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NHS to review 5,500 patient cases after wrong plates used to fix fractures

​NHS Improvement and the British Orthopaedic Association have asked all NHS Trusts in England to review the X-Rays for patients who have been fitted with metal plates to repair fractures since February 2018.

Posted on 13 February 2019

The request was made following cases from an unnamed NHS Trust where the wrong metal plates are reported to have been inserted into patients with fractures. 
The seven patients affected had flexible plates meant for reconstruction inserted rather than a rigid plate designed for fractures. In one particular case, a patient had fallen and the plate buckled, requiring the patient to undergo further surgery to correct the problem.  In another case a patient required further surgery after their plate failed during post-operative physiotherapy.
NHS Improvement said that the mix-up came about because of recent changes in the design of the reconstruction plates meaning that the reconstruction plates and dynamic compression plates are now similar in appearance. The two plates differ in rigidity and strength and are not substitutable.
There is a fear that the problem may be more widespread, and NHS Improvement has stated that the records of 5,500 patients who have had plates inserted for limb fractures since February 2018 will have to be reviewed. It is anticipated that the review will be completed by May.
NHS Improvement National Director for Patient Safety, Dr Aidan Fowler, said: "Patients should not be alarmed and do not need to take any action themselves. The risk of harm is low and their local hospital will contact them if there is a chance that they have been affected.”
Whilst many fractures heal quickly, it can take up to a year for some fractures. The concern remains that patients who have not fully healed could be at risk of not achieving a full recovery if the wrong plate has been inserted.
In order to optimise the healing process, it is crucial that a surgeon uses the appropriate implant which will stabilise the fracture adequately during the healing process, allowing for a healed bone and normal limb function to be achieved.
NHS Improvement has directed any hospital that identifies incorrect plates that have been fitted should work with patients on a care plan. Trusts are also required to report the incident to NHS Improvement, carry out an incident investigation and change theatre processes to ensure the two types of plate are not confused.
Suzanne White,  head of the clinical negligence team at Leigh Day, said:

“Today’s reports  that the incorrect metal plates have been inserted into patients who have had fractures will be of great concern, particularly as they have been inserted into long bones in arms and legs . As someone who has worked as a radiographer, I know only too well what can happen if a fracture does not heal properly. There is little detail at the moment but the fact that potentially 5,500 patients may need to be reviewed, and all hospitals in England are looking into these cases, will be worrying for patients.”