establish the intended lengthening. The purpose of this study was to assess whether digital fluoroscopic navigation (DF) improved the accuracy of planned lengthening in direct anterior approach total hip arthroplasty (DAA-THA). Methods Planned lengthening measurements on 100 consecutive unilateral DAA-THA patients, along with patient characteristics, were prospectively collected by 2 surgeons. One surgeon utilized DF to achieve intended length (n = 50), while the other utilized unaided standard fluoroscopy (SF; n = 50). A third surgeon blinded to the procedures assessed actual limb length using an ipsilateral overlay technique on the 6-week postoperative radiograph. The difference between the mean planned and actual limb lengthening stratified by DF and SF was assessed using bivariate and multivariate statistics. Results The mean (standard deviation) planned lengthening in DF and SF groups was 3.96 (2.1) and 3.47 (2.2) mm, respectively. The mean (standard deviation) actual lengthening in DF and SF groups was 3.11 (4.0) and 0.68 (4.6) mm, respectively. After accounting for age, sex, body mass index, laterality, and the Bone Index, multivariate regression results showed that the average difference between planned and actual limb lengthening in the DF group was significantly lower than that in the SF group (β = −1.92; 95% confidence interval: −3.51, −0.33; P < .02). A greater percentage of patients in the DF group (66% vs 40%) were within 3 mm of the intended plan (P < .01). Conclusions Fluoroscopy helps achieve the intended surgical lengthening in DAA-THA. The use of DF resulted in more accurate execution of lengthening.
Article
Background Total hip arthroplasty (THA) carries a substantial litigative burden. THA may introduce leg length discrepancy (LLD), necessitating a valid and reliable technique for LLD measurement. This study investigates the reliability and validity of techniques quantitively measuring LLD both pre- and post-THA. Methods Embase and MEDLINE databases were searched following PRISMA guidelines for articles assessing either the validity or reliability of LLD measurement techniques. Data was pooled using random effects meta-analysis to derive reliability estimates. Study quality was assessed using the Brink and Louw checklist. Results Forty-two articles with 2059 participants were included. Thirty-three investigated reliability and twenty-five validity. Reliability displayed high heterogeneity. Poor to excellent intra-rater reliability was reported for AP pelvis radiographs, moderate to excellent for CT scanograms, good to excellent for clinical methods and teleradiography, and excellent for bi-planar radiography (BPR). Poor to excellent inter-rater reliability was reported for AP pelvis radiographs and clinical methods, moderate to excellent for teleradiography, good to excellent for CT scanogram and excellent for BPR. The tape measure method is a valid clinical measure of LLD whilst markerless motion analysis and the block method are not. Imaging techniques are appropriately cross-validated with the exception of BPR. Conclusion The reported intra- and inter-rater reliability for most measurement techniques vary widely. The tape measure method is a valid clinical measurement of LLD. Imaging techniques have been appropriately cross-validated, with the exception of BPR, although they lack validation against a common reference technique.
Article
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Establishing the identity of an individual is the foremost criteria for law agencies, medicolegal experts and experts in forensic science to correlate evidences and find motive behind the crime. Forensic science has made an astonishing progress in the field of forensic science from blood grouping to D.N.A fingerprinting& Anthropometry to Dactylography. Nevertheless, the most commonly used tool for identification beyond the forensic laboratories still remains the same i.e. built, complexion, stature, colour of eye, mole, scar mark etc. Hence, the aim of this current study is to establish a relationship between the dimension of foot and stature estimation. The present study was conducted among 200 medical students, out of which 100 were male students and 100 were female students. All the students were between the age group of 20-30 years. The data was analyzed using S.P.S.S (I.B.M version 20, Armonk, NY, U.S.A). The regression analysis showed that there is significant correlation between the foot parameters and stature. Keywords: Foot dimension, stature estimation, medical students, establish, correlate, identity.
