Malpractice by shoulder surgeons

A recent article, Malpractice against shoulder surgeons: what the data say sparked an interesting discussion about malpractice in the practice of shoulder surgery (see link and link).

These authors used a VerdictSearch database to identify 45 malpractice cases. The most commonly litigated procedures were rotator cuff repair (42%), MUA (13%), and humeral open reduction and internal fixation (9%). 

The two most litigated complications were infection and iatrogenic nerve injury as shown below. Nerve injury has been shown to correlate positively with plaintiff victory in litigation.

Pain and loss of range of motion were the most frequent patient complaint in litigated cases. The most commonly cited symptoms for litigation against shoulder surgeons were pain (60%) and loss of range of motion (40%). 

The average age of the patients was 47 years, and 53% of the cases involved a male plaintiff.

Of the 45 cases, 44% ended in physician loss, with the average indemnity paid via verdict being $1,118,714 vs. $416,875 for settlement.

This study should be viewed in the context of a recent article regarding orthopaedic malpractice, Lessons regarding the safety of orthopaedic patient care: an analysis of four hundred and sixty-four closed malpractice claims These authors investigated 464 consecutive closed malpractice claims from the nation's largest insurer of medical liability. They analyzed the claims by anatomical site, type of care rendered, type of allegation, and payment. They calculated an "impact factor" for each claim type by dividing the percentage of total payments for each type by the percentage of total claims for that type. 

Their analysis revealed major concerns regarding patient safety within this series of malpractice claims. One-third of the claims alleged permanent disabling injuries, including amputations, brain damage, and major nerve damage. The highest impact allegations were failure to protect structures in the surgical field (41% of total payments to plaintiffs, 15% of all claims, impact factor of 2.7) and failure to prevent, diagnose, and/or treat complications of treatment (16% of total payments, 7% of all claims, impact factor of 2.3). 

Failure of implant positioning was commonly alleged in arthroplasty cases. In claims related to fracture care, the most common allegations were related to malunions, nonunions, dislocations, failure to protect structures in the surgical field, infection, and treatment complications.

Another recent article examined the Malpractice trends in shoulder and elbow surgery

These authors queried the Westlaw online legal database to identify state and federal jury verdicts and settlements pertaining to shoulder and elbow surgery from 2010-2020 in which an orthopedic shoulder and elbow surgeon was a named defendant. 

Twenty-five such malpractice lawsuits were identified. Most plaintiffs in these cases were adult men, and the majority of cases were filed in the Southwest (28%) and Midwest (28%) regions of the United States. 

The most common anatomic region involved in claims was the rotator cuff (32%), followed by the glenohumeral joint (20%). 

56% of these claims involved surgery. Post-treatment residual pain of mechanical nature was the most common complication seen in claims (56%) followed by complaints of nerve damage.

A large portion of claims resulted after nonoperative treatment.

The jury ruled in favor of the defendant surgeon in most cases (80%).

Another article carried a similar message. The authors of The quality of upper extremity orthopedic care in liability claims filed and claims paid investigated 108 closed upper extremity liability claims from a large United States-wide insurer.  Liability claims were primarily for the care of common problems, such as fractures (n = 52; 48%) or degenerative conditions (n = 24; 26%), rather than complex, unusual conditions. The most common adverse outcomes in these claims were nonunion or malunion of fractures (n = 29; 27%), nerve injury (n = 20; 19%), and infection (n = 13; 12%). Most claims (n = 57; 53%) involved a permanent injury. The surgeon's operative skills were more commonly an issue in paid claims (n = 13; 45%) than in claims without payment (n = 14; 19%). Claims for mismanagement of fractures (n = 52; 48% of all claims) were more likely to result in payment (n = 20; 38%) than nonfracture claims (n = 10; 18%).

The reader may also like to read these posts: 

Patients can sense the quality of their surgeon. 

Conflicts of interest and surgeon liability

Unnecessary surgery.

To recap, the common reasons for malpractice lawsuits are delay in diagnosis and treatment, infection, nerve injury, substandard postoperative care and an improper clinical exam. Of course underlying all of this is establishing and maintaining a good relationship and communication between the patient and the surgeon, starting before surgery with a thorough evaluation with a frank discussion of the alternative treatments and extending through the followup period.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Malpractice

Malpractice trends in shoulder and elbow surgery

These authors sought to examine trends in malpractice claims in shoulder and elbow surgery. They queried the Westlaw online legal database to identify state and federal jury verdicts and settlements pertaining to shoulder and elbow surgery from 2010-2020 in which an orthopedic shoulder and elbow

surgeon was a named defendant. 

