Volume 02 / Issue 03 / August 2014 â boa.ac.uk ... Information Act and was extracted ... costs. Litigation specifically relating to arthroscopic knee surgery was.
l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 39
JTO Peer Reviewed Articles
Litigation claims following arthroscopic knee surgery Will Harrison Contributors: Graeme Wilson, K. Henry Rourke, Joanne Banks
Litigation claims within orthopaedic surgery are the fifth most frequent of all medical specialties1 and are becoming more common in England and Wales2. Orthopaedics accounts for over 40% of litigation across all surgical specialties3. Compensation for proven negligence is awarded on the basis of pain, suffering and loss of amenity as well as the financial losses to the claimant. Surgery of the knee is widely practiced and has a high commercial value. A recent five centre doubleblinded RCT of partial arthroscopic meniscectomy versus sham surgery showed no statistical improvement within the first 12 months4. Despite this, arthroscopic knee surgery is becoming more frequent annually5. There are an estimated 700,000 knee arthroscopies performed each year in the United States of America, with a combined cost $4 billion6. In addition, litigation in the USA has become a major cost and burden to healthcare providers7.
The National Health Service has an established Litigation Authority (NHSLA), founded in 1995, which acts as a mediator for all malpractice claims in England and Wales. All hospital trusts are mandated to provide the NHSLA with details on litigation proceedings. The NHSLA estimated potential liabilities of £16.6 billion across all areas of healthcare8. Previous literature from McWilliams et al on litigation claims following hip and knee arthroplasty surgery have demonstrated significant costs. Over a 15 year period there were 523 claims for knee replacement which cost £21 million9. The current paper analyses the same NHSLA database over the same 15 year period. The British Orthopaedic Association has commented that rising litigation costs are no longer sustainable for the modern NHS10. Our aim was to identify patterns of litigation within arthroscopic knee surgery and provide learning points to protect clinicians from malpractice claims.
Methods Will Harrison
Data was obtained through the NHSLA using the Freedom of
Information Act and was extracted in July 2013. There were 9,865 orthopaedic litigation claims between 1995-2010 within England and Wales available for analysis. The NHSLA database contains a case narrative with a synopsis of the claimants’ complaint. It also details the date of alleged negligence, the date of claim creation, the compensation award and defence costs. Litigation specifically relating to arthroscopic knee surgery was identified within the case narratives using search terms relating to arthroscopy and cruciate ligament reconstruction. Unsettled cases were excluded. Patterns of litigation, subsequent compensation and defence costs were analysed.
Results There were 342 claims relating to arthroscopic knee surgery of which 217 have been settled and are therefore eligible for inclusion in this series. Of these, 125 (58%) were deemed negligent resulting in compensation. Anterior cruciate ligament reconstruction was implicated in 71 cases (33%). A classification of the claim profiles is detailed in Table 1, ranked according to the cumulative cost to the NHS. The sum total of compensation and defence costs was £10 million. The mean compensation per claimant was £47,440 (median £20,000, range £500–£1,270,666). Total defence costs were £4.1 million with a mean cost per case of £18,783, (range £0-180,540).
Conclusions The cumulative cost of over £10 million demonstrates that arthroscopic knee surgery carries a significant litigation burden. McWilliams et al demonstrated that knee arthroplasty resulted in more than twice the number of litigation claims (n=538) than in this series of knee arthroscopy claims (n=217)9. Both papers analyse the same NHSLA database over the same 15 year period. The majority of negligence claims result from events in the intraoperative period. A single case of popliteal artery injury during arthroscopy resulting in amputation had cumulative cost of £1.45 million. Vascular injuries were also the most costly per case in the McWilliams et al arthroplasty litigation paper9. There were five incidences of wrong site surgery. One episode related to an anaesthetist placing the tourniquet and shaving the leg on the incorrect side whilst the surgeon scrubbed. Focused team engagement in the WHO checklist is paramount in preventing “Never Events”. Surgeons are also urged to review the National Patient Safety Guidelines for limb marking preoperatively (www.npsa.nhs.uk). Consenting issues (n=7) related to further procedures being performed without informed consent, for example unplanned microfracture for osteochondral
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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 40
JTO Peer Reviewed Articles
© 2014 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 02, Issue 03, pages 39&40 Title: Litigation claims following arthroscopic knee surgery Author: Will Harrison
Number
Cumulative cost (£)
Mean (£)
Median (£)
ACL failure (non-specific)
18
1,469,000
75,400
67,000
Vascular injury
1
1,450,000
1,450,000
1,450,000
ACL graft failure
13
1,413,000
109,000
44,000
Infection
13
1,400,000
108,000
85,000
Nerve injury
11
920,000
84,000
64,000
Graft harvest injury
3
676,000
225,000
244,000
Unknown
7
445,000
64,000
25,000
Failure to follow-up
4
444,000
111,000
7,000
Retained metal
11
279,000
25,000
13,000
Burns
7
242,000
35,000
12,000
Consent
7
200,000
24,500
15,000
Delayed diagnosis
5
182,000
36,000
19,000
Missed diagnosis intra-op
3
127,000
43,000
14,000
Pain (non-specific)
5
120,000
24,000
14,000
Wrong site surgery
5
98,000
20,000
13,000
Carbon fibre graft
1
98,000
98,000
98,000
Deep vein thrombosis
2
50,000
25,000
n/a
Tourniquet damage
3
35,000
12,000
5,000
Compartment syndrome
1
31,000
31,000
31,000
Scarring
1
2,000
2,000
2,000
Unsterile equipment
1
500
500
500
Table 1: Litigation claims following arthroscopic knee surgery defects. Obtaining consent on the ward and in preoperative waiting areas has been shown to increase the risk of litigation compared to clinic (p
