Patients seek more and more actively compensation for treatment injuries, accidents, infections, and even because of unsatisfied results. Injuries or mistreatment are quite frequently seen in orthopaedic surgery, because operations are increasing and unsatisfactory results can be easily recognised from radiographic documentation.

Compensation can be theoretically sought by three main routes: directly from the orthopaedic surgeon or his insurance company, secondly, from the institution where he is working (or its insurance company) and thirdly, from a statutory system if there is one available. The first two direct compensation mechanisms are based on direct link between the patient and the physician involved. A statutory system can be universal and act more as a no fault compensation system.

Statutory patient insurance was introduced in1987 in Finland (Patient Insurance Act). This act covers all medical treatment, both public and private care in Finland including examination, surgical and nonoperative treatment, inpatient ward treatment, physiotherapy, rehabilitation as well as patient transportation.

All hospitals and companies dealing with medical care need to be insured. The institutions or companies responsible of the medical work owe the policyholder status. Therefore workers in the medical field need not to make their own insurance agreements nor pay any insurance fees to the companies.

The Finnish Patient Insurance Centre handles all claims in Finland, about 7.000 cases yearly, of which about 2.000 will give compensation to the patients. An independent Patient Injury Board stated by the Ministry of Health supervises the Centre.

So far, orthopaedics and traumatology has been the leading speciality in producing injuries. The injuries are divided into six subgroups: 1) treatment injury, 2) infection, 3) equipment-related injury, 4) accident related injury, 5) wrong delivery of pharmaceuticals and 6) unreasonable injury (severe complication with permanent disability after accurate treatment).

The evaluation of patient injury is concentrated on the case itself. The personnel involved to the treatment will not be accused or sued whenever a patient injury has been recognised. This no-guilt principle has been adopted well in Finland.

In the treatment injuries the level of acceptable care is determined by standard of an experienced professional of that speciality he/she represents. That means that an orthopaedic operative or diagnostic procedure will be evaluated compared to the level, which a graduated and experienced orthopaedic surgeon could have normally reached. Infection injuries are considered acceptable and do not lead to compensation when being superficial, or if a deep infection heels within a couple of weeks or months with adequate treatment and without any permanent disability. Traumatic accidents are quite rare as well as breakage of medical equipment and error of delivery of pharmaceuticals in pharmacies. Unreasonable injuries are seen a few yearly.

The prerequisite for compensation is that there has to be an objectively recognised harm to the patient due to a diagnostic or treatment procedure. Patient insurance covers the following costs: 1) medical treatment expenses, 2) other necessary expenses caused by the injury, 3) loss of income on maintenance, 4) pain and suffering, 5) permanent functional defect, and 6) permanent cosmetic injuries.

In 2004 the total costs of compensation paid was 24.2 million e (public health care 88% and private health care12%).

The yearly claim and compensation data is used for comparative analysis between the hospital districts and given also to the medical and surgical societies in order to enhance medical knowledge and skills and prevention of similar injuries in the future.

Patients owe still the possibility to sue the hospital or doctors involved. However, these cases will be normally handled by the Patient Insurance Centre and not by the medical personnel individually. In fact, the amount of trials against medical units or personnel has diminished dramatically after adoption of the Patient Insurance Act in Finland.

We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations.

Our results suggest that the use of the proximal femoral nail may allow a faster postoperative restoration of walking ability, when compared with the dynamic hip screw.

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The Act for Patient Injuries came into force on May 1987 in Finland. This Act covers all medical treatment, both public and private care in Finland including examination, surgical and non-operative treatment, physiotherapy, rehabilitation as well as patient transportation. The Finnish Patient Insurance Centre handles all claims in Finland, about 6.000 cases yearly, of which about 1.700 will give compensation to the patients. So far, operative treatment in orthopaedics and traumatology has produced most injuries. The Centre is supervised by an independent Patient Injury Board stated by the Ministry of Health. The injuries are divided into three subgroups: 1. treatment injuries, 2. injuries caused by infection and 3. true traumatic accidents. In addition, there is a special pool for medicine induced side effects or injuries which is organized in cooperation with pharmaceutical companies selling drugs in Finland.

All evaluation of each individual case is based on probability. If there is more than 50% probability between the suspected treatment phase and injury the precondition for compensation is present.

