The number of clinical negligence claims in the UK is constantly increasing. As a specialty, trauma and orthopaedic surgery has one of the highest numbers of negligence claims. 1. This study analyses NHS Litigation Authority (NHSLA) claims in trauma and orthopaedics between 2004 and 2014. . A formal request was made to the NHSLA under the Freedom of Information Act in order to obtain all data related to claims against orthopaedic surgery. It was found that the number of claims, and percentage of successful claims, has been constantly increasing over this period, with compensation paid of over £349 million.* Errors in clinical management accounted for the highest number of closed claims (2933 claims), costing over £119 million.*. The level of compensation paid out has a significant financial impact on the NHS. Reforms need to be made in order to tackle the high cost of legal fees generated by these claims, which further drain the limited resources available to the NHS

Background. In the UK 70,000 knee arthroplasties are performed each year. Although outcomes from knee arthroplasties are usually excellent, they can nevertheless lead to negligence claims. The aim of this study was to establish the incidence, cost and cause of negligence claims arising from knee arthroplasties. Method. All claims made to the NHS Litigation Authority between 2003 and 2008, where the operation was knee arthroplasty, were included in this study. Data obtained from the NHS Litigation Authority were reviewed, coded and analysed. For negligence to have occurred, patients must have suffered harm as a result of substandard care. Hence the cause of negligence claims was analysed in terms of: (1) Substandard care and (2) Harm caused. Results. There were 326 claims over the five-year period, resulting in an incidence of 65 claims per year. Of the 326 claims, 246 have been closed with 80 remaining open. 40% of closed claims resulted in the payment of damages. The total cost of negligence claims over the period was £6.6 million. Substandard care commonly encountered in negligence claims was: surgical quality (56%), post-op care (23%), and infection control (8%). Harms commonly encountered in negligence claims were: additional/unnecessary operation (30%), pain (23%) and amputation (8%). Conclusion. There is a significant litigation burden associated with knee arthroplasties. The unexpected prominence of additional/unnecessary operation, pain and amputation in negligence claims emphasise the need for patients to be warned about these risks

Claims for clinical negligence are increasing annually. Limb reconstructive surgery recognises ‘problems, obstacles, and complications’ as part of the treatment process, but this does not prevent a claim for an alleged poor result or a complication. We analysed claims for clinical negligence in the National Health Service in England and Wales for issues following limb reconstructive surgery. A database of all 10,456 claims related to Trauma and Orthopaedic Surgery from 1995–2010 was obtained from the NHS Litigation Authority. A Search Function for keywords “Ilizarov, limb reconstruction, external fixation, and pin-site” was used for subset analysis. Data was analysed for type of complaint, whether defended or not, and for costs. 52 claims fitted our filters - 48 were closed, and 4 ongoing. The claims included damage to local structures (n=3), missed compartment syndrome (n=2), premature frame removal (n=5), infection (n=13), wrong-site-surgery (n=1), poor outcome (n=16) and technical error (n=10). Seven patients underwent amputation. The total cost of litigation was £4,444,344, with a mean of £90,700 per settled claim. 40% were successfully defended, with defence cost of £15,322. The mean pay-out for confirmed negligence/liability was £90,056 (£1,500-£419,999, median £45,000) per case. We believe this is the first study looking at complications following limb reconstruction from this perspective. Analysis reveals a spectrum of claims for negligence. Perceived technical errors and poor outcome predominate. Whilst the limitations of the database preclude against identification of whether the procedures were carried out in specialist units, claims for technical errors are a cause for concern. These will be discussed in detail. Outcomes following limb reconstruction are difficult to quantify, and the settling of claims for a perceived poor outcome makes the case for pre-operative counselling and the need for robust outcome measures in our specialty

