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Failure to Examine the Evidence (Episode 3)

Medico Legal

Referral to the Orthopaedic Professor by Angus Strover

The story so far:
1. In the first two episodes the Claimant (a selfemployed professional businessman) was referred to a prominent Knee Surgeon, (Surgeon I) for treatment of recurrent knee pain in a hospital (Hospital 1) 600 miles away from his home .

2. Claimant suffered a dreadful accident in the evening of the operation whilst the quadriceps muscle was paralysed by a local anaesthetic injection administered by the Anaesthetist, when the Claimant was left without support in the lavatory of the ensuite bathroom of his private room.

3. The accident shattered the tibia and fibula and required another operation to mend the fractures.

4. Having recovered from the operation the Claimant was flown 600 miles home to be looked after by his Partner and to be nursed in his own house by the Staff of the General Practitioner who had originally referred him to Surgeon 1.

5. After four days it was apparent that the home nursing was not altogether satisfactory and the Claimant was admitted to the Acute Unit of the Hospital with a swollen leg and his care was taken over by the local Orthopaedic Surgeon (Surgeon 2) who made a clinical, but fallacious diagnosis of an infected wound and treated it with two operations ostensibly to clear up the infection.

6. During the ensuing five months following the operations under the auspices of Surgeon 2 the Claimant was subjected to a monthly radiograph of the affected tibia and fibula.

7. The radiology reports said that the fracture lines were still visible indicating that the repair of the fractures was not progressing normally.

8. About 6 months after the last operation the metaphyseal part of the fracture gave way into hyperextension with pain and swelling of the back of the knee and some of the screws in the were backing out, and the heads of these screws were palpable under the skin which caused considerable consternation with the Claimant and his Physiotherapist who contacted Surgeon 2.

9. Surgeon 2 organised an appointment with the Claimant and gave his opinion that the posterior cruciate ligament had torn and booked an operation for the following month to arthroscope the knee and at the same time to remove the prominent screws.

10. In the meantime the Claimant’s symptoms were relieved by the fitting of a PCL brace.

11. A month later (7 months after the original accident in Hospital 1), the Claimant was called to have an MRI scan that had been arranged by the Claimant’s General Practitioner.

12. The MRI Senior Radiologist reported that “both the Anterior and Posterior Cruciate ligaments are intact. The fat pad and patellar tendon display moderate to
severe fibrosis.”

13. At this stage, following the arthroscopy, Surgeon 2 wrote a referral to an academic Professor of Orthopaedics and Trauma 600 miles away for an opinion on the pathology in the Claimant’s knee, the broken tibia and, in his opinion, the incompetent Posterior Cruciate ligament. 

The referral letter to the Professor of Orthopaedics

1. The referral letter from Surgeon 2 to the Professor was flawed in that although it described the accident which broke the Claimant’s tibia in the Hospital1, the letter claimed that Surgeon 1 had sent his patient home with a “nasty deep infection” and that he, Surgeon 2, “was left to pick up the pieces” by which he implied that he had to clear the infection by radical debridement including pulsed lavage.

2. In the letter to the Professor, Surgeon 2 omitted to give the details of the 2.consecutive operations within 48 hours of each other that had occurred on the pretext of a septic wound 7 months previously.

3. No radiographs, no radiographic reports or laboratory reports (which would have shown the evidence of the absence of infection) were supplied or mentioned in the referral letter to the Professor.

4. The Professor organised an early appointment with the Claimant, and after taking a history and examining the leg and knee he requested a single A-P radiograph and wrote a reply to the referral letter of Surgeon 2.

Referral of the claimant to his Senior Lecturer
1. The Professor replied in his letter to Surgeon 2 saying that he would refer the Claimant to his Senior Lecturer who had experience in the surgical correction of malalignment of long bones.

2. The Senior Lecturer examined the referral letter from Surgeon 2 to the Professor which intimated that the Surgeon 1 had sent the Claimant home with “a nasty deep infection”.

3. The Senior Lecturer correctly said that he would not operate until he had seen a CT scan of the tibia which would be able to show, even at this late stage,
indications of an infection in the areas of bone healing.

4. He requested a CT scan and made another appointment for the Claimant to be seen in the following month once the scan results had been reported.

5. The CT scan was reported by the very experienced and enthusiastic Professor of Radiology who spent time on a careful analysis of the tibia and concluded that there was no evidence of past infection of the bone and that it would be safe to operate without stirring up a past infection. The Professor discussed the situation with the Senior Lecturer, but did not mention the possibility of accurate measurement of malrotation.

6. The Orthopaedic Senior Lecturer examined the Claimant again and on his clinical examination he concluded that the rotational deformity was about eleven degrees.

7. He discussed the details of his prospective operation, to remove the remnants of the previous internal fixation and then to cut the tibial shaft, correct the malrotation and hold the new position of the tibial cut by a new plate and screws applied to the lateral side of the bone, whereas the previous internal fixation had been applied to the medial side.

8. The operation would be the sixth within 13 months and the Claimant was keen to sign consent and to get on what he thought would be the final operation. Consent was signed and a date was set for the operation.

