Compensation claims after knee arthroplasty surgery in Norway 2008–2018

Background and purpose — Orthopedic surgery is one of the specialties with most compensation claims. We assessed the claims following knee arthroplasty surgery reported to the Norwegian System of Patient Injury Compensation (NPE) in light of institutional procedure volume.Patients and methods — We collected data from NPE and the Norwegian Arthroplasty Register (NAR) for the study period (2008–2018). Age, sex, type of claim, and reason for compensation were collected from NPE, while the number of arthroplasty surgeries was collected from NAR. The treating hospitals were grouped by quartiles according to annual procedure volume. The effect of hospital volume on the likelihood of an accepted claim was estimated.Results — NAR received 64,241 reports of arthroplasty procedures, of which 572 (0.9%) patients filed a claim for treatment injury. 55% of the claims were accepted, representing 0.5% of all knee arthroplasties. The most common reason for accepted claim was a hospital-acquired infection, in 28% of the patients, followed by misplaced implant (26%) and aseptic loosening (13%). The hospitals with the lowest annual volume (57 or fewer arthroplasties per year, first quarter) had a statistically significantly larger fraction of granted claims per procedures compared with other institutions.Interpretation — The overall risk of ending up with compensation due to treatment error following knee arthroplasty was 0.5%. The risk of accepted claim was greater for patients operated in the lowest volume hospitals.

The number of knee arthroplasty procedures in Norway has increased over the last decade and is now over 7,000 per year (Ackerman et al. 2017, NAR 2020). About 1 in 5 patients receiving a TKA remains dissatisfied with the result (Gunaratne et al. 2017). Although serious complications are rare, infections, implant loosening, misplaced implants, residual pain, and other complications do occur, with potential detrimental results. To monitor the safety of implants and define the epidemiology of the procedures, the Norwegian Arthroplasty Register (NAR) was established in 1987 (Havelin et al. 2000). NAR provides a comprehensive overview of knee arthroplasties taking place in Norway. Compliance with the registry is 97.6% for primary TKA and 93.2% for revisions (Wiik 2014).Patients who suffer an injury while receiving health services, within either the public or the private healthcare sector, can file a claim with the Norwegian System of Patient Injury Compensation (NPE). 3 criteria must be fulfilled for a claim to be accepted:

1. The injury must have been caused during health services (diagnosis, examination, treatment, care, or lack of such), even if no one is to blame. If the injury is severe and unexpected, compensation may be awarded even where no error or omission in treatment has occurred (for example if infection occurs despite adequate prophylaxis).
2. The injury must have caused financial loss to the patient, except if the injury leads to permanent medical impairment of more than 15%, in which case compensation might be awarded despite financial loss. This might be relevant for retired patients or for patients who can continue to work in spite of the disability.
3. The patient must file a claim within a reasonable time (currently set at 3 years) after the patient realizes that the injury is caused by the treatment or lack of treatment received. The claim is filed with NPE at no cost to the patient.

There is compelling evidence that low surgical volume increases the risk of complications and revision after knee arthroplasty surgery (Jaeschke et al. 1989, Badawy et al. 2013, Pamilo et al. 2015, Badawy et al. 2017). Whether this association is also true for injury compensation has not been studied. We evaluated the claims following primary and revision knee arthroplasty surgery filed with NPE and compared the findings with the results from NAR with a focus on annual hospital procedure volume.     

The Feasibility of Contrast-Enhanced Ultrasound During Uterine Artery Embolization: A Pilot Study

Purpose To evaluate the feasibility of using contrast-enhanced ultrasound (CEUS) during uterine artery embolization (UAE) in order to define the correct end-point of embolization with complete devascularization of all fibroids. Methods In this prospective study of 10 consecutive women undergoing UAE, CEUS was performed in the angiographic suite during embolization. When the angiographic end-point, defined as the “pruned-tree” appearance of the uterine arteries was reached, CEUS was performed while the angiographic catheters to both uterine arteries were kept in place. The decision whether or not to continue the embolization was based on the findings at CEUS. The results of CEUS were compared with those of contrast-enhanced magnetic resonance imaging (MRI) 1 day as well as 3 months following UAE. Results CEUS was successfully performed in all women. In 4 cases injection of particles was continued based on the findings at CEUS despite angiographically complete embolization. CEUS imaging at completion of UAE correlated well with the findings at MRI. Conclusion The use of CEUS during UAE is feasible and may increase the quality of UAE.     

