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A pain in the knee

14 September 2014

Mr D, a 62-year-old manager, had severe pain in both knees, which caused him trouble walking more than 200 yards. He was referred to an orthopaedic clinic for assessment.

At the assessment, consultant Mr M diagnosed bilateral osteoarthritis of his knees. Two weeks later bilateral knee arthroscopies were carried out. At follow-up clinic a week later, Mr D felt his knees had improved.

However, two months later Mr D complained of extreme pain in the left knee and it was decided he should undergo total left knee replacement.

Following the knee replacement, Mr D had physiotherapy. Two months post-surgery, Mr D was happy with his knee replacement. He had returned to work, was driving, and playing golf.

Four months post-surgery, Mr D was reviewed by Mr M after he complained of developing difficulties flexing his knee. Mr M thought Mr D had developed fibrotic changes within the joint and, as a result, manipulation was undertaken under anaesthetic a few months later. The day after the manipulation, Mr D had a disagreement with one of the physiotherapists and discharged himself from hospital. He declined in and outpatient physiotherapy and arrangements for physiotherapy elsewhere.

Early the following year, Mr M saw Mr D and noted that he had benefited from having later physiotherapy, with movement of 100º. However, a number of months later, Mr D had subsequent difficulties and pain. A second opinion obtained from surgeon Ms H stated that the femoral component was too large and a revision knee replacement was carried out. Mr D claimed his pain had been eradicated.

Mr D made a claim against Mr M, stating that he had failed to recognise, from postoperative x-ray, that the femoral implant of the first knee replacement was too large, failed to advise of the need for a revision procedure, and failed to carry out a revision procedure, or refer Mr D to another surgeon. He also claimed a pointless manipulation was carried out under anaesthetic and he had suffered unnecessary pain and inconvenience for more than two years.

Expert opinion

Expert opinion was supportive and there was no criticism of the initial procedure carried out by Mr M. The femoral component was found to be in reasonable size limits and it was stressed that the management of painful stiff knee post-replacement is notoriously difficult – many factors can come into play. During the revision procedure, significant soft tissue release would have been required and this alone may have been responsible for an increased range of motion in Mr D’s knee.

However, experts were critical of the fact that as Mr D was not happy with the result of the knee replacement, the reasons why should have been investigated.

The case was successfully defended at trial and nearly all costs were recovered.

Learning points

  • A poor outcome doesn’t necessarily mean negligence. There was no criticism of the procedure itself by experts.
  • Supportive expert opinion of the technique used in the procedure meant that the case could be defended to trial.
  • Mr M had well-documented the procedure and detailed medical records helped in defence of the case.
1 comment
  • By Evgueny Tchekashkine on 08 February 2017 10:41

    If it was claimed that the cause of restricted knee joint mobility was improperly selected of femoral component size then knee symptoms could be observed after primary surgery immediately and the patient could not return to work, resume all his life activities. Once the patient failed to follow recommended postop rehabilitation the poor functional outcome is most likely anticipated and no surgeon to be blamed for procedure failure.

    Wonder if the patient has learnt the lesson from the first surgery and complied with rehab after revision procedure - possible cause of his knee function satisfaction

     
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