Twenty-five such malpractice lawsuits were identified. Most plaintiffs in these cases were adult men, and the majority of cases were filed in the Southwest (28%) and Midwest (28%) regions of the United States. 

The most common anatomic region involved in claims was the rotator cuff (32%), followed by the glenohumeral joint (20%). 

56% of these claims involved surgery. Post-treatment residual pain of mechanical nature was the most common complication seen in claims (56%) followed by complaints of nerve damage.

A large portion of claims resulted after nonoperative treatment.

The jury ruled in favor of the defendant surgeon in most cases (80%).

Comment: Two prior papers with larger case numbers deserve review.

(1) Lessons regarding the safety of orthopaedic patient care: an analysis of four hundred and sixty-four closed malpractice claims

These authors investigated 464 consecutive closed malpractice claims from the nation's largest insurer of medical liability. Their analysis revealed major concerns regarding patient safety within this series of malpractice claims. One-third of the claims alleged permanent disabling injuries, including amputations, brain damage, and major nerve damage. The highest impact allegations were failure to protect structures in the surgical field (41% of total payments to plaintiffs, 15% of all claims) and failure to prevent, diagnose, and/or treat complications of treatment (16% of total payments, 7% of all claims).  Failure of implant positioning was commonly alleged in joint arthroplasty. In claims related to fracture care, the most common allegations were related to malunions, nonunions, dislocations, failure to protect structures in the surgical field, infection, and treatment complications. 

(2) The quality of upper extremity orthopedic care in liability claims filed and claims paid

These authors investigated 108 closed upper extremity liability claims from a large United States-wide insurer.  Liability claims were primarily for the care of common problems, such as fractures (n = 52; 48%) or degenerative conditions (n = 24; 26%), rather than complex, unusual conditions. The most common adverse outcomes in these claims were nonunion or malunion of fractures (n = 29; 27%), nerve injury (n = 20; 19%), and infection (n = 13; 12%). Most claims (n = 57; 53%) involved a permanent injury. The surgeon's operative skills were more commonly an issue in paid claims (n = 13; 45%) than in claims without payment (n = 14; 19%). Claims for mismanagement of fractures (n = 52; 48% of all claims) were more likely to result in payment (n = 20; 38%) than nonfracture claims (n = 10; 18%).

To recap, the common reasons for a malpractice lawsuit were delay in diagnosis and treatment, infection, nerve injury, substandard postoperative care and an improper clinical exam. Of course underlying all of this is establishing and maintaining a good relationship and communication between the patient and the surgeon, starting before surgery with a thorough evaluation with a frank discussion of the alternative treatments and extending through the followup period.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

What has been accomplished by our shoulder research team over the past year

Each year we're asked to provide a summary of our activities conducted with the support of the Harryman/DePuy endowed Chair for Shoulder Research.

We thought the summary might be of interest to our readers and have posted it here.

Thanks to the support of individual contributors, the Harryman/DePuy Chair continues to yield high quality, clinically important contributions to the foundation of knowledge on which modern shoulder surgery is based. Simply stated, without your support, this research would not have taken place.  This past year our work has focused in several critical areas and I’ve tried to summarize them here.

(1) Propionibacterium infections after shoulder joint replacement

We have noted that infections with Propionibacterium – a normal inhabitant of our skin – can cause problems of joint pain and stiffness after shoulder joint replacement without obvious evidence of infection, such as fever, chills, tenderness or redness. [1] These organisms live in rather than on the skin so that skin surface preparation is not effective in eliminating the bacteria from the surgical field[2]. In fact, we did a study that showed that we could recover Propionibacterium from punch biopsies of the skin in spite of standard surgical skin preparation[3] The subtle evidence of infection can appear long after the surgery[4] so that a high index of suspicion is necessary to pursue the appropriate cultures at the time of all revision surgery and a comprehensive plan of surgical and antibiotic management is necessary to resolve the infection.