Article
Background Interpretation of anchor-based clinical differences in the context of pain and functional change remains undefined. The purpose of this study was to characterize ASES scores for patients after anatomic total shoulder arthroplasty with minimum 1 year follow-up in terms of pain and change in each functional element on the ASES. Methods We performed a retrospective study of a prospective institutional patient database of primary anatomic total shoulder arthroplasties from 2017-2020 with baseline and 1-year postoperative ASES scores. Three clinical outcome groups were established using an anchor-based global rating of change assessment: minimal clinically important difference (MCID), moderate clinical benefit (MCB) and, substantial clinical benefit (SCB). Pain and functional outcomes in each group where then characterized and compared. Results A total of 67 patients were analyzed in terms of demographics and clinical outcomes. Two-thirds (65%) of patients achieved the SCB, 24% achieved the MCB, and 10% achieved the MCID. Washing, reaching for a shelf, and throwing were the most common functional deficits experienced preoperatively and accounted for the largest improvement in function postoperatively. Patients in the MCID group had higher preoperative VAS pain scores (7.1 ± 3.0) than MCB (5.8 ± 2.5) or SCB (5.8 ± 2.2) groups (p=0.0612). The MCID group had the least amount of preoperative functional deficits when compared to the MCB and SCB groups (p=0.041). Postoperative VAS pain scores improved by 5.1 in the SCB, 3.6 in the MCB, and 3.7 in the MCID groups. Functional change in each element of the ASES improved by 1.4/4 in the SCB, followed by 0.9/4 in the MCB group, and 0.05/4 in the MCID group (p<0.001). Conclusion The MCID group had higher preoperative pain scores and the least amount of preoperative functional deficits when compared to the MCB and SCB groups. The MCID was realized through pain improvement only while the MCB and SCB consisted of meaningful improvements in pain and function.
Article
Rezumat Obținerea unui consimțământ informat este o obligație morală și legală înaintea oricărei intervenții chirurgicale. Disfuncţia cognitivă permanentă post-operatorie este o complicaţie frecventă la vârstnici care influenţează prognosticul privind mortalitatea şi calitatea vieţii, fiind rar menționată în formularele de consimțămînt informat. MATERIAL ŞI METODĂ: Am efectuat un studiu prospectiv pe 50 de pacienţi cu vârsta peste 65 de ani operați prin artroplastie totală de șold în intervalul 2009-2012. Ei au beneficiat de testare pre-operatorie a statusului cognitiv prin intermediul MMSE cu maximum 48 de ore preoperator, zilnic în primele 4 zile post-operator şi la 3 luni post-operator. Funcţie de rezultatele obţinute, pacienţii au fost împărţiţi în două grupuri: grupul A-MMSE ≥ 25, grupul B-MMSE < 25. REZULTATE: În urma efectuării MMSE am identificat 33 de pacienţi cu un scor MMSE mai mare sau egal cu 25-grupul A şi 17 pacienţi cu un scor MMSE mai mic de 25-grupul B. Pacienţii incluşi în grupul A au avut o medie MMSE pre-operatorie de 27,8, fara nici o modificare la externare si la 3 luni post-operator; în grupul B media obţinută la testarea MMSE pre-operatorie a fost de 22,8 puncte, 20,82 (p = 0,0028) la externare și mai mică la 3 luni (p = 0,013). Factorul care a influențat statusul cognitiv la 3 luni a fost valorile MMSE-ului pre-operator (p < 0,0001) și factorul predictiv a fost valoarea testării statusului cognitiv efectuată la externare (p < 0,0001). CONCLUZII: În cadrul populaţiei geriatrice, cel mai important factor de risc pentru declinul cognitiv post-operator este reprezentat de statusul pre-operator; pe baza datelor obţinute recomandăm efectuarea unei evaluări cognitivă pre-operatorie și informarea pacientului asupra acestei complicații posibile după artroplastia de șold. Cuvinte cheie: disfuncţia cognitivă post-operatorie, artroplastie de sold, scor mmse
Article
