Expert Perspectives – Understanding Medical Malpractice With Total Hip Replacements

Total hip arthroplasty is widely regarded as one of the most successful orthopedic procedures in terms of patient satisfaction. Pain relief, improved functional independence, and better quality of life are almost always achieved. Nearly a half-million of these procedures are done annually in the United States alone; and the number is increasing steadily with the increased functional demands of our aging population. As with other surgeries, there are no “written down” standards for what is an acceptably well-done total hip arthroplasty and, as expected, the malpractice claim rate is very low. A study from the Netherlands looking at hip arthroplasty malpractice claims from 2000 to 2012, shows the incidence of a claim was less than 0.3 percent.

In a study from the Netherlands looking at hip arthroplasty malpractice claims from 2000 to 2012, the incidence of a claim was less than 0.3 percent. In a 2000 survey of 749 American Association of Hip and Knee Surgeons (AAHKS) members, the five most common sources of claims in which the member was named as the malpractice defendant were, in order of decreasing frequency, the following: nerve injury, leg length discrepancy, infection, vascular injury, and instability. Given the fact that most AAHKS members are doing more knee than hip replacements; it is likely that many of the nerve injuries and most the vascular injuries were related to knee replacement surgery. We can now look separately at these major complications.

In the AAHKS study, over 40 percent of the claims were dismissed and almost 15 percent were still pending. Suggesting, for instance, that not all nerve injuries are the same. Obviously, a dense sciatic nerve injury showing no signs of motor recovery at six months is much more likely to be compensated than transient foot tingling. Both of these examples would qualify as a “nerve injury,” however.

Many times, claims are bundled. Leg length discrepancy is frequently required to achieve hip stability. But severe leg length discrepancy can be associated with nerve injury. A greater than two-centimeter leg length discrepancy requiring an external shoe lift to avoid lumbar spine problems and gait abnormalities is much more of an issue than a one-centimeter leg length discrepancy which can be managed with a heel cup. As a reference, the average leg length discrepancy after total hip arthroplasty is approximately five millimeters. Similar to population norms and certainly not compensable. With childhood disorders such as hip dysplasia, it is frequently impossible to correct leg lengths to within two centimeters. Physician-patient communication is obviously very important in these complex cases so expectations remain realistic. The physician should never promise the patient that leg lengths will be equal after a total hip arthroplasty.

With childhood disorders such as hip dysplasia, it is frequently impossible to correct leg lengths to within two centimeters. Physician-patient communication is obviously very important in these complex cases so expectations remain realistic. The physician should never promise the patient that leg lengths will be equal after a total hip arthroplasty.

Infection is one of the most dreaded complications of any arthroplasty procedure. As it frequently requires multiple subsequent surgeries to reach an acceptable result. Infection can be post-operative or remote. Post-operative infection usually presents with continued wound drainage, with or without fever. Management consists of head and liner exchange along with thorough washout of the hip joint.

Misdiagnosis of infections here is rare. However, delay in treatment can lead to increased risk of infection reoccurrence and associated surgical morbidity. Remote infection commonly results from the spread spread from of bacteria from another source such as gum disease or diverticulitis. Pain without wound trouble is the most common initial complaint of infection, and misdiagnosis is unfortunately much more common. The resulting delay in definitive treatment is the primary source of litigation in these cases. In other words, dDetailed documentation of history and physical exam findings along with early diagnostic lab testing and surgical management are key to successful proof of surgeon diligence and litigation defense.

Remote infection commonly results from the spread from of bacteria from another source such as gum disease or diverticulitis. Pain without wound trouble is the most common initial complaint of infection, and misdiagnosis is unfortunately much more common. The resulting delay in definitive treatment is the primary source of litigation in these cases. In other words, dDetailed documentation of history and physical exam findings along with early diagnostic lab testing and surgical management are key to successful proof of surgeon diligence and litigation defense.

Dislocation rates after total hip arthroplasty have improved in recent years. This is following the widespread adoption of larger femoral head sizes and the increased popularity of alternative approaches; particularly the direct anterior approach. Advances in robotic-assisted surgery may also eventually improve dislocation rates. However, mMost reports still consider the lifelong risk of dislocation between 2 percent and 3 percent though with the highest incidence in the first six weeks after surgery. Once a dislocation occurs, the risk of subsequent dislocations is much higher due to the loss of capsular restraints. Placing blame on the surgeon versus the patient after a dislocation can be difficult.

For instance, a relatively violent dislocation in a patient 10 years post-operative who is involved in a motor vehicle collision can hardly be considered the surgeon’s fault. Multiple dislocations during activities of daily living within the first several weeks of surgery, however, raises concerns for component malposition, change in component position, or poor patient selection such as a stroke patient with residual operative-sided paralysis. These patients may be poor candidates for arthroplasty; because they lack hip muscle control which is essential to maintain compression of the femoral head into the acetabular cup. Patients with psychiatric disorders, mental disabilities, or alcoholism may also be poor candidates for hip arthroplasty because they may be unable to follow post-operative positional precautions.

One can easily see from these examples that most litigation cases after hip arthroplasty are not straightforward. Early or multiple reoperations result in more patient (and surgeon) suffering, but outcomes after many reoperations can still be excellent with way better function than initial preoperative status. Whether or not the additional patient suffering is compensable may have a lot to do with the surgeon’s attitude and timely address of the complication. One notable error is component mismatch, such as mating a 36-millimeter head with a 32-millimeter inner diameter liner. This is clearly substandard care, and it represents a communication breakdown at multiple points by the entire operative team. Nonetheless, the complication is readily identifiable on post-operative x-rays and admitting the mistake along with timely return to the OR (that day ideally) to correct the problem results in essentially no surgical morbidity other than administration of another anesthetic.

Patients and families usually understand this situation, and legal action is infrequent. On the other hand, failure to recognize the complication or, worse, ignoring it, leads to not only the patient sensing betrayal but a more difficult and painful surgical dissection as well. Compensable litigation is all but guaranteed.

In conclusion, there is a wide array of reasons a patient can file a claim after a hip replacement, and a large majority of these claims are dismissed or successfully defended. A thorough, preoperative discussion between surgeon and patient outlining the incidence and management of the most common complications is critical to reducing malpractice litigation. There is no substitute for genuine patient knowledge of reasonable expectations after a total hip arthroplasty to assure satisfaction of both surgeon and patient after the procedure.

References:

Zengerink, I; Hip arthroplasty malpractice claims in the Netherlands: closed claim study 2000-2012, Journal of Arthroplasty, 2016 (article in press).

Upadahay, A; Medical malpractice in hip and knee arthroplasty, Journal of Arthroplasty, 22:6 Supplement II, pgs. 2-7, September 2007.

Clark, CR; Leg length discrepancy after total hip arthroplasty, Journal of the Academy of Orthopaedic Surgeons, 14:1, pgs. 38-45, January 2006.

Ng, VY; Limb length discrepancy after hip arthroplasty, Journal of Bone and Joint Surgery Am., Vol. 95, pgs. 1426-1436, 2013.