Definitions and perceptions of good and poor outcome vary between patients and surgeons, and perceived inadequate outcome can lead to litigation. We investigated outcomes of litigation claims relating to non-union and deformity following lower limb long bone fractures from 1995 to 2010. The database of all 10456 claims related to Trauma and Orthopaedic Surgery was obtained from the NHS Litigation Authority. Data was searched for “deformity, non-union and mal-union”, excluding spine, arthroplasty, foot and upper limb surgery. The type of complaint, whether defended or not, and costs was analysed. 241 claims met our criteria, 204 of which were closed, and 37 unsettled. Deformity/mal-union constituted 97, and non-union 143. Coronal/sagittal deformity cost £4.2 million, mean £45,487 (60% received compensation). Rotational mal-unions cost £1.6 million, mean £114,263 (87% received compensation). Non-union cost £5.3 million, mean £75,866 (60% received compensation). Mean legal fees for coronal/sagittal deformity was £18,772, rotational deformity £37,384, and non-union £24,680. The total cost of litigation was £12.2 million, with a mean of £59,597 per settled claim. The mean pay-out for all confirmed negligence/liability was £56,046 (£1,300–£500,000, median £21,500) per case. Non-union is an accepted complication following fracture surgery. However, this does not mitigate against non-union being seen as representing a poor standard of care. While it is unclear whether the payouts reflect a defensive culture or were due to avoidable errors, and notwithstanding the limitations of the database, we argue that failure of the index surgery should prompt a referral to a specialist centre. The cosmetic appearances of rotational malalignment results in higher compensation, reinforcing outward perception of outcome as being more important than harmful effects. We also note that the database sometimes contained conflicting and incomplete data, and make a case for standardisation of this component of the outcome process to allow for learning and reflection

Background. FORECAST is a prospective longitudinal cohort study exploring mechanism-based prognostic factors for pain persistence in sciatica. Here, we share an update on this largest deeply-phenotyped primary care sciatica cohort. Methods/results. Our cohort includes 180 people with sciatica (score >4 on Stynes’ Sum Score), aged 18–85, within 3 months of symptom onset. Psychosocial factors, self-reported sensory profiling, clinical examination, quantitative sensory testing (QST), biological samples (blood and skin samples), and Magnetic Resonance Neurography of lumbar nerve roots were collected at baseline. Pain persistence was determined at three and twelve months with the Sciatica Bothersomeness Index (SBI) and a numeric pain rating scale (NRS) as primary outcomes. Recruitment nears completion, with 160 participants enrolled to date. 127 and 96 participants have completed 3 and 12 months follow-up respectively. Overall, 56% of our cohort are female, with a mean age (SD) of 54.14yrs (16.57). Ethnicity data approximates local populations. SBI at baseline was (median [IQR]) 13[10-17], and interim longitudinal data shows stepwise improvement at 3 and 12 months. Baseline ‘average’ pain intensity was 5.56 (2.15) for leg pain, and 4.14(2.82) for low back pain (LBP). Overall, pain scores decreased at 3 and 12 months, with greater reductions in leg pain than LBP at 12 months. However, around 55–80% and 40–65% of people reported persistent pain at 3 and 12 months respectively. Conclusion. Leg pain severity was moderate and higher than LBP at baseline. All primary outcome measures demonstrate improvement over time, however 40–65% of patients report persistent pain at 12 months. Conflicts of interest. LR: Paid facilitation of post-graduate courses internationally. SK, MT, FP, KM, WS, CP, CR, SC: No conflicts of interest. GC: Editor in Chief of Health Psychology Review. Director of board of directors, MentalCHealth Care setting NoordWestVlaanderen. JF: Copyright holder of ODI (Oswestry Disability Index). Served on a data monitoring committee for a clinical trial of 2 different surgical approaches to cervical disc herniation (FORVAD). Member of HTA Prioritisation Committee B: Inside hospital Care from 2015-February 2019. Member of HTA Interventional Procedures Panel from 2010–2015. Trustee and board member of 3 spine related charities – Back to Back; British Scoliosis Research Foundation and BackCare. Expert instructed by both claimant and defendant solicitors in negligence and person injury cases. GB: Paid consultancy (RNA-seq) with Ivy Farm and Coding.bio. ABS: Paid post-graduate lecturing internationally. Co-chair NeupSig sciatica working group (unpaid). Sources of funding. This project is funded by UKRI and Versus Arthritis as part of the UKRI Strategic Priorities Fund (SPF) Advanced Pain Discovery Platform (APDP), a co-funded initiative by UKRI (MRC, BBSRC, ESRC), Versus Arthritis, the Medical Research Foundation and Eli Lilly and Company Ltd (Grant MR/W027003/1). Additional funding has been received from the back to back charity to expand longitudinal components of the study. LR has received support with PhD fees from the CSP charitable trust. ABS is supported by a Wellcome Trust Clinical Career Development Fellowship. (222101/Z/20/Z). WS is partly funded through the National Institute for Health and Care Research (NIHR) Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust and King's College London. FP is funded by a Dorothy Hodgkin Career Development Fellowship in Chemistry in association with Somerville College. GB is supported by the Wellcome Trust (223149/Z/21/Z) and Diabetes UK (19/0005984). GC and KRM are partly funded by UKRI and Versus Arthritis as part of the Advanced Pain Discovery Platform (APDP) PAINSTORM (MR/W002388/1). The UKRI and Versus Arhthritis (APDP) are the major funders of FORECAST. All other funders provided either some people support, or funded projects with legacy data that we reuse