The sixth operation, transverse tibial osteotomy
The operation performed by the Senior Lecturer (Surgeon 4) involved removal of the plate and remaining screws but failed to remove the two screws in the shaft of the tibia inserted by Surgeon 2. The Senior Lecturer cut the tibia transversely and applied a new plate on the lateral side of the tibia.

1.It is also of note that the fibula was solidly united and that Surgeon 3 did not osteotomise the fibula when doing his “corrective rotation”.It is common practice to osteotomise the fibula in this procedure in adults

2.The radiograph (below) taken afrter 11 months indicated that there was some callus but the union is not complete

The claimant’s persistent symptons of severe pain
1. The Claimant, whose occupation was desk-bound was losing time at work and not sleeping well at night due to pain and was taking painkillers and anti-inflammatory medication to no avail.

2. The Senior Lecturer discussed the situation with the Professor of Orthopaedics, who suggested that removal of the plate and full weight-bearing exercises to stimulate the bone healing would be appropriate at this stage.

The removal of the plate and screws after 11 months

1. In the operation, which was the seventh procedure, the Senior Lecturer removed the plate and screws and, with the Physiotherapy Department, he instituted full weight-bearing exercises which were painful and performed with some support with a single crutch used on the opposing side.

2. The plate and screws were removed leaving the two screws further down the tibia, which had been inserted by the Surgeon2 during his two operations. There is now the development of a bridge of new bone posteriorly.

3. The Claimant was desperate with knee pain and once again consulted the Professor for a final solution to this unrelenting and constant pain.

4. The pain that the Claimant was having was not only situated in the non-union of the tibia, but also in the soft tissues of the knee itself where the previous MRI scan had shown that the menisci, cruciate ligaments and joint surfaces were healthy but the patellar tendon was inflamed, with patellar tendinopathy and the retro patellar (Hoffa’s) fat pad was scarred and fibrotic.

5. It is well known that patellar tendinopathy and fibrosis of the retro patellar fat pad can be responsible for chronic anterior knee pain.

The decision to cut out the articulating surfaces of the knee joint and insert a revision hinge type of knee prosthesis

1. The Professor was of the opinion that the pain in the leg was generated mostly by the delayed union of the osteotomy and thought that if the osteotomy site were treated by a long-stemmed hinge prosthesis the knee would be pain-free.

2. The Professor decided that the problem would be best treated with a hinged total knee replacement with long stems projecting into the femur and tibia to deal with the painful combination of pathologies.

3. The Revision Total Knee Replacement required the removal of the joint surfaces, the cruciate ligaments and the menisci all of which had not been damaged.The source of the pain was apparently caused by the inflamed and fibrosed patellar tendon and retropatellar fat pad which continued to be painful. As a result the Claimant continued to walk with crutches and could not exercise full weight bearing without pain after the knee replacement has been implanted.

4. The operation was the eighth to be performed on the left lower limb 2 years and 6 months after the accident that had occurred in the original hospital
on the evening of a relatively minor operation on the left knee.

5. It was very unfortunate that the Professor’s operation was a complete failure from the point of view of pain relief and the Claimant was depressed and suicidal following the procedure.

6. His pain in the soft tissues of the knee joint was apparently aggravated by the heavy metallic endoprosthesis. editorial 11:Layout 1 4/3/15 2:59 PM Page 90
EXPERT WITNESS JOURNAL 91 SPRING 2015

7. After more than two years of suffering with the pain and a prolonged treatment with a very Competent Psychiatrist the Claimant did indeed attempt suicide with an overdose of pain killers and alcohol but was discovered by his partner who came home early from work, found the Claimant unconscious and raised the alarm bells successfully.

8. At this stage the Claimant requested an amputation and he discussed the situation with the surgical team, his General Practitioner and his Psychiatrist who warned him that he would quite possibly be troubled with pain in the “Phantom Limb”.

Timing of the saga that ended in amputation Almost four years after the accident that had occurred in the first Hospital1 the following list of surgical procedures had been performed on the left lower limb of the Claimant.

1) Date 0. The first procedure was an arthroscopy and tibial tubercle transfer by Surgeon1 to correct the problem of patella alta (high riding patella) to relieve anterior knee pain.

2) Date 0+1 Second procedure by Surgeon1, 24 hours later was the emergency osteosynthesis of the shattered left tibia due to an accident when the Claimant fell as a result of the effects of a local anaesthetic nerve block and the negligence of the attendant Nurse.

3) Date 0+21 days The Third procedure on the pretext of infection under the care of Surgeon 2.

4) Date 0+23 days. The Fourth procedures 48 hours later to apply more pulsed lavage and insert two screws beyond the tibial plate by Surgeon 2.

5) Date 0+7 months. The fifth procedure 7 months later by Surgeon 2 to arthroscope the left knee and remove some loose screws.

6) Date 0+13 months The sixth procedure By the Senior Lecturer
a) to remove the original plate and screws (omitting 2 screws),

b) to make a transverse osteotomy in the tibia

c) attempt to correct malrotation of the tibia,

d) to apply a new plate and screws to the lateral side of the tibia.

