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.
Every country has its own criteria for consent. In most, a written consent form is used to reflect patient understanding and permision for the procedure to happen. While oral consent has as much legal sway as the written consent form, the presence of a signature acts as proof of discussion. All European hospitals should have a 100% compliance with patient’s signing consent forms, but their completion is often incomplete and inaccurate, have errors of omission and have lead to litigation, poor patient understanding and recall. We (along witht the BOA) introduce an computer programme of procedure specific orthopaedic consent forms. They have been created for most common elective and trauma operations. The forms follow the UK Department of Health guidelines on consent and contain a brief explanation of the procedure, offer alternative therapies/consequences of not having the procedure (where appropriate), the serious risks and commonly occurring complications. They are written in layman’s English (aimed at a reading age of 14 years). Preliminary trials have also shown the time taken to print and complete a pre-designed form is much less than that of the current handwritten form, reducing errors of omission whilst still allowing discussion with the patient. The forms are currently available as word documents from an easily navigable website. With a view towards European usage, the forms can be easily translated to other languages at minimal cost. With support from the British Orthopaedic Association (BOA), the BOA medico-legal committee, the specialist societies and consultant users (via the website) we hope that the project will continue to evolve with a greater selection of procedural consent forms becoming available. It is believed, from the evidence available, that this approach should decrease the incidence of patient misunderstanding, and the potential risk of successful litigation, while encouraging better communication between patients and surgeons.
The aim of this study was to discover if the ulnar styloid is sufficiently consistent in size, shape and position relative to other bony features of the ulna to be used as a reference in pre-operative planning of fixation of broken bones. The comparison of size and shape (together known as form) between bones has recently been facilitated thanks to the advance of technologies designed to allow the comparison of the form of structures using anatomical landmarks. This new class of methods is collectively known as geometric morphometrics. It eliminates the differences in location and rotation of landmark through registration that minimises the sum of squared deviations from each other after scaling. This is Procrustes registration. The residual size and shape information is amenable to statistical analysis. In the present application, the registered Procrustes landmarks are used to compute a mean (reference) shape. The individuals are then compared to this mean/ reference shape. Using principal components analysis (PCA) variations in shape are not only identi-fied, but also quantified. The identification of patterns of deviation from the mean shape is considerably enhanced through the use of 3-D visualistaions of the shape variations represented by the space of the PCA. These analyses indicate that the ulnar styloid is suf-ficiently consistent in location to other anatomical landmarks that it could be used as a radiographic marker in preoperative planning. More importantly, the analysis of this study indicates that the methods of geometric morphometrics are widely applicable to the analysis of 3-D variations in morphology facilitating the analysis and comparison of radiographs. A useful future application will be in the development of 3-D reference morphologies that will allow the surgeon to compare and contrast the morphology of a radiograph of a badly broken (comminuted) bone to a standard one. Eventually computer might assist the surgeon by geometrically and visually showing how and by how much the bone needs reduction. Similarly, applications to the the virtual comparison of diseased and healthy bones might allow quantative and visual comparisons that could aid diagnosis and planning.
The British Orthopaedic Association has endorsed a website,
Our study aims were to establish correlations between the incidence of patellofemoral pain and clinical, functional and radiographic outcomes in Total Knee Arthroplasty (TKR), using the Duracon prosthesis without patella resurfacing. A consecutive cohort of 52 patients (71 knees) were reviewed at a special follow up clinic at a mean of 29 months. All operations were carried out by a single surgeon or under his direct supervision using a standard procedure. Patients were evaluated clinically and asked directly if they had anterior knee pain. American Knee Society Scores (AKSS) and knee alignment were assessed and patients completed SF-12 and WOMAC questionnaires. Standardised 45 degree skyline and standing lateral radiographs were taken and assessed by a single blinded observer, and patella tilt and displacement measured using Gomes’ method, and patella height measured using the Insall-Salvati ratio. Knees with patellofemoral pain underwent triple phase bone scintigraphy using Technetium 99m-MDP with vascular, blood pool and static (3 hour) imaging. Significant patellofemoral pain was identified in 8 knees (11%), in 6 patients. This group had a reduced mean AKSS compared to knees without patellofemoral pain, although 50% still had a good to excellent outcome as judged by the AKSS. Only 2 knees with patellofemoral pain had abnormal alignment (2 and 12 degrees valgus). The mean SF-12 and WOMAC scores did not differ significantly between knees with patellofemoral pain and those without. Patella tilt and displacement were a common finding in this cohort, and could be as great as 17 degrees and 30% respectively without patellofemoral dysfunction. Paradoxically the mean values for these parameters were found to be reduced in knees with patellofemoral pain. Patella height did not substantially vary between knees with patellofemoral pain and those without. Bone scintigraphy of 7 of the knees with patellofemoral pain revealed a spectrum of activity from complete normality (3 knees) to tricompartmental increase in activity (2 knees). Increased activity localised to the patellofemoral articulation was evident in 2 knees. We conclude that despite favourable overall results, the Duracon prosthesis fails to eliminate patellofemoral pain without patella resurfacing. This conflicts with excellent reported results using this anatomic prosthesis with patella resurfacing. The presence of patellofemoral pain correlates well with a poor AKKS, but the role of plain radiography and bone scintigraphy as investigative tools remains unclear.