(2) The Axillary View

Contrary to the opinion of many, it is not necessary to get an expensive CT scan to identify the pathoanatomy of the shoulder before and the results after a ream and run procedure. Instead of a computerized tomographic scan, which costs more money and which subjects the patient to additional radiation, we use a plain axillary view to make the necessary determination of the anatomy of the arthritic shoulder and the effectiveness of the ream and run procedure in restoring the desired shoulder anatomy.[5]

(3) Failure of the glenoid component in total shoulder

The weak link in total shoulder replacement is the glenoid component[6]. While many surgeons are working to develop metal backed glenoid components, our research suggests that these metal backed glenoids have a much higher failure rate than all polyethylene components.[7] We continue to use an all-polyethylene component and are meticulously careful to craft the bone to fit this prosthesis so that the risk of loosening is minimized.

(4) Factors associated with failure of rotator cuff repair.

In a comprehensive review of the published literature, we discovered that – while the number of articles published about rotator cuff repair has increased dramatically over the last three decades – the clinical and anatomic results have not improved with time. In other words the ‘technological advances’ have not yielded better results for the patients. The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery. Retears were associated with more fatty infiltration, larger tear size, and advanced age. Interestingly, patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff. [8]

(5) Learning about improving patient safety by studying malpractice claims.

We reviewed 108 closed upper extremity liability claims from a large United States-wide insurer for events that occurred between 1996 and 2009. We found that liability claims were primarily for the care of common problems, such as fractures or degenerative conditions, rather than complex challenging conditions or disorders, such as deficiencies treated with replantation or tissue transfers. The most common adverse outcomes in these claims were nonunion or malunion of fractures, nerve injury, and infection. Most claims involved a permanent injury. The surgeon's operative skills were more commonly an issue in paid claims than in claims without payment. Claims for mismanagement of fractures were more likely to result in payment than nonfracture claims. We concluded that that the incidence of upper extremity claims made and claims paid may be reduced if surgeons acquire and maintain the knowledge and skills necessary for the care of the common conditions they encounter, including fractures.[9]

(6) The Blog.

Our blog on shoulder arthritis and rotator cuff tears has become immensely popular not only in the US but also in over 100 countries around the world.[10] [11] It now has almost 1000 posts reviewing concepts, recent articles and our cases of interest. There have been almost 500,000 page views as well as a major interest from Twitter and Facebook. The most popular posts include “the shoulder: arthritic or frozen”, “shoulder exercises”, “x-rays for shoulder arthritis”, “shoulder arthritis – what you should know about it” and “rotator cuff and rotator cuff tears – what you should know about them”.

As you can see, in addition to our active practice in helping individuals needing surgical reconstruction of their shoulders, things are busy in the research and teaching domains. All of our activities are supported by your contributions to the Harryman/DePuy Endowed Chair. For your interest and your support, we are most grateful.
If know of others who might like to support our program, please invite them to take a look at this PDF.

If you have any questions about our work or how you might continue to support it, please feel free to drop me an email anytime at matsen@uw.edu. Lot’s more coming up – stay tuned!

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[1] Pottinger P, Butler-Wu S, Neradilek MB, Merritt A, Bertelsen A, Jette JL, Warme WJ, Matsen FA 3rd. Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening.

J Bone Joint Surg Am. 2012 Nov 21;94(22):2075-83.

[2] Matsen FA 3rd, Butler-Wu S, Carofino BC, Jette JL, Bertelsen A, Bumgarner R. Origin of Propionibacterium in surgical wounds and evidence-based approach for culturing Propionibacterium from surgical sites. J Bone Joint Surg Am. 2013 Dec 4;95(23):e1811-7.

[3] Lee MJ, Matsen FA 3rd, Pottinger P, Bumgarner R, Butler-Wu S, Russ S. Propionibacterium Persists In The Skin In Spite Of Standard Surgical Preparation. The Journal of Bone and Joint Surgery. Accepted for Publication.

[4] McGoldrick E, McElvany MD, Butler-Wu S, Pottinger PS, Matsen FA 3rd.

Substantial cultures of Propionibacterium can be found in apparently aseptic shoulders revised three years or more after the index arthroplasty. J Shoulder Elbow Surg. 2014 Jul 8. pii: S1058-2746(14)00248-1.

[5] Matsen FA 3rd, Gupta A. Axillary View: Arthritic Glenohumeral Anatomy and Changes After Ream and Run. Clin Orthop Relat Res. 2014 Mar;472(3):894-902.

[6] Papadonikolakis A, Neradilek MB, Matsen FA 3rd. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013 Dec 18;95(24):2205-12.