Purpose: The objective of this study was to determine the reasons for complaints and describe the judicial means upstream of France's courts following arthroscopy. Methods: This is a retrospective observational study including all compensation records related to arthroscopic surgery, collected from the two leading French insurance organizations: MACSF and Branchet companies, from 2014 to 2018. Three medical experts performed the protocol and analysis. Results: Finally, 247 procedures were included. The most common motives were: the appearance or persistence of pain (43.7%), postoperative infection (29.1%), technical errors (10.5%), nerve damage (5.7%), arterial lesions (2.8%), side errors (2.4%). Knee arthroscopies were more at risk of legal action for infection (p = 0.0006), and for disappointing results or persistent pain (p = 0.001). The first recourse was the conciliation and compensation commission (CCI) in 136 cases (55.1%), the civil court (TGI) in 88 cases (35.6%) and amicable settlement in 23 cases (9.3%). The mean time between surgery and the complaint was 32.8 ± 25.7 months, and was shorter in the case of an amicable procedure (p < 0.001). The lawsuit's mean duration was 15.6 ± 11.2 months, but longer in case of civil proceedings (p < 0.0001). The experts found no negligence in 81.8% of cases (n = 202). Infections were the leading cause of recourse to the conciliation and compensation commission (p < 0.0001), while technical errors were the main reason for complaints settled in an amicable procedure (p = 0.035). It was found more proven negligence in case of amicable procedures (p < 0.0001). The mean amount of compensation was 60,968.45€. No significant difference could be found regarding the median values of compensation between the reason of complaint. The amount of compensation was higher in civil court proceedings than in any others (p = 0.02). Conclusion: The main reasons for arthroscopy litigation in France are reported in this study, specifying how they are managed upstream of possible legal proceedings. The knee is the main joint involved. Patient information, close follow-up associated with early and appropriate management of complications are the main ways to reduce complaints. Level of evidence: IV.
Preprint
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Background Leg length (LL) and offset (OS) are important factors in total hip arthroplasty (THA). Because most LL and OS callipers used in THA depend on fixed points on the pelvis and the femur, limb position could affect measurement error. This study was conducted on a THA simulator to clarify the effects of lower limb position and iliac pin position on LL and OS errors and to determine the permissible range of limb position for accurate LL and OS measurement. Methods An LL and OS measurement instrument was used. Two pin positions were tested: the iliac tubercle and the top of the iliac crest intersecting with the extension of the femoral axis. First, the limb was moved in one direction (flexion-extension, abduction-adduction, or internal-external rotation), and LL and OS were measured for each pin position. Next, the limb was moved in combinations of the three directions. Then, the permissible range of combined limb position, which resulted in LL and OS measurement error within ±2 mm, was determined for each pin position. ResultsOnly 4 degrees of abduction/adduction caused 5-7 mm error in LL and 2-4 mm error in OS, irrespective of pin position. The effects of flexion–extension and internal–external rotation on LL error were smaller for the top of the iliac crest than for the iliac tubercle, though OS error was similar for both pin positions. For LL, the permissible range of the combined limb position was wider for the top of the iliac crest than for the iliac tubercle. Conclusion To minimize LL and OS measurement errors in THA, adduction–abduction must be maintained. The iliac pin position in the top of the iliac crest is preferred because it provides less LL measurement error and a wider permissible range of combined limb position for accurate LL measurement.
Article
* While no single approach for total hip arthroplasty (THA) has been proven to be superior to others in terms of patient outcomes, the direct anterior approach (DAA) is becoming increasingly popular. * All of the described techniques for THA carry a small risk of nerve injury. * Identifying risk factors for nerve injury and mitigating these risks where feasible are imperative in order to reduce the incidence of this complication with any approach for THA.
Article
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.