The aim of this study was to review the data held with the NHSLA database over the last 10 years for negligence in spine surgery with particular focus on why patients ‘claim’ and what is the likely outcome. Anonymous retrospective review. We contacted the NHSLA and asked them to provide all data held on their database under the search terms ‘spine surgery or spine surgeon.’. An excel sheet was provided, and this was then studied for reason of ‘claim’, whether the claim was open/closed and outcome. A total of 67 claims of negligence were made against spinal surgeries during this time (2000-09). The number of claims had increased over the last few years: 2000-03, n= 8, 2004-06, n= 46. The lumbar spine remains the most common area (Lumbar: 55/67, Thoracic : 6/67, Cervical 6/67). Documented reasons for claims were post-operative complications (n= 28; 42%), delayed/failure to diagnose (n=24; 36%), discontent with preoperative assessment including consent (n=2; 3%), intra-operative complications (n= 10; 15%) and anaesthesia complication (n=3; 4%). Twenty were closed and 47 remained open. The number of successful claims was 8/20 (40%). The mean compensation paid out was £33,409 (range was £820.5 to £60,693). The number of claims brought against spinal surgeries is on the increase, with the most common area being the lumbar spine which perhaps is not surprising as this is the most common area of spinal surgery. Common reasons are post-operative complications and delay/failure to diagnose. The ‘success’ of these claims over the last 10 years was 8/20 (40%) with mean compensation paid out was £33,409. Ethics approval: None;. Interest Statement: The lead author is the CEO and founder of a Personal Injury/Medico-Legal company

Our aim was to determine from the general community an understanding of the implications of informed consent, expectations in regard to self-autonomy, appreciation of risk in surgery, the implications of surgical complications, the degree of acceptability of risk for a given complication and views on surgeon liability. One thousand questionnaires were distributed to members of the general public attending the Palmerston North Hospital as outpatients or visitors (inpatients were excluded). Less than 20% of respondents appreciated the concepts of battery, negligence, self-autonomy and confidentiality. 59% wanted to know about potential complications in order to assist them in making a decision on whether or not to proceed with surgery. Given options and a discussion of the risks, 64% wished to take responsibility for which surgical procedure they would undergo. 9% were unaware that surgical procedures had risks of serious complications. 10% would not undertake surgery if the risk of a serious complication was one in a million, while 30% would undertake surgery regardless of the risk involved. 21% felt the surgeon would be liable in the event of an unmentioned rare complication. The grasp of the perceived objective of informed consent is poor amongst the general population. The tolerance for medical negligence is low and expectations in regard to self-autonomy seem unrealistically high. We feel it is necessary to revisit ‘informed consent’ and for the public (and the legal profession) to make ‘informed consent’ a practical goal-orientated patient/doctor friendly process rather than the existing ‘legal obstacle’ that it is

