Dr Clay Nuelle: Welcome to the Arthroscopy Association's Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.
Dr Clay Nuelle: Welcome, everyone. I'm Dr. Clay Nuelle with TSAOG Orthopedics in San Antonio. Today I have the distinct privilege of speaking with Dr. Brett Owens. Dr. Owens is a professor of orthopedic surgery at Brown University in [inaudible 00:00:21] Medicine. Dr. Owens was the author on a paper titled Medical Malpractice Litigation Following Arthroscopic Surgery published in the July 2018 Arthroscopy Journal edition. His co-authors include Kalpit Shah, Adam Eltorai, Sudheesha Perera, Wesley Durand, Govind Shantharam, and Alan Daniels.
Dr Clay Nuelle: Welcome and thank you for joining me Dr. Owens.
Dr Brett Owens: Thanks for having me Clay. I'm excited to be here.
Dr Clay Nuelle: Let's start right off with what you think is the biggest takeaway from the article.
Dr Brett Owens: First of all, I'd like to just thank Arthroscopy Journal for interest in our article, and of course, for having us on board for the podcast. I like to really thank my coauthors, particularly Kal Shah, one of my residents, did a fantastic job with this project from beginning to end. Really the inspiration here was Alan Daniels, one of my partners, who is a spine surgeon who basically tapped into a couple of VerdictSearch and Westlaw, couple of lawsuit data sets and really explored this in spine surgery, which as we know is a little bit more of a treacherous area regarding litigation, etc.
Dr Brett Owens: And we've had a discussion talking about arthroscopies, and kind of our thought was to pull in together and look at arthroscopic surgery in general and the risk of lawsuits. And if we get a larger number, hopefully we can maybe see some of the patterns involved so that's what we did. And we did certainly see some patterns.
Dr Brett Owens: For me probably the biggest takeaway, the thing that jumps out is the knee practice. The majority of these lawsuits were involving the knee. Of the 240 cases that were involved. The majority of them were in the knee. 162 were in the knee. And of the 20 deaths that were involved, 19 were at the knee and 16 of those were ... involved pulmonary embolism. And all the ten wrong-side surgeries that were in this data set were also from the knee. So those were some of my take-homes and certainly vaster complications, patient death ... those were the things that wrong-sided surgeries ... were certainly the ones that were more likely to result in a plaintiff verdict or settlement.
Dr Clay Nuelle: That was definitely interesting. I mean from the medical malpractice ... is not something that any of us necessarily want to talk about all the time. But hey, when you practice long enough, hopefully none of us our never named, but when you practice long enough, you're definitely going to know somebody, whether it be your partner or friend or somebody else that's been named, and I think one of the things in the article that jumped out at me, that you quoted from another article, that 14 percent of orthopedic surgeons are named in a malpractice litigation annually. And so if you think about that, if you add up a 25 or 35 year career, that's a pretty high percentage of surgeons that obviously get named pretty regularly. So it's out there.
Dr Brett Owens: Oh I think you're definitely right. Yeah the saying is that every orthopedic surgeon in our life, at least on average, will be sued once. It certainly is a litigious environment. Certainly, my partner, Alan Daniels and the spine is a little more serious. When we think about that a little bit more, of course, they pay a higher malpractice, but you know one of the most common procedures in orthopedic surgery is in arthroscopy, particularly a knee arthroscopy. The good news for orthopedic surgeons, our take-home message, is that in general there are not a lot of lawsuits. Obviously we don't have the denominator here but over these multiple years covered using a couple of different data sets is relatively small numbers of lawsuits involved given the high volume of these procedures that are being done.
Dr Clay Nuelle: Yeah can you expand a little bit more in regards to the surgeries that are inherently more at risk? Do you think that knee arthroscopy is kind of obviously strictly because there's more of them being done, and then the complications were more of related to DVTs, and so being the lower extremity that has a factor at play. I mean is that the main reasons for it? Or do you think there are other factors at play that necessarily make knee arthroscopy the one that kind of showed up as the most riskier, you know the one that had the most malpractice litigation attached to it?
Dr Brett Owens: Yeah I mean I think it's an interesting point. I would say I would be careful about how our conclusions are based upon the data since this is a collection of cases that were filed that were at least visible through these data set queries. But we were not able to look at the denominator of the cases that were involved so maybe there were some areas that are fewer and particularly maybe wrist or elbow arthroscopy that are a lot fewer done, but of course there are fewer lawsuits.
Dr Brett Owens: I think we really wanted to look at some of the patterns that were involved. And the patterns really did somewhat reflect what kind of makes sense about the practice. The shoulder did have a fair number of cases. A lot of these were neurologic complications which is not surprising given the proximity of the nerves and also the block, block related. We saw a pattern in the hips and in the elbow, where we know that certainly the neurologic structures are close and certainly those ... it makes sense that those are neurologic complications were involved in those. Even though there's not a large number, in elbow there were eight total lawsuits, but seven of those were neurologic. And of those eight, two settled and two were verdicts to the plaintiffs.
