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Cement Implantation syndrome during a hip hemiarthroplasty An 85 year old lady wast brought to the operating theatre for a left hip hemiarthroplasty following a displaced intracapsular neck of femur fracture. Their admission AMTS was 3/10 and they had been consented using a Form 4 (patients lacking capacity). A 'Do Not Attempt Cardiopulmonary Resuscitation' form had been completed pre-operatively with their next of kin. The surgeons were 2 experienced SpRs. The consultant was in the hospital but not in the operating theatre. During cementation the patient developed ventricular tachycardia and lost their cardiac output. Masterclass: Everything happened by the book: - The anaesthetist gave the order to press the emergency buzzer - Within seconds the wound was closed using skin clips - A large Ioban dressing was place over the wound - The patient was turned to a supine position and CPR was commenced - Cardiac output was temporarily - Ultimately the event was unsurvivable but prompt action bought enough time for the patient's family to attend (in theatre) - A team debrief was conducted and the decision was made to stand down the theatre Learning points: Bone Cement Implantation Syndrome is a rare but potentially fatal complication of any procedure involving Orthopaedic cement. A total of 26 deaths had been reported when cement was used during hemiarthroplasty between October 2003 and October 2008. There are certain steps which can be taken to mitigate against this risk: 1) Patient risk factors: Increasing age and comorbidities make patients more susceptible to this complication. Surgeons and anaesthetists should be aware of this and specifically incorporate it into their pre-operativce briefing. 2) Surgical factors: Thorough lavage of the medullary cavity is mandatory. Consider placing a suction catheter to reduce pressure at the cement/marrow vessel interface during cementation. Pressurisation should be appropriate to the surgical scenario; often this means no or very little pressure. 3) Team factors: Communication is key. The surgeon should provide the Anaesthetic team with sufficient warning prior to - and upon - cementation. The decision to perform CPR on a patient with a DNACPR form should ideally be discussed well before the situation arises. If the Surgeon and Anaesthetist agree, it is reasonable to attempt CRP whilst seeking to correct reversible causes. References: Timperley et al. 2009. Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur. Available here

Not overlooking the basics in complex trauma A patient was admitted late at night following an MVC with right-sided femoral and tibial fractures and a left sided open talus fracture. They were taken to the Operating theatre around 11pm where the on call Registrar attempted (unsuccessfully) to reduce the talus. The on call consultant was called and she too struggled to reduce it. A senior foot & ankle consultant (long off the on rota...) was called who performed a medial maleolar osteotomy and managed to get it back in. At around 5am the patient left the operating theatre for ICU. Colleagues were highly critical that the femur had not been fixed or at least stabilized at the same sitting and the patient returned to theatre several hours later for Ex-Fix Learning points: - Polytrauma can be very difficult to manage requires experience. A 15 minute delay to theatre while you discuss the plans and the 'what ifs' would - in this instance - have been time well spent. - Ask someone to set a timer so you don't loose track of time. - Do not be embarrassed to phone a friend if you are struggling. - All injuries were identified in the secondary survey but all 3 operating surgeons failed to attend to the femur at the time of the first operation. This is a type of 'group think'. It might have helped to write the injuries on the white board at the beginning of the case. - Beware of distracting injuries (like the extruded talus) and make sure you are not missing other common or serious problems which require attention.

".... the humeral head ended up on the floor..." Case: Young male with high energy (closed) 4 part intra-articular proximal humeral fracture. Despite the severity and complexity of the injury the decision was made to fix the fracture and the patient was consented for ORIF (but replacement was not discussed). The fracture was accessed via a standard delto-pectoral approach. Upon opening the capsule the broken head 'escaped' and ended up on the floor of the operating theatre, presenting a significant conundrum. Options: - Wash the fragment and put it back? This carries a risk of infection. - Discard the fragment and proceed with a hemiarthroplasty, although the patient has not been consented for this? - Close the wound, wake the patient up and explain / further planning? - Other options? What happened next: The patient was not in immediate danger and so the operation was temporarily suspended. The consultant in charge of the case made several phone calls to senior / trusted colleagues. The above options were discussed and contemporaneous notes documented. The critical fragment was placed in Betadine and copiously irrigated. It was then replaced and fixed. Satisfactory results were achieved and the patient rehabilitated. Unfortunately it failed to unite although infection was never isolated. The patient required arthroplasty and made a complaint. This might be the first time this has happened to you, but it's unlikely it's the first time it's happened ever Lessons: - Although not much literature exists on this topic, AS USUAL THIS HAS HAPPENED BEFORE! Studies on extruded Tali and ACL grafts suggest that the sooner you pick it up and put it in antiseptic the better. - In these situations it is always wise to phone a friend and make acurate and contemporaneous notes.

