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The twisted knee

01 January 2014

Ms C, a 42-year-old risk manager, fell from her horse whilst out riding. At the time of the fall she felt her left knee twist, as her left foot had been caught in the stirrup.

Two days later she presented to her GP, who noted that she had not lost consciousness at any stage, had landed on her outstretched hands and knees and that she had sustained some bruising on her neck. He documented that the medial aspect of the left knee had sustained a bruise, that the cruciate and collateral ligaments were fine and that McMurray’s test was negative. Analgesia, gradual mobilisation and exercise were advised.

Ten days later Ms C reattended her local clinic. It was noted that an effusion had developed in the left knee and the range of flexion had decreased. Physiotherapy was advised. A week later, Ms C presented to the local Emergency Department (ED) with persistent pain, at which point an x-ray excluded any gross bony injury, a splint was provided and she was re-referred to her GP. Her GP duly sought advice from the local orthopaedic team.

A month after the fall, consultant orthopaedic surgeon Mr T reviewed Ms C in his orthopaedic clinic. He noted the above history and found the knee held in approximately 10° of flexion. Attempts to flex or extend the knee were limited by reticence, rather than pain. A significant effusion was also observed. Exquisite tenderness was elicited on palpation over the medial joint line but upon testing the medial collateral ligament, no abnormality was evident.

On balance Mr T felt that Ms C “may simply have sustained bruising along the medial joint line, but any chance of a tibial plateau fracture or a meniscal injury should be excluded”. An MRI scan was requested and Ms C was encouraged to mobilise as and whenever possible, whilst wearing a brace.

A fortnight later, Ms C attended a followup consultation with Mr A, a consultant orthopaedic surgeon. The MRI had yet to be performed. Mr A noted that Ms C had sustained a significant injury to the left knee and that she was limping heavily. Moreover, she was unable to fully extend the knee and could not flex beyond 20° without severe medial joint line pain.

Concerned about a significant disruption of the medial meniscus with or without an associated injury to the anterior cruciate, Mr A advised Ms C that MR imaging was likely to be academic and that urgent arthroscopy was more appropriate. Admission was arranged a week later and the patient consented for an arthroscopic menisectomy. At arthroscopy a large injury to the medial femoral condyle was observed but the menisci were not torn – Ms C was advised that healing would occur with time. After a brief overnight admission due to pain, Ms C was discharged.

However, 48 hours post-arthroscopy, Ms C developed erythema, pain and swelling of her left calf. On the same day she also developed chest pain, following which she attended the ED. Subsequent venography of the left leg did not demonstrate a DVT but a CT pulmonary angiogram demonstrated a number of sub-segmental pulmonary emboli. She was duly anti-coagulated and discharged.

A year after the accident Ms C was assessed at the local chronic fatigue syndrome (CFS) service. At that time, she described fatigue, memory impairment, diminished concentration, word-finding difficulties, myalgia, sensitivity to light and noise, as well as disturbed sleep. Although not formally diagnosed as having CFS, the reviewing physician noted that Ms C’s symptoms were synonymous with those of CFS.

Two years later, Ms C brought a claim against Mr A, alleging that he had negligently performed an arthroscopy in the absence of an MRI scan, unreasonably diagnosed a meniscal tear, failed to obtain informed consent for the procedure, failed to adequately assess the thromboembolic risk postoperatively and failed to administer thromboprophylaxis. As a result of the alleged negligence, she felt that she had undergone an unnecessary arthroscopy, which caused the PE and led to chronic fatigue syndrome.

In defending the claim, expert opinion was sought. Professor D, a consultant orthopaedic surgeon, noted that Mr A’s preoperative working diagnosis was eminently reasonable in light of the claimant’s symptoms and signs, that it is not routine practice to carry out an MRI preoperatively if the clinician is happy with the working diagnosis, and that appropriate written consent was sought, clearly warning of the risks of DVT.

With regard to the assessment of thromboembolic risk, Professor D noted that when Ms C completed a preoperative health questionnaire, there was nothing to suggest any personal or family history of thromboembolic disease. Moreover, Professor D noted that routine anti-DVT prophylaxis is not standard practice prior to or following arthroscopy.

Had a normal MRI result been obtained, Professor D felt that the claimant would still have undergone an arthroscopy due to the persistent nature of her symptoms. Furthermore, he felt it unlikely that the arthroscopy had caused Ms C’s chronic fatigue syndrome.

If the claim had proceeded, MPS’s legal team would have considered commissioning expert evidence from a vascular surgeon to confirm the cause of the PE. However, in light of the supportive expert evidence, liability was denied and the claim was subsequently discontinued; no damages or claimant costs were paid.

Learning points

  • This case underlines the importance of instructing robust experts – highlighted by Professor D’s key role in securing the discontinuance of the claim.
  • A swift conclusion to this case ensured any anxiety suffered by Mr A was limited and MPS did not pay any claimant costs.
  • It is also important to recognise that a complication does not necessarily amount to negligence. Therefore, it is important to cover complications in the consent process and document such conversations diligently.