CASE IN POINT
Judgment for the Defense

INFECTION POST-OP TOTAL KNEE REPLACEMENT

TThe case involves a man in his mid-40s who presented to the defendant, an orthopedic surgeon, with complaints of pain in his left knee (Fig 1-1). He had arthritis of the knee (Fig 1-2) and had been trying conservative treatment, but the knee was not responding, so the defendant recommended a total knee replacement (Fig 1-3) to improve mobility and eliminate pain.

Fig 1-1 --- Click on Images to Enlarge
Fig 1-2
Fig 1-3

A few weeks post-op, the patient returned to the defendant with a subluxation of the patella (Fig 1-4) -his kneecap was out of place. The defendant performed a lateral retinacular release (Fig 1-5) to re-establish the alignment of the patella. After a few more weeks, the patient returned again with the same problem, a dislocated kneecap. The defendant performed an extended release with a scope, through which he cut a little bit more of the retinaculum to help secure and center the kneecap. After both these procedures, the defendant told the patient to wear an immobilizing brace (Fig 1-6) to keep the knee from bending and to help keep the kneecap in place so he could heal. The defendant also told the plaintiff not to return to work for at least 4 weeks.

Fig 1-4
Fig 1-5
Fig 1-6

About a month after the second kneecap release, the patient began presenting with symptoms of infection, including heat and tenderness in the knee and thigh, as well as drainage from the knee. Over the course of the next several weeks, the defendant performed 4 separate arthroscopic (Fig 1-7) debridement, irrigation, drainage, and lavage procedures on the patient to deal with the recurring infection, cleaning out the area as much as possible. On the second recurrence of the infection, the defendant brought in an internal medicine specialist for a consultation. After each procedure, the patient was given antibiotics, and fluid from his knee was sent for testing. All of the cultures came back negative.

Before the defendant performed the final debridement and lavage, he discussed with the patient that if this procedure didn't work, he might need to undergo a 2-stage revision of his left knee. In this procedure, a surgeon would remove the patient's prosthesis, insert an antibiotic spacer and keep him on antibiotics, and then implant a new prosthetic knee. The defendant also discussed with the patient the possibility that if the treatment did not work and the bone became infected, he was in danger of losing his leg. After this final debridement, the defendant referred the patient to another doctor at the orthopedic department. The patient ultimately underwent a successful 2-stage revision surgery.

Fig 1-7

PLAINTIFF'S CLAIM:

A delay in the plaintiff's treatment occurred. When the plaintiff presented to the defendant for a second time with signs of infection, the defendant should have discontinued antibiotics and washout procedures, removed the hardware, and inserted an antibiotic spacer right away, rather than waiting for 2 more months. Additionally, during the second debridement procedure, the defendant made a lateral incision too close to the original incision, resulting in failed healing. The error further delayed the implant of a new prosthesis.

DEFENSE'S ARGUMENT:

The initial total left knee arthroplasty procedure performed by the defendant had no complications. In fact, the procedure went so well that the plaintiff only spent 2 days in the hospital, instead of the typical 5 to 7 days. Patellar subluxation is not a common complication after a total knee replacement; this was the first time the defendant had seen it happen. The doctor recommended that the patient wait the standard 6 to 8 weeks, and insisted on least 4 weeks, before going back to work after surgery. The plaintiff, however, ignored the recommendation and returned to work too early. This may have prevented complete healing of the knee and caused an interior suture to give way, which would explain the patellar dislocation problems and subsequent infection.

When the plaintiff presented with signs of infection for a second time, the defendant immediately admitted him and involved internal medicine because it was a difficult, puzzling case. They hoped to treat the patient based on what bacteria the cultures showed, but the cultures all came back negative.

Regarding the issue of the incorrect second lateral incision, the defendant did not make an incision during the second procedure. Using photos of the patient's leg, the defense team was able to show the incision was from a subsequent doctor's surgery, not the defendants.

After the defendant performed the final debridement procedure, he referred the plaintiff to another doctor because he was not getting enough results from the lab, he was worried about overmedicating resulting in possible damage to the patient's kidneys, and he was worried that the plaintiff could lose his leg. The defendant felt the plaintiff should go to a center where more could be done for him. While the plaintiff did endure an extended recovery, the ultimate outcome was successful implantation of a new prosthesis without the loss of the leg.

VISUAL STRATEGY:

Collaborating with the defense attorneys and physicians, Illustrated Verdict created a visual strategy to help explain the steps taken in the plaintiff's care, supporting the view that the defendant's actions were within the standard of care.

 

The initial diagram was an illustration showing a total knee replacement. (Fig 2-1)
Fig 2-1

 
The second diagram illustrated the lateral retinacular release to help correct the subluxed patella. (Fig 2-2)
Fig 2-2
 
The next illustration depicted the extension of the lateral retinacular release because the plaintiff's kneecap had dislocated again. (Fig 2-3)
Fig 2-3

 
A fourth diagram depicted the first irrigation procedure the plaintiff underwent after presenting to the defendant with symptoms of infection.
(Fig 2-4)
Fig 2-4
 
The next diagram showed the debridement and irrigation procedure the defendant performed after the plaintiff returned again with signs of infection. (Fig 2-5)
Fig 2-5
 
The next two illustrations depicted a third (Fig 2-6) and fourth (Fig 2-7) procedure to irrigate the knee.
Fig 2-6
Fig 2-7
 
Lastly, an image was created to show where the incisions were made on the plaintiff's left knee in all 7 of the surgeries the defendant performed. (Fig2-8)
Fig 2-8
 

This series of visuals helped the defense successfully convey the following key points to the jury:

  • Despite the defendant continually telling the plaintiff to keep wearing his knee brace and not return to work until he was healed, the plaintiff went back to work too soon. This most likely caused the dislocations of the patella that brought about the infection. Working nonstop, the plaintiff never gave his knee time to fully heal.
  • The defendant either re-opened the same midline incision for the debridement procedures or used stab wounds, as opposed to creating new lateral incisions. The point of entry for the stab wounds are on the lateral aspect, near the outside top of the kneecap.
  • Although the defendant performed 7 different procedures on the plaintiff, he made incisions at a few distinct spots as opposed to cutting into the knee in multiple locations, as demonstrated in the final exhibit.
RESULT:
The jury found in favor of the defense. 

“The jury came back in our favor yesterday, 12-0. The boards, as always, were a tremendous help. Thank you for all your hard work.”

- Attorney Jeffrey Atkinson, Gonnerman Reinert, LLC, St. Louis, MO

 

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