What is the scope of the problem in the NHS? One in 20 hospital admissions results in avoidable patient harm [1]. So-called ‘never-events’ such as wrong site surgery and retained surgical instruments may happen as often as 1:100,000 and 1:10,000 respectively [2]. Threat of litigation is highly present in UK practice. Surgical mistakes contribute to the significant burden of NHS clinical negligence claims, with spending on pay-outs and settlements increasing rapidly in recent years, resulting in a bill of around £2.4 billion in 2018-19 [6]. Surgical specialties are documented to have the greatest number of litigious claims, with 2,847 over a ten-year period to 2019, though obstetrics and gynaecology has the highest total value of pay-outs [3]. Over 90% of surgeons report experiencing an intraoperative adverse event, most commonly within the last year. Whilst this can harm patients, the effect on the surgeon themselves can be significant and often overlooked. Amongst those surveyed they almost unanimously expressed strong feelings of anxiety, guilt, sadness, anger, shame, and/or embarrassment but few sought professional psychological counselling [4]. This article originally appeared in The Journal of Trauma and Orthopaedics A full version of this is available for free here _____________________ [1] Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: Systematic review and meta-analysis. The BMJ. 2019;366. [2] Hempel S, Maggard-Gibbons M, Nguyen DK, Dawes AJ, Miake-Lye I, Beroes JM, et al. Wrong-site surgery, retained surgical items, and surgical fires a systematic review of surgical never events. JAMA Surg. 2015 Aug 1;150(8):796–805. [3] Lane J, Bhome R, Somani B. National trends and cost of litigation in UK National Health Service (NHS): a specialty-specific analysis from the past decade. Vol. 66, Scottish Medical Journal. SAGE Publications Ltd; 2021. p. 168–74. [4] Bohnen JD, Lillemoe KD, Mort EA, Kaafarani HMA. When Things Go Wrong: The Surgeon as Second Victim. Vol. 269, Annals of Surgery. Lippincott Williams and Wilkins; 2019. p. 808–9.

Here are some very wise words from a Consultant who has seen it all before! Take a deep breath and step away from the table – obviously if safe to do so Take another deep breath and tell someone senior and sensible in theatre there is a problem. Be cautious about just announcing in theatre, the patient may be awake, rumour control will have it out in the corridor before you can blink and by the time it comes back you will have removed the wrong hand and leg Phone a friend or your boss. Preferably get them to come immediately to the theatre if on site but it not, un-scrub and spend 5 minutes or longer talking to them about your options Get them to join you if feasible and complete case with them there – you will be pretty unsettled and do not want any more issues Write a full operation note Have a cup of tea (or a large quantity of chocolate!) Consider cancelling the rest of the list Debrief team in theatre – don’t forget they will be upset and will be called on by investigation Write a full account immediately and email to yourself and friend +/- Clinical Director/Lead clinician Fill in Datix Contact your defence union Phone your friend/mentor/someone who knows the operation and talk about it. Most complications have been done before...

A junior surgeon gets a horrible surprise during a routine Trapeziectomy Before I start let me state the facts: why did this mistake happen? It happened because I didn't even contemplate that it could happen. All going smoothly “…this is a procedure I have performed 14 times before (both supervised and unsupervised) and assisted a further 7 times. The consultant stood to my right, passing me instruments and the scrub nurse was sat opposite me stabilising the arm...” One false move The anatomy on the back of the wrist can get a little busy. You have to identify the interval between APL and EPB while watching out for the SBRN in order to identify and protect the radial artery. The next step is often to place a McDonald's dissector (or similar) between the base of the 1st Metacarpal and the Trapezium to confirm the location of the 1st CMC joint. "It happened because I didn't even contemplate that it could happen" Warning signs In retrospect everyone agreed that there were warning signs from the beginning. A Trainee too eager to make a good impression? A highly experienced Consultant who was willing to trust them? An incision a few millimetres out of place? Not just taking a few extra seconds to double check the position.... and then triple check.... Holy f******* **** When the 'Trapezium' came out it was more or less whole, which is unusual. It was also massive and some very big alarm bells started to ring. The patient was awake under Regional Anaesthetic, so that needed careful management. The wait for Xray was one of the longest of everyone's lives, and when it arrived it told the whole sorry tale. OK so it's not just me, then? As dreadful as this mistake was it turns out it is not as rare as one might think / hope. As one study showed: "...We distributed the survey to 777 hand surgeons via email... Ninety-nine surgeons responded to our survey. Twenty-three respondents had participated in an excision of the incorrect bone in the wrist. The most common error was partial or complete excision of the scaphoid during a planned excision of the trapezium...." - Caggiano 2017 Managing Full duty of candour was undertaken verbally and in writing. The patient was transferred to to the care of another Surgeon in the region. They underwent an arthroscopy but have not at time of writing (4 years later) required any further surgery. They even elected to have a Trapeziectomy on the other side...

