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A tight situation

01 August 2003

Mrs W, a retired lady in her seventies, had suffered from a painful and stiff left knee for some years. She saw an orthopaedic surgeon, Mr D, who recommended a left total-knee replacement. Mr D had some trouble operating on Mrs W’s knee. He had to use a substantial medial release procedure, stripping the entire postero-medial aspect of the tibia.

Mr D applied a tourniquet around the left thigh to aid haemostasis. This was in place for 2 hours and 10 minutes. This time reflects the degree of difficulty Mr D had during surgery.

The notes show that Mrs W’s left foot turned pink on release of the tourniquet. Mrs W’s postoperative care included a regional epidural infusion for analgesia. In the early postoperative period, Mrs W’s left foot was pale and pulseless with poor sensation.

A little later it seemed pinker, but sensation remained impaired. Two days after the operation it was cool to the touch, numb and poorly perfused. Mr R, consultant vascular surgeon, came to see Mrs W, at her team’s request. Mr R suggested some investigations, although the notes do not show that these were carried out.

Later that day, Mrs W was reviewed by her orthopaedic team. The notes show that the foot was pinker, but couldn’t be actively dorsiflexed at the ankle. The team diagnosed neuropraxia of the left sciatic nerve.

Mrs W was not doing so well the next day. Her left calf was intensely painful and hard. Passive dorsiflexion of the ankle caused severe muscle pain. Mr J arranged pressure gauging of the leg compartments, suspecting a diagnosis of compartment syndrome.

This proved to be the cause of the problem. Mr J performed an immediate fasciotomy, leaving the wounds open, and giving the patient IV antibiotics. Mrs W needed larval (maggot) therapy to treat her healing wounds, an experience she didn’t relish.

Mrs W had significant sequelae from her compartment syndrome. Although the vascular and nerve supplies to her foot were intact, she had marked muscle necrosis. Mrs W was left with a disabling left-sided foot drop. She launched a legal action against Mr J, alleging negligence in the management of her postoperative vascular problems.

Expert opinion

There was some debate amongst the orthopaedic and vascular experts we consulted. On the balance of probabilities, it was thought that ischaemic damage due to prolonged use of the tourniquet, followed by a reperfusion-related compartment syndrome, was the most likely clinical scenario. Treatment after the diagnosis of compartment syndrome was deemed timely and appropriate.

The tourniquet time was held to be at the upper end of the acceptable limit used by a responsible body of orthopaedic surgeons.

The question of liability centred on the speed with which diagnoses were made.

One expert commented, ‘ … there does appear to have been a period of about three days during which the muscle damage developed, and I am afraid that the impression given by the clinical notes … is one of indecisiveness and uncertainty.

‘It should, I think, have been clear that a serious complication was arising, and even though the clinical picture was variable and partially masked by the analgesia (epidural infusion), I believe that the diagnosis should have been made sooner.’

The case was settled for a moderate sum.

Mr R was not held to be liable, in that he saw the patient only once, and gave advice appropriate to the clinical situation at that time.

Learning points

The use of a tourniquet during orthopaedic surgery is not universal. When gaining consent from patients for a procedure where one will be used, it may be wise to give details of its use and the potential effects this could have.

Compartment syndrome is an extremely time-sensitive clinical problem. To prevent significant adverse long-term effects, it must be remedied early in its course. Its pathognomonic features include:

  • Pain disproportionate to the clinical situation
  • Pain on passive stretching of the involved muscles
  • Disturbed skin sensation, in the distribution served by nerves traversing the compartment.