| (H) Dislocation or loosening requiring additional surgery.
(I) If performed on a child age 12 or under, include
the following additional risks: problems with appearance, use, or
growth requiring additional surgery.
(2) Arthroscopy of any joint.
(A) Blood vessel or nerve injury.
(B) Continued pain.
(C) Stiffness of joint.
(D) Blood clot in limb or lung.
(E) Joint infection.
(F) If performed on a child age 12 or under, include
the following additional risks: problems with appearance, use, or
growth requiring additional surgery.
(3) Open reduction with internal fixation.
(A) Impaired function such as stiffness, limp, or change
in limb length.
(B) Blood vessel or nerve injury.
(C) Pain.
(D) Blood clot in limb or lung.
(E) Failure of bone to heal.
(F) Infection.
(G) Removal or replacement of any implanted device
or material.
(H) If performed on a child age 12 or under, include
the following additional risks: problems with appearance, use, or
growth requiring additional surgery.
(4) Osteotomy.
(A) Impaired function such as stiffness, limp, or change
in limb length.
(B) Blood vessel or nerve injury.
(C) Pain.
(D) Blood clot in limb or lung.
(E) Failure of bone to heal.
(F) Infection.
(G) Removal or replacement of any implanted device
or material.
(H) If performed on a child age 12 or under, include
the following additional risks: problems with appearance, use, or
growth requiring additional surgery.
(5) Ligamentous reconstruction of joints.
(A) Continued instability of the joint.
(B) Arthritis.
(C) Continued pain.
(D) Stiffness of joint.
(E) Blood vessel or nerve injury.
(F) Impaired function and/or scarring.
(G) Blood clot in limb or lung.
(H) If performed on a child age 12 or under, include
the following additional risks: problems with appearance, use, or
growth requiring additional surgery.
(6) Vertebroplasty/kyphoplasty.
(A) Nerve/spinal cord injury.
(B) Need for emergency surgery.
(C) Embolization of cement (cement passes into blood
vessels and possibly all the way to the lungs).
(D) Collapse of adjacent vertebrae (bones in spine).
(E) Leak of cerebrospinal fluid (fluid around the brain
and spinal cord).
(F) Pneumothorax (collapsed lung).
(G) Failure to relieve pain.
(H) Rib fracture.
(7) If the following procedures are performed on a
child age 12 or under, problems with appearance, use, or growth requiring
additional surgery should be disclosed.
(A) Arthrotomy (opening of joint).
(B) Closed reduction with or without pin or external
fixation.
(C) Surgical management of open wound.
(D) Partial excision or removal of bone.
(E) Removal of external fixation device.
(F) Traction or casting with or without manipulation
for reduction.
(8) Amputation of limb.
(A) Pain and/or phantom sensation in removed limb.
(B) Need for further surgery.
(C) Infection.
(D) Hemorrhage (severe bleeding).
(E) Difficulty with prosthesis fitting.
(m) Nervous system treatments and procedures.
(1) Craniotomy, craniectomy or cranioplasty.
(A) Loss of brain function such as memory and/or ability
to speak.
(B) Recurrence, continuation or worsening of the condition
that required this operation (no improvement or symptoms made worse).
(C) Stroke (damage to brain resulting in loss of one
or more functions).
(D) Loss of senses (blindness, double vision, deafness,
smell, numbness, taste).
(E) Weakness, paralysis, loss of coordination.
(F) Cerebrospinal fluid leak with potential for severe
headaches.
(G) Meningitis (infection of coverings of brain and
spinal cord).
(H) Brain abscess.
(I) Persistent vegetative state (not able to communicate
or interact with others).
(J) Hydrocephalus (abnormal fluid buildup causing pressure
in the brain).
(K) Seizures (uncontrolled nerve activity).
(L) Need for permanent breathing tube and/or permanent
feeding tube.
(2) Cranial nerve operations.
(A) Weakness, numbness, impaired muscle function or
paralysis.
(B) Recurrence, continuation or worsening of the condition
that required this operation (no improvement or symptoms made worse).
(C) Seizures (uncontrolled nerve activity).
(D) New or different pain.
(E) Stroke (damage to brain resulting in loss of one
or more functions).
(F) Persistent vegetative state (not able to communicate
or interact with others).
(G) Loss of senses (blindness, double vision, deafness,
smell, numbness, taste).
(H) Cerebrospinal fluid leak with potential for severe
headaches.
(I) Meningitis (infection of coverings of brain and
spinal cord).
(J) Need for prolonged nursing care.
(K) Need for permanent breathing tube and/or permanent
feeding tube.
(3) Spine operation, including laminectomy, decompression,
fusion, internal fixation or procedures for nerve root or spinal cord
compression; diagnosis; pain; deformity; mechanical instability; injury;
removal of tumor, abscess or hematoma (excluding coccygeal operations).
(A) Weakness, pain, numbness or clumsiness.
(B) Impaired muscle function or paralysis.
(C) Incontinence, impotence or impaired bowel function
(loss of bowel/bladder control and/or sexual function).
(D) Migration of implants (movement of implanted devices).
(E) Failure of implants (breaking of implanted devices).
(F) Adjacent level degeneration (breakdown of spine
above and/or below the level treated).
(G) Cerebrospinal fluid leak with potential for severe
headaches.
(H) Meningitis (infection of coverings of brain and
spinal cord).
(I) Recurrence, continuation or worsening of the condition
that required this operation (no improvement or symptoms made worse).
(J) Unstable spine (abnormal movement between bones
and/or soft tissues of the spine).
(4) Peripheral nerve operation; nerve grafts, decompression,
transposition or tumor removal; neurorrhaphy, neurectomy or neurolysis.
(A) Numbness.
(B) Impaired muscle function.
(C) Recurrence, continuation or worsening of the condition
that required this operation (no improvement or symptoms made worse).
(D) Continued, increased or different pain.
(E) Weakness.
(5) Transphenoidal hypophysectomy or other pituitary
gland operation.
(A) Cerebrospinal fluid leak with potential for severe
headaches.
(B) Necessity for hormone replacement.
(C) Recurrence or continuation of the condition that
required this operation.
(D) Deformity or perforation of nasal septum (hole
in wall between the right and left halves of the nose).
(E) Facial nerve injury resulting in disfigurement
(loss of nerve function controlling muscles in face).
(F) Loss of senses (blindness, double vision, deafness,
smell, numbness, taste).
(G) Stroke (damage to brain resulting in loss of one
or more functions).
(H) Persistent vegetative state (not able to communicate
or interact with others).
(I) Headaches.
(6) Cerebrospinal fluid shunting procedure or revision.
(A) Shunt obstruction (blockage of shunt/tubing causing
it to stop draining adequately).
Cont'd... |
