Factors predisposing to claims and compensations for patient injuries following total hip and knee arthroplasty

Machine Learning Classification of Psychiatric Data Associated with Compensation Claims for Patient Injuries

BACKGROUND

Adverse events are common in health care. In psychiatric treatment, compensation claims for patient injuries appear to be less common than in other medical specialties. The most common types of patient injury claims in psychiatry include diagnostic flaws, unprevented suicide, or coercive treatment deemed as unnecessary or harmful.

OBJECTIVES

The objective was to study whether it is possible to form different categories of patient injury types associated with the psychiatric evaluations of compensation claims and to base machine learning classification on these categories. Further, the binary classification of positive and negative decisions for compensation claims was the other objective.

METHODS

Finnish psychiatric specialist evaluations for the compensation claims of patient injuries were classified into six different categories called classes applying the machine learning methods of artificial intelligence. In addition, another classification of the same data into two classes was performed to test whether it was possible to classify data cases according to their known decisions, either accepted or declined compensation claim.

RESULTS

The former classification task produced relatively good classification results subject to separating between different classes. Instead, the latter was more complex. However, classification accuracies of both tasks could be improved by using the generation of artificial data cases in the preprocessing phase before classifications. This preprocessing improved the classification accuracy of six classes up to 88% when the method of random forests was used for classification and that of the binary classification to 89%.

CONCLUSION

The results show that the objectives defined were possible to solve reasonably.

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

BACKGROUND AND PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Litigation after primary total hip and knee arthroplasties in France: review of legal actions over the past 30 years

INTRODUCTION

Since the law of March 4, 2002, several modifications have impacted medical practices and their medico-legal implications. In case of an infectious complication not related to a fault of the practitioners (surgeons, anesthetists), the patient has the right to compensation assumed by the care structures. Moreover, the lack of preoperative information is no longer just a failing of the ethical standards but a breach of medical and legal obligations. Then, aims of this study were: (1) to describe the reasons for a lawsuit in France following total primary hip (THA) and total knee (TKA) arthroplasties and (2) to compare litigation characteristics of private and public practices.

MATERIALS AND METHODS

Civil (private practice) and administrative (public practice) court decisions in France between 1990 and 2020 were collected using the two main legal data sources (Legifrance, Doctrine).

RESULTS

Eighty-three TKA and 173 THA cases were identified. Reasons for complaint in primary THA were mainly infection (29%), prosthetic failures (18%), nerves injuries (17%), and leg length discrepancies (11%). The main grounds for complaint in favor of the plaintiff were diagnostic or indication mistakes (100%), infections (80%), especially if a lack of information was recognized (88%). Reasons for complaint following primary TKA were mainly infections (65%) and persistent pain or stiffness (12%). Whatever the reason, the verdict was in favor of the plaintiff in about 2/3 of the cases. THAs were more at risk of appeal in administrative procedures than in civil (p = 0.008). There were more cases of implant failure in civil proceedings (p = 0.008). Indemnities after primary THA was higher in public activity litigation (p = 0.04). There were no differences in verdicts, grounds for complaints, and compensation between public and private practices for primary TKA.

CONCLUSION

The main complaint about all the arthroplasties in France was a septic complication. The lack of information could be an added pejorative element for the final verdict.

Litigation analysis of medical damage after total knee arthroplasty: a case study based on Chinese legal database in the past ten years

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.

Sensor-guided gap balance versus manual gap balance in primary total knee arthroplasty: a meta-analysis

Background

Despite Vast improvements in technology and surgical technique in total knee arthroplasty (TKA), approximately 15–25% TKAs, have suboptimal subjective clinical outcomes. Our study sought to evaluate if sensor-guided balancing improves postoperative clinical outcomes compared to a conventional gap balancing technique.

Methods

We searched Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, and Wanfang database in March 2022 to identify studies involving sensor-guided balancing versus conventional gap balancing technique in TKA. Finally, we identified 2147 knees assessed in nine studies.

Results

Compared with manual gap balancing, Sensor-guided gap balancing resulted in less rate of Manipulation under anesthesia (MUA) (P = 0.02), however more rate of intraoperative additional procedures (P = 0.0003). There were no significant differences in terms of KSS (P = 0.21), KSS Function score (P = 0.36), OKS (P = 0.61), KOOS (P = 0.78), operative time (P = 0.17), Mechanical axis (P = 0.69) and rate of reoperation between two groups.

