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To operate or not to operate?

01 January 2011

Mr B, a 23-year old professional rugby player, fell awkwardly onto his right knee during a training session.

He was sent to see Mr O, a consultant orthopaedic surgeon, three days later, with a stiff, sore and swollen knee. Mr O performed an arthroscopy and found that there was a tear through half to threequarters of the width of the posterior cruciate ligament.

There were no other documented abnormalities within the knee joint. Mr O did not record his preoperative clinical findings and the documentation of the arthroscopy procedure was very limited. Mr O elected to perform an arthroscopic graft reconstruction of the posterior cruciate ligament, utilising an autograft from the emitendinosus and gracilis muscles, secured by a screw. This was performed a week after Mr O’s initial assessment.

Initially Mr B made a good recovery, but a week after surgery he began to experience acute pain, swelling and locking in the affected knee. Mr O sought the opinion of a consultant orthopaedic colleague, Ms F, who performed a further arthroscopy.

Ms F found that the screw had been malpositioned and was impinging upon the surface of the medial femoral condyle, significantly damaging the gliding surface of the articular cartilage. Ms F conducted further surgical intervention, including a tibial osteotomy. Unfortunately, the damage to Mr B’s knee joint was such that he was never able to resume his professional sports career. Mr B began a legal claim against Mr O, alleging that he had performed the surgery inappropriately and incorrectly such that his knee joint was permanently and significantly damaged.

Expert opinion

An orthopaedic sports injury specialist was concerned by many aspects of the case. The failure to document the egree of instability and other clinical findings in the knee joint before arthroscopy meant that Mr B would have difficulty justifying the procedure he had carried out, rather than opting for other, less invasive, interventions. The expert was of the opinion that the likely chances of the recovery of the injury following either conservative management or direct ligamentous repair, with a graft, were around 95%.

The consent process for the procedure did not take into account the risk of Mr B not being able to continue with his sport and livelihood, when more conservative therapy might lessen this risk. Furthermore it was felt that the initial operative error had indeed caused secondary damage to the knee joint, and led to Mr B’s inability to resume his sports career. The claim was settled for a high sum.

Learning points

  • When treating professional competitors, great care must be taken to inform them fully of the risks of adverse outcomes that may affect their ability to carry on with their profession.
  • It is important not to “overtreat” an injury if there are attendant risks in doing so.
  • Good clinical examination is the cornerstone of good clinical practice and documentation of clinical findings, including operating notes, is essential.