Article
BACKGROUND: The purpose of this study is to (1) characterize the most common reasons of medical malpractice litigation against adult reconstruction surgeons and (2) report on the outcomes of these lawsuits. METHODS: The Westlaw legal research database was queried for cases between 2008 and 2018 related to total hip and knee arthroplasty (THA and TKA) in the United States. Causes of the lawsuit, patient characteristics, demographics, state/outcome of verdict or settlement, and indemnity payments were noted. RESULTS: A total of 148 records (81 females [55%], 67 males [45%]; 83 TKAs [56%], 65 THAs [44%]) were included in the final analysis. For all patients, infection was the leading cause for malpractice litigation (22%) followed by nerve injury (20%). For TKA, infection was the most common cause of lawsuit (33%). In THA cases, nerve injury was the most common reason for lawsuit (38%), followed by leg-length discrepancy (26%). Procedural errors were alleged in 72% of cases, while diagnostic and post-surgical errors were cited in 55% and 32% of cases. A defense verdict occurred in 74% of cases, plaintiff verdict in 21%, and parties settled in 5%. CONCLUSION: Infection and nerve injury were the most common reasons for litigation in TKA and THA, respectively. The most likely outcome of these lawsuits was a jury verdict in favor of the surgeon. Regardless, surgeons should be cognizant of the potential for lawsuit due to these complications and should ensure they inform patients of these potential complications of TJA preoperatively.
Article
Aims: The purpose of this study was to examine whether leg-length discrepancy (LLD) following unilateral total hip arthroplasty (THA) affects the incidence of contralateral head collapse and subsequent THA in patients with bilateral osteonecrosis, and to determine factors associated with subsequent collapse. Patients and methods: We identified 121 patients with bilateral non-traumatic osteonecrosis who underwent THA between 2003 and 2011 to treat a symptomatic hip, and who also exhibited medium-to-large lesions (necrotic area ≥ 30%) in an otherwise asymptomatic non-operated hip. Of the 121 patients, 71 were male (59%) and 50 were female (41%), with a mean age of 51 years (19 to 71) at the time of initial THA. All patients were followed for at least five years and were assessed according to the presence of a LLD (non-LLD vs LLD group), as well as the LLD type (longer non-operated side vs shorter non-operated side group). Results: Overall, 68 hips (56%) became painful and progressed to collapse at a mean of 2.6 years (0.2 to 13.8), resulting in 59 THAs (49%). The five-year collapse-free survival rate for the non-LLD group was 59% (95% confidence interval (CI) 46.8 to 71.8) compared with 45% (95% CI 32.9 to 57.5) for the LLD group (p = 0.036), and 66% (95% CI 55.2 to 77.2) for the longer non-operated side group compared with 32% (95% CI 19.1 to 44.9) for the shorter non-operated side group (p < 0.001). Multivariate regression analyses found that large lesions had a higher risk of collapse than medium-size lesions (odds ratio (OR) 4.19, 95% confidence interval (CI) 1.69 to 10.38; p = 0.002). Meanwhile, patients with a LLD < 3 mm (OR 0.20, 95% CI 0.08 to 0.52; p = 0.001) or a longer non-operated leg (OR 0.11, 95% CI 0.04 to 0.28; p < 0.001) after THA were less likely to experience a subsequent collapse. Conclusion: We found that LLD may be a modifiable risk factor for femoral head collapse. Minimizing LLD and particularly avoiding a shorter non-operated limb after THA may lead to a lower risk of collapse of the asymptomatic hip in patients with bilateral non-traumatic osteonecrosis. Cite this article: Bone Joint J 2019;101-B:303-310.
Article
Purpose Over the years, the number of total hip replacements has been steadily increasing. Despite the improvement in surgical results, the number of claims for malpractice is higher. The primary endpoint of this work is to provide an analysis of litigation after hip replacement, to outline what are the instigating causes and costs. The secondary endpoint is to propose a possible preventive strategy for an improved care and a reduction in legal proceedings. Materials and methods The data of this study were collected from medical and legal files and from professional liability insurance of our institution from January 2005 to December 2016. Results Out of a total of 4770 THA, 40 claims were received. Peripheral nerve injuries represent the first cause of litigation (37%), followed by infectious complications, leg length discrepancy, metallosis, dislocations of the implant and a case of deep vein thrombosis. From the analysis of the past trial judgment, complications such as nerve lesions and infections are almost always recognized, as a medical error, with a high percentage of claims settled. Conclusion This study shows the necessity of preventive strategies to reduce the higher number of claims for malpractice in total hip arthroplasty. Some complications such as nerve injuries and infection are frequently considered directly dependent on physician’s errors. Litigations can be reduced providing evidence of a diligent execution of the surgical procedure and of a proper postoperative management: the correct compilation of a specific informed consent and adequate doctor–patient communication.
