Learning from Orthopaedic Cases – Minimise the Risks

Orthopaedic surgeons diagnose and treat a wide range of conditions of the musculoskeletal system, including acute injuries, acquired and congenital disorders and chronic arthritis. According to the Royal College of Surgeons of England, the main procedures undertaken by orthopaedic surgeons are joint arthroscopy, fracture repair, arthroplasty, of which hip and knee replacements are the most common, corrective surgery and general repair procedures on damaged muscles or tendons.

As with all specialties, on occasion, a patient may suffer an adverse outcome following orthopaedic surgery. Such outcomes may result in significant loss of function or permanent damage. As a result, the injured patient may initiate a claim of negligence. The action may not be pursued for a number of years after the original treatment and can result in a substantial financial settlement, including an award of damages arising from a breach of duty, as well as a compensatory award for ongoing care and loss of earnings.

PMP understands that policyholders work in complex and often pressurised environments. We recognise that a medical negligence case almost invariably causes considerable stress to clinicians, regardless of whether a complaint or legal action is ultimately successful. We hope that sharing our experiences of orthopaedic cases and providing some risk management strategies will assist clinicians in reducing their risk.

PMP claims experience

PMP recently reviewed 695 cases notified to us between 2014 – 2020 by consultants working in independent orthopaedic practice.

27% (n190) of these cases related to orthopaedic surgery, including joint replacements and arthroscopies. Orthopaedics, as a specialty, has the highest number of cases amongst PMP clients, followed by plastic surgery (16%) and gynaecology (15%).

Procedures

The greatest number of orthopaedic claims related to knee surgery. The most common procedures were knee arthroscopy and total knee replacements, including malposition of components.

The second most frequent procedures leading to claims related to hip surgery, ie, elective hip replacements and revision surgery.

Chart 1: Most frequent orthopaedic procedures leading to claims

Over half of the adverse events occurred in inpatient settings, and 57% related to surgical treatment; please refer to chart 2:

Chart 2: Orthopaedic surgery: adverse events

The intersection of events

Adverse orthopaedic patient outcomes rarely arise from a single cause; clinical decision-making, procedural complications and ineffective communication between members of the surgical team may all contribute to an adverse outcome.

Of the 190 orthopaedic cases, all had at least one contributory risk factor^**.

^**Contributing risk factors are failures in the process of care that appear to have contributed to the patient outcome and/or to the initiation of the case or had a significant impact on case resolution.

71% identified the clinician’s clinical decision-making as a contributing risk factor, which impacted patient outcomes, illustrated in chart 3.

Chart 3: Orthopaedic surgery: top contributing factors** across all allegations

Suboptimal technical skills such as poor surgical technique may be a contributory factor to a claim. In addition, non-technical skills such as lack of situational awareness, the absence of shared decision-making, poor leadership and team communication are all contributory factors to adverse surgical outcomes. Inadequate informed consent that fails to advise the patient of the possible complications that may arise may also contribute to a patient’s dissatisfaction with the care provided, which ultimately may give rise to a claim or a complaint.

In addition to the above, other factors that contributed to these cases were: administrative errors, poor communication between providers, equipment issues and patient behaviours.

Case studies

Retained surgical body

A patient in her late fifties underwent a total hip replacement.

During the surgery, the placement of a sponge under the acetabular cup was not documented in the operative note. The surgical assistant’s normal method was to place a clip on his own gown as a reminder of the placement of the sponge. The assistant left the operating theatre unexpectedly during the surgery. The consultant surgeon was notified of a missing sponge prior to wound closure; he explored the surgical field, but no sponge was found. He assumed the sponge had been discarded in the clinical waste bin when the assistant had left the operating theatre.

During a follow-up outpatient appointment, five months later, the patient complained of thigh and hip pain. The initial assumption was crepitus. An x-ray revealed that the hip prosthesis was in a good position and the consultant reassured the patient that all was well.

However, the patient’s symptoms continued; a repeat x-ray three months later showed a radio-opaque body in the acetabulum. The patient was readmitted for surgery. During the procedure, the sponge was removed. An abscess had formed and was duly treated with antibiotics.

The patient alleged she had not been fully informed of the findings and no apology had been offered. She subsequently initiated medicolegal proceedings against the consultant.

Contributing factors identified:

• Clinical environment – lack of safe systems, eg, a checklist, within the operating theatre. Using a checklist would have assisted in ensuring all swabs were counted and present pre-closure.
• Clinical judgement – lack of shared decision-making; poor team communication; failure to consider a differential diagnosis.
• Communication – patient not informed of adverse event, ie, the clinician did not comply with the professional duty of candour. In addition, as the adverse event caused moderate harm to the patient, ie, requiring further surgery and a course of antibiotics, it would classify as a notifiable safety incident and thus, the organisation did not comply with the statutory duty of candour.
• Technical skill – retained foreign body, potential performance issue.