Moreover, the evaluation is concentrated to the case itself and the personnel involved will not be accused or sued whenever a patient injury has been recognised. This no-guilt principle has guaranteed that most of the injuries have been reached and evaluated by the Patient Insurance Centre. All the 18 hospital districts in Finland covering both common health services and hospital care have their own policyholder status. Total expenses, both compensation and administrative, will be charged from the districts with a non-profit principle. Private hospitals and smaller units have their own contracts with insurance companies, and medical and dental unions have contracts of their own for individually working physicians and dentists.

The prerequisite for compensation is that there has to be an objectively recognised and measurable harm to the patient due to a diagnostic or treatment procedure. In the treatment injuries the level of acceptable care is determined by standard of an experienced professional of that speciality he/she represents. That means e.g., that an orthopaedic operative or diagnostic procedure will be evaluated compared to the level which a graduated and experienced orthopaedic surgeon could have normally reached. Infection injuries are considered acceptable when being superficial, or if a deep infection heels within a couple of weeks or months with adequate treatment and without any permanent disability. Traumatic accidents are quite rare. These are for example all injuries caused by broken medical equipment, falling of the patient during examination or treatment etc. However, it does not cover falling of the patients if this occurs during the hospital stay while no medical treatment is given.

The yearly claim and compensation data is used for comparative analysis between the hospital districts and given also to the medical and surgical societies in order to enhance medical knowledge and skills and prevention of similar injuries in the future.

Since 1989 we have treated most rotationally or vertically unstable pelvic fractures operatively. An anterior extra peritoneal approach has been used to achieve access to all parts of the anterior ring. This can be combined with the lateral approach on the iliac wing or with posterior approach for the SI and sacral lesions. The extra peritoneal midline approach is created through a 10–15 cm long midline incision beginning from the symphysis. The rectus muscles are not detached. Blunt preparation along the superior ramus gives more space laterally and reveals the obturator foramen. The corona mortis vessels are ligated. The iliac vessels, femoral nerve and the psoas muscle can be gentle elevated with a long hook. The eminential area, linea terminalis as well as the quadrilateral space are then visualised. All essential fragments can be reduced and fixed with plates and screws.

Our study of 101 patients with an unstable pelvic ring (68 rotationally and vertically unstable injuries, 21 lateral compression injuries and 12 open book injuries) showed excellent or good reduction in 88, fair in 11 and poor in 2 cases. The overall functional results were excellent or good in 83, fair in 13 and poor in 5 patients. The correlation between anatomical reduction and good functional result was clear.

Our experience and new data strongly support the use of ORIF in Type C pelvic ring injuries, in Type B- open book injuries, and in markedly displaced Type-B lateral compression injuries. Good reduction and a reliable stability can be achieved. Moreover, short postoperative morbidity and hospital stay as well as full weight bearing after 4 to 8 weeks resulted after adopting ORIF in pelvic fractures. External fixation is still used by us as a temporary bleeding control device before the final operative treatment when the bleeding is considered significant.

Aims: In the present study we evaluated short-term outcome of complex proximal tibial fractures treated with hybrid external þxation. Methods: A retrospective evaluation of 33 tibiae in 31 patients treated with hybrid external þxation; 9 (27.2%) AO type A metaphyseal and 24 (72.8%) type C bicondylar intraarticular proximal tibial fractures. Majority of the fractures (58.1%) were due to high-energy trauma and open fractures constituted 18.2% of all fractures. Percutaneous pinning combined with indirect reduction techniques was used in 14 (42.4%) cases. Mini-open clamp reduction and screw þxation was applied in 12 (36.4%) operations. Open reduction, reconstruction of articular surface, bone-grafting and screw þxation combined with the hybrid frame was used in 7 (21.2%) patients. Results: Uneventful consolidation without complications occurred in 13 (39.4%) patients. The mean time to bony fusion was 18 ± 6.6 weeks. However, in 21.2% of the patients the fracture had not consolidated by 24 weeks. There were 5 (20.8%) primary re-operations due to malreduction of a type C fracture. In addition 3 (33.3%) type A metaphyseal fractures were re-operated upon due to non-union by 24 weeks. Two (6.1%) fractures united in axial malalignment and required an osteotomy. Conclusions: Our þndings suggest that due to high rate of unsatisfactory reductions, hybrid external þxation may not be the method-of-choice in þxation of displaced intra-articular proximal tibial fractures. It may be indicated in þxation of high energy metaphyseal fractures, but includes a signiþcant risk of delayed consolidation.