A simple femoral reaming goes off rails when an unsupervised trainee omits to first pass the ball-tipped guidewire. Just a quick one while I finish the Ward Round... A ST5 Trainee was asked to start the trauma list while consultant finished the ward round. The first case is an infected intramedullary nail, planned for a second debridement and vac change. It was discussed (briefly!) with the trainee who agrees it is with in their current skill set; the plan is to re-ream the canal and place antibiotic beads. Simple, right?! The Trainee reams the canal; the end of the reamer uncouples remaining in the femur! "If you can imagine it, it can happen; even if you can't imagine it, it can happen!!" Wrong! The Consultant is contacted who advised using a pair of long urology forceps to retrieve it, which they are unable to do. A long delay ensues. The Consultant scrubs, retrieves the reamer tip, asks for the ball tip wire back to ream again. Only then does the Trainee realise their error; they had not placed the ball tip guidewire before reaming! Been there, done that... This is an easy mistake to make if you are not overly familiar with the procedure and something which may not have even occured to the Trainee.... of supervising Consultant! The ball tip guide wire is not just a device to guide the reamer across a fracture but is also designed to prevent this complication occurring. The bottom line If you can imagine it, it can happen; even if you can't imagine it, it can happen!! Be sure to check out our Error Log of similar bear traps which lie in wait for you when you least expect them...

A trainee experiences a dilemma when the consultant assigned to supervise him is our of their own depth... How did I feel when I was asked to present my worst surgical mistake?! Horrified, haunted, humiliated! I was an ST4 Orthopaedic trainee. A patient in their mid-50s presented with persistent pain and was listed for revision from a Unicompartmental Knee Replacement (UKR) to a Total Knee Replacement (TKR). Throughout the case there were several significant issues including poor pre-operative planning, technical errors, communication difficulties between members of the surgical team, lack of familiarity with kit and duty of candour with the patient following surgery. What I learnt about knee replacements... and myself After presenting the case, we were able to reflect as a group on the many “system errors” that led up to that operation. We debated what we could have changed to affect the outcome and how each of us would have responded if placed in that situation. "Open discussion of our errors helps raise awareness, encourage debate and promote patient safety" What I would do differently As surgeons it is inevitable that we will make mistakes in both our training and consultant practice. Open discussion of our errors helps raise awareness, encourage debate and promote patient safety. Be sure to read about our other case reports in the Error Log

LFSM: Learning from Surgical Mistakes How to turn mistakes and near misses into positive learning events LFSM was established by a group of Orthopaedic Surgical Trainees to share and discuss our errors in a non-judgemental and open environment. Following the overwhelming success of our first meeting and publication in The Journal of Trauma and Orthopaedics we have decided to create a national forum of peer support for surgeons. What is a surgical mistake? A surgical mistake is a decision or action which produces unwanted consequences, be that for the surgeon or the patient or both. This encompasses everything from very small to very large errors or could, in extremely rare circumstances, result in fatality. Why do mistakes happen? Surgical mistakes result from complex interactions, decisions, and events rather than isolated, individual errors. When analysing mistakes therefore they can never be read in isolation but must be seen in the context of the Healthcare setting and the wider surgical team. Many models of medical errors exist and we will be exploring them over time on this website and in traditional print media. How can I avoid mistakes in surgery? Although they cannot be avoided entirely, the key to minimising mistakes is to acknowledge the mistakes of those who have us, learn with humility from our peers and scrutinise our own practice. Please take a moment to look through our Error Log to see if you recognise any of the mistakes listed and feel free to get in touch to add your own.