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Total hip replacement (total hip arthroplasty) has been described as the “Operation of the Century” (The Lancet 2007). It is one of the most successful procedures to improve the quality of life and relieve the pain of patients afflicted with crippling painful hip arthritis. It was pioneered by Sir John Charnley in the 1960s at Wrightington hospital in Lancashire. The cemented Charnley hip replacement (commonly referred as Low Frictional Torque arthroplasty) performed for the first time in 1962, still remains the Gold Standard when one talks about long term results, now entering the fifth decade of prosthetic survivorship.
Unfortunately, like all other surgical procedures, it has well-recognised although often uncommon complications. Sometimes these complications can give rise to litigation.
One of the common reasons for litigation is nerve injury during surgery. This is a recognised complication in approximately 1% after primary hip replacement. There are important nerves that lie in close proximity to the hip joint and surgeons are trained to protect these nerves. It is important to assess patients thoroughly before surgery to check if there are pre-existing nerve problems or weakness arising from spine conditions. Despite the surgeon’s best efforts however, rarely nerves can get injured. Injury can occur due to pressure, stretch or direct trauma from sharp instruments. However, in as many as 50% of the cases, the cause might remain unknown. If the injury is incomplete the nerve may recover but complete injury may result in permanent long term problems such as pain, reduced sensation or weakness of muscles. Nerve injury is not synonymous with negligent surgery.
Leg length inequality is also a common problem leading to complaints and litigation. It can be associated with dissatisfaction, pain, poor function or even nerve injury. The primary goal of a hip replacement is to relieve pain and achieve a stable hip. It is nearly impossible in every case to assure equal leg lengths. Many patients (up to a third of the normal population) may have unequal leg lengths even before surgery. This may be due various causes such as the arthritis itself, hip deformity, spinal curvature, old fractures of the long bones, pelvic obliquity, or childhood developmental problems.
It is important to perform a meticulous clinical examination of the patient including spinal examination and document leg lengths before surgery. Some asymmetry of leg lengths is almost inevitable after hip replacement even after using techniques to measure leg lengths during surgery. It is important that patients are appropriately counselled and their expectations managed in a realistic manner before surgery. Documentation of intra-operative difficulties in achieving equal leg lengths is also important.
Dislocation (separation of the ball of the hip joint from the socket) is recognised to occur in 1-3% of cases despite appropriate positioning of the components at the correct angles. This may be related to patient factors (such as high BMI, neurological problems) or technical factors (soft tissue tension, offset, impingement of components against bone). Positioning the components of a hip replacement can be difficult even in experienced hands due to variability in the shape of the patients’ bony socket and pelvis, movement during surgery, or the alignment between the spine and pelvis. There is no single perfect angle for positioning components which is correct for all patients and a range of component positions is compatible with a successful outcome. There is no substitute to educating the patient before surgery and looking for factors that might increase this risk.
Persistent pain after hip replacement is sometimes a reason for litigation. Regrettably, a small minority of patients may not get adequate pain relief even with well-performed surgery. Correct patient selection and thorough assessment before surgery goes a long way in avoiding these problems. It is important to avoid pitfalls by ensuring before surgery that the pain is definitely coming from the hip joint arthritis and not from the soft tissues around the hip or from the spine.
Persistent pain is not synonymous with a failed operation. Alternative causes such as infection, loosening, fractures or referred pain from the back also need to be excluded. Infection can have variable presentations and a thorough diagnostic evaluation needs to be performed when evaluating a painful arthroplasty. Infection is not always easy to diagnose and it is not uncommon to find delayed diagnosis of infection in the list of reasons for litigation.
Many of these problems associated with litigation can be avoided or minimised by spending time with the patient before surgery and explaining the benefits and risks of the procedure in detail. Inadequate consenting is also a common allegation in negligence cases. Obtaining informed consent is a methodical process and starts with the first consultation.
It is often difficult to find adequate time in busy clinics to spend with patients and these are real difficulties. The surgeon and the team should ensure that a robust process is followed and the patient is well-informed. There is no substitute for a frank and forthright discussion with the patient before surgery.
Every effort should be made to ensure that the patient has properly understood the risks before proceeding. Use of information booklets, the internet, websites with good quality information, pictures, diagrams, x-rays, models, or audio- visual aids often help in enhancing the patient’s understanding. Giving information at multiple points in time of a patient journey is helpful to enhance their understanding and retention. Most units also have patient education classes to provide information to the patient.
Despite a good process, it is not uncommon to hear a patient state that a particular risk was not explained properly. It is a good idea to check the patient’s understanding of the risks where possible.
The surgeon should also meticulously document the consenting process. Many surgeons routinely copy their clinic letters to the patient to help with their understanding. Recent changes to consent law after the Montgomery judgement have thrown these issues into stark prominence.
In the event of an unfortunate complication, an honest explanation, maintaining open communication (following the duty of candour), acknowledging a problem, and making a genuine attempt to diagnose and treat it can go a long way in avoiding litigation, which any form of health service can ill-afford.
Mr Nikhil Shah can be contacted on:
Nikhil.Shah@consultantcare.com
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