Aims: Meniscus repair has become the procedure of choice for the treatment of meniscal tears whenever possible. However, problems with healing of the repaired meniscus do exist. We have assessed both clinically and with MRI the outcome of meniscal ruptures treated with bioabsorbable arrows. Methods: 74 consecutive patients with 80 longitudinal vertical meniscal tears were treated using polylactide meniscus arrows (Bionx Implants Ltd, Tampere, Finland) during a three year period. Half of the patients had an old meniscal tear (> 6 weeks). The average length of the follow-up was 25 months (range, 6–56 months). The patients who had not received secondary surgery for failed repair during the follow-up period were examined clinically and with MRI. Results: 56 out of 80 meniscal ruptures (70%) healed clinically. However, in 7 of these asymptomatic patients the MRI showed partial healing. In repairs performed in conjunction with ligament reconstruction the healing rate was higher (82%) than in the isolated tears (62%). The poorest results were seen in the very long vertical tears with luxation of the meniscus (43% healing rate). Conclusions: Bioabsorbable arrows offer a good alternative for the treatment of meniscal ruptures, but special attention should be payed on the reliability of the þxation. In long and unstable tears we suggest combined þxation techniques to be used; arrows for the þxation of the posterior horn and inside-out sutures for the corpus area.

Aims: To evaluate the outcome after early angiographic embolization in pelvic ring injuries associated with massive bleeding. Methods: We evaluated prospectively 32 consecutive patients. Special attention was paid to the þndings in angiography, the reliability of embolization, and the þnal result (survive or death). The causes of deaths were evaluated as well as the parameters correlating to this. Results: Angiography showed an isolated arterial injury in 16 (50%) and multiple arterial injuries also in 16 patients (50%). 9 patients had bilateral bleeding. Internal iliac artery and/or its main branches was the source of bleeding in 27 (85%), external iliac artery or its main branches in 2 (6%), and branches of both internal and external iliac arteries in 3 patients (9%).

The embolization was successful in all cases. 11 patients (34%) died. The early deaths (< 24h) were the result of massive bleeding in 4 out of 5 patients. One died to cardiac failure. Six late deaths were the result of MODS. All the died patients had more than one bleeding artery, and 6 had bilateral bleeding. The non-survivors had more severe injuries (mean ISS 51) and were older (mean age 50,2 yrs) than the survivors (mean ISS 41; mean age 43,9 yrs). Conclusions: Angiographic embolization is an effective and life saving procedure. It should be considered in hypotensive patients with unstable pelvic ring injuries who remain haemodynamically unstable following adequate resuscitation with component therapy and external þxation.

Aims: To evaluate technical and clinical results of a new 2-incision technique of rotational acetabular osteotomy. Methods: 27 patients, with a mean age of 40 years, were reviewed after a minimum of 1 year subsequently to rotational acetabular osteotomy, which was done through short low midline and iliac approaches. An analysis of complications, the length of rehabilitation period, time to union of the osteotomy, radiographic correction of acetabular roof, proceeding of hip arthrosis, as well as of clinical status at follow-up, using scores by Merle DñAubigne and Harris, was performed. Results: No major operative complications were observed. The median time to union of osteotomy and a painless status was 10 weeks. Femoral head covering by acetabular roof increased signiþcantly, whereas the range of motion of the operated hip was not compromised by the operation. A signiþcant increase in the mean scores, mainly caused by a decrease in pain, were observed in a subgroup of 20 patients with a minimum follow-up of 2 years. The most signiþcant factor predisposing poor outcome was grave preoperative arthrosis of the hip. Conclusions: This new technique of osteotomy is safe and less traumatic than previous methods, allowing early weight bearing and a fast recovery. The early clinical results are satisfactory

Aims: This presentation deals with our clinical experience based on experimental studies when using bioabsorbable fixation devices in bone, joint and ligament surgery. These devices were clinically introduced by us in the treatment of fractures in the extremities in the mid – 1980’s. Our own list of publications consists of 1137 publications since 1978 including, 26 academic dissertations. Before and during our clinical studies over 6500 animals were operated on in our experimental studies. Macroscopic, radiographic, microradiographic, histologic, histomorphometric and fluorochrome studies were done. Methods: The strength, strength retention, degradation, bone changes, healing of fractures, and injuries, and the fixation properties of the implants were investigated in vivo. Results: In Kuopio (814) and in Helsinki (3555) 4369 operations were done using bioabsorbable self-reinforced (SR) fixation implants mainly polyglycolide or poly-L-lactide during 1984–2001. In Helsinki there were 2766 trauma operations and 789 orthopaedic operations. The postoperative clinical course was uneventful in 82% of the patients. The complications included wound infection in 4.0%, failure of fixation in 3.9%, a non-infectious foreign-body reaction (sinus) in 1.9% (with SR-polyglycolide implants) but not with SR-polylactide implants. Conclusions: Due to the biodegradibility of the devices, implant removal procedures were avoided.