Conclusion

Compared with conventional manual gap balancing techniques, sensors have more balancing procedures being performed. However, it did result in a reduction in the rate of MUA. More extensive, high-quality RCTs are required to verify our findings further.

Compensation claims after hip arthroplasty surgery in Norway 2008-2018

Background and purpose - Orthopedic surgery is one of the specialties with most compensation claims, therefore we assessed the most common reasons for complaints following total hip arthroplasty (THA) reported to the Norwegian System of Patient Injury Compensation (NPE) and viewed these complaints in light of the data from the Norwegian Arthroplasty Register (NAR).Patients and methods - We collected data from NPE and NAR for the study period (2008-2018), including age, sex, and type of complaint, and reason for accepted claims from NPE, and the number of arthroplasty surgeries from NAR. The institutions were grouped by quartiles into quarters according to annual procedure volume, and the effect of hospital procedure volume on the risk for accepted claim was estimated.Results - 70,327 THAs were reported to NAR. NPE handled 1,350 claims, corresponding to 1.9% of all reported THAs. 595 (44%) claims were accepted, representing 0.8% of all THAs. Hospital-acquired infection was the most common reason for accepted claims (34%), followed by wrong implant position in 11% of patients. Low annual volume institutions (less than 93 THAs per year) had a statistically significant 1.6 times higher proportion of accepted claims compared with higher volume institutions.Interpretation - The 0.8% risk of accepted claims following THAs is 1.6 times higher for patients treated in low-volume institutions, which should consider increasing the volume of THAs or referring these patients to higher volume institutions.

Compensation claims after knee arthroplasty surgery in Norway 2008-2018

Background and purpose - Orthopedic surgery is one of the specialties with most compensation claims. We assessed the claims following knee arthroplasty surgery reported to the Norwegian System of Patient Injury Compensation (NPE) in light of institutional procedure volume.Patients and methods - We collected data from NPE and the Norwegian Arthroplasty Register (NAR) for the study period (2008-2018). Age, sex, type of claim, and reason for compensation were collected from NPE, while the number of arthroplasty surgeries was collected from NAR. The treating hospitals were grouped by quartiles according to annual procedure volume. The effect of hospital volume on the likelihood of an accepted claim was estimated.Results - NAR received 64,241 reports of arthroplasty procedures, of which 572 (0.9%) patients filed a claim for treatment injury. 55% of the claims were accepted, representing 0.5% of all knee arthroplasties. The most common reason for accepted claim was a hospital-acquired infection, in 28% of the patients, followed by misplaced implant (26%) and aseptic loosening (13%). The hospitals with the lowest annual volume (57 or fewer arthroplasties per year, first quarter) had a statistically significantly larger fraction of granted claims per procedures compared with other institutions.Interpretation - The overall risk of ending up with compensation due to treatment error following knee arthroplasty was 0.5%. The risk of accepted claim was greater for patients operated in the lowest volume hospitals.

Medico-Legal Issues Related to Hip and Knee Arthroplasty: A Literature Review Including the Indian Scenario

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.

The medial gap is a reliable indicator for intraoperative soft tissue balancing in posterior-stabilized total knee arthroplasty

BACKGROUND

Appropriate soft tissue balance and accurate alignment are important for successful total knee arthroplasty (TKA). However, the optimal technique for establishing and measuring soft tissue balancing remains unclear. The aim of this study was to analyze the intraoperative medial and lateral gap pattern using digital knee balancer in posterior-stabilized (PS) TKA.

METHODS

This study involved 55 patients with medial osteoarthritis who underwent a primary TKA using an image-free navigation system. The extension gap and the flexion gap at 90° knee flexion were assessed using an offset seesaw-type digital balancer. Continuous joint distraction force from 10 lb to 60 lb was applied. Medial gap, lateral gap, and varus angle were measured.

RESULTS

The medial bone gap difference between extension and flexion was constant regardless of the distraction force from 20 lb to 60 lb. The lateral bone gap was significantly greater than the medial bone gap in extension and flexion from 30 lb to 60 lb (P < 0.05). The varus angle changed depending on the distraction force, especially in flexion. The varus angle in flexion was significantly greater than that in extension from 40 lb to 60 lb (P < 0.05).

CONCLUSIONS

The medial bone gap is a reliable indicator unaffected by the distraction force during surgery and is useful for adjusting the medial gap in extension and flexion appropriately to ensure medial stability in PS-TKA. The digital knee balancer and navigation system support both precise gap assessment and surgery.

