The CRIOAc healthcare network in France: A nationwide Health Ministry program to improve the management of bone and joint infection.

BACKGROUND: Bone and joint infections (BJIs) have a major clinical and economic impact in industrialized countries. Its management requires a multidisciplinary approach, and a great experience for the most complicated cases to limit treatment failure, motor disability and amputation risk. To our best knowledge there is not currently national specific organization dedicated to manage BJI. Is it possible to build at a national level, a network involving orthopaedic surgeons, infectiologists and microbiologists performing locally multidisciplinary meetings to facilitate the recruitment and the management of patients with complex bone and joint infection in regional centers? HYPOTHESIS: A national healthcare network with regional labeled centers creates a dynamic that improves the recruitment, the management, the education, and the clinical research in the field of complex BJI. PATIENTS AND METHODS: We describe the history of this unique national healthcare network and how it works, specify the missions confided to the CRIOAcs, evaluate the activity of the network over the first decade, and finally discuss perspectives. RESULTS: The labelling of 24 centers in the CRIOAc network allowed for a meshing of the territory, with the possibility of management of complex BJI in each region of France. A dedicated secure national online information system was designed and used to facilitate decision-making during multidisciplinary consultation meetings. Since October 2012 to June 2017, 4553 multidisciplinary consultation meetings have been performed in the structures belonging to the network, with 34,607 cases discussed in 19,961 individual. Prosthetic joint infections represented 38% (7585/19,961) of all BJIs. Among all the cases discussed, the rate of complexity was of 61% (21,110/34,607) (related to antibiotic resistance, infection recurrence, patient co morbidities). A national scientific meeting was created and a national postgraduate diploma in the field of BJI was launched in 2014. The promotion of education, clinical research and interactivity between each academic discipline and between each labeled centers across the country has synergized the strengths and have greatly facilitated the management of patients with BJI. DISCUSSION: The setting up of the CRIOAc network in France took time, and has a cost for the French Ministry of Health. However, this network has greatly facilitated the management of BJI in France, and allowed to concentrate the management of complex BJI in centers that have significantly gained skills. There is, to our knowledge, no other exemple of such nationwide network in the field of BJI. LEVEL OF EVIDENCE: IV, case series without control group.

Knee arthroplasty and lawsuits: the experience in France.

PURPOSE: Data regarding knee arthroplasty and lawsuit are scarce. With the expected increase in knee arthroplasty over the next 25 years, the number of claims might follow the same trend. Therefore, the most frequent causes of litigation after knee arthroplasty in France, and what is considered as malpractice by the expert, were determined. METHODS: Over 8-year period, data gathered from a French private insurance company specializing in malpractice for private practitioners were analyzed. Demographics, type of knee arthroplasty, reason for claim, details of the legal procedure and the expert's decision were reviewed. RESULTS: One hundred and five claims were processed by four jurisdictions. Most of the cases concerned primary total knee arthroplasty. Surgeons and anesthesiologists were charged in 84 and 16 % of claims, respectively. The most frequent causes of litigation were infection, neurological deficit and unsatisfactory result, whereas the most common reasons for the surgeon's liability, as stated by the expert, were delay in diagnosis or treatment of a complication, infection and technical error. CONCLUSION: Our findings show that frequent complications are not those which raise most of the claims. Patients sue the surgeon when the outcome of the surgery is different from what they were expecting. An unsatisfactory result, according to the patient's point of view, is the second most frequent cause of claim. LEVEL OF EVIDENCE: IV, Economic and Decision Analysis. See the Guidelines for Authors for a complete description of levels of evidence.