Vol 2 | Issue 2 | May-August 2025 | page: 1-3 | Sachin Kale, Arvind Vatkar, Moin Darvesh, Sushant Srivastava, Ojasv Gehlot, Ashok Shyam

Submitted Date: 13-03-2025, Review Date: 28-03-2025, Accepted Date: 22-04-2025 & Published Date: 10-07-2025

https://doi.org/10.13107/joc.2025.v02.i02.18

Authors: Sachin Kale [1], Arvind Vatkar [2], Moin Darvesh [1], Sushant Srivastava [1], Ojasv Gehlot [1], Ashok Shyam [3]

[1] Department of Orthopaedics, D.Y Patil School of Medicine and Hospital, Navi Mumbai, Maharashtra, India.
[2] Director, Jupiter Hospital, Eastern Expressway, Thane, Maharashtra, India.
[3] Department of Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra, India

Address of Correspondence

Dr. Sachin Kale,
Department of Orthopaedics, D.Y Patil School of Medicine and Hospital, Navi Mumbai, Maharashtra, India.
Email: sachinkale@gmail.com

Abstract

Orthopaedic surgery, like all surgical specialties, is inherently associated with the risk of complications. These may arise from patient-related factors, surgical technique, implant-related issues, or post-operative care. The successful management of complications requires a combination of prevention strategies, early detection, transparent reporting, and empathetic communication with patients and their families. This article elaborates on the common complications encountered in orthopaedics, outlines evidence-based strategies for prevention, emphasizes the ethical and clinical importance of reporting complications, and highlights the powerful role of patient and family counselling in mitigating medicolegal risks and preserving the therapeutic alliance.
Keywords: Surgical technique, Implant-related issues, Counselling,Communication

Introduction

Complications in orthopaedic surgery are not just surgical events; they are critical learning opportunities and tests of professional conduct. Despite advances in techniques, instrumentation, and infection control protocols, orthopaedic complications remain a significant contributor to patient morbidity and healthcare costs. Managing these complications effectively not only improves patient outcomes but also safeguards professional integrity and trust.
This article aims to provide an exhaustive understanding of:
• The types and causes of orthopaedic surgical complications
• Prevention strategies at every stage of care
• The ethical imperative and value of complication reporting
• The indispensable role of patient and family counselling
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Types of Complications in Orthopaedic Surgery
Orthopaedic complications can be broadly classified into perioperative and postoperative complications. Each has its own mechanisms, risks, and preventive approaches.

1. Perioperative Complications
a. Neurovascular Injury
• Accidental injury to nerves (e.g., radial nerve during humeral plating ) or vessels (e.g., popliteal artery in TKR)
• May result in permanent disability if not recognized and managed early
b. Anaesthesia-related Issues
• Cardiac events, airway complications, allergic reactions, particularly in high-risk patients
c. Technical Errors
• Malpositioned implants, iatrogenic fractures, cement embolism, thermal necrosis from drilling, intraoperative bleeding

2. Postoperative Complications
a. Infection
• Superficial wound infections to deep-seated implant-related infections
• May require implant removal, debridement, or staged reconstruction
b. Implant Failure
• Mechanical breakage, loosening, or wear due to suboptimal fixation or bone quality
c. Nonunion, Malunion, Delayed Union
• Failure of bone healing due to biological or mechanical failure
d. Joint Stiffness and Contracture
• Due to prolonged immobilization or inadequate physiotherapy
e. Hardware Prominence or Irritation
• Pain or soft-tissue problems requiring removal
f. Venous Thromboembolism (VTE)
• DVT and pulmonary embolism in immobile patients, especially after hip or spine surgery
g. Chronic Pain and Complex Regional Pain Syndrome (CRPS)
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Root Causes and Risk Factors
• Patient factors: Age, comorbidities (diabetes, osteoporosis), smoking, obesity, immunocompromised state
• Procedure-related: Duration of surgery, blood loss, level of contamination, implant type
• Surgeon factors: Inexperience, fatigue, suboptimal technique, poor judgment
• Hospital system factors: Inadequate sterilization, understaffed units, lack of rehab services
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Strategies for Prevention
1. Preoperative Phase
• Comprehensive history, systemic evaluation, and optimization
• Nutritional support and glycemic control
• Identification of infection sources (dental, urinary, skin)
• Accurate imaging and templating
• Detailed informed consent covering all potential risks

2. Intraoperative Phase
• Strict adherence to aseptic techniques
• Timely and effective use of antibiotics
• Use of image intensifier for accuracy
• Gentle tissue handling and minimal tourniquet time
• Correct implant selection and biomechanical alignment