Claims in orthopedic foot/ankle surgery, how can they help to improve quality of care? A retrospective claim analysis

Background

Orthopedic foot/ankle surgery is a high risk specialty when it comes to malpractice claims. This study aims to evaluate the incidence, characteristics and outcome of claims in this area.

Methods

This was a retrospective, 10-year claim analysis, with data from an anonymous database. Baseline claim/claimant characteristics were collected from all orthopedic foot/ankle-related cases.

Results

Of 460 claims in total, most were related to delay in/wrong diagnosis or to (complications of) elective surgical procedures. Whether a claim was settled was related to type of injury (fracture) and type of claim (diagnostic mistake). Median amount disbursed in settled claims was €12,549. Claim incidence did not increase over the years.

Conclusion

Missed fracture diagnosis and “failed”/disappointing results of elective surgical procedures were the most common causes for claims. Sufficient knowledge of missed (foot) fractures and clear communication/expectation management before elective procedures could help to improve quality of healthcare and patient satisfaction.

Bone resection for mechanically aligned total knee arthroplasty creates frequent gap modifications and imbalances

PURPOSE

The objective of this study was to calculate bone resection thicknesses and resulting gap sizes, simulating a measured resection mechanical alignment (MA) technique for total knee arthroplasty (TKA).

METHODS

MA bone resections were simulated on 1000 consecutive lower limb CT scans from patients undergoing TKA. Femoral rotation was aligned with either the surgical trans-epicondylar axis (TEA) or with 3° of external rotation to the posterior condyles (PC). Imbalances in the extension space, flexion space, medial compartment and lateral compartment were calculated.

RESULTS

Extension space imbalances (≥ 3 mm) occurred in 25% of varus and 54% of valgus knees and severe imbalances (≥ 5 mm) were present in up to 8% of varus and 19% of valgus knees. Higher flexion space imbalance rates were created with TEA versus PC (p < 0.001). Using TEA, only 49% of varus and 18% of valgus knees had < 3 mm of imbalance throughout the extension and flexion spaces, and medial and lateral compartments.

CONCLUSION

A systematic use of the simulated measured resection MA technique for TKA leads to many cases with imbalance. Some imbalances may not be correctable surgically and may result in TKA instability. Modified versions of the MA technique or other alignment methods that better reproduce knee anatomies should be explored.

LEVEL OF EVIDENCE

2.

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

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

Medical Malpractice Litigation Following Primary Total Joint Arthroplasty: A Comprehensive, Nationwide Analysis of the Past Decade

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.

Dynamic sensor-balanced knee arthroplasty: can the sensor "train" the surgeon?

Background

Dynamic tibial tray sensors are playing an increasing role in total knee arthroplasty (TKA) coronal balancing. Sensor balance is proposed to lead to improved patient outcomes compared with sensor-unbalanced TKA, and traditional manual-balanced TKA. However, the "learning curve" of this technology is not known, and also whether sensor use can improve manual TKA balance skills once the sensor is taken away, effectively "training" the surgeon.

Methods

We conducted a single-surgeon prospective study on 104 consecutive TKAs. In Nonblinded Phase I (n = 49), sensor-directed releases were performed during trialing and final intercompartmental load was recorded. In Blinded Phase II (n = 55), manual-balanced TKA was performed and final sensor readings were recorded by a blinded observer after cementation. We used cumulative summation analysis and sequential probability ratio testing to analyze the surgeon learning curve in both phases.

Results

In Nonblinded Phase I, sensor balance proficiency was attained most easily at 10°, followed by 90°, and most difficult to attain at 45° of flexion. In Blinded Phase II, manual balance was lost most quickly at 45°, followed by 90°, and preserved for longest at 10° of flexion. The number of cases in the steady state periods (early phase periods where there is a mix of sensor balance and sensor imbalance) for both phases is similar.

Conclusions

A surgeon who consistently uses the dynamic sensor demonstrates a learning curve with its use, and an "attrition" curve once it is removed. Consistent sensor balance is more predictable with constant sensor use.

