Assessing the quality of consent in elective hip and knee arthroplasty: Do modern orthopaedic surgeons make the cut?

INTRODUCTION: Improper consent is a failure of clinical care and also a major cause of litigation within health care authorities. 4% of surgical negligence claims are attributed to improper consenting in the NHS, with an average settlement fee of approximately £40,000 per claim. Improving quality of consenting therefore not only improves patient care but could also reduce healthcare cost. METHOD: A retrospective analysis of 100 elective hip and knee arthroplasties at a district general hospital in the South of England. Clinic letters and consent forms were reviewed, using the British Orthopaedic Association (BOA) consent proforma as a comparison standard. Quality of consent was reviewed based upon inclusion of BOA suggested risks. RESULTS: 40% of hip arthroplasty clinic letters and 20% of knee arthroplasty clinic letters did not include a risk discussion. Common risks on consent forms when compared to BOA standards were 84.8% compliant in knees and 88.8% in hips. Less common risks on consent forms were 100% compliant in knees and 96% in hips. Rare risks on consent forms were 74.8% compliant in knees and 57.7% in hips. Notably blood clots and infection were consented for in almost all patients. Risk of death meanwhile, was only consented for 62% of the time, across both procedures. CONCLUSION: Standard of consenting in this audit falls short of BOA standards. Improvement is needed to improve patient care and avoid medical litigation. An integrated electronic form linking consent process of both outpatient and pre-operative review could be a beneficial intervention.

Bilateral inguinoscrotal hernia with gastric contents and subsequent perforation: Lessons in operative management.

INTRODUCTION: Inguinoscrotal hernias often contain bowel, but it is rare to see it contain part or all of the stomach. These patients tend to present in extremis. PRESENTATION OF CASE: This is the case of a 74 year old gentleman who presented in obstruction and acutely unwell from giant bilateral inguinoscrotal hernias. CT scan confirmed the left hernia contained the majority of the bowel and stomach. He underwent laparotomy and repair of the left sided hernia. Intraoperatively he was also found to have a gastric perforation and underwent distal gastrectomy. 7 days post operatively he returned to theatre for repair of his right sided hernia. The patient made a full recovery. DISCUSSION: Review of similar literature highlights numerous surgical methods in repairing these hernias. A two-stage approach appears to mitigate the risk of abdominal compartment syndrome, whilst also allowing for an interval hernia repair in a non-hostile environment. Gastric perforation repair technique also varies, with majority of literature reporting primary repair. CONCLUSION: We hope our approach to management can help guide others faced with similar challenging cases. Moreover, it highlights some operative challenges including dealing with associated gastric perforation and mitigating the risk of abdominal compartment syndrome.