3. Postoperative Phase
• Adequate pain control to encourage early mobilization
• Use of DVT prophylaxis and anticoagulants where indicated
• Daily monitoring for early signs of infection or complications
• Wound care protocols and dressing guidelines
• Multidisciplinary follow-up with physiotherapists and nutritionists

Swiss Cheese Concept
The Swiss Cheese model, applied in orthopaedics, likens each healthcare professional in the operating theatre to a slice of Swiss cheese, with holes representing potential errors or oversights. When stacked, these slices align to minimize complications only if all team members freely voice concerns. Open communication ensures that gaps in one person’s knowledge or vigilance are covered by others, reducing risks like surgical site infections or wrong-site surgery. By fostering a culture of collaboration and psychological safety in the theatre and wards, the model significantly lowers complication rates, enhancing patient safety and surgical outcomes.

Checklist Concept
Atul Gawande’s checklist concept, inspired by aviation, emphasizes structured protocols to reduce orthopaedic complications. Like pilots using checklists during emergencies, surgical teams employ checklists to ensure critical steps—such as verifying patient identity, surgical site, or antibiotic administration—are never missed. Gawande’s book, *The Checklist Manifesto*, highlights how checklists improve decision-making under pressure, streamline complex procedures, and minimize errors. In dire situations, they provide clarity, ensuring calm, systematic responses akin to plane emergency protocols. Implementing checklists in operating theatres enhances consistency, reduces mortality, and improves outcomes, making them indispensable for safe, high-stakes surgical practice.
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The Need to Report Orthopaedic Complications
Why Complication Reporting Is Essential:
1. Enhances Patient Safety
o Identifies systemic flaws or technique-related issues
o Prevents recurrence of the same error in future patients

2. Fosters Institutional and Surgeon Improvement
o Encourages introspection and professional development
o Promotes refining of surgical protocols

3. Supports Academic Research
o Provides real-world data for evidence-based practice
o Generates knowledge on rare or emerging complications

4. Builds Ethical Medical Practice
o Emphasizes transparency, honesty, and patient-first attitude

5. Legal and Insurance Implications
o Documentation can protect the surgeon in medicolegal cases if handled responsibly

Methods of Reporting:
• Morbidity and Mortality (M&M) conferences
• Surgical audit meetings
• Institutional databases and registries (e.g., NJR, AO databases)
• Case reports in indexed journals
• Internal incident reporting systems
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The Role of Counselling: Before and After Complications
Effective communication can be the game-changer in how complications are perceived and accepted by patients and families.

1. Preoperative Counselling
• Explain the diagnosis, surgical options, goals of treatment, and associated risks
• Emphasize that while all precautions are taken, no surgery is risk-free
• Use diagrams, 3D models, or videos to aid understanding
• Allow adequate time for discussion, questions, and informed decision-making

2. Immediate Postoperative Counselling
• Explain what was done, any intraoperative challenges or deviations
• Set realistic expectations for recovery
• Provide written discharge plans and emergency contact points

3. Counselling in the Event of a Complication
• Disclose the complication honestly, without delay
• Use non-technical language
• Express empathy and reassurance
• Discuss the steps taken to correct the issue and the future plan
• Encourage second opinions if needed to reinforce trust
• Document all discussions meticulously

Benefits of Counselling:
• Builds trust and reduces litigation risk
• Helps patients cope with extended recovery or disability
• Encourages adherence to post-op instructions
• Reinforces the doctor-patient partnership
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Case Example (Hypothetical)
A 65-year-old diabetic male underwent total knee replacement and developed deep wound infection requiring debridement and delayed reimplantation. Early recognition, transparent discussion with family, involvement of infectious disease specialists, and clear communication about timelines helped retain trust. Eventually, a successful revision was done with complete functional recovery.
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Conclusion
Complications are a reality in orthopaedic surgery, but they are not synonymous with failure. The ability to prevent, detect, manage, and most importantly, communicate complications defines a surgeon’s professionalism and maturity. By promoting a culture of honest reporting and ethical counselling, orthopaedic surgeons can ensure patient-centered care, continuous self-improvement, and enhanced safety across the healthcare system.
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Key Learning Points
✅ Complications are not always preventable, but their impact can be minimized with vigilance and planning.
✅ Transparent reporting improves institutional safety and individual accountability.
✅ Patient counselling before and after surgery is essential to manage expectations and build trust.
✅ Informed consent should be dynamic, detailed, and documented.
✅ A multidisciplinary team approach is key to preventing and managing complications effectively.

How to Cite this article: Kale S, Vatkar A, Darvesh M, Srivastava S, Gehlot O, Shyam A | Complications in Orthopaedic Surgery: Prevention, Transparent Reporting, and the Vital Role of Counselling | Journal of Orthopaedic Complications | May-August 2025;2(2):01-03.

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