Commentary:
Good communication and documentation led to a defense verdict for the defendant orthopaedic surgeon.
The Case:
The patient, a 39 YOM (5'11", 299 lbs.), presented to the defendant orthopaedic surgeon with complaints of right knee pain. He was on medications for insulin-dependent diabetes, HTN, hyperlipidemia, and depression. An MRI suggested an anterior cruciate ligament disruption distally, lucency without significant retraction at the ACL insertion site on the tibia, chondromalacia, and meniscal degeneration. The defendant orthopaedic surgeon offered conservative options and arthroscopic evaluation. The patient requested arthroscopy but wanted to wait three weeks until he finished cleaning his property from a recent sewage back up.
One month later, the defendant orthopaedic surgeon performed an arthroscopic partial medial meniscectomy, chondral shaving of the medial femoral condyle, resection of the anterior cruciate ligament stump and medial plica, and chondral shaving of the patella. The patient reported tolerable pain and was discharged home.
The following morning, the patient presented to the ED complaining of right knee pain and swelling. He denied fever and redness to the area. The patient’s vitals were BP 109/57, P 103, R 20, SaO2 97%, and T 97.6. The defendant ED physician noted intact sutures, no sign of erythema or appreciable warmth, and moderate effusion. Pain medications provided good pain relief for the patient. The defendant ED physician did not believe the patient had any evidence of infection and that draining the knee was not in the patient’s best interest. The patient was to follow up with the defendant orthopaedic surgeon or return to the ED.
The defendant orthopaedic surgeon evaluated the patient in his office the same morning of his ED visit. The defendant orthopaedic surgeon changed the dressing, noting the incision looked good with no evidence of erythema or warmth, and no tenderness in the calf. The patient had fullness in the suprapatellar pouch, and was reluctant to move the knee. The defendant orthopaedic surgeon aspirated 10 cc of uncoagulated blood and infiltrated 20 cc of 0.5% bupivacaine with epinephrine. The patient noted pain improvement and was to return in two days.
The patient’s wife called the defendant orthopaedic surgeon that afternoon. She advised that her husband’s pain was returning with an increase in swelling. She removed the bandage and thought there may be a rash. The defendant orthopaedic surgeon discussed the possibilities of DVT and suggested the patient go to the ED if symptoms did not improve.
The patient returned to the ED that evening complaining of right knee pain, swelling, and difficulty breathing. The ED physician reported right lower extremity diffuse swelling with a large area of erythema on the medial aspect of the knee. Labs revealed WBC 4.4 (4.59-11.58), bands 32 (0-12), BUN 28 (6-27), creatinine 2.24 (0.2-1.3), bilirubin 2.2 (0-1.5), AST 140 (5-59), ALT 74 (47-163), and lactic acid 8.5 (0.5-2.2). The ED physician contacted the on-call orthopaedic surgeon, who recommended aspiration. The ED physician sent the aspiration to pathology, which found moderate gram-positive rods. Vancomycin and clindamycin were started.
The on-call orthopaedic surgeon arrived in the ED and attempted another tap; he encountered air. A CT scan revealed gas within the right knee joint and suprapatellar bursa. The CT also showed gas infiltration of the mid and distal thigh, upper calf, and adjacent subcutaneous tissues consistent with gas gangrene. The patient was air-transferred to a level 1 trauma center.
On arrival, the patient was 30 hours post-arthroscopy. He was started on 1 gram IV of linezolid and meropenem. The patient’s admitting diagnosis was septic shock, secondary to infection in the right lower extremity. The diagnosis also speculated possible necrotizing fasciitis versus Fournier's gangrene. The trauma surgeon took the patient to surgery upon arrival. Right hip disarticulation was performed, but the patient continued to deteriorate. The patient went into cardiac arrest and did not survive.
The plaintiff alleged failure to diagnose and treat gas gangrene following knee surgery, resulting in death. The plaintiff’s expert orthopaedic surgeon stated the standard of care required the defendant orthopaedic surgeon to send fluid from the first knee aspiration for a stat gram stain. The plaintiff alleged the defendant orthopaedic surgeon should have been suspicious for infection based on pain complaints and the patient’s history of diabetes. Alleged failure to start the plaintiff on antibiotics was also stated.
The defendant’s two expert orthopaedic surgeons indicated that when the plaintiff returned to the ED and was later evaluated by the defendant orthopaedic surgeon, the knee was not red or unusually swollen. Experts said sending the fluid aspirate for a stat culture is not the standard of care and pre- or post-surgical antibiotics would not be appropriate for a routine arthroscopy. The defense argued the defendant orthopaedic surgeon met the standard of care when performing the plaintiff’s knee arthroscopy. Infection rates are generally very low with this procedure, and an antibiotic would not cover gram-positive rods.
The jury returned a unanimous no-cause verdict for all of the defendants.
---
If you have questions on this topic, please email RiskAdvisor@ProAssurance.com or call 844-223-9648.
