A 23-Year Analysis of the Litigation in Orthopaedic Elbow Surgery.

BACKGROUND: The reasons for malpractice litigation in elbow surgery are not well understood. The aim of this study is to report the most frequently litigated surgeries of the elbow and analyze the reasons for litigation and case outcomes. METHODS: A retrospective review of the Westlaw legal database was performed, and all federal and state jurisdiction litigation cases involving the elbow from 2000-2023 were queried. Cases were excluded if they did not involve an orthopedic surgeon, nor primary elbow injury or procedure. Cases were reviewed for demographic information, surgical procedure based on reference CPT codes, complications, symptoms, and reasons for litigation. Quantitative information, including settlement and indemnity cost to the defendant orthopedic surgeon, was analyzed. Cases were sub-divided based on United States Census Bureau regions and states to assess regional frequency of litigation with ANOVA tests. RESULTS: There were 59 cases meeting inclusion criteria from 2000-2023.The most litigated cases involved were ulnar nerve transposition/release and open reduction and internal fixation of the proximal radius and/or ulna at the elbow. The most litigated complication was claimed nerve damage (46%) and permanent disability (27%). Of the total cases, the most frequently litigated symptoms were nerve damage (46%) and loss of function (37%), while the least frequent was postoperative stiffness (2%). The Pacific region demonstrated the highest litigation rate (20%), while the East South Central, Mountain, and New England regions had the lowest litigation rate (3% each). A favorable verdict was given to the defendant orthopedic surgeon in 59% of the cases. The average loss incurred through settlement was $245,590, while the average indemnity paid through verdict was $523,334. CONCLUSION: Operative fixation of the proximal ulna/radius and ulnar nerve release/transposition are the most litigated procedures of the elbow. Litigation is most associated with nerve injury. Across Census Bureau regions, there is no significant difference in monetary cost incurred through settlements and verdict losses. Although a majority of litigated cases are won by the defending orthopedic surgeon, thorough informed consent and perioperative expectation management may mitigate litigation risk.

Sonographic assessment of the medial ulnar collateral ligament distal ulnar attachment.

OBJECTIVES: The purpose of this study was to determine whether the long distal attachment of the medial ulnar collateral ligament (MUCL) can be delineated on sonography. METHODS: We used 12 fresh-frozen cadaveric elbows for this study. We performed sonography of the elbow using a coronal-equivalent long-axis view of the MUCL. All sonographic examinations and measurements were performed by a board-certified, fellowship-trained musculoskeletal radiologist. Measurements were performed from the anteroinferior aspect of the medial epicondyle to the sublime tubercle and then from the sublime tubercle to the terminal fibers of the MUCL long ulnar attachment. We then measured the length of the MUCL from its attachment at the medial epicondyle of the humerus to the sublime tubercle and then from the sublime tubercle to the distal extent of its terminal fibers at the ulnar attachment with digital calipers. RESULTS: On sonography, the average length of the MUCL from its humeral attachment to the sublime tubercle (transarticular) was 19.6 mm. The average length of the ulnar attachment was 27.9 mm. The MUCL was thickest (mediolateral dimension) at its humeral attachment and tapered as it coursed distally along the ulnar attachment. The MUCL was clearly identified on sonography and in all anatomic specimens. On gross measurement, the average lengths of the transarticular portion of the MUCL and its ulnar footprint were 21.5 and 30.2 mm, respectively. CONCLUSIONS: We have successfully shown that the distal ulnar attachment of the MUCL can be visualized on high-resolution sonography. This preliminary work provides a framework for developing protocols for diagnosis of injuries to the distal ulnar collateral ligament.

Complications in total shoulder arthroplasty.

A wider spectrum of complications associated with shoulder arthroplasty is expected because of the substantial increase in the prevalence of this procedure over the past decade. It is helpful to review the management and methods needed to prevent the most common complications associated with shoulder arthroplasty.