Article
Background: Implant selection in the operating room is a manual process. This manual process combined with complex compatibility rules and inconsistent implant labeling may lead to implant-selection errors. These might be reduced using an automated process; however, little is known about the efficacy of available automated error-reduction systems in the operating room. Questions/purposes: (1) How often do implant-selection errors occur at a high-volume institution? (2) What types of implant-selection errors are most common? Methods: We retrospectively evaluated our implant log database of 22,847 primary THAs and TKAs to identify selection errors. There were 10,689 THAs and 12,167 TKAs included during the study period from 2012 to 2017; there were no exclusions and we had no missing data in this study. The system provided an output of errors identified, and these errors were then manually confirmed by reviewing implant logs for each case found in the medical records. Only those errors that were identified by the system were manually confirmed. During this time period all errors for all procedures were captured and presented as a proportion. Errors identified by the software were manually confirmed. We then categorized each mismatch to further delineate the nature of these events. Results: One hundred sixty-nine errors were identified by the software system just before implantation, representing 0.74 of the 22,847 procedures performed. In 15 procedures, the wrong side was selected. Twenty-five procedures had a femoral head selected that did not match the acetabular liner. In one procedure, the femoral head taper differed from the femoral stem taper. There were 46 procedures in which there was a size mismatch between the acetabular shell and the liner. The most common error in TKA that occurred in 46 procedures was a mismatch between the tibia polyethylene insert and the tibial tray. There were 13 procedures in which the tibial insert was not matched to the femoral component according to the manufacturer's guidelines. Selection errors were identified before implantation in all procedures. Conclusions: Despite an automated verification process, 0.74% of the arthroplasties performed had an implant-selection error that was identified by the software verification. The prevalence of incorrect/mismatched hip and knee prostheses is unknown but almost certainly underreported. Future studies should investigate the prevalence of these errors in a multicenter evaluation with varying volumes across the involved sites. Based on our results, institutions and management should consider an automated verification process rather than a manual process to help decrease implant-selection errors in the operating room. Level of evidence: Level IV, therapeutic study.
Article
The role of patient-specific (PS) technology in total hip arthroplasty remains relatively unexplored. We asked whether PS guides: (1) Reduced average surgical errors? (2) Reduced outlier error frequencies? (3) Could predict the size of implants used? A single surgeon implanted femurs using either standard or PS guides and was blinded to the pre-operative plans. There were significant differences in median leg length errors between standard (3.3 mm) and PS groups (1.4 mm), U = 110, z = –2.3, p = 0.02. In contrast to the PS group, the standard group had significantly more outlier errors and frequently undersized implants. PS guides improve hip arthroplasty surgical accuracy.Abbreviations: PS: patient specific; THA: total hip arthroplasty; LLD: leg length discrepancies; HRA: hip resurfacing arthroplasty
Article
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Payments by the NHS Litigation Authority continue to rise each year, and reflect an increase in successful claims for negligence against NHS Trusts. Information about the reasons for which Trusts are sued in the field of trauma and orthopaedic surgery is scarce. We analysed 130 consecutive cases of alleged clinical negligence in which the senior author had been requested to act as an expert witness between 2004 and 2006, and received information on the outcome of 97 concluded cases from the relevant solicitors. None of the 97 cases proceeded to a court hearing. Overall, 55% of cases were abandoned by the claimants’ solicitors, and the remaining 45% were settled out of court. The cases were settled for sums ranging from £4500 to £2.7 million, the median settlement being £45 000. The cases that were settled out of court were usually the result of delay in treatment or diagnosis, or because of substandard surgical technique.
