Malpractice lawsuits in orthopedic trauma surgery: a meta-analysis of the literature.

Introduction: The objectives for this study were to identify whether diagnostic or procedural errors more commonly resulted in lawsuit, as well as to elucidate how specific variables affected mean indemnity. Methods: Systematic review of English-language articles in the PubMed and Google Scholar databases (through 2020) using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analysis was performed to estimate measures of proportions and differences in mean indemnity. Results: The estimated probability of lawsuits related to orthopedic trauma in overall studies was 23.3%. There were no significant rate differences between main causes of claims (diagnostic vs procedural errors) and areas of injury (upper vs lower). There was no significant difference of mean indemnity between the probabilities of trauma-related claims, diagnostic error, and procedural error. Conclusion: Non-trauma cases were more likely to result in lawsuit than trauma cases. Procedural errors accounted for most malpractice claims. The average indemnity increased according to the higher diagnostic errors, while the indemnity was lower with a relatively higher proportion of procedural errors. The most common cause of litigation varied between studies; however, among the most cited reasons were missed diagnosis/error in diagnosis, improper/substandard surgical performance, and, though not specifically studied in this analysis, errors of informed consent. Level of Evidence: Economic and Decision Analyses Level VI.

How Many Orthopaedic Surgeons Does It Take to Write a Manuscript? A Vignette-Based Discussion of Authorship in Orthopaedic Surgery.

The issue of appropriate authorship designation continues to be a topic of importance because authorship of scholarly work plays an important role in the academic community. It is a recognition of an individual's scholarly work and a factor in academic promotion. The Orthopaedic Trauma Association (OTA) sponsored a minisymposium in 2014 to encourage discussion of the issues that arise in authorship decisions. A residency program director/department chair, a journal editor, a clinical trials coordinator, and a promotions committee member provided viewpoints. In the pages that follow, vignettes are presented along with discussion points to encourage conversation on this topic. Authorship criteria are clearly defined. Authorship based simply on seniority or contribution of cases to clinical trials is inappropriate. Discussion of authorship criteria prior to the initiation of clinical research investigations is a standard that must be met. The International Committee of Medical Journal Editors (ICMJE) guidelines provide a framework for this discussion and should be reviewed by all authors prior to publication. Modifications to published authorship guidelines may be necessary to address some of the scenarios identified here that are not adequately addressed by the existing guidelines.

Bicortical screw fixation of distal fibula fractures with a lateral plate: an anatomic and biomechanical study of a new technique.

One of the potential drawbacks of lateral plating of distal fibula fractures is less than satisfactory fixation of unicortical screws commonly placed in the distal fragment to avoid implant penetration of the ankle joint. This study examines the anatomy of the distal fibula, proposes new techniques for bicortical screw fixation and radiographic evaluation of screw placement, and compares pullout strength of unicortical versus bicortical screws in this area. Sixteen pairs of human cadaver feet were used in this study. It was found that a large percentage of the surface area of the distal fibula is nonarticular and that the distal fibula could be divided into 3 zones with distinct anatomic features. Zone I is defined as the distal most 1.5 cm of the fibula, zone II is the next 1 cm of fibula proximal to zone I, and zone III is defined as the fibula above the ankle joint, starting at just over 2.5 cm proximal to the tip of the fibula. We determined a safe corridor for bicortical screw placement by means of a lateral plate in each zone. An improved radiographic view is described for confirmation of extraarticular screw placement. Screw pullout testing was performed on 8 pairs of fresh-frozen human cadaver fibulas. In both zone I and zone II, the bicortical screw fixation was significantly stronger than the unicortical screw fixation. In zone I, the average pullout strength for the bicortical screw fixation was 2.3 times higher than the unicortical screw fixation. In zone II, the average pullout strength for the bicortical screw fixation was 3.3 times higher than the unicortical screw fixation. This study shows that not only is bicortical screw placement in the distal fibula technically feasible, but it is also biomechanically stronger than unicortical placement in this area.

Amputation osteoplasty.

Amputation osteoplasty is a technique modification promoted by Ertl to enhance rehabilitation after transtibial amputation. Two different techniques for creating sealing of the medullary canal and a distal bone block have been described in the literature. One technique consists of a periosteal sleeve that is sutured over the cut end of the bone. The second technique consists of hinging a segment of fibula into a slot in the cut end of the tibia. The desired goal of amputation osteoplasty is to create an end-bearing limb to enhance rehabilitation. In addition to creation of a bone bridge, Ertl also recommends myoplasty, neuroplasty, individual vessel ligation, and a special skin closure. This report is a small case series of five patients successfully treated with lower extremity amputation osteoplasty, to illustrate the techniques and report initial good results. Two patients had each of the techniques and one patient had both of the techniques. All five patients had good wound healing, accelerated rehabilitation, and the ability to use end-bearing prostheses.

Safe extracapsular placement of proximal tibia transfixation pins.

OBJECTIVE: To identify the anatomic detail of the knee joint capsular insertion site on the proximal tibia, specifically as it relates to transfixation pins. DESIGN: Identification of capsular anatomy by anatomical dissection of cadaveric specimens, with radiography and arthroscopy of patients. SETTING: Cadaveric dissection. OUTCOME MEASURES: Anatomic observation of the capsular attachment site in relation to the tibial articular surface. RESULTS: The capsule inserts four to fourteen millimeters below the articular surface in a regular pattern. The anterior half of the circumference is close to the joint line (less than six millimeters). Posteromedially and posterolaterally, there are extensions distally to fourteen millimeters, occasionally communicating with the tibiofibular joint. CONCLUSION: Transfixing wires and half-pins can be placed in the proximal tibia without capsular penetration if kept more than fourteen millimeters from the subchondral line. If wire placement closer to the joint is required, wires should be placed in Zone 1 (the anterior half) and at least six millimeters from subchondral bone to avoid capsular penetration.