Bile duct obstruction: radiologic evaluation of level, cause, and tumor resectability

In a prospective study of 65 patients with bile duct obstruction, various radiologic modalities were compared for their capability to demonstrate the level and cause of obstruction and to indicate accurately tumor resectability. Ultrasound (US) was performed in 65 patients, computed tomography (CT) in 51, direct cholangiography (DC) in 57, and angiography in 35. The level of obstruction was correctly indicated by US in 95% of patients and by CT in 90%, and the cause was correctly indicated by US in 88%, by CT in 63%, and by DC in 89%. In predicting tumor resectability, US was correct in 71% of patients, compared with 42% for CT, 58% for DC, and 25% for angiography. US therefore appears to be the single most useful modality in the evaluation bile duct obstruction.     

Increased frequency of HLA-DPw2 in pauciarticular onset juvenile chronic arthritis

Thirty-six unrelated Danish patients with pauciarticular Juvenile Chronic Arthritis (PJCA) and 120 controls were typed for HLA-DPw1-w6 and the local specificity CDPHEI with bulk-expanded Primed Lymphocyte Typing (PLT) cells. The frequency of HLA-DPw2 was 52.8% in PJCA patients and 16.7% in controls (relative risk, RR = 4.5; P less than 0.001). The antigens HLA-Dw5 and/or Dw8 were present in 50% of the patients and in 21.3% of the controls (RR = 4.2; p less than 10(-3)). DPw2 was not associated (in linkage disequilibrium) with Dw5/w8 in patients or in controls, and the DP and D associations with PJCA were independent of each other. However, the combined presence of DPw2 and Dw5 and/or Dw8 gave a significantly higher risk of PJCA than each antigen alone indicating interaction of DP and DR gene products. PJCA is the first disease definitely found to be associated with a DP antigen.     

HLA-D and -DR antigens in genetic analysis of insulin dependent diabetes mellitus

Summary Three groups of patients with insulin-dependent diabetes mellitus, ascertained by different procedures, were investigated for HLA-A, B, C and D antigens (n=164), and a subset (n=93) for HLA-DR. Both HLA-D/DR3 and D/DR4 were strongly positively associated and D/DR2 was negatively associated with insulin-dependent diabetes. HLA-DR4 was found to be a better marker for insulin-dependent diabetes than Dw4. The HLA-B associations (B8, B15 and B18) were clearly secondary to the increases of HLA-D/DR3 and D/DR 4. The HLA associations did not differ between familial and isolated cases indicating that these two groups may well have a common genetic background. Based on analysis of HLA-haplotype sharing in affected sibling pairs, a simple dominant model of inheritance could be ruled out, and a simple recessive model was found unlikely. The relative risks for the HLA-Dw3,4 and HLA-DR3,4 phenotype were 21.2 and 44.4 respectively and exceeded those of both the HLA-Dw3 and HLA-DR3 (5.6 and 4.3) as well as the HLA-Dw4 and DR4 (10.1 and 10.5) phenotypes. This argues against an intermediate genetic model but further studies are needed to clarify whether there is more than one susceptibility gene for insulin-dependent diabetes mellitus within the HLA-system. Note. A list with detailed data on all patients is available from the authors on request.     

Access to contraceptive services among unmarried young people in the north-east of China

Objective The concerns about the potential threats of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) have increased, since, in China, there is a lack of sexual education and condom use is rare. A community-based survey was conducted in September 2001 in Changchun city among 1227 unmarried young people aged 15-24 years (619 males and 608 females) to assess risky sexual practices and the obstacles to accessing appropriate contraceptive and other services. Method The study comprised a survey employing self-administered questionnaires, as well as key informant interviews, focus group discussions and in-depth interviews. This paper investigates the factors associated with young people's access to contraceptive services. Results Results showed that 16% of young people had experienced premarital sexual intercourse and, among them, only 48.2% used contraceptive methods during the first sexual intercourse; 29.9% used a condom. Drug stores were the main source of contraceptives. Conclusions While data are sparse, findings suggest that the hostile and judgmental attitudes of providers, as well as the lack of counseling and privacy, were the key obstacles that unmarried youth encountered in their search for contraceptive services. Findings suggest the need for a reorientation of the contraceptive services to focus on unmarried youth, and generally to make contraceptive services more accessible to young people.