Article
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Decisions to allocate resources in health care are increasingly influenced by relative cost effectiveness. To warn decision makers of some of the pitfalls currently found in cost effectiveness league tables and to suggest how meaningful comparisons may be made between health care technologies a published league table was scrutinised by examining its sources. This showed some of the methodological problems surrounding such tables and how such difficulties could be reduced in future. The source studies in the table featured different years of origin, discount rates, health state evaluations, settings, and types of comparison programmes; all of these differences may raise problems for meaningful comparison. Decision makers need to assess the relative value for money of competing health care interventions. In the absence of systematic comparisons such assessments are likely to take place informally. This will probably have a worse risk-benefit trade off than the formalized use of league tables.
Article
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Total hip and total knee arthroplasties are well accepted as reliable and suitable surgical procedures to return patients to function. Health-related quality-of-life instruments have been used to document outcomes in order to optimize the allocation of resources. The objective of this study was to review the literature regarding the outcomes of total hip and knee arthroplasties as evaluated by health-related quality-of-life instruments. The Medline and EMBASE medical literature databases were searched, from January 1980 to June 2003, to identify relevant studies. Studies were eligible for review if they met the following criteria: (1). the language was English or French, (2). at least one well-validated and self-reported health-related quality of life instrument was used, and (3). a prospective cohort study design was used. Of the seventy-four studies selected for the review, thirty-two investigated both total hip and total knee arthroplasties, twenty-six focused on total hip arthroplasty, and sixteen focused on total knee arthroplasty exclusively. The most common diagnosis was osteoarthritis. The duration of follow-up ranged from seven days to seven years, with the majority of studies describing results at six to twelve months. The Short Form-36 and the Western Ontario and McMaster University Osteoarthritis Index, the most frequently used instruments, were employed in forty and twenty-eight studies, respectively. Seventeen studies used a utility index. Overall, total hip and total knee arthroplasties were found to be quite effective in terms of improvement in health-related quality-of-life dimensions, with the occasional exception of the social dimension. Age was not found to be an obstacle to effective surgery, and men seemed to benefit more from the intervention than did women. When improvement was found to be modest, the role of comorbidities was highlighted. Total hip arthroplasty appears to return patients to function to a greater extent than do knee procedures, and primary surgery offers greater improvement than does revision. Patients who had poorer preoperative health-related quality of life were more likely to experience greater improvement. Health-related quality-of-life data are valuable, can provide relevant health-status information to health professionals, and should be used as a rationale for the implementation of the most adequate standard of care. Additional knowledge and scientific dissemination of surgery outcomes should help to ensure better management of patients undergoing total hip or total knee arthroplasty and to optimize the use of these procedures.
Article
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Concurrent head-to-head comparisons of healthcare interventions regarding cost-utility are rare. The concept of favorable cost-effectiveness of total hip or knee arthroplasty is thus inadequately verified. In a trial involving several thousand patients from 10 medical specialties, 223 patients who were enrolled for hip or knee replacement surgery were asked to fill in the 15D health-related quality of life (HRQoL) survey before and after operation. Mean (SD) HRQoL score (on a 0-1 scale) increased in primary hip replacement patients (n = 96) from 0.81 (0.084) preoperatively to 0.86 (0.12) at 12 months (p < 0.001). In revision hip replacement (n = 24) the corresponding scores were 0.81 (0.086) and 0.82 (0.097) respectively (p = 0.4), and in knee replacement (n = 103) the scores were 0.81 (0.093) and 0.84 (0.11) respectively (p < 0.001). Of 15 health dimensions, there were statistically significant improvements in moving, usual activities, discomfort and symptoms, distress, and vitality in both primary replacement groups. Mean cost per quality-adjusted life year (QALY) gained during a 1-year period was euro 6,710 for primary hip replacement, euro 52,274 for revision hip replacement, and euro 13,995 for primary knee replacement. Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is twice that gained from hip replacement.
