What can be done to reduce the rise in orthopaedic negligence claims?

The reasons for orthopaedic claims are wide-ranging, but usually arise from the patient having an unsatisfactory outcome. This can range from postoperative pain and infection to permanent nerve damage, amputation, and in some cases death.

There are some key recurring themes, however, and a review of historic orthopaedic claims against the Medical Defence Union (MDU) relating to private treatment listed the following reasons for claims:  postoperative complications, delayed diagnosis, intraoperative complications and consent.

• Postoperative complications: This consistently makes up the largest number of claims. Infection, poor wound healing, blood clots, and nerve damage are common postoperative complications but if they are not managed appropriately these tends to lead to claims.
• Delayed diagnosis: Allegations of delayed diagnosis or referral are also common and include missed or delayed diagnoses of tendon ruptures, sarcoma, vascular necrosis, ligament/cartilage tears, spinal and other fractures, osteomyelitis, dislocations and nerve damage.
• Intraoperative complications: A not-insignificant number of claims arise from problems during the course of a procedure. These include: equipment or other foreign body left in the patient after surgery, chemical or diathermy burns, scarring or nerve damage, incorrect equipment used or the lack of available equipment resulting in surgical procedures being abandoned, delayed treatment and additional procedures required. Other claims involve severe bleeding due to perforation or puncture injury, nerve damage, due to poor operative technique, intraoperative fractures and non-union of fractures due to poor surgical technique, for example, mal-positioning.
• Consent: This is a common theme in all areas of medicine and it is no surprise therefore that many claims are centred around the failure of practitioners to fully inform patients about the risks of surgery, especially in complex procedures.

As far as orthopaedic claims are concerned the risk of a worse outcome or long-term damage, including nerve damage, is a key theme together with allegations that patients consented to unnecessary procedures where symptoms were likely to resolve with conservative management rather than surgical intervention.

Claims involving orthopaedic surgery are made for a wide variety of reasons, but there are some common risk factors, which, if managed appropriately, can help to reduce risks:

• Better communication with patients. Provide patients with detailed information on all treatment options verbally and in writing, and make sure they have appropriate time to make a decision.
• Better communication between staff. Promoting a culture of teamwork, open communication, and mutual respect within orthopaedic departments. Multidisciplinary team meetings, case reviews, and regular handovers should be the norm to ensure continuity of care.
• Consider more conservative treatment options, and whether all avenues have been exhausted before recommending invasive procedures to patients – particularly in spinal or joint replacement surgery.
• See the patient ‘as a whole’ not just the isolated issue at hand. This includes consideration of comorbidities and psychological factors.
• Give appropriate safety netting and post-operative advice so the patient knows in what circumstances to return for further advice and have a low threshold for early intervention when issues arise.
• Make sure that the full range of equipment and necessary components are available and are the correct components for that patient before surgery.
• Implement clear, evidence-based protocols for common orthopaedic procedures to reduce variability in care, including checklists, standardised diagnostic processes, and decision-making frameworks that are regularly reviewed and updated.
• Finally, encouraging clinicians to acknowledge mistakes when they occur and report them through incident reporting to lead to a better understanding of what went wrong and how to prevent it in the future.

Looking at these, the biggest single factor seems to be communication and while the incidence of clinical negligence claims in orthopaedics continues to be high, a focus on better communication all-round could help reduce the frequency of these claims and ultimately improve patient care outcomes.