The aim is: to point out, in respect of Italian case law trends, the concept and the boundaries of surgeon malpractice liability in evaluating and implanting new prosthesic materials. The surgeon is liable for damages caused by fraudulent intention or fault during his clinical and operating activity. In a civil perspective, it could be the result of either a breach of a contract or a tort, depending on the existing relationship between the surgeon and the patient; but in both case there might be a serious inexperience or a light imprudence or negligence to admit a fair compensation for damages. While in a criminal perspective, the personal injuries might be the result of a serious fault also in the area of imprudence and negligence to admit the application of criminal sanctions. Of course, personal liability of surgeon stands by vicarious liability of health unit. Civil sanctions are more effective than criminal sanctions, not only because they have a wider area of application, but also because they are more incisive in quantitative terms, considering the new guidelines on pecuniary and biological damages that make out, at the same time, a compensatory and punitive function. The surgeon, to be sure not to be affected by civil and criminal actions, might inform the patient about the operating features and the consequences of non operating, follow standardized protocols, use products and materials tested and certified by the most influential scientific literature, be care of post-operating effects and adopt all remedies and treatments that can eliminate or reduce post-operating risks, use the best and up-to-date techniques available. In any case he is not liable for unforeseeable events, even if they are in a causative relationship with surgical activity

Two discrete legal factors enable the surgeon to treat an injured patient the fully informed, autonomous consent of the adult patient with capacity via civil law; and the medical exception to the criminal law. This article discusses current concepts in consent in trauma; and also considers the perhaps less well known medical exception to the Offences against the Person Act 1861, which exempts surgeons from criminal liability as long as they provide ‘proper medical treatment’.

Cite this article: Bone Jt Open 2024;5(7):565–569.

To establish the incidence of litigation in Cauda Equina Syndrome (CES) and the causes of litigation. Review of 10 years of abbreviated records of the National Health Service litigation authority (NHSLA) (1997-2007) and eight years of medical negligence cases (MNC) reported on by the two senior authors (2000-2008). Patients who experienced CES and litigated. There were 117 patients in the NHSLA records and 23 patients in the MNC group. Review of timing of onset, delay in diagnosis, responsible specialist, place, and resulting symptoms. NHSLA cases. 62/117 cases were closed. The responsible specialists were as follows. Orthopaedic. 60. Accident and Emergency. 32. Other. 25. The commonest failure was delay in diagnosis, and the commonest complications were “neurological”, bladder and bowel. MNC cases. F:M;17/6. L4/5 13 cases, L5/S1 9 cases. The responsible specialist was orthopaedic (7), other (7) and in 8 cases the opinion was that there was no case to answer. Delay to treatment averaged 6.14 days. 18/23 patients described bowel and bladder symptoms, the information was not available in the remainder. Litigation is major problem in CES. In most cases orthopaedic surgeons are litigated against, and bowel and bladder symptoms remain the most disturbing cause of litigation. These surgeons are mostly not spinal specialists. In most successful cases of litigation there is considerable delay in diagnosis and management. Where there is incomplete Cauda Equina Syndrome urgent or emergency investigation and treatment is mandatory

Fracture is the only clinically relevant aspect of osteoporosis—a major public health problem in many countries. The strongest predictor for a new fragility fracture is a previous one. For instance, a patient with one osteoporotic vertebral compression fracture has about a seven-fold increased hip fracture risk; a patient with two compression fractures a 14-fold hip fracture risk. Today, we have evidence based and efficient osteoporosis drugs as well as non-pharmacologic methods for fracture prophylaxis. In risk group patients it often is possible to halve the fracture risk. The orthopaedic surgeon is the first and sometimes the only doctor a fracture patien sees. Therefore, as orthopaedic surgeons, we have a great opportunity—and indeed an onus—to identify patients with increased fracture risk, and to do something about it. Imagine patients with myocardial infarction or stroke discharged from hospital without blood pressure control or having a biochemical profile taken? Such negligence is, alas, not uncommon for patients with fragility fractures. We must think in terms of absolute fracture risk, and implement today’s evidence based knowledge. Secondary prophylaxis should be an integrated part in fracture treatment. And this calls for a multidisciplinary and multiprofessional teamwork including surgeons, geriatricians, endocrinologists and general practitioners, as well as nurses, physiotherapists and a wide range of other paramedical specialists. Such “fracture chains” will reduce the number of unnecessary and preventable injuries and will have a great impact in terms of cost and suffering. This symposium will give an overveiw of fracture-preventing strategies