[7] Matsen FA 3rd, Papdonikolakis A. Metal-Backed Glenoid Components Have A Higher Rate Of Failure And Fail By Different of Bone and Joint Surgery. 2014 Jun 18;96(12):1041-1047.

[8] McElvany MD, McGoldrick E, Gee AO, Neradilek MB, Matsen FA 3rd. Rotator Cuff Repair: Published Evidence on Factors Associated With Repair Integrity and Clinical Outcome. Am J Sports Med. 2014 Apr 21.

[9] Matsen FA 3rd, Stephens L, Jette JL, Warme WJ, Huang JI, Posner KL.

The quality of upper extremity orthopedic care in liability claims filed and claims paid.

J Hand Surg Am. 2014 Jan;39(1):91-9

[10] http://shoulderarthritis.blogspot.com/

[11] Albania, Algeria, Argentina, Armenia, Australia, Austria, Bahrain, Bangladesh, Barbados, Belarus, Belgium, Belize, Bosnia, Brazil, Bulgaria, Canada, Chile, China, Columbia, Costa Rica, Croatia, Cyprus, Czech Republic, Denmark, Dominican Republic, El Salvador, Egypt, Eritrea, Estonia, Finland, France, Georgia, Germany, Greece, Herzegovina, Hong Kong, Hungary, India, Indonesia, Iraq, Ireland, Isle of Man, Israel, Italy, Japan, Jordan, Kenya, Kuwait, Laos, Latvia, Lebanon, Libya, Lithuania, Malaysia, Malta, Mauritius, Mexico, Moldova, Mongolia, Morocco, Nambia, Nepal, Netherlands, New Zealand, Norway, Oman, Pakistan, Panama, Peru, Philippines, Poland, Portugal, Puerto Rico, Réunion, Romania, Russia, Saudi Arabia, Serbia, Singapore, Slovakia, Slovenia, South Africa, South Korea, Spain, Sri Lanka, Sweden, Switzerland, Syria, Taiwan, Thailand, Trinidad and Tobago, Turkey, Ukraine, United Arab Emirates, United Kingdom, United States of America, Venezuela, Vietnam, and Yemen.

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Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Lessons Regarding the Safety of Orthopaedic Patient Care: An Analysis of Four Hundred and Sixty-Four Closed Malpractice Claims

Lessons Regarding the Safety of Orthopaedic Patient Care: An Analysis of Four Hundred and Sixty-Four Closed Malpractice Claims

This article, which we published in the current issue of the Journal of Bone and Joint Surgery, concerned the allegations of malpractice in a large series of closed claims. It provides some lessons regarding how such claims might be avoided and how patient safety may be optimized.

We've reproduced the abstract here:

Background:
An orthopaedic malpractice claim alleges that the patient sustained a preventable iatrogenic injury. The analysis of a representative series of malpractice claims provides a unique view of alleged orthopaedic adverse events, revealing what can potentially go wrong across a spectrum of practice settings and anatomic locations. The goal of this study was to identify high-impact targets in order to institute measures to reduce claims through efforts focused on patient safety.

Methods:
The authors investigated 464 consecutive closed malpractice claims from the nation’s largest insurer of medical liability. We analyzed the claims by anatomical site, type of care rendered, type of allegation, and payment. We calculated an “impact factor” for each claim type by dividing the percentage of total payments for each type by the percentage of total claims for that type.

Results:
Our analysis revealed major concerns regarding patient safety within this series of malpractice claims. One-third of the claims alleged permanent disabling injuries, including amputations, brain damage, and major nerve damage. The highest impact allegations were failure to protect structures in the surgical field (41% of total payments to plaintiffs, 15% of all claims, impact factor of 2.7) and failure to prevent, diagnose, and/or treat complications of treatment (16% of total payments, 7% of all claims, impact factor of 2.3). Spine procedures had high impact (1.9), representing 28% of dollars paid and 15% of claims, with 45% of spine claims involving death or severe permanent injury. Failure of implant positioning was commonly alleged in hip and knee arthroplasty. In claims related to fracture care, the most common allegations were related to malunions, nonunions, dislocations, failure to protect structures in the surgical field, infection, and treatment complications. Total payment for the eighty-eight claims paid was $17,917,614 (U.S. dollars adjusted to 2009).

Conclusions:
Regarding clinical relevance, this analysis suggests risk areas for targeted efforts to improve patient safety and reduce malpractice claims.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.


See from which cities our patients come.


See the countries from which our readers come on this post.