AAOS Bulletin - October, 2005

Reviewing the CORR medicolegal issues symposium

By John Harp, MD

The April 2005 issue of Clinical Orthopaedics and Related Research (CORR), sponsored by the Association of Bone and Joint Surgeons, included several papers as part of a symposium addressing Medicolegal Issues in Orthopaedics.1 Several components of risk management wove a common thread in the symposium articles:

• Orthopaedic surgeons must keep up-to-date in all relevant clinical areas.

• The doctor-patient relationship and communication are the foundation of risk management.

• Wrong-site surgery is avoidable with current protocols.

• Documentation provides a “safety net” when litigation does occur.

After setting the stage by reprinting a chapter from Blackstone’s “Commentary on the Laws of England,” CORR provided a wide range of articles, which are briefly abstracted below regarding key points for risk management.

The trial bar viewpoint

If you believe the proverb “know thine enemy,” this paper, “An Overview of Medical Malpractice Litigation and the Perceived Crisis,” by S. Gerald Litvin, Esq., is a must-read.

The defense counsel’s perspective

In their article “The Defense Counsel’s Perspective,” Peter J. Hoffman, Esq.; Joan D. Plump, Esq.; and Marcie A. Courtney, Esq., note that the doctor-patient relationship is a crucial component of risk management. A strong relationship may diminish the chance of litigation in the face of a poor outcome.

Other essential components for a successful defense include staying informed of recent developments in your area of practice and keeping appropriate documentation.

Wrong-site surgery

The AAOS “Sign Your Site” protocol can prevent this uncommon but devastating complication, says author S. Terry Canale, MD, in “Wrong-site Surgery: A Preventable Complication.” A time-out in the operating room before the anesthetic is administered to verify patient identification, positioning, operating team preparedness, equipment, implants and availability of manufacturer’s technical assistance is essential. The time-out should be documented.

Trauma

In “Orthopaedic Trauma for the General Orthopaedist: Avoiding Problems and Pitfalls in Treatment,” authors Steven A. Olson, MD, and Anthony S. Rhorer, MD, note that the American College of Surgeons’ Advanced Trauma Life Support system is widely accepted as a standard for early care of the trauma patient. However, a similar system does not exist for orthopaedic treatment of trauma patients. The Eastern Association for the Surgery of Trauma algorithm for the assessment of spinal trauma2 can be followed for a methodical approach to all spinal injuries and may even reduce legal exposure in the event of a missed diagnosis.

A patient with an open fracture requiring staged reconstruction should be counseled early about the possible complications, and these conversations should be documented in the medical record. Clinical findings from physical exam should be documented in enough detail that another physician examining the patient can determine if a compartment syndrome is developing. Regional anesthetics should be used with caution in situations where there is a concern of compartment syndrome because resulting peripheral vasodilatation may affect compartment pressures.

Sports medicine

Two articles examined medicolegal issues in sports medicine: “Medicolegal Issues in Sports Medicine” by Alison K. Sanders, BS; Blake R. Boggess, DO; Scott J. Koenig, BA; and Alison P. Toth, MD; and “Medicolegal Issues Affecting Sports Medicine Practitioners,” by Albert W. Pearsall IV, MD; John E. Kovaleski, PhD, ATC; and Sudhakar G. Madanagopal, MD.

The leading causes of sports-related death in high school athletes are cervical spine injury, cardiac conditions and heat injury. Action plans for medical emergencies on both the competitive and practice fields should be in place; furthermore, periodic practice drills using the plan are needed. Having automated external defibrillators readily available is encouraged.

Recent thought in the treatment of heat injury is that ice baths may increase skin vasoconstriction and decrease heat transfer from the body core.

The American Academy of Neurology classification is a valuable resource for evaluation and triage of concussion injuries. If a player is transferred to a hospital, it is important to communicate directly with the emergency room physicians about the players’ mental status at the time of injury. Transient quadriplegia is a rare injury and the return to play consideration is complex.

Oddly enough, the physician can be a litigation target when an athlete is disqualified from play, especially if a college or professional career is at stake.

Shoulder injuries

Lawrence D. Higgins, MD, covered the “Medicolegal Aspects of Orthopaedic Care for Shoulder Injuries.” He points out that anterosuperior escape of the humeral head after shoulder surgery is a debilitating complication that can be avoided with proper patient selection and detailed knowledge of the pathology and treatment options.

Hand conditions

According to Allen P. McDonald III, MD, and Gary M. Louire, MD, in “Complex Surgical Conditions of the Hand: Avoiding the Pitfalls,” high-risk diagnoses include compartment syndrome, flexor digitorum profundus avulsions, and pediatric phalangeal neck fractures. This article includes an excellent review of the decompression technique for the 10 hand compartments. The authors also point out that endoscopic carpal tunnel release has a steep learning curve and should only be attempted by surgeons very familiar with the open techniques.

Hip and knee arthroplasty

This paper on the “Medicolegal Aspects of Hip and Knee Arthroplasty” by David E. Attarian, MD, and Thomas P. Vail, MD, lists in detail the documentation requirements for all stages of care for arthroplasty patients to avoid common or high-exposure pitfalls. Documentation of the standard of care along with quick diagnosis and treatment of catastrophic complications is the best defense if litigation follows these difficult situations.

Foot and ankle

When patient expectations exceed the probable treatment outcome, litigation can ensue, notes Mark E. Easley, MD, in “Medicolegal Aspects of Foot and Ankle Surgery.” Common examples are arthritis after a Lisfranc injury or the development of Charcot neuroarthropathy in a diabetic patient after minor trauma.

Even ankle sprains can result in unmet expectations if patients are not educated about the possibility of associated injuries (osteochondral lesions or syndesmosis injuries, to name a few) that can delay recovery. Failure to diagnose peripheral vascular disease before surgery can lead to litigation because the foot does not have adequate reserve for healing.

References

1. Levin LS, ed. Section I, Symposium: Medicolegal Issues in Orthopaedics. Clin Orth Rel Res 433: 2-81, 2005

2. http://www.east.org/tpg.html


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