7) Date 0+23 months The Seventh procedure in Hospital3 by the Senior Lecturer

a) to remove the plate and screws and mobilise the Claimant weight bearing to complete the bony union of the osteotomy.

8) Date 0+30 months The 8th procedure in Hospital 4 by the Professor to insert along-stemmed “Revision, hinged Knee Replacement”.

9) Date 0+42 months The 9th procedure by Surgeons 3 and 4 together to remove the Knee Replacement and provide an above-knee amputation of the left leg;

The strange behaviour of Surgeon 2

Please give your opinions by ticking the relevant boxes.

1. Surgeon 2 was an elderly and well-thought-of Orthopaedic Surgeon in his own area, but he had, for the past two or three years experienced a drop in referral to him from the local GP and the Sports Medicine Specialist who had been sending their referrals 600 miles to a group of Surgeons (including Surgeon 1) who specialised in surgery of the knee.

2. This reduction in his own Private Practice was evidently irritating Surgeon2 and he was obviously piqued to know that the Claimant, who had previously been treated by him, had been referred to away from his area to have an operation by a Knee Surgeon who had become popular with the local doctors.

3.When the Claimant, who was well-known by Surgeon 2 and had been previously treated unsuccessfully by Surgeon 2, had returned from the more distant group having had an accident in the Hospital there, Surgeon 2 took over the Claimant’s treatment with glee and fabricated the diagnosis of “a nasty deep infection” which was never substantiated by the laboratory results.

4. Once the farce had been initiated, Surgeon 2 obviously had to continue with the treatment of the illusion by operating as he did, with all the medical and surgical treatment that would be appropriate for the diagnosis of sepsis.

5. On the evening of the hospitalisation of the Claimant, Surgeon2 claimed that he was unable to attend to his patient that night and brought in the younger Trauma surgeon to do the first “emergency operation” ostensibly to clear the infection.

6. Then 48 hours later he repeated the procedure and added 2 more screws into the tibial fragment beyond the plate on the tibia.

7. Surgeon 2 was obviously cognisant with the fact that his surgical interference using pulsed lavage would be likely to delay the union of the fractures, but took care to request six-weekly radiographs, the reports of which he did not store in his records but he made sure that the Physiotherapists received his fabricated reports of progressive boney union.

8. For instance after the first 6 weeks the Radiologist wrote in his report that the fracture lines were “still visible” .

9. Surgeon 2 wrote a letter to the Senior Physiotherapist that the fractures were “healing nicely” and admonished the Senior Physiotherapist that it was appropriate to begin weight-bearing exercises at this stage.

10. This charade with the radiographic reports under his left hand and his fabricated report in the form of a letter tendered to the Senior Physiotherapist
in his right hand continued for six months until the partially united fracture collapsed.

11. Do you agree that the advice from Surgeon 3 to the Senior Physiotherapist was disingenuous and dangerous for the Claimant?

Yes ? No ? Uncertain ?

12. In your opinion, would you agree that Surgeon 2 was again being disingenuous in requesting 6-weekly radiographs and not passing the Radiologist’s reports to the Physiotherapists?

Yes ? No ? Uncertain ?

(4) When, after six months, the Claimant had collapsed with pain and swelling at the back of the knee, and felt some of the screw heads palpable under the skin backing out, do you agree that Surgeon2 was particularly disingenuous in making a false diagnosis of a ruptured posterior cruciate ligament?

Yes ? No ? Uncertain ?

(5) In your opinion would you agree that the backing out of 4 screws and the incident of hyperextension, pain and swelling together with the backing out of screws were indications of delayed union that had been caused by the operations involving pulsed lavage under the care ofSurgeon 2?

Yes ? No ? Uncertain ?

(6) The indications for the operations at the medical school and their outcomes

1, Do you agree that the Professor of Orthopaedics and the Senior did not do sufficient preoperative imaging, including CT studies to measure the exact rotation of the prior to the operation performed by the Senior Lecturer?.

Yes ? No ? Uncertain ?

2, Do you agree that failure to osteotomise the well-united fibula may have been the reason for delayed union following the osteotomy performed by the Senior Lecturer?

Yes ? No ? Uncertain ?

3, When the osteotomy was taking more than 11 months to unite, and the Professor suggested removal of the plate and screws, did the osteotomy unite?

Yes ? No ? Uncertain ?

4, Would you have osteotomised the fibula at that stage?

Yes ? No ? Uncertain ?

5, After the plate and screws were removed did the osteotomy unite?

Yes ? No ? Uncertain ?

6, Given that the knee joint had normal articular surfaces, cruciate ligaments and menisci, do you think that the Knee Replacement should have dealt successfully with the pain that the Claimant was having in his knee joint?

Yes ? No ? Uncertain ?

7, Would you agree to the amputation as a final solution to the painful lower limb?

Yes ? No ? Uncertain ?

This is a true story. If you would like to comment, please send your comments to me via the Expert Witness journal or if reading on-line via the downloadable word document.

The next episode will be on the opinion of the Orthopaedic expert Witness in this case - Don’t miss it!