Article
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A survey of the American Association of Hip and Knee Surgeons was performed to investigate the perceptions and experiences of medical malpractice litigation and related concerns among its active members. Responses showed that 78% of responding surgeons had been named as a defendant in at least 1 lawsuit alleging medical malpractice. Sixty-nine percent of lawsuits in the survey had been dismissed or settled out of court, and median settlement amounts were in the range of 51,000to51,000 to 99,000. Nerve injury was the most commonly cited source of litigation, followed by limb length discrepancy, infection, vascular injury, hip dislocation, compartment syndrome, deep vein thrombosis, chronic pain, and periprosthetic fracture. Survey data suggest that there are targets for surgeon education and awareness that could improve the quality of patient communication and the informed consent process.
Article
Reviewing litigation brought against health institutions is a clinical governance issue and can help to prevent further cases. While large-scale databases are rare, the British National Health Service Litigation Authority deals with claims brought against all public health trusts in England. We reviewed all 2312 successful cases pertaining to adult orthopaedic claims between 2000 and 2006 in an effort to establish trends of litigation and highlight specific areas of concern such that orthopaedic health care could be potentially improved. A total of 1473 entries had sufficient detail to be considered in our study. There were 4,847,841 elective and trauma-related orthopaedic procedures performed between 2000 and 2006 in the United Kingdom. Compared with the number of cases performed, the frequency of successful litigation is relatively low but financially costly to the National Health Service. From 2000 to 2006, a total of more than US$321,695,072 was paid in adult orthopaedic surgery-related settlements. The most common reason for successful litigation was due to the presence and sequelae of infection (123 cases). In the remaining cases, successful litigation appeared to be related to two common themes: the consent process and the mismanagement of orthopaedic conditions, particularly fractures, cauda equina syndrome, and compartment syndrome. These findings highlight the fact that education and vigilance remain important components of orthopaedic training as many of the cases of successful litigation had a preventable cause.
Ortho Consent British Orthopaedic Association: Hip. http:// www.orthoconsent.com/body2.asp?BodyPartID=4 (date last accessed 8
  • No Authors Listed
No authors listed. Ortho Consent. British Orthopaedic Association: Hip. http:// www.orthoconsent.com/body2.asp?BodyPartID=4 (date last accessed 8 October 2012).
The NHS Litigation Authority Factsheet 1: Background Information
  • No Authors Listed
  • Nhsla
No authors listed. NHSLA. The NHS Litigation Authority Factsheet 1: Background Information, 2011. http://www.nhsla.com/NR/rdonlyres/C9A80E89-2BFA-44F5- A01C-90B86D765B2D/0/NHSLAFactsheet1August2011.pdf (date last accessed 8 October 2012).
The NHS Litigation Authority Factsheet 2: Financial Information, 2011. www.nhsla
  • No Authors Listed
  • Nhsla
No authors listed. NHSLA. The NHS Litigation Authority Factsheet 2: Financial Information, 2011. www.nhsla.com/NR/rdonlyres/465D7ABD-239F-4273-A01E- C0CED557453D/0/NHSLAFactsheet2financialinformation200708.doc (date last accessed 8 October 2012).
The cost of defensive medicine
  • Cm Hettrich
  • Rc Mather
  • Mk Sethi
Hettrich CM, Mather RC, Sethi MK, et al. The cost of defensive medicine. AAOS Now 2010;4.
Orthopaedic Claims in Private Practice
  • K Roberts
  • Mdu Services
  • Ltd
Roberts K. MDU Services Ltd. Orthopaedic Claims in Private Practice, 2007. http:// www.the-mdu.com/section_hospital_doctors_and_specialists/ topnav_advice_centre_1/hidden_Article_title_index.asp?doctype=advice&user- Type=hospital (date last accessed 8 October 2012).
Orthopaedic Claims in Private Practice
  • Mdu Services Ltd