SLR - December 2019 - Albert A. Elhiani
Reference: Senard, Olivia, et al. “Reasons for Litigation in Arthroplasty Infections and Lessons Learned.” The Journal of Bone and Joint Surgery, vol. 101, no. 20, 2019, pp. 1806–1811., doi:10.2106/jbjs.19.00101.Scientific Literature Review
Reviewed By: Albert A. Elhiani, DPM
Residency Program: Cedars Sinai Medical Center – Los Angeles, CA
Podiatric Relevance: With growing enthusiasm for total ankle arthroplasties, it is important to be aware of the potential pitfalls. Orthopedic literature provides excellent insight into management of periprosthetic complications. The objective of this study was to analyze legal claims associated with perioperative arthroplasty infections in an attempt to identify the cause of litigation in order to prevent it.
Methods: This level IV retrospective case series analyzes claims data of private practitioners for periprosthetic infections from 2010 to 2014. The study was conducted in France, where medical records, legal correspondence, judgements and expert arguments were analyzed. Forty-five periprosthetic infections were included and met the IDSA guideline of an infection with a sinus tract that either communicates with the prosthesis, has purulence, or has two or more cultures with the same organism. Three stages of infection corresponded to when the patient presented with the symptoms, with stage one or early being <1 month, two being delayed one to six months, and three being late-onset at >6 months postoperatively. Deviations from therapeutic guidelines were identified with the primary focus on the delay of diagnosis, inadequate antibiotic therapy, and inadequate surgical treatment. Additionally, the medical legal component determined if infections were health-care related, non- health care related or of unknown etiology. This algorithm helped the judicial committee determine who was responsible.
Results: The analyzed medical files included 21 knee arthroplasties, 21 hip arthroplasties, two shoulder arthroplasties and one ankle arthroplasty. Forty-four of the 45 infections were confirmed by at least two perioperative cultures of the same organisms. In 36 episodes the infections were mono-microbial with the most common causative agent being coagulase-negative staphylococci. On average each patient underwent 2.9 surgical reoperations and 7.6 months of cumulative antibiotics. An infectious disease specialist was consulted in 29 of the cases, however, in 24 percent of the 45 cases (11 patients), the request was made only after several debridements or antibiotic treatments. Of note 34 deviations from current medical guidelines were noted that accounted for 64 percent (28 of 45) of the claims. These deviations were noted to be diagnosis delay, inadequate antibiotic therapy, or medico-surgical treatment. Thirty-six cases were deemed healthcare associated infections. Six were attributable to the surgeon or hospital. Thirty were not medico-surgical error, however, law suits were paid by the organizational fund set aside for these issues. The remaining eight patients were not compensated.
Conclusions: As ankle joint arthroplasty gains momentum in the podiatric surgical world so will the complications and the inevitable lawsuits that are associated with them. Early and prompt consultation of an infectious disease specialist may lead to better adherence to the appropriate antimicrobial therapies. We must therefore have close follow up to appropriately identify complications if and when they do arise and involve other physicians when appropriate.