We review all litigation brought against English Orthopaedic departments involving children under the age of 16 and attempt to highlight areas where they might be avoided. The NHSLA (the National Health Service Litigation Authority) is a special Health Authority responsible for handling negligence claims made against NHS bodies in England. In addition to dealing with claims when they arise, there is an active risk management programme to help raise standards of care in the NHS and hence reduce the number of incidents leading to claims. By analysing the claims data, we have had the opportunity to see trends for which Trusts have litigation brought against them, how much this costs the Health Service and most importantly how this information can aid in clinical practice. Between 1995 until 2005/06 there were 408 cases involving orthopaedics in England that had reached a conclusion. Of those considered in our study (341), by far the most common broad category for litigation is missed or delayed diagnosis of a condition 179 cases (57% of all litigation cases) with 44% (80 cases) of those being upper limb traumatic injuries. Humeral supracondylar fractures and elbow injuries constitute 24% (44 cases) of all missed diagnoses with each having an average total payout of £27,998. Missed or poorly managed developmental disorders of the hip (DDH or SUFE) also have large total payouts. Other common causes for litigation are intra-operative errors with poor results/complications for fixation of humeral supracondylar fractures again being the most common. Complications of plasters also represent 7.3% of all claims, all with high total payouts. In assessing these trends, we suggest highlighting the potential for error during training of juniors and taking extra care during clinical practice. There are also implications identified for the planned provision of Orthopaedic care of children

Aims

The primary aim of this study is to assess the survival of the uncemented hydroxyapatite (HA) coated Trident II acetabular component as part of a hybrid total hip arthroplasty (THA) using a cemented Exeter stem. The secondary aims are to assess the complications, joint-specific function, health-related quality of life, and radiological signs of loosening of the acetabular component.

Background Prescriptive guidelines for selection of implants for hip arthroplasty are likely to become increasingly established, on grounds of safety, cost and effectiveness. Such guidelines were introduced in the UK by the National Institute of Clinical Excellence (NICE) in 2000. Most departments were non-compliant in one or more respects, and knowledge of the recommendations was limited among clinicians. Concern exists that the recommendations may replace the Bolam Test in cases of clinical negligence in future. Materials and Methods The recommendations of NICE, from the initial documentation to the present, were scrutinised alongside experience of other nationally-funded or managed healthcare systems in Europe and North America. The evolution of guidance from 1999 onwards, together with the areas of potential difficulty were identified. Results Potential difficulties were encountered in relation to a number of implants in widespread use in the UK, particularly in relation to the choice of acetabular component (cup), despite the fact that cup loosening accounts for a third of revisions. The use of cup and stem from different manufacturers was also identified as a cause of concern. Discussion Departments face a choice of adopting the recommendations of NICE in their entirety or continuing with established practice, with the attendant risk of future litigation should certain implants prove to be unacceptable as clinical results become available through the National Registry. Continuation with established practice may be acceptable, even in respect of implants not recommended by NICE, provided data collection activity is maintained. We propose an algorithm through which individual departments may maintain compliance with NICE without altering departmental practice

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

During revision hip surgery, damage to the sciatic nerve is due most commonly to excessive tension. While the nerve is strong in tension and is able to tolerate this remarkably, it is sensitive to lateral compression against angled structures and it is likely that tension causes injury by such pressure. In a personal series of 441 revision hip procedures, sciatic nerve injury occurred in 9 recognised cases:. 2 were complete with no useful recovery. 2 were severe with some incomplete recovery. 3 were predominantly lateral popliteal with incomplete recovery. 2 were transient and clinically fully recovered. In only two of these were the cause and the time of injury identifiable. In these cases, pain was not a serious feature but in eight separate medico-legal cases, burning pain of variable distribution has been the most serious complaint. Medical negligence has been successfully sustained on the grounds of res ipsa locitur. Regrettably, patients must be given informed consent with yet another potential hazard being listed. We have found that in normal individuals the range of straight leg raising varies between 30 and 90 degrees. Towards the limit of this range the nerve is tight and a crude cadaveric test indicated a tension force of 40 newtons! In an athlete this may be extreme and yet the nerve does not complain. Excluding direct compression (e.g. by a retractor) and thermal injury, we suggest that the tension developed during unguarded straight leg raising while the patient is still anaesthetised is a serious risk factor. After even conservative lengthening, the tension rises alarmingly during such action. It is possible that pre-existing lumbar degenerative disk disease can contribute to the hazard and be source of pain