Dr Brett Owens: Hip arthroscopy, three of the five were neurologic complications, and only one of those was awarded to the plaintiff, and four you know tolled to the defense. So in each of these, kind of makes sense given the anatomy involved. I think you're right, the take-home points in knee is the sheer volume of knee arthroscopy. Certainly that was reflected in the number of lawsuits. I think certainly lower extremity surgery is, and certainly a lot of these being in patients with comorbidities, we see risk of DVT with resulting pulmonary embolism, and sometimes even death, unfortunately. Of the 20 deaths that were in this set, 19 of them were from the knee and 16 of them were the result of pulmonary embolism. And that is concerning, so certainly has overlays on how we practice and maybe recommendations regarding DVT prophylaxis.
Dr Clay Nuelle: Did you routinely use any type of DVT prophylaxis for your routine arthroscopies or any of your knee arthroscopies in particular?
Dr Brett Owens: I do. I think that if the patient doesn't have any history I usually use a baby aspirin. I don't have clear data on that. Most of us rely on, at least on the arthroplasty world, for the long term data on at least for DVT and fatal pulmonary embolism, prophylaxis with aspirin. I tend to not want to use a riskier blood thinner unless the patient has a known history of a clot or a clotting disorder.
Dr Brett Owens: Oftentimes, patients are on blood thinners and certainly we try to resume those and coordinate with their primary care doctor, hematologist, etc. But what we don't know by looking at this data set, before we really make conclusions based upon it, is that we don't know any of the history of the patients. We don't know if they were, had a clear predisposition to clot. Maybe they were already on a blood thinner and it was kind of known that they would be at risk for clots. So we really know very little about it, but again, the real take-home message is that death from pulmonary embolism certainly sometimes, at least we've seen here with this query, is that it does sometimes result in lawsuit and I think something as simple as a baby aspirin oftentimes people will use.
Dr Brett Owens: So yes. To answer your question, I do. Do you?
Dr Clay Nuelle: I do yeah. I do the same thing as you unless they have some sort of contraindication or they have some other condition where they're already taking an anti-coagulation. I do a baby aspirin even for even just routine or relatively straightforward knee scopes. Yeah, like you, I don't know if that's necessarily based on the kind of perfect science or perfect literature, but especially after reading this study, I've kind of been bolstered to say that I would definitely continue that, or make sure that that happens all the time.
Dr Brett Owens: All you need is one, right?
Dr Clay Nuelle: I mean exactly-
Dr Brett Owens: I used to not do it in kids and I had a 16 year old get a DVT and a PE. She was alright. But again, all it takes is one and you certainly have to think about that. Another question that I always get asked by my residents is prophylaxis for shoulders. And I usually don't. It's very rare. That said, a couple of years ago, I had ... I did have an upper extremity DVT from a shoulder arthroscopy. So I guess I'll have to ask your opinion there on that.
Dr Clay Nuelle: Yeah, I don't routinely do it for shoulders myself, but I have partners that do. Some of my shoulder arthroscopy partners do routinely do it, especially for some of the bigger cases where the patient's in deep sort of position for a prolonged period of time, in an arm holder. That sort of thing.
Dr Brett Owens: They're for arthroplasty for sure.
Dr Clay Nuelle: Right, for arthroplasty. Now you mentioned ... one thing that was interesting to me ... you mentioned the blocks and some of the litigation being related to blocks. It's interesting. I almost expected there to be a little bit more related to that because I think that anyone, with the prevalence of blocks becoming more and more prevalent, there's multi-modal pain management that we're all trying to work with. We've all experienced blocks that maybe lasted a little longer or even had persistent neurologic compromiser issues. I'm kind of actually surprised that it wasn't even a little more frequently, but I guess that's a good thing.
Dr Brett Owens: I think it is a good thing. I think it's not ... I was surprised we didn't see a little more in the shoulder also. Certainly that's one area where we see, not just the surgeon involved, but the surgeon, the anesthesiologist, and anesthetist, and of course usually the facility that's involved also. And as you know, it can sometimes be confusing, especially to the patients and the lawyers, you know what was involved, why there's a anesthetist afterwards. And we've all seen them in our practice, usually to the surgeon, the anesthesiologist is pretty clear particularly with the distribution, but you know sometimes it's not clear.
Dr Brett Owens: But we all see the literature, blocks really is primarily produced by anesthesiologists and primarily pain control, etc. And most of the conclusions is that they're safe and I think surgeons usually see the follow up a lot better than the anesthesiologist because we're seeing it in the office all the time. And we all have patients that come in with numb fingers, numb toes, etc. And sometimes the block is to blame. The good news is yes, at least in my practice, I've seen most of these do come back even though it certainly is always here with the surgeon when you're watching someone kind of complain of a numb area and you never mind a motor complication.
Dr Clay Nuelle: Absolutely. Dr Owens' article title Medical Malpractice Litigation Following Arthroscopic Surgery can be found in the July 2018 issue of the arthroscopy journal or online at www.arthroscopyjournal.org. Dr. Owens, thank you for joining us today.
Dr Brett Owens: Great. Thanks for having us. I had a great time.
Dr Clay Nuelle: Great. This concludes this edition of the Arthroscopy Journal Podcast. Thank you for joining us. Please join us next time.