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A catalogue of errors

01 January 2014

Ms M, a 58-year-old woman, saw Mr A, a consultant orthopaedic surgeon, with a history of left-sided knee pain. She had seen him several years previously with a similar complaint – at that time, an arthroscopy had demonstrated degenerative change in both medial and lateral compartments of the knee. Upon being re-consulted, Mr A performed a second arthroscopy – severe degenerative changes and bone-on-bone contact were observed. Ms M was duly listed for a leftsided total knee replacement, which was performed three months later.

When undertaking the consent procedure Mr A indicated that he would be performing a left total knee replacement, that the indications for surgery were pain relief and improved mobility, and that the serious and frequently occurring risks had been fully discussed.

The procedure was performed through a midline incision. The finding, as anticipated, was gross tri-compartmental osteoarthritis. The prosthesis was inserted, the patellar osteophytes were trimmed but the patella was not resurfaced. The operating note does not record any untoward intraoperative events. Routine antibiotics and thromboprophylaxis were prescribed.

The following day an x-ray was performed. This showed that the tibial component of the prosthesis had been sited in a suboptimal position. Over the course of a week, the nursing notes consistently commented that it was very painful for Ms M to move her leg, that she was profoundly immobile and that physiotherapy was almost impossible. Mr A repeatedly suggested that Ms M should be mobilised – unhappy with this advice, Ms M pursued a second opinion. This was provided by Mr B.

Seven days after the operation, Mr A wrote to Ms M’s GP. In this letter he stated that the operation seemed to go very well but that the postoperative x-ray demonstrated a suboptimal result. He indicated that revision should not be pursued aggressively and that there were both advantages and disadvantages to this conservative approach. Moreover, he reported that most of Ms M’s pain was in the thigh.

Three days after the correspondence and ten days after the original operation, revision surgery was undertaken by Mr B. The operating note described the suboptimal position of the tibial component and recorded a fracture of the medial tibial plateau. The component was replaced and the patella resurfaced. A swab taken at the time of revision grew a coagulase negative Staphylococcus but this was thought to be a contaminant. The claimant made a reasonable recovery and was duly discharged four days later.

Follow-up was arranged by Mr B and Ms M was seen six weeks later. At that time, the wound had healed and Ms M was walking with a stick. The knee was a little stiff but physiotherapy was ongoing.

At this point a second issue supervened. Ms M complained of severe lower back pain and left-sided sciatica – an MRI scan of the lumbar spine demonstrated an L4/5 disc protrusion. A concurrent CRP of 35 and ESR of 31 were felt to be of questionable relevance and were attributed to delayed wound healing and the MRI finding.

Further follow-up, six months later, found that Ms M was walking without the aid of a stick. The knee was a little warm. The range of movement was 5° to 100° and it was considered that the knee was improving.

Fifteen months after the first operation, Ms M’s GP referred her to a rheumatologist, Dr L, on account of persistent knee and back pain. He requested a bone scan, which was reported as showing probable peri-prosthetic sepsis. Ms M was then referred back to Mr B who performed a diagnostic arthroscopy. This demonstrated an extensive synovitis and Staphylococcus epidermis was isolated from the biopsies obtained. A protracted course of antibiotic therapy ensued.

Two years after the original operation, a stepped explant was undertaken. Over a period of several months, the operative wounds healed and satisfactory x-ray appearances were obtained. However, Ms M continued to be troubled by persistent pain.

Six months later Ms M made a claim against Mr A. It alleged that Mr A was negligent on multiple counts, in that he had fractured the tibial plateau at the time of the original surgery, failed to identify the fracture during surgery and then failed to take remedial action intraoperatively.

Moreover, it alleged that Mr A had been negligent in failing to proceed urgently to revision surgery and in persistently advising Ms M to mobilise, despite her severe pain, the concerns expressed at multidisciplinary team meetings and all the clinical and radiological indications that the knee joint was mal-aligned.

Ms M also claimed that were it not for Mr A’s negligence, the total knee replacement would have been successful and she would have recovered swiftly following surgery. Furthermore, Ms M alleged that she would have been relieved of her preoperative symptoms and would not have required a further revision for approximately two decades. It was also suggested that the initial revision, the ensuing septic arthritis, the subsequent arthroscopy and the final two-stage revision were all consequent to Mr A’s negligence.

Expert evidence was sought from Mr D, a consultant orthopaedic surgeon, with regards to breach of duty and causation. Although Mr D acknowledged that Mr A was not aware of any adverse event occurring during the original operation, he was highly critical of Mr A for failing to act on the immediate postoperative x-rays, failing to proceed urgently to revision surgery and for repeatedly advising Ms M against an early revision.

He was also critical of the persistent advice to mobilise and acknowledged that, in his opinion, this was one of the worst total knee replacements he had seen. Moreover, Mr D felt that the subsequent operations Ms M underwent were a result of Mr A’s breach of duty during the index operation. In terms of breach of duty, Mr A made the tibial cut in the wrong direction. This led to poor placement of the tibial component with fracture of the posterior tibial cortex, which is surgery that falls below an acceptable standard of care.

The claim was settled for a substantial sum.

Learning points

  • Adverse outcomes and mistakes are part of a doctor’s working life. Acknowledging this, responding to such events in a timely manner and being open, help to reduce the impact of these events on both the patient’s wellbeing as well as the doctor’s professionalism.
  • In this instance, the highly critical expert evidence required swift action to control costs – in cases such as this, prompt settlement was appropriate. Strong expert opinion guides the approach of both MPS and the members involved.