Alleged improper performance of hip surgery

A 69-year-old male patient underwent revision surgery of a previous hip replacement. Following the surgery, the patient experienced subluxations over the next three months coupled with severe pain. He reported this to the consultant at his outpatient follow-up appointments and was prescribed pain medication and physiotherapy.

The patient remained unhappy with the surgical outcome and ultimately sought a second opinion. At this appointment, a scan revealed an unstable left hip.

The acetabular component was mal-positioned and a screw was discovered to be exiting medially past the pelvic brim. The patient underwent a second revision surgery but was left with chronic pain and required a cane for ambulation.

The patient commenced legal proceedings against the first consultant.

Contributing factors identified:

• Technical skill – poor surgical technique.
• Clinical judgement – delay in responding to the patient’s continued post-operative complaints.
• Informed consent – inadequate discussion of potential surgical complications.

Poor management of patient

During a game of football, a nineteen-year-old male patient sustained a fracture to his tibia/fibula.

The patient was referred to a private consultant who undertook a surgical repair of the fracture – open reduction internal fixation (ORIF).

Post-operatively, on day one, a Saturday, the nursing staff noticed that the patient’s toes were dusky and his pedal pulse was difficult to palpate. The patient complained of numbness. The nursing staff contacted the consultant, who asked them to continue to observe.

The consultant visited the patient on the following Monday morning, day three post-operatively and diagnosed compartment syndrome. Emergency surgery was arranged and carried out.

The patient suffered osteomyelitis, had further surgical interventions and the possibility of a future below knee amputation.

The patient initiated proceedings against the consultant, alleging delay in surgery and non-response to his changing clinical condition.

Contributing factors identified:

• Clinical judgement:
  • Lack of/inadequate patient assessment – failure to rule out an abnormal finding.
  • Lack of patient monitoring – physiological status.
• Communication – poor communication among clinical staff.
• Documentation – insufficient/lack of documentation of clinical findings.
• Technical performance.

Recommendations to minimise risks in orthopaedic surgery

Below is a summary of key learning points from the analysis of PMP cases. Please note, it is not an exhaustive list of recommendations.

1. Consultants should ensure their skills and knowledge of surgical techniques are regularly updated and that they follow best practice guidance.
2. In accordance with the GMC’s “Decision making and consent”, clinicians should ensure they have a meaningful discussion with the patient prior to the procedure to enable the patient to make an informed choice. This will include details of the surgical procedure, risks (known complications including the possibility of chronic pain), benefits and alternatives, including conservative treatment. In addition, consider what is most important to the individual patient, taking into account their lifestyle and employment.
   • Provide information leaflets and consider directing the patient to useful websites.
   • Try to make sure that the information shared with patients about the options is objective. Do not pressurise a patient to accept your advice about the intervention.
   • Document in detail the content of your discussion in the patient’s medical records.
3. Communicate effectively with the patient, demonstrating empathy when required.
4. If the patient is self-funding an intervention, ensure they are provided with clear information about all the costs involved, including those associated with post-operative follow-up. In addition, ensure they are made aware of their right to a refund or return of deposit if they change their mind about the proposed treatment plan.
5. On the day of admission, recheck the patient’s understanding of the intervention and allow time for any further questions. Document this discussion in the patient’s record. At this point, a consent form should be provided detailing the procedure and the risks and benefits associated with it. Keep a copy in the patient’s medical records and provide the patient with a copy.
6. Ensure any post-operative deterioration and/or complications are communicated, investigated and managed in a timely and appropriate manner. These details should be recorded in the patient’s medical records.
7. Although much of healthcare is performed to a high standard, when things go wrong and the patient experiences an adverse outcome, it is important to investigate, explain and apologise to the patient. Please refer to the GMC’s “Openness and honesty when things go wrong: The professional duty of candour.” If you receive a complaint from a patient or a patient suffers an adverse event, please call the PMP medicolegal helpline as soon as possible, in line with the terms and conditions of your policy. The helpline is provided by our legal partners, Clyde & Co, and is available to PMP customers 24/7. Contact details can be found on your policy documents or customer card. The PMP medicolegal helpline team can assist customers in preparing an appropriate response.
   • In addition, the healthcare provider, when a notifiable safety incident has occurred, must comply with the statutory duty of candour.
8. An adverse event should be used as an opportunity to reflect, learn and adapt changes to a clinician’s practice and ultimately to improve care.
9. It is of paramount importance that all clinical staff maintain clear and accurate medical records. These contemporaneous records will form the basis of any medicolegal defence, should this be necessary. Indeed, records are often sought and relied upon many years after the initial event.
10. Consultants should ensure they have adequate professional indemnity insurance to cover all the interventions they undertake. In addition, they should notify their indemnity insurer of any changes to their scope of practice, in line with the terms and conditions of their policy.