Patient claims in prosthetic hip infections: a comparison of nationwide incidence in Sweden and patient insurance data

Background and purpose - Patients in Sweden are insured against avoidable patient injuries. Prosthetic joint infections (PJIs) resulting from intraoperative contamination are regarded as compensable by the Swedish public insurance system. According to the Patient Injury Act, healthcare personnel must inform patients about any injury resulting from treatment and the possibility of filing a claim. To analyze any under-reporting of claims and their outcome, we investigated patients' claims of PJI in a nationwide setting Patients and methods - The national cohort of PJI after primary total hip replacement, initially operated between 2005 and 2008, was established through cross-matching of registers and review of individual medical records. We analyzed 441 PJIs and the number of filed patients' claims, with regards to incidence, outcome, and any national, sex-linked or socioeconomic differences. Results - We identified 329/441 (75%) patients with PJIs as non-claimants. 96% of the filed claims were accepted. 64 (57%) of claimants sustained permanent disability. 2 factors were found to statistically significantly reduce the odds of filing claims: patient's age above 73 years and fracture as indication for surgery. There were no significant national, sex-linked, or socioeconomic differences. Interpretation - The incidence of patients' claims of PJI is low but claims are usually accepted when filed. Healthcare personnel should increase their knowledge of the Patient Injury Act to inform patients about possibilities of eligible compensation.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Hip Arthroplasty Malpractice Claims in the Netherlands: Closed Claim Study 2000-2012

BACKGROUND

A total hip arthroplasty (THA) is a successful and reliable operation with few complications. These complications however, do form a potential source for compensation claims. In the Netherlands, there are no studies available concerning filed claims after THA. The aim of this study was to determine the incidence of claims related to THAs in the Netherlands and the reasons to claim, which claims lead to compensation, the costs involved for the insurer, and the demographics of the claimants.

METHODS

In this observational study, we analyzed all closed claims from 2000 to 2012 from the national largest insurer of medical liability and compared it to data from our national implant registry in the Netherlands. With the intention to contribute to prevention, we have identified the demographics of the claimant, the reasons for filing claims, and the outcome of claims.

RESULTS

Overall, 516 claims were expressed in 280 closed claim files after THA. Claims were most often related to sciatic nerve injury (19.6%). Most claimants were women (71.6%) with an average age of 63.1 years. The median cost per compensated claim is €5.921.

CONCLUSION

The claimant is more likely to be female and to be younger than the average patient receiving a THA. The incidence of a claim after a THA is 0.14%-0.30%. Nerve damage is the most common reason to file for compensation. The distribution in reasons to claim does not resemble the complication rate in literature after a THA. The outcome of this study can be used to improve patient care, safety, and costs.

Can We Really "Feel" a Balanced Total Knee Arthroplasty?

BACKGROUND

Balancing techniques in total knee arthroplasty are often based on surgeons' subjective judgment. However, newer technologies have allowed for objective measurements of soft tissue balancing. This study compared the use of sensor technology to the 30-year surgeon experience regarding (1) compartment loads, (2) soft tissue releases, and (3) component rotational alignments.

METHODS

Patients received either sensor-guided soft tissue balancing (n = 10) or manual gap balancing (n = 12). Wireless, intraoperative sensor tibial inserts were used to measure intracompartmental loads. The surgeon was blinded to values in the manual gap-balancing cohort. In the sensor cohort, the surgeon was unblinded, and implant trials were placed after normal releases were performed to guide further ligament releases after femoral and tibial resections, as needed. Load measurements were taken at 10°, 45°, and 90°.

RESULTS

The sensor cohort had lower medial and lateral compartment loading at 10°, 45°, and 90°. The sensor group had lower mean differences in intercompartment loading at 10° (-5.6 vs -51.7 lbs), 45° (-9.8 vs -45.9 lbs), and 90° (-4.3 vs -27 lbs) compared to manually balanced patients. There were 10 additional soft tissue releases in the sensor cohort (2 initial ones before sensor use), compared to 2 releases in the gap-balanced cohort. In the gap-balanced cohort, tibial trays were positioned at a mean 9° external rotation, compared to a mean 1° internal rotation in the sensor-guided cohort.

CONCLUSION

Sensor-balanced total knee arthroplasties provide objective feedback to perform releases and potentially improve knee balancing and rotational alignment. Future work may clarify whether these changes are beneficial for our patients.