Aims: A series of pelvic bone tumors with special reference to innovative operative procedures were examined. Methods: The series consisted of all patients treated surgically for pelvic bone tumors between 1981–2001. Results: There were 65 benign and 120 malignant tumors. Of the 65 benign tumors most were only biopsied or resected. Reconstructive methods were needed 16 cases, mostly they were cysts in the acetabular region that were þlled with cancellous bone.

48 of the malignant bone tumors were more than just biopsied. 32 were only resected, four hemipelvectomies were performed. 12 resections with reconstruction were done, þve times with endoprostheses, three times with PMMA, three times with bone grafting and once with osteosynthesis. The endoprosthetic solutions included two large pelvic reconstructions. Two large defects in the posterior pelvic ring were reconstructed with autogenous þbular grafts.

Pelvic rings left open after resection were susceptible to fatigue fractures, these cases were all treated conservatively. Large anterior reconstructions were reinforced with meshes to prevent herniation. Conclusion: In selected cases good function and stability is possible after large pelvic ring resections

We reviewed 110 patients with an unstable fracture of the pelvic ring who had been treated with a trapezoidal external fixator after a mean follow-up of 4.1 years. There were eight open-book (type B1, B3-1) injuries, 62 lateral compression (type B2, B3-2) and 40 rotationally and vertically unstable (type C1-C3) injuries.

The rate of complications was high with loss of reduction in 57%, malunion in 58%, nonunion in 5%, infection at the pin site in 24%, loosening of the pins in 2%, injury to the lateral femoral cutaneous nerve in 2%, and pressure sores in 3%. The external fixator failed to give and maintain a proper reduction in six of the eight open-book injuries, in 20 of the 62 lateral compression injuries, and in 38 of the 40 type-C injuries. Poor functional results were usually associated with failure of reduction and an unsatisfactory radiological appearance. In type-C injuries more than 10 mm of residual vertical displacement of the injury to the posterior pelvic ring was significantly related to poor outcome. In 14 patients in this unsatisfactory group poor functional results were also affected by associated nerve injuries. In lateral compression injuries the degree of displacement of fractures of the pubic rami caused by internal rotation of the hemipelvis was an important prognostic factor.

External fixation may be useful in the acute phase of resuscitation but it is of limited value in the definitive treatment of an unstable type-C injury and in type-B open-book injuries. It is usually unnecessary in minimally displaced lateral compression injuries.

We reviewed 27 patients with small-fragment fractures or osteotomies treated by internal fixation with absorbable self-reinforced poly-L-lactide pins. The follow-up time ranged from eight to 37 months. The two most common indications were chevron osteotomy of the first metatarsal bone for hallux valgus and displaced fracture of the radial head. No redisplacements occurred, and there were no signs of inflammatory foreign-body reaction. Biopsy in two patients 20 and 37 months after implantation showed that no polymeric material remained.

Biodegradable rods of polyglycolide or lactide-glycolide copolymer were used in the internal fixation of a variety of fractures and osteotomies in 516 patients. A clinically manifest foreign-body reaction occurred in 41 patients (7.9%), producing a fluctuant swelling at the implantation site after an average of 12 weeks. Spontaneous sinus formation or surgical drainage yielded a sterile exudate containing liquid remnants of the degrading implants. After prompt drainage this discharge subsided within three weeks. Histological examination showed a typical nonspecific foreign-body reaction with abundant giant cells both in patients with the reaction and in some patients with an uneventful clinical course. The factors determining the nature of the reaction were probably related to the local capacity of the tissues to clear the polymeric debris. The reactions did not influence the clinical or radiographic results, but recognition of the incidence and the features of the reaction is necessary in view of the increasing use of such implants.

Fifty-six patients with displaced malleolar fractures had open reduction and fixation of the fracture fragments using, by random selection, either biodegradable implants or metal AO plates and screws. The cylindrical biodegradable implants were made of polylactide-glycolide copolymer (polyglactin 910). The complications, radiographic results and functional recovery were studied prospectively. After follow-up of at least one year, no significant differences emerged in the complication rate or in the results of treatment between the two methods of fixation. Because of the advantage of avoiding the need to remove metal fixation after union, we now use biodegradable internal fixation routinely to treat displaced malleolar fractures.