Routine metalwork removal, in asymptomatic patients, remains a controversial issue in our daily practice. Current literature emphasized the potential hazards of implant removal and the financial implications encountered from these procedures. However, there is little literature guidance and no published research on current practice. To estimate the current state of practice of orthopaedic surgeons in the United Kingdom regarding implant removal for limb trauma in asymptomatic patients, an analysis of the postal questionnaire replies of 36% (500 out of 1390) of randomly selected UK orthopaedic consultants was performed by two independent observers. 47.4% replies were received. A total of 205 (41%) were found to be suitable for analysis. The most significant results of our study I: 92% of orthopaedic surgeons stated that they do not routinely remove metalwork in asymptomatic skeletally mature patients. II: 60% of trauma surgeons stated that they do routinely remove metalwork in patients aged 16 years and under, while only 12% of trauma surgeons do routinely remove metalwork in the age group between 16–35 years. III: 87% of the practising surgeons indicated that they believe it is reasonable to leave metalwork in for 10 years or more. IV: Only 7% of practising trauma surgeons replied to this questionnaire have departmental or unit policy. No policy is needed for metalwork removal, as most of the orthopaedic surgeons were complying with literature guidance supporting the potential risks associated with implant removal, in spite of the limited number of departmental or units’ policies on implant removal and the paucity of the literature documenting the current practice. However, there is a discrepancy among trauma surgeons in relation to metalwork removal between patient age groups. This indicates guidelines would be helpful to guide the surgeon for the best practice. This is important from a medico-legal standpoint because surgeons are being criticised for not achieving satisfactory results in negligence cases

We have performed a study comparing the radiological results of Total hip replacements performed by a single, experienced specialist hip surgeon with those reported from the Trent Regional Arthroplasty Study (TRAS) [presented at BOA congress 2000]. Results from TRAS have revealed that inadequate cementation grades and a cement mantle width of < 2mm were the most significant associations predicting early aseptic loosening. Interestingly, their respective incidences were as large as 20% and 50% in a random sample of THRs from the TRAS register. Data is lacking as to whether poorer radiographic cementation grades have a trend towards individual surgeons or whether they are more evenly distributed amongst the surgical population including those adhering to modem techniques. Therefore, we have undertaken an independent review of A-P and lateral radiographs of 33 consecutive Charnley THRs performed by a specialist hip surgeon using carefully controlled modem cementing techniques and compared the results with the same random cohort of THRs from the TRAS. Our results show that the specialist surgeon achieved a significantly higher proportion (82%) of complete cement mantles (> 2mm in all zones) than those achieved by TRAS (50%) [Chi. 2. =7. 79, p=0. 0052]. This suggests that improved cement mantles can be achieved by the adoption of carefully controlled modem cementing techniques. However, use of the Barrack system of grading was unable to detect differences in cementation quality between specialist (88%) and TRAS group (81%) [Chi. 2. =0. 235; p=0. 631 suggesting less sensitivity in this technique for assessing cementation quality. These results are important for the following reasons. Achievement of adequate mantle (> 2mm) can be improved upon by adoption of carefully controlled modem cementing technique. However, regardless of the method of assessment of cementation quality, approximately 18% will appear ‘inadequate’ despite modern techniques suggesting that factors outside the surgeon’s control are involved in determining cementation grade. This has important medico-legal implication in the current climate in which surgeons are being criticised, in negligence cases arising out of the 3M Capital Hip experience, for achieving ‘inadequate’ cementation