Patient injuries in primary total hip replacement

Background and purpose - Although the results of primary total hip replacements (THRs) are generally excellent, sometimes serious complications arise. Some of these severe complications are considered to be patient injuries. We analyzed primary THR-related patient injuries in a nationwide setting. Patients and methods - We evaluated all the primary THR-related patient injury claims in Finland between 2008 and 2010. We used the original medical records and 2 nationwide registries, the Care Register for Social Welfare and Health Care and the Patient Injury Claim Register. Results - We identified 563 claims, 44% of which were compensated (n = 250). Of these 250 compensated claims, 79% were considered to be avoidable (treatment injuries) and 21% were severe unexpected infections (with a preoperative infection risk of less than 2%). The most common type of technical error was cup malposition (31%). High-volume hospitals (with an annual primary THR volume ≥ 400) had a lower patient injury rate. In lower-volume hospitals (with an annual primary THR volume of < 400), the relative risks (RRs) of patient injury for any reason, due to technical errors, or because of cup malposition were 2-fold (95% CI: 1.6-3.1), 4-fold (95% CI: 2.3-6.2), and 9-fold (95% CI: 3-28), respectively, compared to high-volume hospitals. Interpretation - Our study provides the first comprehensive nationwide data on THR-related patient injury types. Hospital volume was associated with the quality and quantity of errors detected. An annual hospital volume of ≥ 400 primary THRs was established as a protective factor against patient injuries.

Knee arthroplasty and lawsuits: the experience in France

PURPOSE

Data regarding knee arthroplasty and lawsuit are scarce. With the expected increase in knee arthroplasty over the next 25 years, the number of claims might follow the same trend. Therefore, the most frequent causes of litigation after knee arthroplasty in France, and what is considered as malpractice by the expert, were determined.

METHODS

Over 8-year period, data gathered from a French private insurance company specializing in malpractice for private practitioners were analyzed. Demographics, type of knee arthroplasty, reason for claim, details of the legal procedure and the expert's decision were reviewed.

RESULTS

One hundred and five claims were processed by four jurisdictions. Most of the cases concerned primary total knee arthroplasty. Surgeons and anesthesiologists were charged in 84 and 16 % of claims, respectively. The most frequent causes of litigation were infection, neurological deficit and unsatisfactory result, whereas the most common reasons for the surgeon's liability, as stated by the expert, were delay in diagnosis or treatment of a complication, infection and technical error.

CONCLUSION

Our findings show that frequent complications are not those which raise most of the claims. Patients sue the surgeon when the outcome of the surgery is different from what they were expecting. An unsatisfactory result, according to the patient's point of view, is the second most frequent cause of claim.

LEVEL OF EVIDENCE

IV, Economic and Decision Analysis. See the Guidelines for Authors for a complete description of levels of evidence.

Dental treatment injuries in the Finnish Patient Insurance Centre in 2000-2011

Objective The Patient Insurance Centre in Finland reimburses patients who sustained injuries associated with medical and dental care without having to demonstrate malpractice. The aim was to analyse all dental injuries claimed through the Patient Insurance Centre over a 12-year period in order to identify factors affecting reimbursement of claims. Methods This study investigated all dental patient insurance claims in Finland during 2000-2011. The injury cases were grouped as (K00-K08) according to the International Classification of Diseases (ICD-10). Calendar year, claimant's age and gender, dental disease group and health service sector were the explanatory factors and the outcome was the decision of a claim. Multiple logistic regression modelling was used in the statistical analyses. Results The total number of decisions related to dental claims at the PIC in 2000-2011 was 7662, of which women claimed a clear majority (72%). Diseases of the pulp and periapical tissues (K04) and dental caries (K02) were the major disease groups (both 29%). Of the claims 40% were eligible for reimbursement, 27% were classified as insignificant or unavoidable injuries and 32% were rejected for other reasons. The proportion of reimbursed claims declined during the period. Patients from the private sector were more likely to be eligible for compensation than were those from the public sector (OR = 1.89, 95% CI = 1.71-2.10). Conclusions The number of dental patient insurance claims in Finland clearly rose, while the proportion of reimbursed claims declined. More claims received compensation in the private sector than in the public sector.

A new method for defining balance: promising short-term clinical outcomes of sensor-guided TKA

Recently, technological advances have made it possible to quantify pounds of pressure across the bearing surface during TKA. This multicenter evaluation, using intraoperative sensors, was performed for two reasons: 1) to define "balance" 2) to determine if patients with balanced knees exhibit improved short-term clinical outcomes. Outcomes scores were compared between "balanced" and "unbalanced" patients. At 6-months, the balanced cohort scored 172.4 and 14.5 in KSS and WOMAC, respectively; the unbalanced cohort scored 145.3 and 23.8 in KSS and WOMAC (P < 0.001). Out of all confounding variables, balanced joints were the most significant contributing factor to improved postoperative outcomes (P < 0.001). Odds ratios demonstrate that balanced joints are 2.5, 1.3, and 1.8 times more likely to achieve meaningful improvement in KSS, WOMAC, and activity level, respectively.