Litigation costs are significant and increasing annually within the National Health Service (NHS) in England.

The aim of this work was to evaluate the burden of successful litigation relating to hip surgery in England. Secondary measures looked at identifying the commonest causes of successful legal action.

A retrospective review was conducted on the National Health Service Litigation Authority (NHSLA) database. All successful claims related to hip surgery over a 10 year period from 2003–2013 were identified. A total of 798 claims were retrieved and analysed.

The total cost of successful claims to the NHS was £66.3 million. This compromised £59 million in damages and £7.3 million in NHS defence-related legal costs. The mean damages for settling a claim were £74,026 (range £197-£1.6million). The commonest cause of claim was post-operative pain with average damages paid in relation to this injury being £99,543. Nerve damage and intra-operative fractures were the next commonest cause of claim with average damages settled at £103,465.

Legal action in relation to hip surgery is a considerable source of cost to the NHS. The complexity of resolving these cases is reflected in the associated legal costs which represent a significant proportion of payouts. With improved understanding of factors instigating successful legal proceedings, physicians can recognise areas where practice and training need to be improved and steps can be taken to minimise complications leading to claims.

Background

Irrigation and débridement (I&D), often with exchange of modular polyethylene components, is commonly used to treat acute periprosthetic infection (PPI) following total joint arthroplasty. Two-stage revision, the “Gold Standard” for PPIs' is more invasive, requires more resources, creating controversy over recommended initial treatment of PPIs. This study seeks to determine the success rate of an “intent to treat” approach utilizing I&Ds with progression to two stage revisions as required.

Earlier diagnosis is one of the key aims in achieving improved outcomes for patients with cancer. In general, the earlier a tumour is diagnosed, the easier it will be to treat and the greater the chance of cure. We have investigated how tumour size at diagnosis and duration of symptoms, both of which may act as a proxy for delay in diagnosis have varied over a 25 year period and whether there is evidence of improvement.

Data were available for 2568 patients with primary bone sarcomas and 2366 with soft tissue sarcomas. The mean size at diagnosis was 10.7 cm for bone tumours and 9.9cm for soft tissue sarcomas. The size of bone sarcomas had not changed with the passage of time but there had been a slight decrease in the size of soft tissue sarcomas (10.3 cm before 2000 vs 9.6cm after 2000, p=0.03). The duration of symptoms reported by patients varied widely with a median of 16 weeks for bone sarcomas and 26 weeks for soft tissue sarcomas. The median duration of symptoms for bone sarcomas had actually increased since 2000 (16 weeks before to 20 weeks after 2000, p⋋0.01), whilst it remained unchanged for soft tissue sarcomas. Further analysis showed that females tended to present with smaller tumours than males and that slower growing tumours (eg. liposarcoma and chondrosarcoma) tended to be larger and have a longer duration of symptoms than other tumours. 15% of patients with a soft tissue sarcoma had undergone a previous inadvertent excision – and this % has not changed over 20 years. Younger patients had smaller soft tissue soft tissue sarcomas than older patients but there was little difference for bone sarcomas.

To evaluate blood transfusion practice in hip and knee arthroplasty, the development of evidence based guidelines, their implementation and prospective analysis of change. An audit was carried out in 4 stages to complete the loop. Stage 1: Retrospective analysis of blood transfusion practice in primary and revision hip and knee arthroplasty. Review of case notes, nursing record, anaesthetic sheet and pathology results from a computer database was carried out. Rates of transfusion, patients’ body weight and height, peri-and post-operative blood loss, use of anticoagulants, drains, surgical approach, type of implant and cement, grade of surgeon and anaesthetist and haemodynamic complications were recorded. Stage 2: Literature search to develop evidence based guidelines for blood transfusion.

The data in stage 1 was evaluated in the light of those guidelines to determine appropriateness of blood transfusion. Stage 3: Dissemination and implementation of guidelines. Anaesthetic, Orthopaedic and audit departments were involved. Guidelines were presented, discussed, finalised and circulated.

Stage 4: Prospective re-evaluation of blood transfusion practice was undertaken. Parameters as in stage 1 plus documentation of reason for blood transfusion by the prescriber were recorded.

For stage 1, 97 Hip arthroplasty (86 primary and 11 revisions) and 119 Total knee arthroplasty procedures (109 primary and 10 revisions) over a period of 26 weeks were studied. Blood transfusion rate was 50.5% (49/97) in hip arthroplasty and 28.5% (34/119) in knee arthroplasty. Evidence based guidelines were developed. 55% transfusions were thought to be inappropriate in the light of guidelines. Following completion of stage 2 and 3, prospective audit of blood transfusion practice was initiated. It was compulsory for the person prescribing blood to document the indication. Data was collected on a daily basis for 15 weeks. In that period 150 joint replacements were undertaken. 77 hip arthroplasty (71 primary and 6 revisions) and 73 knee arthroplasty procedures (66 primary and 7 revisions) were undertaken. Blood transfusion rates for hip arthroplasty decreased to 18% (14/77) and for knee arthroplasty to 5.4% (4/73).

Overall transfusion rates decreased from 83/216 (38.5%) to 18/150 (12%) after implementation of guidelines. This represents an overall reduction of 68%.

Conclusion: A multidisciplinary approach and putting evidence based practice in place has resulted in reduced blood transfusion rates in hip and knee arthroplasty in our institution. We feel this change is an example of implementation of evidence-based practice.

The Department of Health and the Public Health Laboratory Service established the Nosocomial Infection National Surveillance Scheme (NINSS) in response to the need to standardise the collection of information about infections acquired in hospital. This would provide national data that could be used as a ‘benchmark’ by hospitals to measure their own performance. The definition of superficial incisional infection (skin and subcutaneous tissue), set by Centers of Disease Control (CDC), should meet at least one of the following criteria: I: Purulent drainage from the superficial incision. II: The superficial incision yields organisms from the culture of aseptically aspirated fluid or tissue, or from a swab, and pus cells are present. III: At least two of the following symptoms and signs of inflammation: pain or tenderness, localized swelling, redness or heat, and a. the superficial incision is deliberately opened by a surgeon to manage the infection, unless the incision is culture-negative or b. clinician’s diagnosis of superficial incisional infection.

This study assessed the interobserver reliability of the superficial incisional infection criteria, set by the CDC, in current practice.

The incisional site of 50 consecutive patients, who underwent elective primary joint arthroplasty (Hips & Knees), were evaluated independently by four observers. The most significant results of the study I: All four observers achieved absolute agreement (kappa=1) for Purulent wound discharge and clinical diagnosis of wound infection. II: The four observers obtained good agreement for pain criteria (kappa=0.76, III: There was significant disagreement (fair to poor) between all four observers for the following criteria: Localized swelling (kappa=0.34), Redness (kappa=0.33) and tenderness (kappa = 0.05).

This is the first study to assess the reliability of the criteria, as set by the CDC and recommended by NINSS, for the diagnosis of superficial incisional infection and shows the Criterion III is not reliable and we recommend it should be revised. Failure to do so could lead to inaccurate statistics regarding hospital wound infection and detrimental effect on hospital trusts in the setting of league table.