Distal ulna leiomyosarcoma treated with custom polymethylmethacrylate prosthesis with a 4-year follow-up.

BACKGROUND: Intraosseous leiomyosarcoma is a rare neoplasm having an aggressive biologic behavior. The distal end of the ulna is a very uncommon site for this type of primary bone tumor frequently mistaken for benign lesions. En bloc resection of the distal ulna with reconstruction is a valid option as a limb salvage procedure for the treatment of this difficult problem, minimizing local recurrence while preserving hand function. CASE DESCRIPTION: We present an unusual case of a 63-year-old woman with a primary leiomyosarcoma arising from the distal end of the ulna treated successfully with a wide excision and custom distal ulna, with 4-year follow-up and no recurrence. LITERATURE REVIEW: Tumors to develop at the distal end of the ulna have been reported as part of large series such as Dahlin and few case reports. According to Cooney, Exner, and Mankin, reconstruction for distal ulnar neoplasms is not necessary to maintain function. However, Noble and Laurentin-Perez disagree because stabilization of the distal ulna following large resection, as in our case, can be a significant problem with associated pain and weakness due to a decreased interosseous space with ulnar stump impingement on the radial metaphysis and ulnar translation of the carpus. CLINICAL RELEVANCE: Custom methacrylate in situ radioulnar joint prosthesis for reconstruction of a large segment of the distal ulna can be a valid option to reestablish the mechanical continuity of the forearm, reducing pain and improving strength and function.

Partial subscapularis release for total shoulder arthroplasty: a biomechanical comparison of two techniques.

BACKGROUND: Glenohumeral joint exposure during total shoulder arthroplasty (TSA) is obtained by releasing the subscapularis (SSC) with either an osteotomy or a tenotomy. Recently, concerns regarding SSC dysfunction after TSA have been raised. In order to avoid this complication, alternative surgical approaches that release the inferior 50% or 10% of the tendon have been described. While a 10% release of the SSC would theoretically lower the likelihood of postoperative SSC dysfunction, releasing 50% would provide greater surgical exposure but possibly have a weaker SS attachment. Therefore, we sought to compare the SSC attachment strengths of these two techniques. MATERIALS AND METHODS: Each of eight matched pairs of cadaveric shoulders were tested. The inferior 10% of the SSC tendon was released on one side. On the contralateral side, the inferior 50% of the SSC was released and then repaired with a 5.5 mm suture anchor. The specimens were then mechanically tested to failure. RESULTS: The load to failure for the 10% release specimens was 682 ± 153 N and 493 ± 212 N for the 50% release specimens (p = 0.036). Failures in both groups occurred mainly at the musculotendonous junction. DISCUSSION: The SSC humeral attachment strength after releasing the inferior 10% was 30% greater than the 50% re- lease with repair. Thus, although releasing the inferior 50% of the SSC tendon may provide greater surgical exposure, maintaining the SSC with minimal release may be preferable in decreasing the rate of post TSA SSC dysfunction.

Coding practices affect the cost of distal radius fracture care.

The purpose of this study was to determine the impact of an Emergency Medicine Department's billing practices on the total cost of care for distal radius fractures. This study identified patients by International Classification of Diseases, Ninth Revision (ICD-9) billing codes treated by the Department of Orthopaedic Surgery (DOS) and Department of Emergency Medicine (DEM) at the University of Arizona. In every case, the surgical modifier 54 was used. The billing records in each case for the DEM and the DOS were reviewed. When the fracture was manipulated and the DEM was the attending of record for the initial visit, the total cost of fracture care was increased by $500. When the fracture was not manipulated, the total cost of fracture care was increased by $270. Although more than one-third of patients had surgery by the DOS, the DEM used a global billing code that indicates "restorative" treatment. This is an example of the manipulation of Current Procedural Terminology coding to enhance revenue generation with increased cost to the healthcare system, and no added value to outcome.